Project ECHO An Innovation in Healthcare Delivery Treatment of Hepatitis C January 26, 2012 Saverio Sava, MD First Choice Community Healthcare Associate Professor UNM Family & Community Medicine

Who We Are A Federally Qualified Community Health Center System Founded in 1972 Provider of Primary Medical, Dental, Behavioral Health and WIC Services2 A major Safety Net Provider to the Uninsured and Underinsured in Bernalillo, Valencia, Sandoval, Torrance, Guadalupe, Santa Fe, and Socorro Counties in Central New Mexico An Incubator for Innovation, Change & Community Development 8 Locations in 3 Counties Serving 50,000 Patients with over 200,000 Visits Annually

Our Facility Locations in Central New Mexico Counties Serviced Bernalillo Guadalupe Sandoval Santa Fe Socorro Torrance Valencia

First Choice Locations

Celebrating Successes Project ECHO Celebrating Successes

Innovations in Primary Care Project ECHO Utilizes the specialty expertise of an Academic Health Center in partnership with Primary Care and Public health practices in rural and undeserved communities.

Project ECHO What project ECHO represents is a bold experiment that implements a new approach to providing care.

Project ECHO Hepatitis C A Growing Concern

Hepatitis C: A Global Health Problem 170 Million Carriers Worldwide, 3-4 MM new cases/year EAST MEDITERRANEAN 20M WEST EUROPE 9 M FAR EAST ASIA 60 M U.S.A. 4 M SOUTH EAST ASIA 30 M AFRICA 32 M WHO estimates that 170 million persons or 3 % of the world’s population are infected with hepatitis C and 3 to 4 million persons are newly infected each year. The prevalence of HCV in some countries in Africa, the Eastern Mediterranean, South East Asia and Western Pacific is high compared to some countries in Europe and North America. According to the National Health and Nutrition Examination Survey of 1988 to 1994, the NHANES survey, and other population-based surveys, nearly 2% of Americans test positive for the hepatitis C antibody. This prevalence corresponds to an estimated 4 million Americans infected with HCV. SOUTH AMERICA 10 M AUSTRALIA 0.2 M Source: WHO 1999 13

HEPATITIS C IN NEW MEXICO HEPATITIS C IN NEW MEXICO Estimated number is greater than 28,000 In 2004 Less than 5% had been treated Without treatment 8,000 patients will develop cirrhosis between 2010-2015 with several thousand deaths 2300 prisoners diagnosed in corrections system (expected number is greater than 2400) - None treated Highest rate of chronic liver disease/cirrhosis deaths in the nation

GOALS GOALS Develop capacity to safely and effectively treat Hepatitis C in all areas of New Mexico and to monitor outcomes Develop a model to treat complex diseases in rural locations and developing countries

METHOD METHOD Use Technology (multipoint videoconferencing and internet) to leverage scarce healthcare resources Disease Management Model focused on improving outcomes by reducing variation in processes of care and sharing “best practices” Case based learning: Co-management of patients with UNMHSC specialists (Learning by Doing) HIPAA compliant centralized database to monitor outcomes Arora S, Geppert CM, Kalishman S, et al: Acad Med. 2007 Feb;82(2): 154-60.

Rural New Mexico RURAL NEW MEXICO RURAL NEW MEXICO 121,356 sq miles Underserved Area for Healthcare Services 121,356 sq miles 1.83 million people 42.1% Hispanic 9.5% Native American 17.7% poverty rate compared to 11.7% nationally >22% lack health insurance 32 of 33 New Mexico counties are listed as Medically Underserved Areas (MUAs) 14 counties designated as Health Professional Shortage Areas (HPSAs)

STEPS STEPS Train physicians, nurses, pharmacists, educators in Hepatitis C Train to use web based software - “ihealth” Conduct telemedicine clinics – “Knowledge Network” Initiate co-management – “Learning loops” Collect data and monitor outcomes centrally Assess cost and effectiveness of programs

COMMUNITY PARTNERS BENEFITS TO RURAL CLINICIANS No-cost CMEs and Nursing CEUs Professional interaction with colleagues with similar interest – Less isolation with improved recruitment and retention A mix of work and learning Obtain HCV certification Access to specialty consultation with GI, hepatology, psychiatry, infectious diseases, addiction specialist, pharmacist, patient educator

How well has model worked for Hepatitis C ? 500 HCV Telehealth Clinics have been conducted >5000 patients entered HCV disease management program CMEs/CEs issued: 6100 CME/CE hours issued to ECHO Clinicians for Hep C. Total CME hours 27,000 at no cost

The Hepatitis C Trial

Objectives To train primary care Clinicians in rural areas and prisons to deliver hepatitis C treatment to rural populations of New Mexico To show that such care is as safe and effective as that given in a University Clinic To show that Project ECHO improves access to hepatitis C care for minorities

Participants Study sites Intervention (ECHO) Community-based clinics: 16 New Mexico Department of Corrections: 5 Control: University of New Mexico (UNM) Liver Clinic Subjects meeting inclusion / exclusion criteria Community cases seen by primary care physicians Consecutive University patients

Principal Endpoint Sustained viral response (SVR): no detectable virus 6 months after completion of treatment

Developing New Standards of Practice for Hepatitis C 407 hepatitis C patients met inclusion and exclusion criteria Age: 43.0 ± 10.0 years Men: 63.3% Minority: 65.2% Genotype 1: 57.0% Log10 viral load: 5.89 ± 0.95 Treatment sites UNMH: 146 ECHO site: 261

Treatment Outcomes Outcome ECHO UNMH P-value N=261 N=146 Minority 68% 49% P<0.01 SVR (Cure) Genotype 1/4 50% 46% NS SVR (Cure) Genotype 2/3 70% 71% SVR=sustained viral response NEJM : 364: 23, June 9-2011, Arora S, Thornton K, Murata G

Conclusions Rural primary care Clinicians deliver hepatitis C care under the aegis of Project ECHO that is as safe and effective as that given in a University clinic Project ECHO improves access to hepatitis C care for New Mexico minorities

KNOWLEDGE IMPORTANT - NOT TITLE FORCE MULTIPLIER HEALTHCARE IN NEW MEXICO Chronic Disease Management is a Team Sport Community Health Worker Medical Assistant Primary Care Nurse Hepatitis C Asthma and COPD Substance Use and Mental Health Disorders

Project ECHO Organizational Challenges & Barriers to Implementation In a Community Health Center

Transforming our Healthcare System Project ECHO Ideological Financial Training & Staffing Transforming our Healthcare System

“Replacing the Lost Primary Care Effort” Project ECHO Ideological Barriers “It’s Not What We Do” “Replacing the Lost Primary Care Effort”

Project ECHO Financial barriers Effects on productivity Buying Provider Time & Staff Support Fixed Payment Systems for FQHC’s Prevention May Save $$$ but….

Project ECHO Training & Staffing Rapid Turnover of Support Staff Increasing difficulty Recruiting PCP’s

Project ECHO Transforming our Healthcare System How do we advocate so innovations that work are disseminated? How do we institutionalize programs so they grow beyond individual champions?

Steps for Successful Implementation. Project ECHO Steps for Successful Implementation.

Steps for Successful Implementation. Project ECHO Steps for Successful Implementation. 1. Start with a champion.

Project ECHO Steps for Successful Implementation. 1. Start with a champion. 2. Administration must buy in early.

Project ECHO Steps for Successful Implementation. 1. Start with a champion. 2. Administration must buy in early. 3. Involve multiple key staff member.

Project ECHO Steps for Successful Implementation. 1. Start with a champion. 2. Administration must buy in early. 3. Involve multiple key staff member. 4. Key on staff satisfaction & retention.

Project ECHO Steps for Successful Implementation. 1. Start with a champion. 2. Administration must buy in early. 3. Involve multiple key staff member. 4. Key on staff satisfaction & retention. 5. Highlight positive patient experiences.

Project ECHO Steps for Successful Implementation. 1. Start with a champion. 2. Administration must buy in early. 3. Involve multiple key staff member. 4. Key on staff satisfaction & retention. 5. Highlight positive patient experiences. 6. Highlight your program in organizational reports and newsletters.

Project ECHO Use the success of Project ECHO to explore other practice modifications that will likewise contribute to changing the face of how we deliver healthcare.

Medicine & Public Health Into the New Millennium Ten Great Public Health Achievements - United States 1900 - 1999 • Vaccinations • Safer Workplace • Decline in Deaths from Coronary Heart Disease • Sanitation • Healthier Mothers and Babies • Motor-Vehicle Safety • Safer and Healthier Foods • Family Planning • Fluoridation of Drinking Water • Recognition of Tobacco use as Health Hazard JAMA, April 28, 1999

Project ECHO The greatest impact on healthcare in this millennium will be through system innovations on how health care is delivered to improve the health of our communities.