1. Project ECHO (Extension for Community Health Outcomes) Joanna Katzman, MD, MSPH Director of Project ECHO ® Pain and University of New Mexico Pain Center Department of Neurosurgery University of New Mexico Health Sciences Center

2. The mission of Project ECHO ® is to expand the capacity to provide best practice care for common and complex diseases in rural and underserved areas and to monitor outcomes. 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 Trust

3. U.S.A. 4 M SOUTH AMERICA 10 M AFRICA 32 M EAST MEDITERRANEAN 20 M SOUTH EAST ASIA 30 M AUSTRALIA 0.2 M Source: WHO 1999 WEST EUROPE 9 M FAR EAST ASIA 60 M A Global Health Problem Over 170 Million Carriers Worldwide, 3-4 Million new cases/year

4. Estimated number is greater than 28,000 In 2004 less than 5% had been treated  2,300 prisoners were HCV positive (~40% of those entering the corrections system), none were treated New Mexico

5. Good news … Curable in 70% of cases Bad news … Severe side effects:  anemia (100%)  neutropenia >35%  depression >25% No Primary Care Physicians treating HCV Treatment

6. 121,356 square miles 2.08 million people 47% Hispanic 10.2% Native American 19% poverty rate compared to 14.3% nationally 21% lack health insurance compared to 16% nationally 32 of 33 New Mexico counties are listed as Medically Underserved Areas (MUAs) 14 counties designated as Health Professional Shortage Areas (HPSA’s) (Statistics from 2013) Rural New Mexico Underserved Area for Healthcare Services

7. Develop capacity to safely and effectively treat HCV in all areas of New Mexico and to monitor outcomes. Develop a model to treat complex diseases in rural locations and developing countries. 2003 - Goals of Project ECHO ®

8. 2015 - Goals of Project ECHO ® (Extension Community Healthcare Outcomes) Increase capacity to safely and effectively treat common and chronic diseases and to monitor outcomes Develop a model to treat complex diseases in rural locations and developing countries Multiply expertise of specialists by optimizing telehealth technology Adherence to best practices to reduce variation in care Arora, Kalishman, Dion, et al. (2011). Health Affairs. 30(6) pp. 1176-1184

9. Four Point ECHO Model 1.Increase Capacity of patients seen by primary care pain champions- (Leverage ECHO platform) 2.Educate Primary Care - formal didactic curriculum, theme-based modules 3.Case Based Learning – de-identified, HIPAA compliant 4.Monitor Outcomes Arora, Thornton, Murata. (2011). NEJM. 364(23) pp. 2199-2207

10. Project ECHO ® Pain: Bridging the Gap Between Primary and Specialty Care

11. Copyright 2013 Project ECHO® Force Multiplier Use Existing Community Clinicians Specialists Primary Care Physician Assistants Nurse Practitioners Chronic Pain Rheumatoid Arthritis + Rheumatology Consultation Substance Use and Mental Health Disorders

12. Core Pain Publications

13. Katzman et al. (2014). Innovative Telementoring for Pain Management. Journal of Continuing Education in the Health Professionals. 34(1) pp. 76-84, DOI: 10.1002/chp UNM Project ECHO Pain

14. Katzman et al. (2014). Innovative Telementoring for Pain Management. Journal of Continuing Education in the Health Professionals. 34(1) pp. 76-84, DOI: 10.1002/chp UNM Project ECHO Pain

15. UNM Project ECHO Pain Curriculum 2014-2015

16. Module 2: Opioids and Addiction Week : 1.Opioid Indications and Use 2.Chronic Opioid Treatment: Medical Concerns 3.Chronic Opioid Treatment: Behavioral Concerns 4.Addictions and Chronic Pain 5.Non-Opioid Chronic Pain Medications

17. ECHO Pain: Bridging the Gap between Primary and Specialty Care 1- Leverages Technology 2- Improves Coordination of Care 3- Increases Communication between Services 4- Improves Primary care Knowledge, self- efficacy and attitudes Katzman et al. (2014). Innovative Telementoring for Pain Management. 34(1) pp.76-83 Katzman. (2013). Making Connections 3 New Immune Pharmacology. 8(3) pp. 489-493

18. Learning Capacity Time Increasing Gap Transforming Primary Care with Knowledge Networks “Expanding the Definition of Underserved Population”

19. Map of Hub and Spokes **Accepted for publication by Military Medicine, May 9, 2015

20. Diversity of Participants in Army Pain ECHO: ECHO Pain Collaboration Participant Credential Percentages (ECHO Pain Boot Camp Only) CredentialsPercentage (%)* Doctor of Medicine (MD), Doctor of Osteopathic Medicine (DO)24.7 Nurse Practitioner (NP), Physician’s Assistant (PA), Doctor of Pharmacy (PharmD), Registered Pharmacist (RPh), Doctor of Psychology (PsyD), Doctor of Philosophy (PhD) 18.0 Licensed Physical Therapist (LPT), Doctor of Chiropractic (DC), Licensed Acupuncturist (Lac), Licenced Occupational Therapy (OTRL) 10.0 Registered Nurse (RN), Licensed Practical Nurse (LPN)12.7 Other34.6 *Percentages out of a total of 150 unique individuals [Other includes: Administrator, Bachelor of Science (BS), Bachelor of Arts (BA), Certified Occupational Therapy Assistant, Distance Education Coordinator, Sergeant (SGT), Home Care Aide (HCA), Health Technician, Integrated Modalities Coordinator, Licensed Physical Therapist Assistant (LPTA), Licensed Massage Therapist (LMT), Noncommissioned Officer in Charge (NCOIC), Program Analyst, Program Manager, Program Manager Assistant, and Registered Yoga Therapist (RYT)] **Accepted for publication by Military Medicine, May 9, 2015

21. Phases I-IV: Hub Readiness Replication Model Phase IPreparatory4 weeks Effectively establish technology and staffing requirements for hub and spoke sites Phase IIPreliminary4 weeks Hub and spoke observation of ECHO Pain Clinic and completion of two- day ECHO Boot Camp training Phase IIITraining6 weeks Hub and spoke teams participate and present patient cases to the ECHO Pain Clinic Phase IVRoll-Out6 weeksHub team launches and facilitates independent Army Pain ECHO while maintaining connection to ECHO Pain Military Medicine 2016:181(3):227-33

22. No-Cost Continuing Medical Education and Continuing Education Units Eligible for Army Pain ECHO Clinicians Phase IPhase IIPhase IIIPhase IV Northern Regional Command Medical (NRMC) 166 1128.58* 2721831 Southern Regional Medical Command (SRMC) 320448873.5 Pacific Regional Medical Command (PRMC) 508459.5168767.25 Europe Regional Medical Command (ERMC) DNC395.5206129.5 Western Regional Command (WRMC) 1696320Not Yet Started Totals26902303.510943601.25 *Two separate boot camps were held by the Pain ECHO team (in person) for participants from both SRMC and NRMC. CME credits were not separated between the two in-person groups. Total CME Credits obtained from the Army Pain Roll Out through May 2014 = 9,688.75 hours **Accepted for publication by Military Medicine, May 9, 2015

23. In-Person vs. Video/Tele-Conference (VTC) Boot Camp Trainings ABCD p value0.030.850.430.21 NRMC & SRMC N=34 PRMC & ERMC N=25 **Accepted for publication by Military Medicine, May 9, 2015

24. In-Person vs. Video/Tele-Conference (VTC) Boot Camp Trainings (Cont.) Not Effective Very Effective 12345 A.Attending the teleECHO Mock Clinic was: Strongly Disagree Strongly Agree 12345 B. The ECHO Pain Boot Camp increased my motivation to provide the best care possible for patients. Strongly Disagree Strongly Agree 12345 C. During the ECHO Pain Boot Camp I learned new ideas and concepts about how to apply the ECHO model. Strongly Disagree Strongly Agree 12345 D. I am excited about the opportunity to learn and educate others via the ECHO Pain Clinic. Compares the in-person and virtual (video) ECHO Boot Camp trainings. The in-person trainings were statistically overall more beneficial to the participants, although participants were equally as satisfied with both platforms. It should be noted that during the virtual (video) trainings, one (hub) participant did travel to the ECHO Pain site for in-person mentoring. **Accepted for publication by Military Medicine, May 9, 2015

25. Focus Group Frequency of Comments **Accepted for publication by Military Medicine, May 9, 2015

26. VA – Scan ECHO Pain 7 VA Scan Pain VISNS 5 fully staffed “Hubs” Primary Touch 200 Primary Care Clinicians regularly connect weekly to one of the 7 VA SCAN ECHO pain Hubs Secondary Touch 46, 000 patients were managed in CBOCs nationwide by the 200 primary care clinicians with pain >3/10 Tertiary Touch Force Multiplication of Primary Care Pain Champions teaching their colleagues (numbers unknown at present) Communication with Susan Kirsh, MD VA Office of Specialty Care Transformation

27. Indian Health Service ECHO Pain and Addiction “Essential Trainings” The Indian Health Service began ECHO Pain/Addiction July 2013 The Indian Health Service began “Essential Trainings” in Pain and Addiction for all prescribing clinicians in their Federal agency. From Jan 2015-May 2015, IHS require 5 hours of mandated pain and addiction training (Module 2) via adobe connect format 1,447 clinicians have taken the training and 8,320 no-cost CMEs have been awarded Am J Public Health- 2016 May

28. ECHO Replication in US: University of Washington (HCV, Chronic Pain, HIV, Multiple Sclerosis) – Seattle, WA University of Chicago (Hypertension, Breast Cancer Survivorship/Women’s Health, Pediatric ADHD, Childhood Obesity, HCV) – Chicago, IL University of Nevada (Antibiotic Stewardship, Autism (closed group, by invitation only), Diabetes/General Endocrinology, Gastroenterology, Rheumatology, Sports Medicine, Mental Health: Professional Development Groups (closed groups, by invitation only), Mental Health Clinic Director’s Group (closed groups, by invitation only), Marriage & Family Therapy Intern Supervision Clinic (closed groups, by invitation only) – Reno, NV University of Utah (HCV, Advanced Liver Care, Chronic Pain) – Salt Lake City, UT Florida/Caribbean AIDS Education and Training Center, University of South Florida (General HIV, Adolescents/Pediatrics HIV, HCV/HIV Co-Infection, Psychiatry & HIV, Spanish Language HIV) – Tampa, FL Harvard/Beth Israel Deaconess Medical Center (HCV, Gerontology – ECHO AGE) – Boston, MA St. Joseph’s Hospital & Medical Center (HCV) – Phoenix, AZ Community Health Center, Inc. (HIV, HCV, Chronic Pain, Opioid Addiction – Buprenorphine, Coaches International—supporting Quality Improvement and Specialists) – Middletown, CT LA Net (AAPA Preventive Care, Nephrology, Adult Psychiatry) – Los Angeles, California UNM: Center for Development and Disability (Autism) – Albuquerque, NM UNM: Envision NM (Childhood Overweight Medical Management, Pediatric Nutrition, Psychiatry, Asthma/Pulmonary) – Albuquerque, NM CHI St. Luke’s Health (HCV, HBV, Infectious Disease) – Houston, TX University of California Davis (Pain Management) – Davis, CA University of Wyoming, Wyoming Institute for Disabilities (Assistive Technologies) – Laramie, Wyoming Ochsner Health System (Liver Care) – New Orleans, LA University of Texas MD Anderson Cancer Center (Cervical Cancer Prevention) – Houston, TX Oregon Health and Science University/Health Share of Oregon (Psychiatric Medication Management) – Portland, OR University of Rochester Medical Center (Geriatric Mental Health) – Rochester, New York Visiting Nurses Association Health Group (Care Transition) – Red Bank, New Jersey

30. ECHO Replication Sites Worldwide: ECHO Ontario (Chronic Pain) – Queens University & University of Toronto Ontario, Canada National AIDS Control Organization and Maulana Azad (HIV) – New Delhi, India Institute of Liver and Biliary Sciences (HCV) – New Delhi, India Universidad de la República (Liver Disease) – Montevideo, Uruguay West/North West Hospitals Group (Diabetes) – Galway, Ireland Northern Ireland Hospice (Hospice Care) – Belfast, NI National Institute for Mental Health Services (NIMHANS) (Mental Health and Drug Addiction) – Bangalore, India