New Mexico has an expansive amount of land populated with few people. It has been a pioneer in extending the reach of medical specialists into rural areas using video teleconferencing technology to train primary care clinicians. For the first time, this approach will soon be used to train front-line, mid-level health providers to identify and treat mental and substance use disorders among underserved people who live in rural areas.
Project ECHO (Extension for Community Healthcare Outcomes) is an approach distinct from telemedicine, where video conferencing technology is used to actually provide service directly to the patient. The ECHO approach, however, utilizes video conferencing to train primary care clinicians to treat chronic illnesses and conditions, such as diabetes, complex care, chronic pain, HIV/AIDS, rheumatologic disorders, and dementia, among others. “Often, Project ECHO’s rural partner primary care sites will divide up responsibility for the different conditions,” said Dr. Miriam Komaromy, Associate Director of Project ECHO. “One doctor will attend the teleECHO clinic for diabetes, another for chronic pain, another for HIV. That greatly extends the skill and capacity of the practice as a whole.”
Project ECHO started with a program for hepatitis C, which was a serious problem in rural New Mexico, with less than 5% of those affected receiving treatment. Treatments for hepatitis C were known and available but had serious side effects that needed extensive management, requiring specialist knowledge. Project ECHO’s Disease Management Model focused on improving outcomes by reducing variation in processes of care and sharing “best practices.” Rigorous statistical analysis of the knowledge gained by program participants proved key to measuring the effectiveness of the program. This analysis quantified whether the doctors who took part in the video conferences were able to provide more informed care as a result of the training. Results showed that the rural clinicians who had ECHO support and mentoring were able to treat hepatitis C just as effectively and safely as specialists in an academic medical center.
The success of the hepatitis C program led to widespread replication at academic medical centers across the United States, including Harvard University, University of Washington, University of Chicago, University of Utah, and many others, as well as in the Department of Defense and medical centers in India and Vietnam. Project ECHO now seeks to pioneer community mental health care with their new program, ECHO Access.
“Mental health care is really a problem for rural populations. Other models that aim to expand access rely on importing a specialist, who would treat as many people as they could, but then leave,” Dr. Komaromy said. The approach this time is somewhat different—instead of specialists, two-person teams that consist of a community health worker and a family nurse practitioner will be trained together. The teams will receive fourteen seminar days of training, which will consist of lectures and case-based learning. All eight teams participating in ECHO Access will then present cases for guidance and mentorship from specialists at the Integrated Addictions and Psychiatry TeleECHO clinic each week.
“The teams will work together on specific cases, with the community health worker screening people for mental health issues, referring the person to the nurse practitioner for diagnosis and a treatment plan. The community health worker will then support the treatment plan and provide case management,” said Dr. Komaromy. “We will do regular evaluation surveys of the people receiving treatment. Are their symptoms improving? Do they have a job? Housing?”
“This is a better and less expensive way to serve patients in a rural setting where there is little access to specialty care,” Dr. Komaromy stated. “They often have complex health histories, with medical, mental health and substance abuse issues.” Being able to bring specialist-level knowledge to meet their needs in the primary care setting will make a difference in their care and in their lives.
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