Project ECHO

An Innovation in Healthcare DeliveryTreatment of Hepatitis C

January 26, 2012Saverio Sava, MD

First Choice Community HealthcareAssociate Professor

UNM Family & Community Medicine

Who We AreA Federally Qualified Community Health Center System Founded in 1972

Provider of Primary Medical, Dental, Behavioral Health and WIC Services2

A major Safety Net Provider to the Uninsured and Underinsured in Bernalillo,

Valencia, Sandoval, Torrance, Guadalupe, Santa Fe, and Socorro Counties in Central

New Mexico

An Incubator for Innovation, Change & Community Development

8 Locations in 3 Counties

Serving 50,000 Patients with over 200,000 Visits Annually

Our Facility Locationsin Central New Mexico

Counties Serviced

Bernalillo

Guadalupe

Sandoval

Santa Fe

Socorro

Torrance

Valencia

First Choice Locations

Project ECHO

Celebrating Successes

Innovations in Primary Care

Project ECHO

Utilizes the specialty expertise of an Academic Health Center in partnership with Primary Care and Public health practices in rural and undeserved communities.

Project ECHO

What project ECHO represents is a bold experiment that implements a

new approach to providing care.

Project ECHO

Hepatitis CA Growing Concern

U.S.A. 4 M

SOUTH

AMERICA

10 M

AFRICA 32 M

EAST MEDITERRANEAN

20M

SOUTH EAST ASIA30 M

AUSTRALIA0.2 M

Source: WHO 1999

WEST EUROPE

9 M

FAR EAST ASIA60 M

170 Million Carriers Worldwide, 3-4 MM new cases/year

Hepatitis C: A Global Health Problem

HEPATITIS C IN NEW MEXICO

~ Estimated number is greater than 28,000

~ In 2004 Less than 5% had been treated

~ Without treatment 8,000 patients will develop cirrhosis between 2010-2015 with several thousand deaths

~ 2300 prisoners diagnosed in corrections system (expected number is greater than 2400) - None treated

~ Highest rate of chronic liver disease/cirrhosis deaths in the nation

HEPATITIS C IN NEW MEXICO

GOALS

~ Develop capacity to safely and effectively treat Hepatitis C in all areas of New Mexico and to monitor outcomes

~ Develop a model to treat complex diseases in rural locations and developing countries

GOALS

METHOD

~ Use Technology (multipoint videoconferencing and internet) to leverage scarce healthcare resources

~ Disease Management Model focused on improving outcomes by reducing variation in processes of care and sharing “best practices”

~ Case based learning: Co-management of patients with UNMHSC specialists (Learning by Doing)

~ HIPAA compliant centralized database to monitor outcomes

Arora S, Geppert CM, Kalishman S, et al: Acad Med. 2007 Feb;82(2): 154-60.

METHOD

Underserved Area for Healthcare Services

Rural New Mexico

•121,356 sq miles•1.83 million people•42.1% Hispanic•9.5% Native American•17.7% poverty rate compared to 11.7% nationally•>22% lack health insurance

•32 of 33 New Mexico counties are listed as Medically Underserved Areas (MUAs)•14 counties designated as Health Professional Shortage Areas (HPSAs)

RURAL NEW MEXICORURAL NEW MEXICO

STEPS

~ Train physicians, nurses, pharmacists, educators in Hepatitis C

~ Train to use web based software - “ihealth”

~ Conduct telemedicine clinics – “Knowledge Network”

~ Initiate co-management – “Learning loops”

~ Collect data and monitor outcomes centrally

~ Assess cost and effectiveness of programs

STEPS

COMMUNITY PARTNERS~ No-cost CMEs and Nursing CEUs

~ Professional interaction with colleagues with similar interest – Less isolation with improved recruitment and retention

~ A mix of work and learning ~ Obtain HCV certification

~ Access to specialty consultation with GI, hepatology, psychiatry, infectious diseases, addiction specialist, pharmacist, patient educator

BENEFITS TO RURAL CLINICIANS

How well has model worked for Hepatitis C ?

500 HCV Telehealth Clinics have been conducted

• >5000 patients entered HCV disease management program

CMEs/CEs issued:6100 CME/CE hours issued to ECHO Clinicians for Hep C. Total CME hours 27,000 at no cost

The Hepatitis C Trial

ObjectivesTo train primary care Clinicians in rural areas and

prisons to deliver hepatitis C treatment to rural populations of New Mexico

To show that such care is as safe and effective as that given in a University Clinic

To show that Project ECHO improves access to hepatitis C care for minorities

ParticipantsStudy sites

Intervention (ECHO) Community-based clinics: 16 New Mexico Department of Corrections: 5

Control: University of New Mexico (UNM) Liver ClinicSubjects meeting inclusion / exclusion criteria

Community cases seen by primary care physiciansConsecutive University patients

Principal Endpoint

Sustained viral response (SVR): no detectable virus 6 months after completion of treatment

Developing New Standards of Practice for Hepatitis C

407 hepatitis C patients met inclusion and exclusion criteriaAge: 43.0 ± 10.0 yearsMen: 63.3% Minority: 65.2%Genotype 1: 57.0%Log10 viral load: 5.89 ± 0.95Treatment sites

UNMH: 146 ECHO site: 261

Treatment Outcomes

OutcomeOutcome ECHOECHO UNMUNMHH

P-P-valuvalu

eeN=261N=261 N=146N=146

MinorityMinority 68%68% 49%49% P<0.0P<0.011

SVR (Cure) SVR (Cure) Genotype 1/4Genotype 1/4

50%50% 46%46% NSNS

SVR (Cure) SVR (Cure) Genotype 2/3Genotype 2/3

70%70% 71%71% NSNSSVR=sustained viral response

NEJM : 364: 23, June 9-2011, Arora S, Thornton K, Murata G

ConclusionsRural primary care Clinicians deliver hepatitis C care

under the aegis of Project ECHO that is as safe and effective as that given in a University clinic

Project ECHO improves access to hepatitis C care for New Mexico minorities

HEALTHCARE IN NEW MEXICO

Primary Care Nurse

Medical Assistant

Community Health Worker

Hepatitis C

Asthma and COPD

Substance Use and Mental Health Disorders

KNOWLEDGE IMPORTANT - NOT

TITLEChronic Disease Management is a Team Sport

FORCE MULTIPLIER

Project ECHO

Organizational Challenges & Barriers to

ImplementationIn a Community Health Center

Project ECHO

IdeologicalFinancial

Training & StaffingTransforming our Healthcare System

Project ECHO

Ideological Barriers

“It’s Not What We Do”“Replacing the Lost Primary Care

Effort”

Project ECHO Financial barriers

Effects on productivity Buying Provider Time & Staff Support Fixed Payment Systems for FQHC’s Prevention May Save $$$ but….

Project ECHO

Training & Staffing

Rapid Turnover of Support StaffIncreasing difficulty Recruiting PCP’s

Project ECHO

Transforming our Healthcare SystemHow do we advocate so innovations that

work are disseminated?How do we institutionalize programs so

they grow beyond individual champions?

Project ECHO

Steps for Successful Implementation.

Project ECHO

Steps for Successful Implementation.

1. Start with a champion.

Project ECHO

Steps for Successful Implementation.

1. Start with a champion.

2. Administration must buy in early.

Project ECHOSteps for Successful Implementation.

1. Start with a champion.

2. Administration must buy in early.

3. Involve multiple key staff member.

Project ECHOSteps for Successful Implementation.

1. Start with a champion.2. Administration must buy in early.3. Involve multiple key staff member.

4. Key on staff satisfaction & retention.

Project ECHOSteps for Successful Implementation.

1. Start with a champion.2. Administration must buy in early.3. Involve multiple key staff member.

4. Key on staff satisfaction & retention.5. Highlight positive patient experiences.

Project ECHOSteps for Successful Implementation.

1. Start with a champion.2. Administration must buy in early.3. Involve multiple key staff member.

4. Key on staff satisfaction & retention.5. Highlight positive patient experiences.

6. Highlight your program in organizational reports and newsletters.

Project ECHO

Use the success of Project ECHO to explore other practice modifications that will likewise contribute to

changing the face of how we deliver healthcare.

Medicine & Public HealthInto the New Millennium

Ten Great Public Health Achievements - United States 1900 - 1999

• Vaccinations

• Safer Workplace

• Decline in Deaths from Coronary Heart Disease

• Sanitation • Healthier Mothers and Babies

• Motor-Vehicle Safety

• Safer and Healthier Foods

• Family Planning

• Fluoridation of Drinking Water

• Recognition of Tobacco use as Health Hazard

JAMA, April 28, 1999

Project ECHO

The greatest impact on healthcare in this millennium will be through system

innovations on how health care is delivered to improve the health of our communities.