The COVID-19 pandemic and knowledge of this novel disease has pushed our medical communities to identify new ways of learning. When the pandemic hit, medical experts suddenly found themselves facing an illness they knew little about and struggling to rapidly learn about how best to prepare and care for patients. With assistance from Penn State University’s Huck Institute and Social Sciences Research Institute, our Project ECHO at Penn State was rapidly able to mobilize and provide a platform for sharing much-needed, and ever-changing, information on COVID-19.
About Project ECHO
Project ECHO (Extension for Community Health Outcomes) launched at the University of New Mexico in 2003 with a focus on treating hepatitis C. At the time, Dr. Sanjeev Arora was frustrated that thousands of people in New Mexico could not get the treatment they needed, because his clinic was only one of two in the state that could treat hepatitis C. The goal was to meet local healthcare needs by improving capacity of primary care physicians to treat hepatitis C in their own communicates. By putting local clinicians together with specialist teams at academic medical centers in weekly virtual clinics, Project ECHO shares knowledge and expands treatment capacity. The result: better care for more people and close to home. A 2011 study published in the New England Journal of Medicine showed that the quality of hepatitis C care provided by Project ECHO-trained clinicians was equal to that of care provided by university-based specialists.
The heart of the ECHO model is its hub-and-spoke knowledge-sharing networks, led by expert specialist teams (hub), mentoring multiple community providers (spokes) via teleconferencing. Providers have the support of specialists for advice and referral, creating an effective triage system and direct linkage to care. The ECHO model is not “telemedicine” where specialists assume the care of the patient; it is a guided model aimed at practice improvement, in which providers retain responsibility for patients, and patients are able to receive high quality care when they need it, within their own communities. 60-minute sessions are structured to include introductions to create a welcoming environment, 30 minutes discussing a case or scenario presented by a spoke, a 15-minute brief lecture, and time for debrief and closing.
Project ECHO utilizes case-based, collaborative learning to support discussion of learners’ challenges and barriers to guideline implementation, enhancing education and supporting changes in practice. It is an all teach, all learn model, in which a team of experts facilitates discussion of real-life scenarios that the participants bring for discussion. In turn, the experts gain a greater understanding of day-to-day difficulties providers face. The ECHO model has significant strengths when compared to traditional training in that it allows for remote learning and utilizes case discussions that match the context and capacity of participants. Further, learners have the ability to make real-time changes in practice, as participation equips them to make timely and informed health decisions and leverage expertise of specialists, especially during this rapidly evolving pandemic.
Since 2003, Project ECHO has been utilized in 401 institutions in 40 countries addressing more than 100 health conditions and public health topics. Project ECHO differs from traditional learning in that the bulk of the 60-minute session is spent in case-based discussion and mentorship. In this “all teach, all learn” environment, providers gain skills and confidence and specialists learn new approaches for applying their knowledge across diverse cultural and geographical contexts. Because of its utility and proven success at increasing workforce capacity, Project ECHO has gained policymaker attention. In 2016, the US Senate passed the Expanding Capacity for Health Outcomes (ECHO) Act, legislation aimed to increase access to healthcare in rural areas by authorizing the US Department of Health and Human Services (HHS) to study the Project ECHO model. This bill would require the Secretary of HHS to study the model and examine the impact on addressing mental and substance use disorders and chronic diseases, the impact on provider capacity and workforce issues and the delivery or healthcare services in rural areas and medically underserved areas.
The ECHO model is of particular value for our rural communities. Only about 10 percent of physicians practice in rural areas of the country despite nearly one-fourth of the population living in these areas. Rural areas have higher rates of some chronic diseases and face many challenges, including transportation, connectivity, and isolation. Further, it can be difficult to recruit healthcare providers to work in rural and underserved areas, and opportunities for professional development and support in these areas can be difficult. The goal of Project ECHO is to provide the same level of healthcare to rural patients with chronic diseases as can be obtained in an urban setting. A secondary goal is to provide rural healthcare practitioners with a level of interaction and support commensurate with their urban counterparts to enhance their technical competence and decrease their feelings of professional isolation.
Project ECHO at Penn State launched on November 28, 2018 with a focus on Medication Assisted Treatment for Opioid Use Disorder through a SAMHSA funded grant. Since then, the Penn State ECHO team has launched 10 different topics through the ECHO platform for health-related professionals and community organizations, providing over 1,075 continuing medical education credits delivered to 280 participants. To date, ECHO programs have largely focused on disseminating chronic disease management information to community clinics. However, the ECHO movement’s explosive growth across the globe provides the opportunity for outstanding responsiveness in the setting of a pandemic, such as for COVID-19.
COVID-19 ECHO series
Project ECHO is uniquely positioned to connect medical and policy expertise to health systems, hospitals, clinical providers and communities during an infectious disease outbreak. Through its hub-and-spoke model, ECHO can provide rapid support in knowledge dissemination of the latest outbreak updates as well as assist with adapting guidelines into practice. Community clinics and clinical providers benefit from this expertise as well as standardization of approaches to address outbreaks, ensuring communities receive guideline-concordant care. Additionally, the ECHO model has the ability to reach directly into minority and medically underserved communities, which often have lower rates of health literacy and higher rates of poverty, underinsurance, and lack of health care access. Recognizing that successful engagement of health systems, providers, and communities in guideline-concordant practices during the pandemic had the potential to save lives, Project ECHO at Penn State launched a COVID-19 ECHO series on March 20.
The COVID-19 ECHO series at Penn State aimed to inform providers and administration of the latest best practices in emergency preparedness and patient treatment for COVID-19. Session topics were chosen to equip participants with strategies to address challenges presented as a result of the coronavirus pandemic. Together, experts and participants collaborated to discuss common scenarios related to diagnosis and care as well as difficult, complex or challenging presentations of an organization, clinic, hospital or patient management scenario. During our COVID-19 series, we have enrolled 700 participants from 31 states and 6 countries. A total of 41 topics have been presented, ranging from addressing appropriate personal protective equipment, outpatient testing and primary care response, guidance for hospitalists, and ICU level care. In addition, we have discussed mental health concerns during a pandemic for both patients and providers, communicating with family and visitors, and preventing provider burnout. We’ve also had our Penn State experts tackle important populations of patients, including addressing opioid use disorder, healthcare response to intimate partner violence, efforts to reach minority patients, and the impact that the pandemic can have on our children. Our academic medical center is positioned to highlight education and research efforts related to the pandemic, including a session discussing medical student value-added roles, the role of the citizen science, and a discussion of research studies available for patients with COVID-19.
In addition to connecting with healthcare providers and administrators, and in order to reach rural and underserved communities, sessions for community organizations and the general public are being delivered. Our first community-focused ECHO session has garnished over 2,000 views on YouTube (https://bit.ly/PSUECHOCOVID-19). Project ECHO at Penn State has partnered with REACH (Racial and Ethnic Approaches to Community Health), a national program administered by the Centers for Disease Control and Prevention (CDC) to reduce racial and ethnic health disparities, to offer sessions in Spanish and Nepalese. Our first session delivered in Spanish reached 140 Hispanic community leaders and members via Zoom and Facebook Live. Sessions delivered in Spanish and Nepalese include home management, diabetes management for COVID-19 patients, family resources for managing mental health and helping families to be health and active during the pandemic.
As the pandemic has evolved, it has become clear that nursing homes are ground zero for COVID-19. Across the nation, nursing home residents with COVID-19 are the largest population coming to hospitals, requiring ventilators, and dying from the virus. Pennsylvania nursing homes are particularly devastated with 19,071 cases of COVID-19 and more than 4,117 deaths, as of June 9, 2020, accounting for more than half of the state’s coronavirus deaths. The COVID-19 pandemic shines a spotlight on the infection control principles for some of America’s frailest, most vulnerable patients. Though the CDC outlines several strategies to assist nursing homes in addressing the pandemic, effective implementation requires organizational capacity, staff engagement and problem solving that can task organizations lacking appropriate training, resources and support. We conducted a needs assessment in April 2020 with nursing home administrators and staff (n=71) that indicated several challenges to implementing infection control strategies, including lack of infection control training, managing resident transfers, preventing transmissions, information overload, and staff wellbeing. Nursing homes are where the most vulnerable and impacted population in the pandemic live. Project ECHO at Penn State launched a separate series that provided essential information to the front-line staff who need it most, offering six sessions specific to this population.
Project ECHO is where treatment, prevention, research, technology and learning converge. We understand the power of sharing medical and public health knowledge across miles and disciplines. But we also understand we can’t do it alone. To learn more about how you can support Project ECHO at Penn State, visit https://ctsi.psu.edu/echo/ or email echo@psu.edu.