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. List of First Choice Locations Almada Belen South Broadway Los Lunas Alamosa Health Commons North Valley South Valley Mountain Valley and Regional Center Los Padillas Rio Grande High School –School based Health Center

6. Project ECHO Celebrating Successes

7. 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.

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

12. Project ECHO Hepatitis C A Growing Concern

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

14. 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 HEPATITIS C IN NEW MEXICO

15. 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 GOALS

16. 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. METHOD

17. Underserved Area for Healthcare Services Rural New Mexico 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) RURAL NEW MEXICO

18. 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 STEPS

19. COMMUNITY PARTNERS ~ 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 BENEFITS TO RURAL CLINICIANS

20. 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

21. The Hepatitis C Trial

22. 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

23. 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

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

25. 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

26. Treatment Outcomes OutcomeECHOUNMH P- value N=261N=146 Minority68%49%P<0.01 SVR (Cure) Genotype 1/4 50%46%NS SVR (Cure) Genotype 2/3 70%71%NS SVR=sustained viral response NEJM : 364: 23, June 9-2011, Arora S, Thornton K, Murata G

27. 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

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

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

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

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

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

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

35. 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?

36. Project ECHO Steps for Successful Implementation.

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

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

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

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.

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.

42. 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.

43. 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.

44. 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

45. 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.