Transcript UNM Project ECHO Pain - Texas Primary Care and Health Home

Project ECHO (Extension for
Community Health Outcomes)
Joanna Katzman, MD, MSPH
Director of Project ECHO® Pain and University of New Mexico Pain Center
Department of Neurosurgery
University of New Mexico Health Sciences Center
The mission of Project ECHO® is to
expand the capacity to provide best
practice care for common and complex
diseases in rural and underserved areas
and to monitor outcomes.
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 Trust
A Global Health Problem
Over 170 Million Carriers Worldwide, 3-4 Million new cases/year
WEST
EUROPE
9M
U.S.A.
4M
EAST
MEDITERRANEAN
20 M
FAR EAST ASIA
60 M
SOUTH EAST ASIA
30 M
AFRICA
32 M
SOUTH
AMERICA
10 M
Source: WHO 1999
AUSTRALIA
0.2 M
New Mexico
• Estimated number is greater than 28,000
• In 2004 less than 5% had been treated
 2,300 prisoners were HCV positive (~40% of
those entering the corrections system), none
were treated
Treatment
Good news …
• Curable in 70% of cases
Bad news …
• Severe side effects:
 anemia (100%)
 neutropenia >35%
 depression >25%
• No Primary Care Physicians treating HCV
Rural New Mexico
Underserved Area for Healthcare Services
• 32 of 33 New Mexico
• 121,356 square miles
counties are listed as
• 2.08 million people
Medically Underserved
Areas (MUAs)
• 47% Hispanic
• 14 counties designated as
• 10.2% Native American
Health Professional
• 19% poverty rate compared Shortage Areas (HPSA’s)
to 14.3% nationally
• 21% lack health insurance
compared to 16% nationally
(Statistics from 2013)
2003 - Goals of Project ECHO®
Develop capacity to safely and effectively
treat HCV in all areas of New Mexico and to
monitor outcomes.
Develop a model to treat complex diseases in
rural locations and developing countries.
2015 - Goals of Project ECHO ®
(Extension Community Healthcare Outcomes)
• Increase capacity to safely and effectively treat
common and chronic diseases and to monitor
outcomes
• Develop a model to treat complex diseases in rural
locations and developing countries
• Multiply expertise of specialists by optimizing
telehealth technology
• Adherence to best practices to reduce variation in
care
Arora, Kalishman, Dion, et al. (2011). Health Affairs. 30(6) pp. 1176-1184
Four Point ECHO Model
1.Increase Capacity of patients seen by primary care
pain champions(Leverage ECHO platform)
2.Educate Primary Care - formal didactic curriculum,
theme-based modules
3.Case Based Learning – de-identified, HIPAA
compliant
4.Monitor Outcomes
Arora, Thornton, Murata. (2011). NEJM. 364(23) pp. 2199-2207
Project ECHO ® Pain: Bridging the
Gap Between Primary and
Specialty Care
Force Multiplier
Use Existing Community Clinicians
Specialists
Primary
Care
Physician
Assistants
Nurse
Practitioners
Chronic Pain
Rheumatoid Arthritis + Rheumatology Consultation
Substance Use and Mental Health Disorders
Copyright 2013 Project ECHO®
Core Pain Publications
UNM Project ECHO Pain
Katzman et al. (2014). Innovative Telementoring for Pain Management. Journal of Continuing Education in the Health Professionals. 34(1) pp. 76-84, DOI: 10.1002/chp
UNM Project ECHO Pain
Katzman et al. (2014). Innovative Telementoring for Pain Management. Journal of Continuing Education in the Health Professionals. 34(1) pp. 76-84, DOI: 10.1002/chp
UNM Project ECHO Pain Curriculum 2014-2015
Module 2: Opioids and Addiction
Week:
1. Opioid Indications and Use
2. Chronic Opioid Treatment: Medical
Concerns
3. Chronic Opioid Treatment: Behavioral
Concerns
4. Addictions and Chronic Pain
5. Non-Opioid Chronic Pain Medications
ECHO Pain: Bridging the Gap between
Primary and Specialty Care
1- Leverages Technology
2- Improves Coordination of Care
3- Increases Communication between Services
4- Improves Primary care Knowledge, selfefficacy and attitudes
Katzman et al. (2014). Innovative Telementoring for Pain Management. 34(1) pp.76-83
Katzman. (2013). Making Connections 3 New Immune Pharmacology. 8(3) pp. 489-493
Transforming Primary Care with
Knowledge Networks
Increasing Gap
Time
“Expanding the Definition of Underserved Population”
Map of Hub and Spokes
**Accepted for publication by Military Medicine, May 9, 2015
Diversity of Participants in Army Pain
ECHO: ECHO Pain Collaboration
Participant Credential Percentages (ECHO Pain Boot Camp Only)
Credentials
Percentage (%)*
Doctor of Medicine (MD), Doctor of Osteopathic Medicine (DO)
24.7
Nurse Practitioner (NP), Physician’s Assistant (PA), Doctor of Pharmacy (PharmD),
Registered Pharmacist (RPh), Doctor of Psychology (PsyD), Doctor of Philosophy
(PhD)
18.0
Licensed Physical Therapist (LPT), Doctor of Chiropractic (DC), Licensed
Acupuncturist (Lac), Licenced Occupational Therapy (OTRL)
10.0
Registered Nurse (RN), Licensed Practical Nurse (LPN)
12.7
Other
34.6
*Percentages out of a total of 150 unique individuals
[Other includes: Administrator, Bachelor of Science (BS), Bachelor of Arts (BA), Certified Occupational Therapy
Assistant, Distance Education Coordinator, Sergeant (SGT), Home Care Aide (HCA), Health Technician, Integrated
Modalities Coordinator, Licensed Physical Therapist Assistant (LPTA), Licensed Massage Therapist (LMT),
Noncommissioned Officer in Charge (NCOIC), Program Analyst, Program Manager, Program Manager Assistant, and
Registered Yoga Therapist (RYT)]
**Accepted for publication by Military Medicine, May 9, 2015
Phases I-IV: Hub Readiness Replication
Model
Phase I
Preparatory
4 weeks
Effectively establish technology and staffing requirements for hub and
spoke sites
Phase II
Preliminary
4 weeks
Hub and spoke observation of ECHO Pain Clinic and completion of twoday ECHO Boot Camp training
Phase III
Training
6 weeks
Hub and spoke teams participate and present patient cases to the
ECHO Pain Clinic
Phase IV
Roll-Out
6 weeks
Hub team launches and facilitates independent Army Pain ECHO while
maintaining connection to ECHO Pain
Military Medicine 2016:181(3):227-33
No-Cost Continuing Medical Education and Continuing
Education Units Eligible for Army Pain ECHO Clinicians
Phase I
Northern Regional
166
Command Medical (NRMC)
Southern Regional Medical
Phase II
Phase III
Phase IV
272
1831
448
873.5
1128.58*
320
Command (SRMC)
Pacific Regional Medical
508
459.5
168
767.25
DNC
395.5
206
129.5
1696
320
Not Yet Started
Not Yet Started
2690
2303.5
1094
3601.25
Command (PRMC)
Europe Regional Medical
Command (ERMC)
Western Regional Command
(WRMC)
Totals
*Two separate boot camps were held by the Pain ECHO team (in person) for participants from both SRMC
and NRMC. CME credits were not separated between the two in-person groups.
Total CME Credits obtained from the Army Pain Roll Out through May 2014 = 9,688.75 hours
**Accepted for publication by Military Medicine, May 9, 2015
In-Person vs. Video/Tele-Conference
(VTC) Boot Camp Trainings
5
4.97
4.96
4.9
4.86
4.81
4.79
4.8
4.79
4.73
4.7
4.64
4.6
4.5
4.4
Northern Regional Medical Command (NRMC) & Southern Regional
Medical Command (SRMC)
A
p value
B
Pacific Regional Medical Command (PRMC) & Europe Regional
Medical Command (ERMC)
C
D
A
B
C
D
0.03
0.85
0.43
0.21
NRMC & SRMC N=34
PRMC & ERMC N=25
**Accepted for publication by Military Medicine, May 9, 2015
In-Person vs. Video/Tele-Conference
(VTC) Boot Camp Trainings (Cont.)
A. Attending the teleECHO Mock Clinic was:
Not Effective
1
Very Effective
2
3
4
5
B. The ECHO Pain Boot Camp increased my motivation to provide the best care possible for patients.
Strongly Disagree
1
Strongly Agree
2
3
4
5
C. During the ECHO Pain Boot Camp I learned new ideas and concepts about how to apply the ECHO model.
Strongly Disagree
1
Strongly Agree
2
3
4
5
D. I am excited about the opportunity to learn and educate others via the ECHO Pain Clinic.
Strongly Disagree
1
Strongly Agree
2
3
4
5
Compares the in-person and virtual (video) ECHO Boot Camp trainings. The in-person trainings were
statistically overall more beneficial to the participants, although participants were equally as satisfied with
both platforms. It should be noted that during the virtual (video) trainings, one (hub) participant did travel to
the ECHO Pain site for in-person mentoring.
**Accepted for publication by Military Medicine, May 9, 2015
Focus Group Frequency of Comments
**Accepted for publication by Military Medicine, May 9, 2015
VA – Scan ECHO Pain
7 VA Scan Pain VISNS
5 fully staffed “Hubs”
Primary Touch
200 Primary Care Clinicians regularly connect weekly to one of the 7 VA
SCAN ECHO pain Hubs
Secondary Touch
46, 000 patients were managed in CBOCs nationwide by the 200 primary
care clinicians with pain >3/10
Tertiary Touch
Force Multiplication of Primary Care Pain Champions teaching their
colleagues (numbers unknown at present)
Communication with Susan Kirsh, MD VA Office of Specialty Care Transformation
Indian Health Service ECHO Pain and
Addiction
“Essential Trainings”
• The Indian Health Service began ECHO
Pain/Addiction July 2013
• The Indian Health Service began “Essential
Trainings” in Pain and Addiction for all prescribing
clinicians in their Federal agency.
• From Jan 2015-May 2015, IHS require 5 hours of
mandated pain and addiction training (Module 2)
via adobe connect format
• 1,447 clinicians have taken the training and 8,320
no-cost CMEs have been awarded
• Am J Public Health- 2016 May
ECHO Replication in US:
• University of Washington (HCV, Chronic Pain, HIV, Multiple Sclerosis) – Seattle, WA
• University of Chicago (Hypertension, Breast Cancer Survivorship/Women’s Health, Pediatric ADHD,
Childhood Obesity, HCV) – Chicago, IL
• University of Nevada (Antibiotic Stewardship, Autism (closed group, by invitation only), Diabetes/General
Endocrinology, Gastroenterology, Rheumatology, Sports Medicine, Mental Health: Professional
Development Groups (closed groups, by invitation only), Mental Health Clinic Director’s Group (closed
groups, by invitation only), Marriage & Family Therapy Intern Supervision Clinic (closed groups, by
invitation only) – Reno, NV
• University of Utah (HCV, Advanced Liver Care, Chronic Pain) – Salt Lake City, UT
• Florida/Caribbean AIDS Education and Training Center, University of South Florida (General HIV,
Adolescents/Pediatrics HIV, HCV/HIV Co-Infection, Psychiatry & HIV, Spanish Language HIV) – Tampa, FL
• Harvard/Beth Israel Deaconess Medical Center (HCV, Gerontology – ECHO AGE) – Boston, MA
• St. Joseph’s Hospital & Medical Center (HCV) – Phoenix, AZ
• Community Health Center, Inc. (HIV, HCV, Chronic Pain, Opioid Addiction – Buprenorphine, Coaches
International—supporting Quality Improvement and Specialists) – Middletown, CT
• LA Net (AAPA Preventive Care, Nephrology, Adult Psychiatry) – Los Angeles, California
• UNM: Center for Development and Disability (Autism) – Albuquerque, NM
• UNM: Envision NM (Childhood Overweight Medical Management, Pediatric Nutrition, Psychiatry,
Asthma/Pulmonary) – Albuquerque, NM
• CHI St. Luke’s Health (HCV, HBV, Infectious Disease) – Houston, TX
• University of California Davis (Pain Management) – Davis, CA
• University of Wyoming, Wyoming Institute for Disabilities (Assistive Technologies) – Laramie, Wyoming
• Ochsner Health System (Liver Care) – New Orleans, LA
• University of Texas MD Anderson Cancer Center (Cervical Cancer Prevention) – Houston, TX
• Oregon Health and Science University/Health Share of Oregon (Psychiatric Medication Management) –
Portland, OR
• University of Rochester Medical Center (Geriatric Mental Health) – Rochester, New York
• Visiting Nurses Association Health Group (Care Transition) – Red Bank, New Jersey
ECHO Replication Sites Worldwide:
• ECHO Ontario (Chronic Pain) – Queens University &
University of Toronto Ontario, Canada
• National AIDS Control Organization and Maulana Azad
(HIV) – New Delhi, India
• Institute of Liver and Biliary Sciences (HCV) – New Delhi,
India
• Universidad de la República (Liver Disease) – Montevideo,
Uruguay
• West/North West Hospitals Group (Diabetes) – Galway,
Ireland
• Northern Ireland Hospice (Hospice Care) – Belfast, NI
• National Institute for Mental Health Services (NIMHANS)
(Mental Health and Drug Addiction) – Bangalore, India