Implementing ECHO

(Extension for Community Healthcare Outcomes)

To Strengthen Nurse Case Management

Improve Patient Outcomes

BACKGROUND ON NEW MEXICO

NEW MEXICO CHALLENGES

• Decrease in TB Nursing Expertise

• Actual decrease in number of nurses to provide NCM services

• Low incidence state –

• Average 50 active cases per year/2.4 rate

• ~17 – 20 active ongoing cases

• TB Mortality in NM

• Close to 20% vs. 5% (U.S. wide)

Extension for Community HealthCare Outcomes

ECHO PACKAGES CONCEPTS

• Video Conferencing

• Case-based learning

• Promotion of best practices

• Outcome Monitoring

At Project ECHO our mission is to democratize medical knowledge and help get best practice care to underserved people all over the world. Our goal is to improve the lives of 1 billion people by 2025.

Supported by New Mexico Department of Health, Agency for Health Research and

Quality, New Mexico Legislature, the Robert Wood Johnson Foundation, the GE

Foundation and Helmsley Charitable Trust

ECHO ACT PASSES IN U. S. SENATE AND HOUSE OF REPRESENTATIVES

• Bipartisan support for Expanding Capacity for Health Outcomes (ECHO) pass unanimously

• November 29, 2016

• Health & Human Services to report on technology-enabled collaborative learning and capacity building models, which connect specialist to primary care thru videoconferencing to facilitate case-based learning, dissemination of best practices and evaluation of outcomes

ECHO Telehealth vs. Telemedicine

ECHO Telehealth

ECHO Supports Community Based

Primary Care Teams Patients reached with specialty

knowledge & expertise

Traditional Telemedicine

Specialist Manages Patient Remotely

Hepatitis C

HEPATITIS C TREATMENT IN NEW MEXICO

2004

UNMHSC

Center for Digestive Diseases Clinic

Treated Approximately 250 patients/year

Project ECHO Partners

Treat Approximately 1,100

patients/year

2016

UNMHSC

Center for Digestive Diseases Clinic

Treated Approximately 100 patients/year

10

TB ECHO…..WHEN IT ALL BEGAN

• November 2012 – TB/HIV Four Corners presentation • heard Dr. Arora talk about HCV

• Hmmmm – that could work for TB

• 2013 – Discussions with Bruce Struminger at ECHO

• 2015 – Serious planning began • Attended Project ECHO immersion • March 24 – Formal launch • April 2015 – First TB ECHO clinic

NM DOH TB ECHO 2 YEAR ANNIVERSARY

April 17, 2017

VIDEO – CONFERENCING TECHNOLOGY

• Public Health Nurses meet once per month

• Get to “see” your colleagues

• Facilitates conversation

• Less isolation

VIDEO – CONFERENCING TECHNOLOGY

• Public Health Nurses meet once per month

• Get to “see” your colleagues

• Facilitates conversation

• Less isolation

CASE BASED LEARNING

• Every active TB case presented monthly • By local public health nurse • 20 cases/month

• Standardized TB Template for

presentation • QA for missing data • Important for ongoing NCM

• TB Medical Director

• Provides orders on cases during clinic

• Active exchange of information & learning

TOOLS OF THE TRADE….. TB PRESENTATION TEMPLATE

VARIETY OF CASES PRESENTED……..

Pulmonary vs

Ex-Pulmonary

Extra – Pulmonary Sites

73%

27%

40%

20%

13% 13%

7% 7%

0

1

2

3

4

5

6

7

Pleural Eye and earappendages

Bone and/orJoint

Genitourinary Pericardium Meningeal

Nu

mb

er o

f ca

ses

6

3

2 2

Pulmonary

Ex -pulm

1 1

EXTRA PULMONARY TB: POTTS DISEASE CASES

PROMOTION OF BEST PRACTICES

• Improve patient outcomes

• Community of practice

• Strengthen TB Nurse Case Management Skills

• Increase skills AND confidence in those skills

• Short Didactic (10-15min)

• Clinical and programmatic topics

• Continuing Education Credits available

• Available for other ECHO clinics to use

WHAT HAVE WE DONE? OUTCOME MONITORING

• 20 ECHO clinics held (end of Dec 2016) • 76 unique patients presented by 25 nurses

• 334 total presentations

• Total of 785.5 Continuing Education Units awarded • 20 didactic sessions

• Attendance consistently strong – 16 PHNs (average)

• Monthly Evaluation following clinic

• Self – efficacy Survey – Public Health Nurses • Initial and month seven (7)

• Efficient & Cost effective model • Provide education of public health nursing workforce

• Platform for standardized monthly review of cases

TB NURSE SELF-EFFICACY ASSESSMENT

0

1

2

3

4

5

6

7

Opt-out HIV testing interpret IGRA

results

Interpret Smear

results

Interpret NAAT/PCR Interpret culture

results

Interpret DST Idenfity Culture

conversion

Mean Likert Scale Scores tested April, 2015 and October, 2015

Mean score April Mean score October

TB NURSE SELF-EFFICACY ASSESSMENT

0

1

2

3

4

5

6

7

Effective NCM Patient

education

Identify side

effects

Identify High Risk

Contacts

Test High Risk

Contacts

Initiate Window

Treatment

Identify End of

Infectious Period

April, 2015 and October, 2015

THOUGHTS…… TO PONDER

• How could I use ECHO in my program?

• What are logistics/barriers to implementation?

• While pondering – let’s look across the US and globally

• How other programs utilizing ECHO

TB ECHO Program implementation and preparation in 2015 & 2016:

• Viet Nam – launched first TB ECHO in February 2015, focus on MDR & XDR • Pre-XDR and XDR cases being considered for bedaqualine treatment

• New Mexico – launched in April 2015 • Low burden state; all active TB cases with a focus on nurse case management

• Washington State DOH/Univ of WA— launched in September 2015 • Active cases plus LTBI cases

• Navajo Area Indian Health Service – launched January 2016 • IHS, Navajo Nation, NM DOH, AZ DOH, CDC DTBE collaboration

• Colorado DOH w Denver Health launched July 2016

• Kenya NTP MDR TB ECHO launched July 2016

• US-Mexico Border Health Initiative TB Program [CDC DGMQ & DTBE] launching Spring 2017 • Management of MDR and complex bi-national TB cases • CDC DGMQ/DTBE, MX NTP, NM Office of Border Health & UNM Project ECHO collaboration

• Haiti, India, Namibia, Botswana, Georgia, & Guatemala TB Programs in preparation • MDR TB case consultation

VietNam MDR TB ECHO February 20152015

Navajo Nation TB ECHO

Navajo Nation TB ECHO

US-MX BORDER TB ECHO

• Pilot Project to develop ECHO platform for binational TB Programs

• Border Health Commission

• New Mexico office of Border Health

• Oral & transcription translation

• Bilingual intake form

WASHINGTON STATE TB ECHO

TB ECHO in Washington

TB ECHO® Team

38 LHJs

18 FQHCs

11 Primary Health Clinics

4 State

Government

3 RTMCCs

TB ECHO® Team

38 LHJs

18 FQHCs

11 Primary Health Clinics

4 State

Government

3 RTMCCs

Sessions

• 23 sessions

• 127 participants

• Average 23 per session

• CME/CNEs offered

Sectors • 35% Primary Care

• 61% Public Health

• 3% RTMCC

Professions

• 53 RN/PHNs

• 42 Medical Providers

• 32 Support Staff

Focus: TB Infection

Partner Organizations: • University of Washington

• Washington State Department of Health

• Firland Northwest Tuberculosis Center

Rating (1=Strongly disagree, 5=Strongly

agree)

TB ECHO in Washington

3.4 3.6 3.8 4 4.2 4.4 4.6

My self-efficacy

Ability to apply knowledge

learned

Ability to share knowledge

learned

Ability to answer questions

My feeling of professional

support

Comfort in presenting cases

Participation in TB ECHO has increased my...

OVERVIEW OF TB-ECHO CASE MANAGEMENT

• Augments Colorado’s current TB Program services • Started in July 2016

• Facilitated by the state’s TB Education and Training Coordinator and TB Nurse Consultant

• Local public health nurses present their active TB cases for discussion amongst participants while getting real-time feedback from TB subject matter experts

• Patient confidentiality is maintained, as no identifying information (name, DOB, etc.) is shared.