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A Workforce That Can Do More: Project ECHO at Ten Years Brings Behavioral Health Care to Underserved Areas



July 8th, 2013

The author is a senior vice president at the Robert Wood Johnson Foundation and the director of its Health Care Group. He has been with the foundation for more than ten years.

At a June 14 event in Washington, D.C., Bob Corcoran, the president and chairman of the GE Foundation, observed that our health care workforce needs to be “upgradable.”  In today’s world, clinicians on the front lines of care must adapt. They must be able to absorb new knowledge and develop new skills, so that they can do more for more patients.

Project ECHO, an innovative model for lifelong clinical learning and collaborative practice, shows us how. It creates a new operating platform, if you will, that expands the capacities of primary care clinicians to manage serious, chronic conditions they weren’t trained to manage in school–conditions such as hepatitis C, chronic pain, and rheumatoid arthritis.

Launched in 2003 at the University of New Mexico Health Sciences Center, initially as a way to expand access to hepatitis C treatment, the ECHO model is catching fire, with implementations under way at nearly a dozen partner sites. The newly launched ECHO Institute, supported by a four-year, $5 million grant from the Robert Wood Johnson Foundation (RWJF), is working to spread ECHO, both nationally and globally. The foundation has supported ECHO since 2009, initially with a four-year, $5 million grant to strengthen the model within New Mexico.

Now, through a new grant from the GE Foundation, Project ECHO is taking on behavioral health care. This is an area where primary care could and should do more but is not, because our health care system siloes behavioral health care from physical health care.

“We’ve had a separate mental health system in this country for some time … [I]t was unequal, and most people never went to it,” said Michael Hogan, who is a former commissioner of mental health in three states (Connecticut, New York, and Ohio) and is now an independent consultant. Hogan also spoke at the D.C. event, “Innovations in Primary Care: Expanding Capacity to Treat Mental Health and Other Chronic Diseases,” which was sponsored by the RWJF, the GE Foundation, and University of New Mexico Health Sciences Center.

The new ECHO initiative funded by the GE Foundation will integrate behavioral health care with primary care. By bringing behavioral health care expertise into primary care settings, one can greatly expand access to the more specialized treatment that many patients with mental health and addiction problems require.

Project ECHO will train teams of nurse practitioners and community health workers to screen for, diagnose, and treat mental illness and substance abuse in eight community health centers across New Mexico, a state with serious problems in accessing care. Through weekly videoconference clinics, these primary care teams around the state will work with behavioral health care specialists at the University of New Mexico to manage patients with complex needs.

In this way, “you’re building psychiatric primary care,” Hogan said. Currently, he added, a person with depression who sees a primary care physician has only a 50 percent chance of getting a diagnosis and only a 25 percent chance of getting clinically appropriate treatment.

Project ECHO’s approach will bring mental health care and substance abuse treatment to patients in settings that are familiar and comfortable to them. It also will ensure that patients’ behavioral health care is integrated and coordinated with their primary health care needs.

What’s really important here is that this approach—using telementoring and knowledge-sharing to build primary care capacity in local communities—works across conditions. “The disease doesn’t matter,” said Coleen Kivlahan, senior director of health care affairs at the Association of American Medical Colleges. “The critical thing is attaching those teaching hospitals to community settings.”

Kivlahan, a practicing primary care physician, believes the ECHO model represents an important opportunity for academic medical centers to increase their effects on clinicians at all levels and in all areas of the country, and, through them, on everyday patient care.

Don Weaver, medical director for the National Association of Community Health Centers, agreed. “Project ECHO links the best of two worlds: the best of primary care on the front lines—where you have a trusting relationship with the people you’re privileged to serve—and the best of the academic health centers—where they have the expertise and are willing to share it.”

The result is a workforce that can do much more. “After a year of participation [in ECHO], the primary care clinician becomes as good as the specialist at the university, and now, all of a sudden, the capacity to treat this patient who’s living in a rural area has grown tenfold,” said Sanjeev Arora, the liver disease specialist at the University of New Mexico Health Sciences Center who created Project ECHO.

An evaluation published in the New England Journal of Medicine found that outcomes of hepatitis C treatment through ECHO were the same as those at a university medical center; it also showed the potential for ECHO to reduce—and even eliminate—racial and ethnic disparities in treatment outcomes.

For ten years now, Project ECHO has been instrumental in bringing high-quality care to patients living in underserved areas who have a range of complex physical health needs. It is gratifying to see this model move more broadly to address behavioral health, where there is so much need.

At the D.C. event, Corcoran noted that virtually every family is affected in some way by mental illness or addiction. The terrifying mass shootings this past December at Sandy Hook Elementary School brought this home to GE. The company, based in Fairfield, Connecticut, has 150 employees who live in Sandy Hook and Newtown, sixteen of whom are parents of children at that school.

The Project ECHO model can help us do a better job in behavioral health care. One of the great things about the ECHO model is that it is a unifier: It will break down the walls between behavioral health care and primary care, just as it is breaking down the walls between specialty care and primary care and between those who have knowledge and those who don’t. It is breaking down distance and other barriers to care, as well.

If we continue to follow and expand the ECHO model—as I believe we must—we will have a more cohesive and more effective health care system. We will have fewer and fewer “underserved” communities, because more and more patients will get the care they need, regardless of where they live.

Bob Corcoran is right. Our workforce needs to be upgradable, and Project ECHO is the operating platform we need to make that happen.

Editor’s notes:

Read more about Project ECHO

John Lumpkin of the RWJF, “Despite Political Uncertainties, an Emerging Model Shows Health Care Transformation Is Possible,” on the RWJF’s Pioneering Ideas blog, January 3, 2011.

Sanjeev Arora of the University of New Mexico Medical School and coauthors, “Partnering Urban Academic Medical Centers and Rural Primary Care Clinicians to Provide Complex Chronic Disease Care,” Health Affairs, June 2011.

RWJF web page on Project ECHO: http://www.rwjf.org/en/grants/grantees/project-echo.html

RWJF, “Project ECHO Launches National Institute to Spread Transformative Care Model; Embarks on Initiative with GE Foundation to Expand Mental Health Care Access,” June 14 press release.

Read more about the GE Foundation’s health funding programs here. Grant seekers: Please note that the foundation’s program focused on health in the United States “does not accept unsolicited requests for support,” says its online Fact Sheet titled “Developing Health.”

 

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