December 2016

Project ECHO: Expanding access to treatment for mental health and substance use disorders by supporting primary care teams with the ECHO model

Miriam Komaromy, MD, FACP, FASAM
Associate Professor of Medicine
Associate Director, Project ECHO
University of New Mexico School of Medicine


Typical case presentation:

A physician from a small community in southern NM presents a patient whom she is seeing in clinic. Personal identifying information about the patient is not shared on the network. 

Case presentation: Patient is a 44-year-old man insured by Medicaid who worked in the oil fields near the Texas border.  He has developed a methamphetamine use disorder while using stimulants to tolerate the boredom and long work hours required of him, and subsequently developed an opioid use disorder when using opioids to combat the stimulation of the methamphetamine. He has lost his job because of his substance use, and has begun participating in a counseling program. He is no longer using large amounts of methamphetamine but continues to smoke heroin several times per day. 

Discussion: After the case presentation the conversation is opened for clarifying questions, and other PCPs ask about social support, trauma history, housing, and urine drug screen results. The specialists ask about the patient’s motivation to change and about information contained in the prescriptions monitoring program. 

Then suggestions are made regarding participation in peer-support programs, assisting the patient in applying for subsidized housing, offering him medication treatment with buprenorphine/naloxone, and prescription of a naloxone rescue kit for overdose prevention.

Follow-up: In a subsequent follow up presentation the patient has stabilized on buprenorphine, but is experiencing anxiety, flashbacks, and nightmares related to childhood domestic violence.  Recommendations include participation in a Seeking Safety group and prescription of prazosin for the nightmares.


ECHO is a model for training and supporting primary care teams to provide high quality care for common, complex diseases, such as hepatitis C, type 1 diabetes, and substance use disorders. ECHO (echo.unm.edu), which stands for Extension for Community Healthcare Outcomes, uses video conferencing to connect disease specialists with multiple primary care teams simultaneously. Case-based learning is the key method used to provide training and support for the primary care teams, allowing them to gain knowledge and confidence, and eventually provide care for these problems independently (figure 1).

The ECHO model was developed at the University of New Mexico Health Sciences Center by Dr. Sanjeev Arora, and has since been replicated in more than 100 academic medical centers around the world. It began with a focus on treatment of hepatitis C, and has proven to be highly effective for this purpose, with treatment outcomes achieved by PCPs with ECHO support that are equivalent to those achieved by academic specialists (Arora, NEJM, 2011).

Integrated Addictions and Psychiatry (IAP) teleEcho Clinic

Soon after the first teleECHO clinic was started for hepatitis C in 2003, a second teleECHO clinic was launched in 2005 that was focused on mental health and substance use disorders (SUDs) (Komaromy, 2016). This clinic, called the Integrated Addictions and Psychiatry (IAP) teleECHO clinic, has been in continuous operation since 2005 at the University of New Mexico Health Sciences Center.

See related story by New Mexico family practitioner Dr. Leslie Hayes, 2016 White House Champion of Change for Advancing Prevention, Treatment and Recovery:

Paging All Doctors: There's a Better Way to Treat the Opioid Addiction Crisis

The IAP teleECHO clinic is staffed by an addiction specialist (who is also an internist), a psychiatrist, and a counselor/social worker. At times the experts have also included a psychiatric nurse, a community health worker, and a pharmacist. Participants are mostly drawn from community health centers in New Mexico, but also include clinicians from public health, specialty addiction treatment programs, Indian Health Service and other Native healthcare organizations, jail healthcare workers, and private practice providers, among others.

Primary care team members who participate include physicians, nurse practitioners, physician assistants, nurses, counselors, pharmacists, community health workers, and medical assistants.

A typical IAP teleECHO clinic starts with a brief didactic presentation by one of the specialists, which is followed by case presentations and discussion. Cases are real, de-identified patient cases selected and presented by the primary care participants.

Participants present patients from their own practice who have SUDs or mental health disorders. One of the team of specialists acts as a facilitator, and first elicits clarifying questions about the patient case from the other participants and the specialists, and then elicits recommendations for care from the participants and the specialists. Each case provides an opportunity for teaching and collaborative discussion about how to provide the best quality care for patients who have SUDs and mental health disorders.

Between 2008 and 2015 more than 950 patient cases (both mental health and substance use disorders) have been presented during the IAP teleECHO clinic. More than 9000 hours of CME/CEU have been provided. An average of 147 participants join the teleECHO clinic each year. Opioids are the substances that have been presented and discussed most frequently (31% of total SUD cases), followed by alcohol and cannabis.Other substances that were the focus of discussion included cocaine, carisoprodol, benzodiazepines, tobacco, methamphetamine, and dextromethorphan.

Figure 1:



Multiple primary care providers and teams from around the region present de-identified cases of patients who have substance use disorders, and receive teaching and feedback from their colleagues and from addiction specialists at the University of New Mexico ECHO Institute.

Expanding the Echo Model

Recently there has been a great deal of interest in replicating the ECHO model for expansion of mental health and substance use disorder treatment. Several federal agencies have solicited proposals for projects based on the ECHO model, including the Substance Abuse and Mental Health Services Administration(SAMHSA), SAMHSA's Center for Substance Abuse Treatment (CSAT), the Agency for Healthcare Research and Quality (AHRQ) and the Health Resources and Services Administration (HRSA). Numerous teams have visited the ECHO Institute in New Mexico to learn how to implement an ECHO program focused on these disorders in their own institution or state.

Among others, three notable national initiatives are supporting expansion of the use of the ECHO model for treatment of SUDs:

AHRQ has funded several states (CO, PA, NC, and OK) to expand treatment of opioid use disorder with state-based initiatives that use the ECHO model.

SAMHSA’s Center for Substance Abuse Treatment (CSAT) supported a pilot project conducted by the American Society of Addiction Medicine (ASAM) and the ECHO Institute to offer a Fundamentals of Addiction Medicine ECHO (FAME) program in 2016. This program was offered to individuals who had participated in a day-long Fundamentals of Addiction Medicine face-to-face course that ASAM offers at its annual meeting. The FAME teleECHO offered two-hour weekly sessions for 16 weeks. The didactic curriculum covered the basics of screening, diagnosis, and treatment of SUDs in the primary care setting. Addiction Medicine specialists from across the US and from Canada participated as guest specialists, offering the weekly didactic presentations and acting as a guest case-discussant during that teleECHO session. Participants were PCPs and general psychiatrists who were also drawn from across the US and from Canada. Satisfaction with the course was very high, and many participants requested an ongoing Fundamentals of Addiction Medicine teleECHO program.

Finally, HRSA has recently funded an initiative to provide nationwide teleECHO clinics focused on treatment of opioid use disorder. Participation is free of charge and offers free CME/CEU credits. This effort is led by the ECHO Institute and involves collaboration with other institutions that will be acting as ECHO “hubs," offering teleECHO clinics out of their organization: Billings Clinic in MT, University of Washington, University of New Mexico, Boston Medical Center, and a collaborative of organizations in Western NY state. Each of these hubs will offer a two-hour teleECHO clinic twice per month, and all will offer a standardized 12-session curriculum on screening, diagnosis, and treatment of opioid use disorder. The target audience is primary care teams practicing in Federally Qualified Health Centers (FQHCs), with a special focus on serving the needs of the FQHCs that received funding to expand substance use treatment services from HRSA in 2016. All primary care team members are encouraged to participate in these interdisciplinary teleECHO clinics, including physicians, nurse practitioners, physician assistants, counselors, nurses, medical assistants, and community health workers. Teams can choose to participate in the teleECHO clinics offered by any one of the hubs, and teleECHO clinics will be offered throughout the week.

In addition to the six national interdisciplinary teleECHO clinics, the ECHO Institute will offer two specialized teleECHO clinics focused on treatment of opioid use disorder: one for counselor/social worker/psychologists, and another for CHW/MA’s.

To learn more and to sign up, please visit: echo.unm.edu/opioid

 

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