Abstract
Introduction:
The Extension of Community Health Outcomes (ECHO) is a global movement that aims to decentralize the knowledge of specialists to primary care. A pilot, ECHO palliative care project in Thailand, was introduced to enhance the implementation of palliative care practice.
Objective:
To assess learners’ and palliative care specialists’ perceptions toward the ECHO palliative care project to improve and expand the project in the future.
Setting:
A total of 15 hospitals in 7 provinces in Northern Thailand, including provincial and district hospitals.
Methods:
A qualitative study was conducted among learners (primary care providers) and palliative care specialists who participated in the pilot program. Semi-structured interviews were used to explore the potential impact of the project on clinical practice, the strengths and weaknesses of the ECHO program and platform in the Thai context, and suggestions for expansion. Thematic analysis was used for qualitative analysis. Pre- and post-confidence scores, using a 5-point Likert Scale, for palliative care practice among learners were analyzed using paired T-tests.
Results:
Twenty participants were interviewed: 15 learners and 5 palliative care specialists. The confidence in practicing palliative care after participating in the ECHO palliative care project significantly increased for the learners, from 2.93 (95% CI, 2.49-3.38) to 3.93 (95% CI, 3.68-4.19) points (P = .003). Three themes emerged through the process evaluation of the pilot ECHO palliative care project: (1) applicable lessons that can translate to practice, (2) an effective learning program and assessable platform, and (3) suggestions for expansion.
Conclusion:
The ECHO palliative care project increased confidence in providing palliative care for primary care providers in Thailand. Through capacity building, participants reported applying the knowledge to improve local health services and develop a network for consultations and referrals. There is potential for expansion of the ECHO palliative care project in Thailand.
Keywords: palliative care, primary care, medical education, ECHO program
Introduction
Palliative care is a specialized medical field that focuses on enhancing the quality of life for patients and families facing a serious or life-threatening illness. 1 This comprehensive care addresses all aspects of health, including physical, mental, social, and spiritual. 2 As a result, a multidisciplinary team is required to work with patients and their families to provide health care throughout the dying process. 3 Care needed during the end-of-life and dying process includes symptom management for the patient, such as pain, nausea and vomiting, constipation, or shortness of breath. It extends to addressing psychological problems experienced by family members, such as burnout, depression, and grief during the post-dying period.4,5 For palliative care, continuity of care from tertiary to primary care is critical as support and care can be provided at home, in the community, or in a primary care setting. 6
In Thailand, palliative care has been developing since 1990. 7 The Ministry of Public Health continues to deliver an integrated policy of palliative care operations under Section 12 of the National Health Act. 8 As a result, primary care physicians must be able to lead a multidisciplinary team to care for palliative patients in their community. 9 However, there was a lack of palliative care specialists in Thailand. 7 Palliative care specialists are mostly in university and tertiary hospitals. 10 Developing a model for training and distribution of this knowledge and skills to local practice and primary care units is crucial in developing countries such as Thailand.
Project Extension for Community Healthcare Outcomes (ECHO) initially started in the USA to improve the quality of care for patients with Hepatitis C in rural New Mexico. 11 The model, which involves case-based learning and short didactic lectures, has demonstrated that the quality of care for hepatitis C patients provided by family physicians was similar to those provided by specialists in referral hospitals. 12 The ECHO model, which has now become a global movement, has been expanded to many areas of medicine, such as HIV/AIDS, gender equity, emergency preparedness and response, and palliative care. 13 The ECHO model has the potential to expand and distribute knowledge and skills in the field of palliative care to all primary care sectors and multidisciplinary teams. 14 However, as the ECHO model originated from a developed country, there is less evidence that such an ECHO Model can have a similar impact on the quality of care services in a developing country such as Thailand.
For Thailand, only 1 ECHO site is affiliated with Faculty of Medicine, Chiang Mai University. The pilot, ECHO Palliative Care project, was implemented to educate, facilitate discussion, and share best practices on palliative care affecting patients and families. However, there were questions about whether an online learning program could enhance capacity building in palliative care practice in the Thai context and whether the program platform was appropriate for physicians to schedule busy working time. 15 The perception of the ECHO palliative care project to primary care practice needed to be evaluated. As such, this study aimed to assess the learners’ and specialist palliative care specialists’ perceptions toward the ECHO palliative care project to culturally tailor and expand it in the future.
Methods
Hospital Levels in Thailand
In Thailand, district and community hospitals provide primary care outpatient services as well as limited capacity for in-patient services. Both secondary and primary care settings are constrained in terms of infrastructure (30-120 beds) and personnel resources, as only major specialties are available. Consequently, patients who require complex care from sub-specialists will be referred to tertiary hospitals at the provincial level, such as for palliative care.
Family Medicine Discipline and Training
The family medicine training curriculum spans a 3-year duration. All residents undergo training and work in the Outpatient Department, Inpatient Department, and Home Visit Service mostly in community settings. Family Medicine residents have a chance to study palliative care topics and to provide service but vary by setting as palliative care is considered a sub-specialty in family medicine. The Project ECHO Palliative program augments the training of the family medicine residents to decentralized knowledge from Palliative Care specialists.
Overview of the ECHO Palliative Care Project
Similar to previous literature, 16 the goal of the ECHO palliative care project was to educate, facilitate discussion, and share best practices in palliative care in Thailand. Primary health care professionals would consult with palliative care physicians and multidisciplinary teams for the appropriate and personalized management of their patients. This project involved palliative care specialists and family medicine residents in Thailand’s northern region. This project was started on a bi-monthly basis. The schedules were set and managed by palliative care specialists and focused on common issues encountered in primary care settings.
Each ECHO palliative online session has 4 basic components: (1) Palliative case presentation, (2) Discussion and sharing for case management, (3) Didactic lectures on topics in palliative case management by palliative care specialists, and (4) Following up on the outcome of the previous case. All online sessions used multipoint video-conferencing software (ZOOM).
Palliative case presentation
Family medicine residents or family physicians who functioned as the primary physicians responsible for each patient would present a challenging case under their care. The presentation would include information about the patient’s demographic data, prior history, illness, symptoms (eg, pain or dyspnea), family and caregivers, and the service system. These presentations were geared to focus on issues that require consultations with the experts and other participants.
Discussion and sharing for case management
Following the case presentation, the project would allow experts and participants to discuss and share standard management guidelines or alternative perspectives on case management and planning. This could include the availability of shared resources between hospital settings.
Topics in palliative case management
The final section featured a brief lecture, 15 to 20 min, by a palliative care expert on a topic related to the case-based problems, including cancerous wound care, withdrawal of mechanical ventilator, palliative care in a COVID-19 pandemic situation, palliative care in end-stage renal disease, symptom management at the home of a dying patient, and advance care planning in non-cancer patients.
Following up on previous cases
Progressions of previous cases presented, including management outcomes, case status, and additional plans, were followed up when appropriate.
Design
This qualitative study of the ECHO palliative care project in Thailand focused on the perspective of learners and palliative care specialists participating in the 1-year program. The ECHO program evaluation guide recommended that evaluation results are most helpful when focusing on the program’s outcomes and processes. 17 Thus, we conducted semi-structured interviews of learners and palliative care specialists focusing on the process and the outcomes of participating in the ECHO palliative care project. The interview questions for each aspect are shown in Table 1.
Table 1.
Questions Used for the Interviews.
| Evaluation aspects | Learners | Palliative care specialists |
|---|---|---|
| Outcome evaluation | What is your opinion on the ability of the ECHO Palliative Project to provide care for your palliative care practice? | What is your opinion on learners’ outcomes from the ECHO Palliative Project? |
| Process evaluation | What is your opinion about the ECHO palliative program? Probing - Learning topics - Accessing - Limitations - Suggestions for expansion |
What is your opinion about the ECHO palliative program? Probing - Learner’s participation - Case scenario - Limitations - Strength of the program - Program organization - Suggestions for expansion |
Study Population
Participants were recruited from 35 learners and 10 palliative care specialists who participated in the ECHO palliative care project over a year. We included the participants after the program finished for 3 months. The learners were 15 family medicine residents mixed from first to third year from 15 hospitals across 7 provinces in Northern Thailand. The palliative care specialists are a multidisciplinary team consisting of palliative care physicians, palliative care nurses, pharmacists, and public health practitioners. Figure 1 shows the area of learners and palliative care specialists.
Figure 1.
Area of learners and palliative care specialists.
Project ECHO Palliative involved 15 hospitals in northern Thailand. The learners came from district or provincial hospitals. The palliative care specialists came from provincial hospitals.
Data Collection
The pilot ECHO palliative care project ran from August 2020 until July 2021. The participants’ confidence in providing palliative care was assessed before and after the entire year of participation using a scored question: "What is your confidence in providing palliative care?" A Likert Scale, ranging from 0 (low confidence) to 5 (high confidence), was employed for the assessment.14,17
The semi-structured interviews were conducted between August and October 2021. The interview questionnaire was adapted from a practical guide for Project ECHO Evaluation. 17 This guideline covers both outcome and process evaluation (Table 1). A research assistant not involved in the ECHO palliative care project was trained in the interview method and interview questions by WJ and NB. Purposive sampling was used to select the participants from various settings. All participants were informed of the research study and were asked for consent and permission to audio record the interview. Each interview lasted around 20 min and was conducted by video teleconference. Interviewed information included general characteristics (age, gender, career, and level of working hospital), pre-post confidence score in palliative care, and questions for evaluating the program’s outcome and processes regarding the impact of clinical practice and perception of the ECHO program.
The interviews were transcribed verbatim. Data collection and analysis were carried out iteratively by WJ and NB. The interview ended when the data saturation of the core analytic content had been achieved. In total, 20 participants were interviewed: 15 learners (out of 35) and 5 (out of 10) palliative care specialists.
Data Analysis
The data sets were uploaded into NVivo (version 12). Each transcript was read multiple times to aid familiarization and to check the accuracy of each transcript. Two independent researchers (NB and WJ) led the analysis by using both deductive and inductive thematic analysis. 18 We started with deductive analysis using a practical guide for Project ECHO Evaluation 17 (Table 1). Next, inductive analysis was performed creating codes based on the qualitative data itself. Then, preliminary results were discussed with KP, NN, LJ, ND, and CA. The coding was developed from patterns in the text data. The identified codes were compared, and the similarities and differences were discussed until a consensus on the emergent themes and subthemes was reached. All authors read and contributed to the manuscript. For statistical analysis, a Wilcoxon signed-rank test was used to compare learners’ pre- and post-participation confidence scores in palliative care practice. The analysis was conducted using STATA version 16.
The study was reported according to The Standards for Reporting Qualitative Research (SRQR) guidelines. The SRQR is a list of 21 items considered essential for complete, transparent reporting of qualitative research. 19
Results
Of the 20 participants, 15 were learners, and 5 were palliative care specialists. Most participants were female (73.3% of learners and 100% of the palliative care specialists). The mean age was 28.93 ± 2.6 years old and 42.6 ± 14.3 years old for learners and palliative care specialists, respectively. (Table 2). A Wilcoxon signed rank test revealed a significant increase in confidence regarding the practice in palliative care, n = 15, Z = 2.668, P = .008.
Table 2.
Participant Characteristics.
| Characteristics | Learners (n = 15) | Palliative care specialists (n = 5) |
|---|---|---|
| Age (mean ± SD) (min-max) | 28.93 ± 2.6 (27-36) | 42.6 ± 14.3 (29-60) |
| Female (%) | 11 (73.3) | 5 (100.0) |
| Hospital levels (%) | ||
| District hospitals | 7 (46.7) | 0 (0) |
| Provincial hospitals | 8 (53.3) | 5 (100.0) |
From the semi-structured interviews, the impact and acceptability of the ECHO palliative care project can be illustrated in 3 themes: (1) applicable lessons that can translate to practice, (2) effective learning program and assessable platform, and (3) suggestions for expanding. Table 3 demonstrates the themes and subthemes of the study’s results.
Table 3.
Impact and Acceptability of the ECHO Palliative Care Program.
| Theme 1 applicable lessons that can translate to practice |
| Subtheme 1.1 Using Lessons Learning to help provide comfort care for palliative patients |
| Subtheme 1.2 Understanding and integration of different roles of a multidisciplinary team in palliative care |
| Subtheme 1.3 An establishment of a palliative care system in a primary care setting. |
| Theme 2 benefits of using the educational structure of the ECHO model |
| Subtheme 2.1 Teaching by palliative care experts enhances the quality and depth of content |
| Subtheme 2.2 The ECHO palliative care project motivates adult learning |
| Subtheme 2.3 Easy to access with an online platform |
| Themes 3 suggestion for program expansion |
| Subtheme 3.1 Increase the interactive teaching conference |
| Subtheme 3.2 Understand time constraints and consider “on-demand” options |
| Subtheme 3.3 Create supportive infrastructure |
| Subtheme 3.4 Dissemination of project's usefulness |
Theme 1 Applicable Lessons That Can Translate to Practice
Impact on practice is an important outcome of the training program. Learners demonstrated the value of incorporating palliative care into their practices and health care systems. Three subthemes were identified, including using palliative care skills for providing comfort care, understanding the roles of the multidisciplinary team in palliative care, and developing an initial palliative care system in a primary care setting.
Subtheme 1.1: Using lessons learned to help provide comfort care of palliative patients
Most learners reflected that they could apply knowledge from the ECHO program to their practice. Various approaches to common clinical issues and skills for palliative care, including symptom control, advanced care planning, and communication skills, were examined and discussed. Learners felt more confident in providing management to palliative care patients and their families, resulting in improved quality of care and comfort for the patient and family.
“The content was easy to understand and practical. Although the case was complicated and had many problems, palliative specialists could always manage it. For example, when I care for a patient with multiple problems, especially patients who need to do advance care plans. Sometimes, their family may not understand the prognosis. I can use communication methods learned from the project or even from learning guidelines for symptom management, for example, nausea and vomiting.” (Learner 3; female 36 years old)
“There are issues that are common in palliative patients. Once I learn how to solve the problem, I can apply it to patients who have the same conditions.” (Learner 1; female 28 years old)
Subtheme 1.2: understanding and integration of different roles of a multidisciplinary team in palliative care
In the primary care context, multidisciplinary teams are often not available. Knowledge and experience in utilizing a multidisciplinary team is still limited. The learners reported that they could understand the role of each discipline and the integration of each expertise in taking care of palliative patients. There are multidisciplinary teams in primary care settings, but their capacity may be limited in palliative care. Primary care physicians will need to develop a deeper understanding and proficiency in areas usually provided for by multidisciplinary teams.
“In ECHO palliative, there is in-depth and specialized teaching. Sometimes, when I finish general practice and become a family physician, it may not be sufficient. However, in performing palliative ECHO, other disciplines such as rehabilitation or nutrition may be involved to assist.” (Learner 6; male 28 years old, district hospital)
“I still did not understand the picture of palliative care. It is because I didn’t study at the university hospital. I work at a community hospital where people rarely envision themselves as part of a team. So, I wrote a comment that I wanted to learn from ECHO palliative. After ECHO Palliative was established, I understood the role of palliative care and saw different perspectives. A multidisciplinary profession, including nurses, pharmacists, and social workers, came together to give suggestions. I think it’s very good.” (Learner 10; female 34 years old, district hospital)
Subtheme 1.3: An establishment of a palliative care system in a primary care setting
Collaboration between learners and facilitators from many levels of hospital centers (district hospitals, provincial hospitals, and tertiary referral hospitals) in the ECHO palliative care project led to the development and implementation of the palliative care system in primary care settings. The learners from district and provincial hospital levels identified the improvement of the palliative care system in their hospitals that increased the quality of palliative care. These included the import of opioid medication and the conduction of referral management.
“I had a chance to present my palliative case at the ECHO conference. From the discussion, we found that one of the problems was the limitation of morphine in my district hospital, which should be requested. Therefore, I addressed the hospital administration and committee with this suggestion. It seemed to work. Right now, my hospital has morphine in the form of MST, and we don’t need to refer patients to the provincial hospital to receive morphine.” (Learner 10; female 34 years old, district hospital)
“There was a case of a patient whose home was within the boundary between two hospitals. He relocated and was then lost follow-up from Hospital A because he was living in Hospital B’s catchment area. After this case was presented in the project, Hospital A coordinated with Hospital B. The patient received better support in palliative care.” (Learner 4; female 28 years old, district hospital)
Theme 2 Benefits of Using the Educational Structure of the ECHO Model
The learning program and platform can reflect the quality of the operation of a training program. Four main subthemes were found, including (1) teaching by palliative care experts enhances learning effectiveness, (2) the ECHO palliative care project motivates adult learning, (3) learning and sharing palliative care practice, and (4) easy access with an online platform.
Subtheme 2.1: Teaching by palliative care experts enhances learning effectiveness
Most learners said that palliative care experts provided them with accurate and clear knowledge and skills that could be applied in practice. The palliative care specialists also demonstrated the value of comprehensive palliative care specialist cooperation, which improved patient health care quality. The palliative care specialists believed that by planning their instruction for ECHO sessions, learners could apply their knowledge to care for their palliative patients.
“The details are easy to understand. For example, when the case has a problem that needs more knowledge for management, the palliative care specialists were able to explain the point, like answering my question. They also help by providing recommendations. They attempt to explain it in such a way that it can be applied as easily as possible. It’s helpful for the hospital, especially the hospital that doesn’t have a palliative doctor. Our knowledge and experience may not be sufficient to care for palliative patients.” (Learner 8; female 28 years old, provincial hospital)
Subtheme 2.2: The ECHO palliative care project motivates adult learning
Many learners were motivated to enhance their potential, knowledge, and skills in palliative care practice, expressing a desire to learn and deepen their expertise in this field regarding palliative patients prevalent across various settings. The ECHO palliative care project emerged as 1 accessible way for them to pursue these goals. This initiative facilitated knowledge sharing among participants and created a collaborative environment conducive to learning. However, there were limitations in understanding the patient’s context and progression among learners.
“It’s about wanting to know as well. Sometimes, the project has documents about session details. I’ll see if there are any interesting cases, and I’ll join this ZOOM because I’ve already encountered a case with the same condition and could not manage it. And if I can apply the knowledge to my patients, I’d like to participate again.” (Learner 11; female 28 years old, district hospital)
“All patients need palliative care, meaning that every hospital has palliative patients, and many physicians in the primary care hospitals want to learn about palliative care as well as the residents in tertiary care hospitals.” (Learner 2; female 28 years old, provincial hospital)
“ECHO is like telling a palliative case story and consulting. We will see broader opinions and guidelines on how to take care of palliative patients. We can choose which one can be applied to the patient appropriately. The results will come out better. Perhaps our opinion alone would be rather narrow.” (Learner 4; female 28 years old, district hospital)
“There were limitations as we hadn’t cared for the patient. I didn’t examine the patient. And I didn’t look at the patient in the long term. If we go around the palliative ward, we’ll know the progression and how to adjust the medication. But the patients we brought to the conference were rarely followed up (in the conference).” (Learner 11; female 28 years old, district hospital)
Subtheme 2.3: Easy to access with the online platform
Learners from rural hospitals stated that this online learning platform allowed them to get an education and training anywhere. They could access palliative care consultations from a specialist without needing to travel. The palliative care specialists also illustrated that this platform allows physicians and other multidisciplinary teams in each setting to join the learning.
“It’s an advantage that we can study at any time. You don’t have to worry about who’s busy. Call it an online study. . . .. . .. It’s not like an onsite study where you have to study together. I need to find a day.” (Learner 6; male 28 years old, district hospital)
“It is like a channel that allows us to discuss cases with real palliative experts. We do not have to travel to meet the specialist.” (Learner 8; female 28 years old, provincial hospital)
“This makes it possible to transfer knowledge to medical students at other hospitals. I see that sometimes the students in local hospitals join us, too. They also learned with us, for example, hospitals A, B, or C (provincial hospitals).” (The palliative care specialists; female 55 years old, nurse)
Themes 3 Suggestion for Program Expansion
The participants mentioned ways to improve the program’s quality and increase learners’ ability. From the interview, suggestions for expanding the ECHO palliative care project in the future were offered by both learners and the palliative care specialists, including 4 subthemes: (1) making conference learning more interactive, (2) flexible schedules, (3) organizing a learning system and supporting resources, and (4) increasing the advertisement to other areas and target group.
Subtheme 3.1: Increase the interactive teaching conference
The palliative care specialists and learners expressed similar concerns regarding promoting interactive learning. The engagement would differ from face-to-face learning, such as an onsite conference because the curriculum was delivered online. This platform could require strategies like an interactive questions and answers section, voting, and quizzes to get learners’ attention and engagement.
“I want the project to increase participation’s attention. Such as by asking questions, can encourage learners to be more involved.” (Learner 11; female 28 years old, district hospital)
“If it is learning via ZOOM, interaction is usually less. The project may have to increase interactions, such as having exams and randomly asking the students to answer. This will get more learners involved.” (The palliative care specialist; female 39 years old, palliative care physician)
Subtheme 3.2: Understand time constraints and consider “on-demand” options
From the learners’ side, all the learners who attended the project were physicians from different hospitals and settings. During the day, taking care of patients comes top on the list of priorities. Each setting had a different amount of workload, which was occasionally unpredictable and disrupted the learners’ pre-planned learning schedule. The time of the pilot program was set from 12.15 to 13.30, which affected some learners. However, most participants suggest other periods, such as the weekends or non-working hours.
“It is quite difficult to attend because we need to manage hospital cases. Sometimes, we don’t attend, but we open it (ZOOM). This is the reality. Maybe we’re stuck in the case or called to the emergency room. We barely had time to eat. So, it makes it difficult for us to be always available (during lunchtime).” (Learner 7; female 28 years old, district hospital)
Subtheme 3.3: Create supportive infrastructure
Some learners had a problem with internet access in their working areas, especially in rural areas. Support has been suggested, including a reliable network internet infrastructure and the management of an audio system.
“The concern would be about the internet signal. Sometimes we’re in the hospital, and we need to go to some area that has a good internet spot to attend the project.” (Learner 8; female 28 years old, provincial hospital)
“The real obstacle is the signal. Sometimes it resonates or freezes.” (Learner 6; male 28 years old, provincial hospital)
Subtheme 3.4: Dissemination of project’s usefulness
Learners expressed that advertisement could be crucial for a program’s expansion. Advertising could increase learners’ awareness and communicate the benefits of the project. The palliative care specialists recommended that there should be more channels for disseminating this learning conference, such as YouTube, internet media, or academic presentations. Furthermore, the palliative care specialists suggested that palliative care knowledge and skills would be essential for other learners or disciplines, for example, medical students or other specialists.
“There should be more publicity, for example, promote in the group of the Royal College of Family Medicine or the resident group from different places as well, such as on Facebook or website.” (Learner 7; female 28 years old, district hospital)
“There should be an opportunity for medical students or other specialists to participate. It’s probably useful. This can enhance their skills and experiences for them in the future.” (The palliative care specialist, female 60 years old, social worker)
“If possible, we should encourage residents to present their cases because there are many useful palliative care specialist lectures and comments. We can also support the team here to present the work at conferences or maybe release it to other media outlets such as online media YouTube; it would be helpful. It seems that it should be spread more widely.” (The palliative care specialist; female 60 years old, social worker)
Discussion
ECHO palliative care project was conducted to expand the integration of palliative care into primary care in Thailand. Our setting is 1 of more than 200 hubs around the world. We examined the impact of the program on clinical practice and the acceptability of the program. Results suggested that after attending the program, the confidence score in palliative care skills increased significantly. As for the perceived impact and acceptability of the ECHO palliative care project, 3 themes emerged: (1) applicable lessons that can translate to practice, (2) the learning outcomes and accessible platform, and (3) suggestions for expanding.
The ECHO palliative care project seems to have effective learning outcomes. Participants, particularly family medicine residents, and physicians, who attended the program reflected the increased confidence and capability in providing palliative care. Similarly, in the ECHO palliative care project in Canada, India, and Bangladesh, healthcare providers who participated in the project reported statistically significant improvements in knowledge, self-efficacy, and satisfaction with managing children with pain.20,21 Family physicians are the mainstay of providing care for palliative patients. 9 This is an opportunity to improve the family medicine residency training curriculum in palliative care. 22 The ECHO palliative care project is a potential solution to the problem of spreading the skills and knowledge of palliative care to primary care clinicians on the front lines. 23 The learner can also understand the role of multidisciplinary teams in palliative care and apply knowledge gained from multidisciplinary teams to approach their patients. Palliative care incorporates all aspects of health: biological, mental, social, and environmental, 24 so it needs the cooperation of a multidisciplinary team to play their unique roles, such as drug storage and nutrition counseling, in providing holistic care to the patients and families.5,22
The project not only improved learners’ clinical practice but also led to the development and implementation of a palliative care system in their settings, including operating the opioid drug system and referral system. Integrating palliative care contributes to strengthening the healthcare system. 25 Opioids are the main medications necessary for palliative conditions and pain control. Management of opioid medicine targeted for symptom control would increase patients’ quality of life. 26 Another critical aspect of palliative care is the referral system. The ECHO program’s platform emphasizes sharing care management and contributes to networking from multiple levels of hospitals that, lead to referral work. Referring palliative patients to palliative care specialists can reduce patient and family distress and ensure appropriate end-of-life care. 27
Our results suggested that the ECHO palliative care project was well received. Accessing the online education platform from anywhere for learners and palliative care specialists was easy. Teaching sessions were conducted by palliative care specialists with the cooperation of multiple primary care partners. Palliative skills were traditionally trained in a hands-on session. However, many providers do not have opportunities to further their studies and leave their jobs behind. 14 The project facilitates the unification of palliative specialists scattered in a distant area into a teaching team. It could reduce the barriers to obtaining education, including the lack of palliative care specialists and the distance from a tertiary care hospital.28,29 The ECHO palliative care project also enhanced adult education by motivating learners facing similar problems in caring for palliative patients to participate in the project. It creates a community of practice for primary healthcare professionals and leads to best practices for palliative care. 14 Physicians from any hospital can learn about palliative care discuss, and share ways to solve patients’ problems. The previous literature on ECHO palliative care projects from Ireland, India, and Bangladesh showed similar results regarding being comfortable and accessible from anywhere with the internet and improving knowledge by sharing ideas among healthcare professionals.14,21 Moreover, this platform enhances continuous learning so that the learners can be naturally motivated and decide to participate by themselves. 30 The palliative care specialists would provide the reliable and practical knowledge necessary for taking care of palliative patients. Therefore, specific decisions and treatment plans for these patients would also be made.31,32 Furthermore, working with healthcare professionals from various hospital levels and community leaders can help result in better continuity of care. 23
The ECHO palliative care project in Thailand has the potential for expansion. There were many suggestions for program improvement and expansion, including enhancing interaction during the sessions, developing a supportive system for learners, and increasing advertising and targeting of learners. The interactive teaching style is important for the lecturers. This is the crucial way of gathering learners’ attention and resulting in effective learning. 33 Teaching via an online platform may reduce direct interaction. As suggested by our participants, the lecturers need to use an interactive teaching technique or style, such as asking questions, testing, or group work. 34 Thus, 1 key success factor of the ECHO model is centered on training the trainer in delivering tele-information. 35 Availability was reported as the common issue. As providers, our learners had a barrier to attending the sessions. Providing sessions for learning in every hospital may be difficult but essential. 36 Other ECHO projects also had availability as an issue but were dealing with different time zones. 21 ECHO projects require a stable internet network or Wi-Fi as an online program. Organizing learning systems and support resources such as good network internet systems or accessible recorded videos of learning sessions need to be prepared. 37 Lastly, advertisements could be an option to increase access and further promote the ECHO program. 38 In the digital era, many usable social media platforms exist for advertisements.
The ECHO model is well developed in the United States but is in its early stages of expansion to developing countries. Our findings represent the perception of participants from a wide range of practice locations, both from the learners’ and palliative care specialists’ sides from Thailand. The current study adds to the literature on the feasibility, impact, and acceptability of ECHO palliative care projects in developing countries. However, there were some limitations in this study. First, we could not include all the participants in the project. However, we had representation from both the learners’ and palliative care specialists’ perceptions. Second, the ECHO palliative care project is new in Thailand, and our study was limited to 1 pilot ECHO palliative care project in Northern Thailand. The outcomes might not reflect the features of the palliative community of practice in other regions of Thailand or other countries. Other aspects of the impact of the ECHO palliative care project should also be covered. Further studies should explore additional elements such as the sustainability of the ECHO program, its direct impact on patient outcomes, cost savings, and the program’s cost-effectiveness.
Conclusion
Participants from the pilot ECHO palliative care project in Thailand reported increased confidence in providing palliative care. Both learners and palliative care specialists perceived its effectiveness, highlighting the enhanced application of acquired knowledge in patient care and work systems, along with the benefits of primary care capacity building. These positive outcomes indicate the potential suitability of the ECHO project as a palliative care model. To facilitate expansion, it is crucial to consider training the trainer and ensuring the availability of necessary equipment.
Acknowledgments
We thank all research participants, care providers, and palliative care speciallists, who kindly supported the ECHO palliative care project.
Footnotes
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding: The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by a Grant from the Faculty of Medicine, Chiang Mai University (grant number 043/2563) and partially supported by Chiang Mai University (RG11/2566).
Ethical Approval: This study was reviewed and approved by the Institutional Ethics Committee of the Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand (Ethical approval number: 227/2021).
ORCID iDs: Thawalrat Ratanasiri 
https://orcid.org/0000-0002-9269-9116
Wichuda Jiraporncharoen
https://orcid.org/0000-0002-8131-6474
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