Amplifying Expertise in Rural West Virginia through Project ECHO: Impactful Partnerships and Community-Engagement

Abstract

Background:

Limited specialty care access is a major contributor to rural health disparities. Extensions for Community Healthcare Outcomes (ECHO) is an innovative training and education strategy to address the need for trained specialty care in rural areas, such as West Virginia (WV). This manuscript describes the successful implementation of ECHO projects in diverse subject areas facilitated by unique partnerships between the West Virginia Clinical and Translational Science Institute (WVCTSI) and its practice partners.

Objectives:

WV Project ECHO aims to provide education and training in specialty areas through the use of technology and partnerships.

Methods:

A case-based session coupled with a brief relevant didactic presentation is used to amplify rural provider specialty expertise through education of primary care physicians (PCPs) in specific clinical areas. Foundational partnerships and impact are described.

Conclusions:

Key lessons learned include leveraging existing partnerships and implementing projects based on provider needs. A unique result of WV Project ECHO is WV Medicaid’s decision to accept case presentations made during the Hepatitis C ECHO session as the specialty consultation requirement (e.g., hepatologist or infectious diseases) for Medicaid coverage of hepatitis C drugs, thus increasing the number of patients receiving Hepatitis C treatment. A multi-partnered community approach facilitated by the widespread use of a technology-based provider education platform has facilitated the availability of curative therapy for a potentially fatal disease.

Background

Rural Americans face major health disparities such as higher rates of disease and worse health outcomes. A significant factor contributing to rural health disparities is the lack of specialty physicians in rural areas.¹ Long travel distances, transportation barriers, and social isolation further reduce access to specialty care that may be available outside of rural communities. A 2005 Institute of Medicine report highlighted the need for primary and specialty care collaboration to improve the quality of care for rural patients.¹ However, nearly fifteen years later, rural patients still lack access to specialty care, perpetuating health disparities. These disparities are likely to continue unless there exist significant efforts to increase access to specialty care.

Extensions for Community Healthcare Outcomes (ECHO), the ECHO model^™, is a novel medical education platform developed to specifically address the need for specialty care in rural areas. Dr. Sanjeev Arora, University of New Mexico (UNM), established ECHO in 2003 as a solution to the unmet needs of thousands of rural hepatitis C (HCV) patients. HCV may be cured with several months of therapy, yet many HCV-infected persons in rural communities may not receive needed treatment due to a lack of access to specialty care.² The ECHO model engages specialty experts to provide distance training to rural providers via a hub-and-spoke knowledge-sharing network. Primary care clinicians thereby acquire specialty care knowledge relevant to patients in their communities.³ The model addresses rural health disparities using four core principles: 1) amplification through technology, 2) sharing of best practices, 3) case-based learning, and 4) monitoring outcomes (Figure 1).³ Unlike telemedicine where a specialist manages a patient remotely, ECHO provides an expert team (Hub) that, through use of multi-point video conferencing, conducts virtual clinics with community providers (Spokes) (Figure 2).

Figure 1:

ECHO Core Principles

Figure 2:

ECHO vs. Telemedicine

Similar to New Mexico (NM), West Virginia (WV) is a rural state lacking access to specialty care providers. WV ranks at or near the bottom in most U.S. chronic disease categories, with the highest rate of drug overdose deaths⁴ and near the highest rates of cancer⁵ and cardiovascular mortality,⁶ and acute hepatitis C. As in NM, delivering HCV treatment in WV is challenging. Infectious diseases (ID) specialists are only available at a few large medical centers throughout the state, resulting in long appointment wait times (i.e. > 6 months) and frequently insurmountable transportation needs due to the state’s mountainous terrain. An additional barrier is WV Medicaid’s requirement that HCV drugs be prescribed by or in conjunction with a board-certified gastroenterologist, hepatologist, or infectious diseases physician.⁷ One southern WV community health system, Cabin Creek Health Systems (CCHS), was faced with increasing numbers of HCV patients, frustrating administrators and providers due to their lack of expertise in the area of HCV treatment. Serving 17,300 patients annually, CCHS estimates 25% of their patients are dealing with some type of substance use disorder. As a result, CCHS’s administrators and clinicians approached the West Virginia Clinical and Translational Science Institute (WVTCSI) in 2015, seeking a solution to this problem.

The WVCTSI was created in 2012 through the Clinical and Translational Research (CTR) award, U54GM104942, from the National Institute of General Medical Sciences. This five-year award, successfully renewed in 2017, addresses the state’s major health disparities through partnerships and capacity-building initiatives. WVCTSI and CCHS leadership recognized the potential of the ECHO model to address the state’s most pressing needs, such as HCV. As a result, HCV became the focus of the first WV ECHO project, with future projects anticipated to address other unmet clinical needs. WV Project ECHO secured support from the Claude Worthington Benedum Foundation on behalf of CCHS, and the first WV ECHO project focusing on HCV was launched in May 2016. Today, there are seven clinically distinct WV Project ECHOs: HCV/HIV, Medically Assisted Treatment (MAT) for opioid use disorder, General Psychiatry, Chronic Pain Management, Endocrinology, Chronic Lung Disease Management, and Cardiac Health, all developed in response to the needs of the primary care providers in WV.

This manuscript demonstrates the application of the ECHO model in WV and the successful leveraging of existing partnerships between federally-funded initiatives (i.e., WVCTSI) and rural health systems. The result, WV Project ECHO, is a sustainable model that effectively meets the growing needs of rural primary care providers and their teams.

Methods

Infrastructure and Partnerships

WV Project ECHO had the necessary infrastructure and partnerships to successfully develop and launch the model in WV. The WVCTSI, the WV Practice-Based Research Network (WVPBRN), and the WV Primary Care Association (WVPCA) were the foundational partners with well-established relationships that antedated WV Project ECHO (Figure 3). The substantial leadership, vision, resources, and reach of the CTSI, provided these existing partnerships with exponential opportunity for growth. These partnerships were reinforced through the successful completion of past collaborative projects between various organizations and WVCTSI with the dissemination of results back to community members. WVCTSI provided the fundamental administrative infrastructure needed for WV Project ECHO to succeed and expand; specifically, the leadership and staff to plan, develop, and implement the necessary steps for successfully launching ECHO. Importantly, WVCTSI’s established research and medical partnerships facilitated the recruitment of specialists to the Hub. Critical to the recruitment of primary care practices was the WVCTSI associated Practice-Based Research Network, comprised of 107 sites and over 700 provider members across the state. Many of the WV Practice-Based Research Network sites are Federally Qualified Health Centers (FQHCs) or Rural Health Clinics (RHCs), often located in remote areas and serving rural populations with limited access to medical resources. WV Practice-Based Research Network sites were eager to receive training that enhanced the availability of specialty expertise and, therefore, constituted the majority of spoke sites.

Figure 3:

WV Project ECHO Development and Partnerships

The third foundational partner of WV Project ECHO is the WV Primary Care Association, a private, non-profit organization representing safety-net health care providers across WV. The WV Primary Care Association represents 31 FQHCs/FQHC look-alikes and 1 rural primary care center while also providing care for more than 450,000 patients.⁸ The WV Primary Care Association assisted with the development and recruitment, working with its Chief Medical Officers to identify pressing clinical topics after HCV and to inform the community of primary care clinicians about the educational opportunities presented by WV Project ECHO. The Primary Care Association also plays an important role in disseminating information around the WV Project ECHO Program. These partners met during the fall and winter of 2015 to learn about the ECHO model and lay groundwork for launching the HCV ECHO in May 2016.

Implementation

Hub and Spoke Recruitment:

The Hub teams are made up of 13 different departments within West Virginia University and the WV branch of the National Institute for Occupational Safety and Health (NIOSH). Utilizing its partnerships, WV Project ECHO was able to do disseminate recruitment materials as well as plan a kick-off event inviting primary care organizations to attend and learn more about the program. Another recruitment tool was the availability of continuing medical education (CME) credits for all Spoke and Hub members. For Hub recruitment, WV Project ECHO utilized the WVCTSI partnership through the West Virginia University Health Sciences Center to recruit interdisciplinary panels that included specialists, pharmacists, nurses, therapists, and social workers. Hub and Spoke recruitment is never closed for any of the ECHO projects, and WV Project ECHO is in constant contact with its recruitment partners, ensuring new participants are added in a timely fashion.

Session Design:

Each ECHO project meets for 1 hour twice a month via Zoom video conferencing software. During the sessions, 1–2 de-identified cases are presented by Spoke members followed by a 15–20 minute didactic presentation from the Hub. The sessions are interactive and discussion-based with the case presentations at the forefront, creating the case-based learning environment.

An important product of WV Project ECHO is the development and implementation of efficient, de-identified case forms and a database on the Oracle platform to track all projects and cases. The implementation of the case forms was born out of the need for standardized forms that were easy for participating providers to access and complete in a HIPAA compliant fashion. These case summary forms were developed by WV Project ECHO in collaboration with the WVCTSI and can be accessed on any device or platform. Providers can copy and paste information into the forms from their respective electronic medical records (EMR). A subsequent secure database was also created to enable WV Project ECHO case tracking and follow-up across all ECHO project areas. WV Project ECHO staff reviews the cases and “scrub” the cases for any potential protected health information (PHI) before sending it to Hub members for review. Cases are continuously collected, and a queue is developed when multiple cases are submitted. The development and implementation of both the case forms and database have facilitated PCP engagement while consistently maintaining fidelity to the ECHO model and providing innovation to the ECHO community.

To serve as a basis for didactic presentations, Hub members collaboratively develop a curriculum beginning with the background and basics of the particular subject area. Each project has a yearly subject-area curriculum that covers a variety of topics (Figure 4) covered through the didactic presentations which may also include updates on treatment guidelines, medications, and insurance. Participants also request additional didactic presentations based on their patient population and clinical training needs. Additionally, Hub members tailor didactic presentations based on trends in the group’s questions and current clinical guidelines.

Figure 4:

HCV/HIV Curriculum Flyer

Results

Since its inception in 2016, WV Project ECHO has been highly productive (Figure 5) with over 4,500 total participants across all projects and in 11 states (Figure 6). Although there is no direct patient contact or consultation, the ECHO interdisciplinary approach improves access to care by equipping a wide range of healthcare professionals with the necessary skills to treat within their scope of practice patients with specialty care needs, thus, allowing patients to be treated in primary care settings closer to home and avoiding or reducing transportation barriers.

Figure 5:

WV Project ECHO Stats

Figure 6:

WV Project ECHO Spokes

The initial WV Project ECHO addressing HCV launched in May 2016 and was very well received, based on anecdotal feedback received on the program. Although the WV Project ECHO program has not completed a formal evaluation that looks at factors such as retention and health outcomes, the West Virginia University Health Sciences Office of Continuing Education does perform an annual evaluation of all programs that request CME credit. Using a scale of 0 to 5, where 0 means poor and 5 means excellent the West Virginia University Health Sciences Office of Continuing Education reported a rating of 4 out of 5 in both the programs impact and overall rating based on the providers who attended in 2019.⁹ Combining this data with the anecdotal feedback from providers has provided evidence that WV Project ECHO is making an impact and warrants the expansion that has occurred. WV Project ECHO has also seen several significant benefits realized from the implementation of the program. These benefits include:

1. Prior to implementation of the HCV ECHO, specialty consultation with either a hepatologist, gastroenterologist, or infectious diseases expert was required by WV Medicaid before providing coverage for HCV treatment. This requirement often imposed long appointment wait times and hours of travel for patients. Shortly after HCV ECHO implementation, WV Medicaid ruled that PCP case presentation during an ECHO session fulfilled the requirement of specialty consultation, providing HCV treatment for the presented patient promptly and often saving hours of patient travel time, not to mention delays in treatment while waiting for a specialist appointment.

2. Essential to the success of the ECHO model is the sharing of best practices. Such was the case with the implementation of the standardized Department of Defense pain rating scale¹⁰ across practices of PCPs attending the chronic pain management ECHO. In another example, the MAT ECHO reviewed (over several sessions) the WV Department of Health and Human Resources Office of Health Facility Licensure & Certification’s (OHFLAC) guidelines for prescribing MAT in the primary care setting.¹¹ By reviewing these guidelines during the MAT ECHO, the participating Spoke sites gained the knowledge and confidence to implement MAT while knowing they have an experienced resource for questions about these guidelines.

3. An unanticipated benefit of Project ECHO has been the problem-solving that occurs among ECHO members (PCPs and specialists) during ECHO sessions. Often faced with the same barriers to effective care, solutions to specific problems are shared, resulting in relationship building among PCPs and specialists in disparate geographic locations. For example, spoke sites are sharing how they document and track HCV patients through their electronic medical records (EMR) as well as how they perform follow-up visits for HCV patients.

4. 4. WVPBRN providers that participate in ECHO sessions often become their clinic “expert” in a specific content area (e.g., hepatitis C), advising other local providers on care and available resources for patients. For example, a rural clinic provider who has been attending the HCV ECHO since its launch has become the clinic “expert,” now treating almost all HCV patients presenting at that clinic.

An innovative aspect of WV Project ECHO is that it was initiated and facilitated by a clinical and translational science institute based within an academic medical center. WVCTSI has facilitated WV Project ECHO’s implementation and growth by providing the necessary administrative infrastructure as well as the required partnerships. Thus, linking ECHO programs to an existing institutional structure with access to specialty care expertise, resources, partners, and communities can be a viable model for other states considering ECHO implementation. Additionally, the WV experience underscores the critical role of community engagement in building an ECHO platform responsive to the needs, concerns, and realities of rural primary care.

Limitations

Limitations of the ECHO model include finding the optimal time for most rural PCPs to participate in the WV Project ECHO Program. Polling was done with potential Spoke sites which found the lunch hour was generally the best time for providers to participate. Nevertheless, recruiting new Spoke sites and new providers has remained a challenge at times, due to busy clinician schedules. Additionally, recruiting case presentations has been a challenge at various points for a given clinical topic. The biggest limitation of the WV Project ECHO program is the lack of a formal evaluation that includes outcome indicators beyond attendance, number of new ECHO projects, etc. In the beginning, WV Project ECHO focused on getting the initial project up and running and meeting the needs of the participants, rather than conducting a formal evaluation. The rapid expansion of the program has been the biggest indicator of success; to date, most of the evaluation data is anecdotal provider feedback and most resources have been spent on the expansion of the program. Additionally, there has not yet been an evaluation of patient outcomes, including unintended consequences, or patient perspectives.

Conclusions

WV Project ECHO has amplified specialty expertise among rural providers in West Virginia. Key to the success of these additional ECHO Projects has been strong collaborations between community providers and academic medical center specialists while maintaining a high level of support to these providers. For example, WVPBRN members and WVPCA medical officers inform on programmatic needs for the expansion ECHOs which results in relevant programming. Such community engagement subsequently enhances the relationship with WV Project ECHO spokes and partners – a critical outcome. By implementing the ECHO model using a provider-centered approach and utilizing established partners and infrastructure, WV Project ECHO strives to meet the needs of rural primary care physicians in WV. The ECHO model has provided an avenue for collaboration and the establishment of a learning collaborative among providers in WV that did not previously exist, all at no cost to the health care providers or patients. A future enhancement of this collaboration will be to do an extensive evaluation of the WV Project ECHO program which will include qualitative and quantitative data. For example, we will look at project-specific treatment rates as well as questions around patient retention and knowledge enhancement.

Obtaining funding for WV Project ECHO is critical to its sustainability and, to that end, multiple strategies for funding have been successful. The first strategy has been small foundation support. The Claude Worthington Benedum Foundation provided startup money, allowing WV Project ECHO to get off the ground and established. The second successful strategy has been collaborating on grant applications that can involve ECHO. For example, WV Project ECHO is collaborating with the West Virginia University (WVU) Department of Behavioral Medicine, WVU School of Public Health, and the state of WV on the Substance Abuse and Mental Health Services Association (SAMHSA) grant addressing opioid use disorder. The grant funds provide protected time for Hub members and continuing education credits for participants of addiction-related ECHO projects. These projects include the MAT, HCV/HIV, Chronic Pain, and Psychiatry ECHO projects. These strategies, combined with the already committed support from the WVCTSI, which provides funding for the ECHO staff and some CME costs, have created a bridge between the WVCTSI and external support opportunities. WV Project ECHO will continue to build partnerships within WVU and beyond to create opportunities for future external funding.

In conclusion, WV Project ECHO, based within an academic center for translational research in a rural state ranking near the bottom in most health outcomes, provides an effective platform for specialty expertise amplification and primary care collaboration to positively impact rural health.