Implementing ECHO (Extension for Community Healthcare Outcomes) To Strengthen Nurse Case Management Improve Patient Outcomes
Implementing ECHO
(Extension for Community Healthcare Outcomes)
To Strengthen Nurse Case Management
Improve Patient Outcomes
BACKGROUND ON NEW MEXICO
NEW MEXICO CHALLENGES
• Decrease in TB Nursing Expertise
• Actual decrease in number of nurses to provide NCM services
• Low incidence state –
• Average 50 active cases per year/2.4 rate
• ~17 – 20 active ongoing cases
• TB Mortality in NM
• Close to 20% vs. 5% (U.S. wide)
Extension for Community HealthCare Outcomes
ECHO PACKAGES CONCEPTS
• Video Conferencing
• Case-based learning
• Promotion of best practices
• Outcome Monitoring
At Project ECHO our mission is to democratize medical knowledge and help get best practice care to underserved people all over the world. Our goal is to improve the lives of 1 billion people by 2025.
Supported by New Mexico Department of Health, Agency for Health Research and
Quality, New Mexico Legislature, the Robert Wood Johnson Foundation, the GE
Foundation and Helmsley Charitable Trust
ECHO ACT PASSES IN U. S. SENATE AND HOUSE OF REPRESENTATIVES
• Bipartisan support for Expanding Capacity for Health Outcomes (ECHO) pass unanimously
• November 29, 2016
• Health & Human Services to report on technology-enabled collaborative learning and capacity building models, which connect specialist to primary care thru videoconferencing to facilitate case-based learning, dissemination of best practices and evaluation of outcomes
ECHO Telehealth vs. Telemedicine
ECHO Telehealth
ECHO Supports Community Based
Primary Care Teams Patients reached with specialty
knowledge & expertise
Traditional Telemedicine
Specialist Manages Patient Remotely
Hepatitis C
HEPATITIS C TREATMENT IN NEW MEXICO
2004
UNMHSC
Center for Digestive Diseases Clinic
Treated Approximately 250 patients/year
Project ECHO Partners
Treat Approximately 1,100
patients/year
2016
UNMHSC
Center for Digestive Diseases Clinic
Treated Approximately 100 patients/year
10
TB ECHO…..WHEN IT ALL BEGAN
• November 2012 – TB/HIV Four Corners presentation • heard Dr. Arora talk about HCV
• Hmmmm – that could work for TB
• 2013 – Discussions with Bruce Struminger at ECHO
• 2015 – Serious planning began • Attended Project ECHO immersion • March 24 – Formal launch • April 2015 – First TB ECHO clinic
NM DOH TB ECHO 2 YEAR ANNIVERSARY
April 17, 2017
VIDEO – CONFERENCING TECHNOLOGY
• Public Health Nurses meet once per month
• Get to “see” your colleagues
• Facilitates conversation
• Less isolation
VIDEO – CONFERENCING TECHNOLOGY
• Public Health Nurses meet once per month
• Get to “see” your colleagues
• Facilitates conversation
• Less isolation
CASE BASED LEARNING
• Every active TB case presented monthly • By local public health nurse • 20 cases/month
• Standardized TB Template for
presentation • QA for missing data • Important for ongoing NCM
• TB Medical Director
• Provides orders on cases during clinic
• Active exchange of information & learning
TOOLS OF THE TRADE….. TB PRESENTATION TEMPLATE
VARIETY OF CASES PRESENTED……..
Pulmonary vs
Ex-Pulmonary
Extra – Pulmonary Sites
73%
27%
40%
20%
13% 13%
7% 7%
0
1
2
3
4
5
6
7
Pleural Eye and earappendages
Bone and/orJoint
Genitourinary Pericardium Meningeal
Nu
mb
er o
f ca
ses
6
3
2 2
Pulmonary
Ex -pulm
1 1
EXTRA PULMONARY TB: POTTS DISEASE CASES
PROMOTION OF BEST PRACTICES
• Improve patient outcomes
• Community of practice
• Strengthen TB Nurse Case Management Skills
• Increase skills AND confidence in those skills
• Short Didactic (10-15min)
• Clinical and programmatic topics
• Continuing Education Credits available
• Available for other ECHO clinics to use
WHAT HAVE WE DONE? OUTCOME MONITORING
• 20 ECHO clinics held (end of Dec 2016) • 76 unique patients presented by 25 nurses
• 334 total presentations
• Total of 785.5 Continuing Education Units awarded • 20 didactic sessions
• Attendance consistently strong – 16 PHNs (average)
• Monthly Evaluation following clinic
• Self – efficacy Survey – Public Health Nurses • Initial and month seven (7)
• Efficient & Cost effective model • Provide education of public health nursing workforce
• Platform for standardized monthly review of cases
TB NURSE SELF-EFFICACY ASSESSMENT
0
1
2
3
4
5
6
7
Opt-out HIV testing interpret IGRA
results
Interpret Smear
results
Interpret NAAT/PCR Interpret culture
results
Interpret DST Idenfity Culture
conversion
Mean Likert Scale Scores tested April, 2015 and October, 2015
Mean score April Mean score October
TB NURSE SELF-EFFICACY ASSESSMENT
0
1
2
3
4
5
6
7
Effective NCM Patient
education
Identify side
effects
Identify High Risk
Contacts
Test High Risk
Contacts
Initiate Window
Treatment
Identify End of
Infectious Period
April, 2015 and October, 2015
THOUGHTS…… TO PONDER
• How could I use ECHO in my program?
• What are logistics/barriers to implementation?
• While pondering – let’s look across the US and globally
• How other programs utilizing ECHO
TB ECHO Program implementation and preparation in 2015 & 2016:
• Viet Nam – launched first TB ECHO in February 2015, focus on MDR & XDR • Pre-XDR and XDR cases being considered for bedaqualine treatment
• New Mexico – launched in April 2015 • Low burden state; all active TB cases with a focus on nurse case management
• Washington State DOH/Univ of WA— launched in September 2015 • Active cases plus LTBI cases
• Navajo Area Indian Health Service – launched January 2016 • IHS, Navajo Nation, NM DOH, AZ DOH, CDC DTBE collaboration
• Colorado DOH w Denver Health launched July 2016
• Kenya NTP MDR TB ECHO launched July 2016
• US-Mexico Border Health Initiative TB Program [CDC DGMQ & DTBE] launching Spring 2017 • Management of MDR and complex bi-national TB cases • CDC DGMQ/DTBE, MX NTP, NM Office of Border Health & UNM Project ECHO collaboration
• Haiti, India, Namibia, Botswana, Georgia, & Guatemala TB Programs in preparation • MDR TB case consultation
VietNam MDR TB ECHO February 20152015
Navajo Nation TB ECHO
Navajo Nation TB ECHO
US-MX BORDER TB ECHO
• Pilot Project to develop ECHO platform for binational TB Programs
• Border Health Commission
• New Mexico office of Border Health
• Oral & transcription translation
• Bilingual intake form
WASHINGTON STATE TB ECHO
TB ECHO in Washington
TB ECHO® Team
38 LHJs
18 FQHCs
11 Primary Health Clinics
4 State
Government
3 RTMCCs
TB ECHO® Team
38 LHJs
18 FQHCs
11 Primary Health Clinics
4 State
Government
3 RTMCCs
Sessions
• 23 sessions
• 127 participants
• Average 23 per session
• CME/CNEs offered
Sectors • 35% Primary Care
• 61% Public Health
• 3% RTMCC
Professions
• 53 RN/PHNs
• 42 Medical Providers
• 32 Support Staff
Focus: TB Infection
Partner Organizations: • University of Washington
• Washington State Department of Health
• Firland Northwest Tuberculosis Center
Rating (1=Strongly disagree, 5=Strongly
agree)
TB ECHO in Washington
3.4 3.6 3.8 4 4.2 4.4 4.6
My self-efficacy
Ability to apply knowledge
learned
Ability to share knowledge
learned
Ability to answer questions
My feeling of professional
support
Comfort in presenting cases
Participation in TB ECHO has increased my...
OVERVIEW OF TB-ECHO CASE MANAGEMENT
• Augments Colorado’s current TB Program services • Started in July 2016
• Facilitated by the state’s TB Education and Training Coordinator and TB Nurse Consultant
• Local public health nurses present their active TB cases for discussion amongst participants while getting real-time feedback from TB subject matter experts
• Patient confidentiality is maintained, as no identifying information (name, DOB, etc.) is shared.