‘You need a whole team’: How a virtual mentoring program has helped bring care closer to rural patients

By the time Sanjeev Arora’s patient had trekked the 200 miles to his office to treat the illness destroying her liver, it was too late. What had kept her away before — a long waiting list and monthly travel for the intensive hepatitis C treatment she needed — was now no match for the deep belly pain that had begun to interfere with her day job. But the disease had progressed too far, and the woman passed away months later.

“I asked myself, ‘Why did she have to die when all the medications are available, the testing is available, and here I am with the knowledge to treat it?’” said Arora, a practicing internal physician at the University of New Mexico and the founder of a provider training program called Project ECHO that aims to equip rural caregivers with specialty expertise.

It’s that question that has led Arora to spend nearly two decades building the program, which now trains far-flung providers across the U.S. and other parts of the world. Every week, ECHO participants — often rural nurse practitioners or medical assistants — assemble over video conference to present a challenging patient case to a group of their peers and a team of ECHO specialists. It’s a chance to ask questions and get advice on care, including how to address social factors like housing and transportation. The work fills what experts see as a gaping need for specialty care in remote communities, where traditional forms of telehealth have failed to make inroads.

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The novel approach to telehealth — or telementoring, as Arora calls it — is a simple, yet elegant solution. Rather than giving a single specialist a fish by connecting them to a rural patient, ECHO teaches multiple rural providers to fish by giving them the skills they need to treat scores of local patients.

“When you compare it against telehealth writ large, it does something a lot of other frameworks don’t — it generates a multiplication factor greater than one,” said Ryan McBain, a policy researcher at the RAND Corporation and the lead author of a systematic review of Project ECHO published in 2019 that analyzed 52 previous studies of the program. Indeed, for all of telehealth’s growth, it still largely does not meet the needs of many rural patients who lack broadband and have no specialists within hundreds of miles.

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“With the U.S. suffering from a physician shortage that’s likely to increase over the coming 10 years and impact rural areas the most, we need more programs like this to ensure we don’t widen gaps in health disparities,” Ruby Gadelrab, CEO of digital health platform MDisrupt and an advisor to health tech companies, told STAT. “It’s a novel way to scale and disseminate best-in-class clinical expertise and bring it closer to the patients.”

But ECHO’s path forward — or the ability to scale its success — is far from certain. Even as ECHO, which stands for Extension for Community Healthcare Outcomes, has grown, it still relies on volunteer participants and an unsteady flow of grants and donations. And while there is a strong body of research supporting ECHO’s efforts in areas with easily quantifiable health outcomes such as hepatitis C, researchers have only just begun to assess its impact on conditions such as mental health and chronic pain.

Perhaps more importantly, unlike more traditional forms of telehealth which directly link providers to patients, there is no clear billing mechanism for ECHO’s telementoring approach, leaving it vulnerable to changes at the provider, county, and state level.

“It’s not clear what the business model is for something like this. That’s the open question.” said Kaakpema ‘KP’ Yelpaala, CEO of health communications startup InOn Health and an advisor to the American Hospital Association’s Rural Health Task Force.

Even if there were a steady stream of funding to build its reach, the program may not always be able to secure enough specialists to staff its ranks. The challenge, as Arora said, isn’t just that there aren’t enough specialists to care for patients in rural areas — it’s that many areas of medicine don’t have enough providers at all, anywhere.

“Telehealth is not a good solution if you have an absolute shortage of specialists,” he said.

At its current scale, ECHO’s dedicated team of specialists is key to helping dozens hundreds of rural providers like Karly Pippitt, a primary care doctor and assistant professor of family and preventive medicine at the University of Utah School of Medicine who participated in an ECHO program in 2017.

“As a primary care physician, I so appreciate any additional support for those difficult cases that I’m not sure what to do with,” Pippitt told STAT. “It [has] truly made a difference.”

Project ECHO participants meet to discuss patient cases with providers across the country. Courtesy ECHO

On a recent Wednesday afternoon, Laura Bush, a nurse practitioner at the First Nations Community HealthSource in Albuquerque, N.M., sat before a bookshelf teeming with thick medical volumes as her screen filled with the Zoom windows of a dozen other nurse practitioners and medical assistants and a handful of specialists from Project ECHO. She dove into talking with the group about one of her patients, a middle-aged man who was waking up in the middle of the night soaked in sweat and experiencing deep bone pain. His symptoms suggested tuberculosis, but the man also had a severe case of hepatitis C. He also had schizophrenia and regularly smoked methamphetamine, two factors which in the past had made it difficult to ensure he stuck with his treatment.

“The challenge with this gentleman is it’s hard to get him to go to appointments,” Bush told the group.

Karla Thornton, the session’s facilitator and an associate director at Project ECHO who specializes in hepatitis C, suggested Bush treat her patient’s hepatitis first, since it had advanced enough to cause liver cirrhosis. Looking at his lab tests, Thornton said, it appeared the man’s tuberculosis had gone dormant, giving them more time to address it. And because tuberculosis and hepatitis C medications don’t mix, Bush couldn’t treat both illnesses at once anyway.

The next person to chime in was Jasen Christiansen, an ECHO psychiatry and addiction medicine specialist and the medical director of the behavioral health integration department at the University of New Mexico. Christiansen is considered by his peers to be one of ECHO’s most vital members because his advice helps ensure patients have the basic resources they need to stick to their treatment — which, in the case of Bush’s patient, would likely include access to transportation for his appointments, a place to sleep, and daily medications.

“Is he housed? I’m just wondering, you know, what his adherence to pills is going to be like,” Christiansen asked.

After input from Christiansen, Arora, and others, Bush left the meeting armed with a plan of action: start her patient on the hepatitis medication, barring any new test results, and address the tuberculosis later.

That team-based approach has been at the core of Project ECHO since it began in the early 2000s. Since then, it has grown from a single initiative in hepatitis C to a multidimensional program with 22 subspecialties in areas including addiction, behavioral health, dermatology, and reproductive health. The organization has more than 600 offices internationally and has trained caregivers at leading medical centers including Harvard, Rutgers, the University of Chicago, and the University of Washington.

In the earliest days of the program, Arora had to hunt for providers who wanted to take part. He drove around New Mexico’s rural communities. He found 21 primary care providers willing to treat patients with hepatitis C so long as Arora mentored them. But with one glance at the treatment protocol, the providers balked at the risks they might not know how to manage.

Arora picked up the phone and started calling specialists to lend their expertise. Some agreed to participate, and Arora hosted his first ECHO session: a conference call that connected a gastroenterologist, pharmacist, and psychiatrist with a group of rural providers who would use their expertise to treat their patients.

“The key insight there was that we needed case-based learning, or what we now call an iterative guiding practice — an all-teach, all-learn process,” Arora said.

That approach appears to have benefits both for providers and patients. While rural providers like Bush say they learn as much from one another during the ECHO sessions as they do from ECHO specialists, ECHO specialists say they learn the most from rural providers, who tend to have a deeper understanding of their patients and their environment. Some research suggests that understanding can lead to more trusting relationships between patients and providers, leading to more effective and consistent care.

“A big part of what keeps them coming back is that there’s a colleague in a similar practice who’s figured out a solution to a problem they’re having.”

Bruce Struminger, Project ECHO associate director

“Participants may show up to hear from a specialist, but a big part of what keeps them coming back is that there’s a colleague in a similar practice who’s figured out a solution to a problem they’re having,” said Bruce Struminger, an ECHO associate director and an associate professor of medicine at the University of New Mexico. “That network effect is hugely important.”

In recent years, the team approach to care has gained steam among digital health startups, primary care companies, and telemedicine giants alike who say it offers more opportunities for patients to share openly with their providers and to discuss health-related issues often left out of traditional doctor-patient interactions, such as access to child care, nutritious food, and transportation.

“For chronic conditions, it’s not just about getting the patient on the right drug or the right treatment. You have to address the patient as a whole person — not just prescribing medications or doing diagnostics — but doing sleep and employment and housing and transportation,” said Andrew Matzkin, a partner at the consulting firm Health Advances. “To do that well, you need a whole team.”

A growing body of evidence suggests the ECHO approach can work well for patients and providers in certain scenarios. A 2011 paper published in the New England Journal of Medicine compared, head-to-head, the outcomes of a group of several hundred patients treated for hepatitis C by ECHO-trained primary care providers against those of another group treated for the same disease by specialists at the University of New Mexico’s hepatitis clinic. The research found that patients treated by ECHO-trained providers achieved similar or better outcomes than those treated by specialists.

Not only did patients treated by ECHO-trained providers achieve a sustained viral response — defined as having an undetectable level of hepatitis C six months after treatment — they also experienced slightly fewer adverse events, such as cirrhosis or fibrosis, than those treated by traditional specialists. A more recent paper published in July 2021 in JAMA Network Open came to similar conclusions, finding that patients treated by ECHO-trained providers were significantly more likely than those treated by other providers to receive best-in-class medications for hepatitis C.

“When you drill into the most rigorous studies available for patient-related outcomes, I think the evidence is quite promising,” said McBain.

But while numerous studies have demonstrated ECHO’s effectiveness in training providers in hepatitis C, the research in other specialties is still preliminary. McBain’s study, for example, concluded that while the program was tied to increases in provider knowledge and beneficial patient outcomes for diseases including chronic pain and diabetes, the quality of that evidence was too poor to draw any clear-cut conclusions.

“This approach seems particularly powerful for clinical issues that are highly prevalent in resource-constrained areas and relatively easy to treat with the appropriate clinical protocols,” Yelpaala said. “Outside of that, I’d say I’m not sure.”

Perhaps in part because of the preliminary nature of some of that research, ECHO clinicians thread a fine needle when presenting the program to their patients, explaining that while they rarely leave a meeting with a single solution to a problem, they tend to walk away with more clarity about the best next steps for their care.

“I’ll tell my patients, you know, ‘I’m going to present your case next week to this group of specialists, and then we’re going to meet again, and at that point I’m going to have some expertise and I’m going to be more confident that we’re doing the right thing,’” said Struminger.

Looking forward, ECHO faces steep challenges. The program is largely dependent on primary care providers who participate to expand their skills and gain continuing education credits. And payment for the program, which is entirely free to providers and patients, relies on a fluctuating influx of philanthropy and grant funds because there is no mainstream reimbursement mechanism for ECHO.  The fee-for-service model most of the U.S. health care system uses rewards caregivers for the quantity of services they provide, rather than the quality of those services. Within that setup, even traditional telehealth providers have long struggled to get paid for their services.

“That’s a significant issue for us,” Arora said. “To do this more broadly, we need to be embedded in the system and not just treated as an add-on.”

Over the past several years, there has been a concerted movement among private and public payers away from the fee-for-service model toward what is known as value-based care that ties payment to quality of services — a shift that could significantly boost the reach and appeal of programs like Project ECHO, according to experts. A 2019 report by Change Healthcare found 48 states were implementing value-based reimbursement programs. Under a value-based care model, providers are rewarded both for generating positive outcomes and operating efficiently.

“If ECHO continues to publish and demonstrate that it can improve health outcomes, reduce costs, and improve access,” said Gadelrab, “payers and health systems will be forced to consider novel payment modalities for programs like this.”

ECHO’s dependence on grants proved to be a significant obstacle for Pippitt, the primary care physician who participated in one of its neurology programs in 2017. Although she benefited from the program, she hasn’t participated in another since then, as the grant expired shortly after she completed it.

Another barrier ECHO faces is its reliance on volunteers. The program’s primary means of recruitment is through regular visits to clinics and academic medical centers, where ECHO members invited to give lectures or presentations ask the audience for a volunteer or “local champion” to try out the program. Those volunteers must then request time off their typical duties to participate in the sessions.

“You can’t just spend 15 or 30 minutes and learn how to do really complex diabetic care,” said McBain. “It takes a lot of intensive mentorship and a long period of going through these case studies before people become comfortable in their own skin outside the ECHO context.”

Source: STAT