1. 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

2. 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

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

4. First Choice Locations

5. Celebrating Successes
Project ECHO
Celebrating Successes

6. 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.

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

11. Project ECHO
Hepatitis C
A Growing Concern

12. 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

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 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

14. 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

15. 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 Feb;82(2):

16. 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)

17. 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

18. 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

19. 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

20. The Hepatitis C Trial

21. 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

22. 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

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

24. 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: ± 0.95
Treatment sites
UNMH: 146
ECHO site: 261

25. 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 , Arora S, Thornton K, Murata G

26. 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

28. 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

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

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

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

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

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

34. 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?

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

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

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

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

39. 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.

40. 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.

41. 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.

42. 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.

43. Medicine & Public Health Into the New Millennium
Ten Great Public Health Achievements - United States
• 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

44. 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.