Assessing Impact of Show-Me ECHO on the Health of Missourians: Two Examples

Abstract

Show Me ECHO is a model for interprofessional collaboration that utilizes telehealth technologies to share evidence-based medical knowledge to improve patient outcomes and minimize variation in care for underserved populations. To measure ECHO outcomes, Show Me ECHO develops both an evaluation of clinical outcomes for patients as well as assessing learner outcomes on the Kirkpatrick Typology of Evaluation. This paper describes evaluation models for Dermatology and Childhood Asthma ECHOs.

Introduction

In 2017, Missouri ranked as one of the unhealthiest states in the union: Health Rankings Report positioned Missouri 40^th out of 50 states.^1–2 Lack of access to timely and quality care significantly contributes to this ranking.¹ Further, Missouri declined by 16 slots since 1990, which is one of the largest observed declines.² This report uses behaviors, community and environment, policy, and clinical care as determinants to evaluate health outcomes.² Missouri ranks in the bottom 31 to 40 states in premature, cancer, and drug deaths, and at the 43^rd place in self-reported smoking rates (22 percent of adults in Missouri are smokers, compared to 17 percent nationally). ²

Preventable hospitalizations, with estimated costs of over $30 billion annually, are one of the largest financial burdens on health care systems. ² Average discharge per 1,000 Medicare enrollees is 49.4, however, Missouri has one of the highest numbers of preventable hospitalization of all states, 56.6 per 1,000 enrollees.² Studies show that lack of accessible and effective primary care services, as well as inadequate preventative and routine outpatient care, are key drivers of preventable hospitalizations. ^2–3 Further, patients who live in physician shortage areas are 70% more likely to have preventable hospitalizations and poorer outcomes than patients with adequate access to healthcare services. ^3–4

The Missouri Telehealth Network (MTN) leads a Show-Me ECHO (Extension for Community Healthcare Outcomes) Project, with the primary goal of capacity building and telementoring for primary care providers (PCPs) practicing in rural and underserved areas in order to improve healthcare outcomes and reduce costs. Providers from isolated areas often have large patient panels, with complex and difficult to manage conditions. Management is further complicated by the geographic distance from specialists and large medical centers. Project ECHO bridges this gap and broadens access by utilizing telehealth technologies, case-based learning, and collaborative communities of practice.⁵

Project ECHO is an innovative model for interprofessional collaboration, which supports the diagnostic management team approach.⁶ It utilizes telehealth technologies to share and democratize evidence-based medical knowledge and best practices with the aim of reducing variation in care. ⁶ Project ECHO literature demonstrate increased competence and improved practice of participating PCPs, as well as greater work satisfaction due to collaboration and networking with the ECHO specialty hub team. ⁶

Since the first pilot in 2014, Show-Me ECHO has experienced significant and sustained growth and now supports 22 unique ECHOs with both medical and non-medical topics (Appendix 1). The number and diversity of ECHO programs uniquely positions Show-Me ECHO to explore different approaches to help us understand the impact of Show-Me ECHO on Missouri. We are committed to systematically collecting and analyzing data to understand the Show-Me ECHO programs’ impact on the health of Missourians. This paper highlights two approaches: 1) the first demonstrates an increase in the number of dermatologic diagnoses and claims after participation in the Dermatology ECHO, and 2) the second shows improvement in asthma outcomes for patients in counties served by providers that participated in Asthma ECHO. By looking at chronic conditions and an acute, high mortality condition, we achieve a clearer understanding of one of Show-Me ECHOs goals, to have a positive impact on Missouri’s underserved populations.

Dermatology Example

A recent Show-Me ECHO pilot study showed that providers participating in Dermatology ECHO on average see patients with skin conditions between 2.9 (pediatric) and 3.3 (adult) years before the primary care provider presented the patient’s case in a Dermatology ECHO session. ⁷ However, almost half of the cases were incorrectly diagnosed, and in over 80 percent of adult and 70 percent of pediatric cases, the treatment was either modified or changed as recommended by the Dermatology ECHO hub team. ⁷ This earlier study showed that participation in Dermatology ECHO raised the diagnostic concordance of participating participants with the expert hub team from 49% at the beginning of participation to 69% after robust participation. ^7–8

To build on the pilot work we explored the impact of continuous participation in Dermatology ECHO on participating providers’ skin disease diagnostic management efforts. Available literature suggests that improved diagnostic ability of providers reduces medical errors and improves patient outcomes. ⁹

Materials and Methods

We wished to better understand the impact of Dermatology ECHO on participating providers’ diagnostic accuracy using Medicaid (MO HealthNet) claims data. Here, aggregate participation data and claims data provide an avenue to go beyond the current literature focused on comparing non-dermatologists and dermatologists. ^10–11 Our approach to combine ECHO participation and claims data allowed us to assess the influence of continuous telementoring on improvement in diagnostic accuracy.

Participants

Participants were 47 clinicians who joined Dermatology ECHO sessions from November 2015 – June 2017. After applying our inclusion and exclusion criteria (Table 1), a total of 41 Dermatology ECHO participants’ data were analyzed. Baseline data were collected for 12 months prior (November 2014 – October 2015) and 12 months after participating in Dermatology ECHO. All participants had unique start dates, and we adjusted the pre- and post-timeframe for each participant to include the relevant 12-month participation period.

Table 1.

Inclusion and Exclusion Criteria

Inclusion criteria	Exclusion criteria
Active participant of Dermatology ECHO (registered with ECHO to present and discuss cases) Primary care provider (MD, DO, PA, APRN, ACCN, FNP) Licensed (if applicable), certified and practicing in Missouri	Not signed up as participant of Dermatology ECHO Medical specialist (dermatologist) Dermatology ECHO hub team member Student or resident Not licensed/certified in Missouri and/or not practicing in Missouri

Materials

We used online Show-Me ECHO registration data to collect the number of ECHO sessions, number of CME didactics, number of CME credits, and number of attendees in Dermatology ECHO. Through the University of Missouri (MU) MO HealthNet Data Project, we obtained de-identified claims data. We used a total of 20 dermatologic diagnoses (Table 2): ICD 9 codes were used for claims submitted prior to October 1, 2015, and ICD 10 codes were used for claims submitted after that date.

Table 2.

Dermatology Diagnoses Used in the Analysis

Most common dermatologic diagnoses	Less common, but important to recognize in primary care
Acne vulgaris Pruritus Benign neoplasms Skin infections Melanoma Warts/Molluscum Psoriasis Eczema/dermatitis Rosacea Skin cancer	Brown recluse spider bite Granuloma annulare Necrobiosis lipoidica diabeticorum Pigmented purpura (capillaritis) Bullous pemphigoid Morphea/lichen sclerosis Alopecia areata Tinea versicolor Neurodermatitis/lichen simplex chronicus Subacute lupus erythematosus

Results

Total attendance and Participation

Dermatology ECHO started in November 2015 and has had a total of 133 sessions to date (December 2019), and 234 individual participants. Individual participants included primary care physicians, advanced practice nurses, medical, nursing, and physician assistant students, medical residents, specialists as well as other learners interested in skin conditions – providers from other states, school nurses, educators, etc. Sessions are offered twice monthly, during a one-hour meeting. Each session consists of: 1) a 15 minute Continuing Medical Education approved didactic and, 2) a number of real-life case presentations and 3) discussions and mentoring from ECHO Hub Team members.

Over 414 CME credits have been awarded, and all participants attended an average of 10 sessions.

Claims with Dermatologic Diagnoses

The 47 providers included in this study diagnosed 50 patients with one of the 20 diagnoses included in this study 12 months prior to their participation in Dermatology ECHO (Table 3). We observed an increase of 584 percent, and a total of 342 patients diagnosed during the 12 months after participating in Dermatology ECHO. In addition, a total number of claims submitted prior to participation in Dermatology ECHO was 59. We observed a 666 percent increase, and a total of 452 claims submitted 12 months after joining Dermatology ECHO.

Table 3.

Claims with Dermatologic Diagnosis

Pre-ECHO		Post-ECHO
Number of patients with dermatologic diagnosis	Number of Mo HealthNet claims (total visits) with dermatologic diagnosis	Number of patients with dermatologic diagnosis	Number of Mo HealthNet claims (total visits) with dermatologic diagnosis
50	59	342	452

Dermatology conclusion

Significant increases in the number of dermatologic diagnoses and claims during the post-ECHO period is suggestive of improved diagnostic accuracy of participating providers. Current literature shows that lack of adequate dermatological training for primacy care practitioners often results in low self-efficacy and knowledge of diagnosis and management of skin conditions. ¹² Together with our earlier study on diagnostic concordance, this pilot study of diagnostic claims strongly suggests that the ECHO model is effective in increasing the diagnostic accuracy of participating providers.

Asthma example

The childhood Asthma ECHO is an endeavor of the University of Missouri (MU) Asthma Ready Communities^® (ARC) in collaboration with Show Me ECHO and the Missouri Asthma Prevention and Control Program (Missouri Department of Health and Senior Service and the Center for Disease Control and Prevention-MAPCP). MAPCP/ ARC work to reduce childhood asthma burden in Missouri. The Show Me ECHO framework, through its use of telehealth technology, extends the reach of the MAPCP/ARC to patients and providers in Missouri’s rural and other underserved areas. Established in 2015, the Asthma Show-Me ECHO meets weekly for four-week sessions that occur annually in January, February, May, June, September, and October. Similar to the Dermatology ECHO, Asthma ECHO includes Continuing Medical Education didactic sessions and providers’ presentations of their patients for mentoring and discussion by the ECHO Hub Team and participants. Childhood Asthma ECHOs are grounded in well-validated standards of care and measurement of patient outcomes. Use of Medicaid administrative claims supports interesting opportunities to assess the effectiveness of specific elements of ECHO sessions for more than 50,000 Missouri children.

In 2018 the “Asthma Best Practices” study began to assess the impact of Asthma ECHO on provider adoption of best practices and subsequent changes in health outcomes for patient panels using a quality improvement model. The specific aim of this program is to reduce the rate of uncontrolled asthma for patients of participating pediatricians and family physicians. An asthma best practices item inventory survey was developed and completed by 55 participating Asthma ECHO providers. Results showed that only 33.6% of asthma best practices were described as routine in day-to-day asthma care by clinicians during the baseline year. After participation in the QI Asthma ECHO the number of best practices reported as routine doubled. These newly adopted best practices included standardized asthma education delivery, consistent coaching for better inhalation technique, routinely confirming ICS medication adherence, dispatching home and school preventative asthma services for high risk patients. Medicaid health service utilization analysis including change in patterns of dispensed asthma medications such as inhaled corticosteroids (ICS), short acting beta agonists (SABA), systemic oral steroids (SOS), acute care visits, and total costs of health care are compared from baseline year (2017) to impact year (2019) as well as randomized comparative provider panels in similar urban sites. Results are pending over the summer 2020.

This article is the first phase of assessment on the impact of the Childhood Asthma ECHO model, describing outcomes for patients residing in counties of Asthma ECHO provider participants. The next phase is to identify the patient population of ECHO provider participants to assess changes in practice patterns and patient outcomes through a pre/post ECHO participation analysis.

Materials and Methods

Participants

From August 2015 and November 2019, 680 providers representing multiple health care professions participated in Show Me Asthma ECHOs. Providers participated in at least one of 144 sessions. During these sessions, 191 cases were reviewed. Of the 191 cases, 185 were new and six were follow up cases. During this time, 755.75 Continuing Medical Education units were awarded to 178 individuals. To consider the outcomes for patients, Medicaid patients from Missouri counties with providers that participated in ECHO were analyzed using MO HealthNet administrative claims data.

Materials

Asthma is a chronic condition with: 1) established diagnostic criteria 2) evidenced-based best practice guidelines for treatment, and 3) medications based on disease state. Evaluation criteria have been established as norms for understanding both the effectiveness and cost effectiveness of treatment. Asthma ECHO uses evaluation criteria from prior MU Childhood Asthma Initiative field projects that have been modified to address the use of telehealth technology. The indicators used to track patient outcomes are aligned with Center for Disease Control (CDC) HEDIS measures including hospitalizations, ER visits, and office visits as well as utilization of classes of maintenance and rescue drugs.

In state fiscal year 2018, MO HealthNet covered approximately 45% ¹³ of Missouri’s child population, or about 620,000 children, which is typical of the past several years. The MO HealthNet population is particularly well aligned with the underserved geographies targeted by the Show Me ECHO program. Via MO HealthNet claims, the following outcomes were obtained for patients with a primary or secondary diagnosis of asthma: prescribing and pick-up patterns for systemic oral steroids (SOS), short-acting bronchodilator inhalers (SABA), and inhaled corticosteroids (ICS), office visits, emergency department visits, days of hospitalization.

Data evaluation included Missouri state fiscal years 2015 – 2018 and Missouri counties from which ECHO participants practice. The MU Childhood Asthma ECHO evaluator determined the assignment of counties to the ECHO/Non-ECHO categories.

Results

Asthma Cases Reviewed by ECHO Provider Participant Counties

Asthma ECHO has served 680 providers in 29 Missouri counties during fiscal years 2015–2018. Approximately 40,000 cases of childhood asthma per year were identified by Missouri Department of Social Services, MO HealthNet Division, ‘DCN’ case number. ‘Childhood’ cases are defined as 18 years of age and younger.

Outcomes for Asthma Cases from ECHO Provider Participant Counties

Asthma management protocols seek to avoid exacerbations requiring ‘rescue’ interventions through appropriate maintenance medications and medical management. Table 4 illustrates data from ECHO provider participant counties. Between FY15 and FY18, the average number of hospital days and the average number of prescriptions for ‘rescue’ (SOS/SABA) medications both declined as anticipated. Additionally, ICS prescriptions on average have increased as desired, as have billable office visits. Conversely, the average number of emergency department visits ticked up slightly, though in the context of the positive outcomes realized in types of prescriptions used, the decrease in hospitalizations, and the increase in office visits, the increase in emergency department usage is likely explained by increased awareness of risk by ECHO participant providers, families, and patients.

Table 4.

Asthma ECHO Outcomes

Outcome Measures	FY15	FY18
Number of Asthma Cases/DCN*	41,587	39,793
Rescue Drugs
Number SOS**	31,360	26,847
SOS/DCN	0.85	−.75
Number SABA***	94,630	87,555
SABA/DCN	2.26	2.19
Maintenance Drugs
Number ICS****	46,358	50,735
ICS/DCN	1.13	1.27
Rescue Visits
Hospital Days	2,390	1,726
Hospital Days/DCN	0.06	0.04
Emergency Department Visits	8,138	6,638
Emergency Department Visits/DCN	0.14	0.17
Maintenance Visits
Office Visits	17,562	21,741
Office Visits/DCN	0.46	0.55

^*DCN = Document Control Number/Patient ID assigned by MO HealthNet

^**SOS = Systemic Oral Steroids

^***SABA = Short-acting Bronchodilator Inhalers

^****ICS = Inhaled Corticosteroids

Asthma Conclusion

A growing body of literature suggests that childhood asthma is most successfully managed through a multi-disciplinary approach.¹⁴ The Missouri Asthma Prevention and Control Program, MU ARC^® and Show Me Asthma ECHO are grounded in this approach, including clinicians and educators from multiple fields (such as physicians, advanced practice nurses, school nurses, and asthma educators) to educate and train community-based providers and family members in chronic disease management. This approach has produced the desired results of decreasing emergency department visits and hospitalizations.¹⁵ Missouri.

Additional work is needed to specifically understand Asthma ECHO’s selective impact. A county-based analysis to date shows positive changes, but does not assess the selective impact of either MAPCP/ARC or Show Me Asthma ECHO interventions. Next steps include identifying Asthma ECHO provider participants by cohort, intervention inputs, patterns of participation, and geography, as well as indications of adoption of best practices. Additionally, because it is possible to tie ECHO provider participants to their patients, there is opportunity to measure the influence of the ECHO model not just on individual providers but on their practice setting and local provider communities.

Discussion

A 2019 Health and Human Services Report to Congress describes widespread use of ECHO and ECHO-like programs consistently show positive effects. Further, the report concluded “existing empirical evidence for their impact on patient and provider outcomes remains modest”. ^16p3 Since inception Show-Me ECHO had 3,330 unique Missouri attendees across ECHOs, hosted 863 ECHO sessions and provided 21,215 instructional hours to participants¹⁷ Beyond these substantial contributions to enhance the knowledge of Missouri providers, Show-Me ECHO is committed to systematically collecting and analyzing data that will help us to better understand how participation in Show-Me ECHO impacts the health of Missourians. Given the number and variety of Show-Me ECHOs, the team is uniquely positioned to explore different approaches that will help us understand what works for whom and under what conditions. The Dermatology and Asthma ECHO examples take different approaches but both illuminate the positive influence of ECHO on the health of Missourians. Assessing the effectiveness of ECHO models on health is a complex task, requiring both qualitative and quantitative approaches. Kirkpatrick’s typology of evaluation is a helpful model to evaluate the effectiveness of educational programs and educational innovations.¹⁸

First modified to be applicable in business, the five levels range from satisfaction with the training program to return on investment and results for the business (Figure 1). Kirkpatrick’s model has also been adapted for use in health education and continuing education programs. Here the hierarchical model moves from learner satisfaction with the educational program to demonstrated benefits to patients.^19–20 As one moves toward the tip of the triangle gathering evidence becomes more challenging and requires more robust data collection. The first levels focus on learners while level four and above seek to analyze changes to organizations and improvements in patient outcomes. Show-Me ECHO’s collaboration with the University of Missouri (MU) MO HealthNet Data Project assists Show-Me ECHO in accessing data needed to analyze impact on patients. Kirkpatrick’s model is limited in that it aims to measure anticipated outcomes. It does not ask the questions more broadly, such as what outcomes (positive, negative, intended, unintended) did we observe and why did we achieve the outcomes?²¹

Figure 1.

Kirkpatrick’s Typology of Evaluation

Since its inception, Show-Me ECHO has routinely collected data on learner reaction and learner perceptions’ of learning consistent with Kirkpatrick’s first levels. The 2018 Show-Me Project ECHO Evaluation Report is one example.²² Data collected from Show-Me ECHO inception to summer 2019 indicate strong satisfaction with ECHO participation. Show-Me ECHO also collects self-efficacy survey data and these data are consistent with the literature on the four stages of competence. Here leaners move from: a) being unaware they lack proficiency to b) an awareness but not yet proficient, to c) able to use new knowledge and skills with effort and finally to d) performing the new skill is automatic.²³ Six-month post Show-Me ECHO participation surveys demonstrate decreased self-efficacy as compared to pre participation surveys. Importantly, this trend reverses with continued ECHO participation and respondents report improved self-efficacy over baseline data. Show-Me ECHO survey respondents recognize the impact participation in ECHO has on the care they provide to their patients. For example, of the 39 unique individuals participating in over 125 sessions of Dermatology ECHO Continuing Medical Education (CME) surveys, 99% of respondents agreed or strongly agreed with the statement “After attending the Dermatology ECHO, I am better able to care for patients in my practice with skin conditions”. In the future, these self-reported data will be supplemented by analysis of changes in practice. However, the participant’s self-reported responses suggest changes in behavior and help to inform Kirkpatrick’s third level.

To ultimately change knowledge, behavior, and improve the health of Missourians, providers must be willing to participate. Show-Me ECHO has successfully improved provider participation and their knowledge of disease identification and management across Show-Me ECHOs. For example, 1,840 unique healthcare providers joined Show-Me ECHO by 2017, 250 patients were cured of hepatitis C, 60 melanomas diagnosed, and 100% of families in Missouri now live within 60 miles from an ECHO autism provider. ¹⁷

Overall Conclusion

What started as a pilot in 2014 has grown into 22 Show-Me ECHO offerings (Appendix 1) providing multiple opportunities for Missouri providers to enhance their knowledge, to receive mentoring from specialists, and to “give their patients the right care, in the right place, at the right time.”²³ With this growth comes a responsibility to assess the effectiveness of these programs and to collect evidence about the impact on patients and providers. The dermatology and asthma studies described here illustrate Show-Me ECHO’s movement toward the higher levels of Kirkpatrick’s model and toward a better understanding of the ECHO models impact on the health of Missourians. We invite you to join an ECHO and engage in our learning communities. To join visit www.showmeeho.org.

Appendix 1

SHOW-ME ECHO

• Uses videoconferencing to create learning collaboratives of primary care physicians and specialists.

• Uses the principals of adult learning theory: after a short didactic, case-based learning is employed.

• Primary care physicians (PCPs) can present their own patient cases to gain insights and recommendations on care delivery.

• Hub teaching teams include multi-disciplinary specialists from across the state.

• Primary care physicians participate using their tablet, laptop, or desktop.

• Most are twice monthly over lunch.

• No-cost CME is granted for participation.

• All ECHOs are shame-free, collegial, and fun and we all learn from each other.

• Show-Me ECHO offers ample support for PCPs that want to participate.

• Simply go to showmeecho.org to get started.

Show-Me ECHO Project	Expertise Available To Participants	Session Schedule	Time	To Learn More Contact
Autism	Developmental Pediatrician, Child Psychologist, Child/Adolescent Psychiatrist, Dietitian, Resource Coordinator, Health Literacy Expert, Parent Advocate/Educator	First and Third Wednesday of the Month, Year-Round	Noon-1 pm	Shelly Gooding: (573) 884-5935; goodings@health.missouri.edu
Asthma	Clinicians in Pediatrics, Allergy and Environmental Assessment, Health Literacy Expert, Nursing and Asthma Education Specialists	Each Tuesday in January, February, May, June, September, October.	Noon-1pm	Shelly Gooding: (573) 884-5935; goodings@health.missouri.edu
Child Psychiatry	Child Psychiatrist, Pharmacist, Psychologists, Social Worker, Developmental Pediatrician, Health Literacy Expert	Second and Fourth Fridays May–October and November–April	Noon-1pm	Lauren Dahm: (573) 882-8240; dahml@health.missouri.edu
Community Health Worker	Community Health Workers, Educators, Community Resource Specialists, Behavioral Health Specialist, Nurse Care Manager, Health Literacy Expert	First and Third Tuesdays of the month	2pm–3pm	Shelly Gooding: (573) 884-5935; goodings@health.missouri.edu
Dermatology	General Dermatologists, Pediatric Dermatologists, Dermatopathologist, Nurse Practitioner, Clinical Psychologist	First and Third Fridays and Second Wednesday Every Month	Noon-1pm	Lauren Dahm: (573) 882-8240; dahml@health.missouri.edu
Hepatitis C	Hepatologist Clinical Psychologist Nurse Resource Specialist, Pharmacist, Health Literacy Expert	First and Third Fridays of the Month, Year-Round	Noon-1pm	Beth Monson: (573) 884-3847; monsonb@health.misssouri.edu
HIV	Physician, Clinical Pharmacist, HIV Nurse, HIV Medical Case Management Expert, Treatment Adherence Expert, Behavioral Health Expert	Second and Fourth Thursday of the month Year-Round	Noon-1pm	Wendy Hough: (573)884-3048; houghw@health.missouri.edu
Opioid Use Disorder	Psychiatrist, Psychologist, Social worker, Addictionologist, Pharmacist, Health Literacy Expert	Second and Fourth Fridays, Year-Round	11:45–1pm	Beth Monson: (573) 884-3847; monsonb@health.misssouri.edu
Pain Management	Chronic Pain Management Specialist, Clinical Psychologist, Pharmacist, Physical Therapist, Social Worker, Sleep and Pain Specialist, Health Literacy Expert	Second and Fourth Thursday From January – June and September – December	Noon-1pm	Beth Monson: (573) 884-3847; monsonb@health.misssouri.edu
Maternal Health	OB-Gyn, Maternal-Fetal Medicine, Labor and Delivery Nurse, Neonatologist, Psychiatrist, Pharmacist, Social Worker	TBD	Noon-1pm	Wendy Hough: (573)884-3048; houghw@health.missouri.edu
Neonatal Abstinence Syndrome (NAS)	Neonatologist, Pediatrician, Neonatal Outreach Educator, Lactation Consultant, Pharmacist, Social Worker	First and Third Thursday of the month Year-Round	Noon-1pm	Lauren Dahm: (573) 882-8240; dahml@health.missouri.edu
Oral Health	Dentist, Periodontist, Endodontist, Dental Hygienist, Pathologist, Pediatric Dentist, Oral Surgeon, Pharmacist	Second Wednesday of the Month	Noon-1pm	Wendy Hough: (573)884-3048; houghw@health.missouri.edu
Diabetes	Endocrinologist, Primary Care Physician, Behavioral Health Specialist, Nephrologist, Pharmacist, Community Health Worker, Diabetes Educator, Dietician	First and Third Tuesday of the month Year-Round	Noon-1pm	Beth Monson: (573) 884-3847; monsonb@health.misssouri.edu
Kidney Disease	Nephrologist, Social Worker, Dietician, Pharmacist, Diabetes Educator, Transplant Nurse, Patient Advocate	First and Third Thursday of the month Year-Round	Noon-1pm	Shelly Gooding: (573) 884-5935; goodings@health.missouri.edu
Developmental Disabilities	Behavior Analyst, Psychiatrist, Patient Advocate, Caseworker, Pharmacist	Second and Fourth Thursday of the month Year-Round	Noon-1pm	Lauren Dahm: (573) 882-8240; dahml@health.missouri.edu
Hypertension	Cardiologist, Internist, Nephrologist, Psychologist, Exercise Kinesiologist, Pharmacist, Dietician, Social Worker	Second and Fourth Monday of the month Year-Round	Noon-1pm	Wendy Hough: (573)884-3048; houghw@health.missouri.edu
Trauma Informed Schools	Principal, Program Training, School Counselor, Social Worker, District Administrator	First and Third Tuesday of the Month Year-Round	1:30–2:30pm	Wendy Hough: (573)884-3048; houghw@health.missouri.edu
Autism: Behavior Solutions	Behavior Analyst, Pediatric Psychologist, Child Life Specialist, Child Neurologist, Parent Advocate	First and Third Monday of the Month Year-Round	11:45am–1pm	Lauren Dahm: (573) 882-8240; dahml@health.missouri.edu
Head Start	MO Head Start Director, Developmental Disabilities Expert, Child Psychologist, Trauma Informed Care Specialist, Early Head Start Director, Developmental Pediatrician, School Administrator, DHSS System Expert, Parent Advocate	Third Wednesday of the Month Year-Round	11am-Noon	Wendy Hough: (573)884-3048; houghw@health.missouri.edu
Certified Peer Specialist	Mental Health Manager, Credentialing and Training Expert, Peer Support Training Specialist, Recovery Specialist, Homeless and Probation Specialist, Trauma Informed Care Specialist, Director of Transitional Operations	First and Third Wednesday of the Month Year-Round	11am-Noon	Beth Monson: (573) 884-3847; monsonb@health.misssouri.edu
COVID-19	Department of Health and Senior Services Director, Clinical Quality Improvement, Infectious Disease, Emergency Medicine, Health Ethics	Every Monday	Noon-1pm	Beth Monson: (573) 884-3847; monsonb@health.misssouri.edu
Telemedicine (General)	Telehealth Resource Center Directors, Telemedicine Manager, Program Manager, Medical Director, Telebehavioral Health	Every Tuesday	9am–10am	Lauren Dahm: (573) 882-8240; dahml@health.missouri.edu