Throughout India, patients have significant trouble accessing needed healthcare services. This is especially true for chronic conditions that require specialty care like diabetes, tuberculosis, HIV, and mental health illnesses. Individuals who live in rural areas face even more challenges due to the scarcity of specialty care and long distances families must travel to receive adequate care. For those who do access specialty services, the costs of those services are often prohibitive and lead many families to experience considerable financial hardship in order to attain needed care for their family member.
A key bottleneck in integrating these patients into the health system is ensuring that healthcare providers, especially in rural settings, have access to the training and on-going support they need to serve patients with complex diseases. To send a specialist to each of these rural communities would be prohibitively expensive. Project ECHO, developed in New Mexico to address similar disparities and obstacles to care, provides a cost effective way to address the need for greater expertise at the local level.
Project ECHO® (Extension for Community Healthcare Outcomes) dramatically improves both capacity and access to specialty care for rural and underserved populations. This low-cost, high-impact intervention is accomplished by linking expert inter-disciplinary specialist teams with primary care clinicians through teleECHO™ clinics, in which the experts mentor primary care clinicians to help them manage their patient cases and share their expertise via mentoring, guidance, feedback and didactic education. This enables primary care clinicians to develop the skills and knowledge to treat patients with common, complex conditions in their own communities which reduces travel costs, wait times, and avoidable complications. Technology is used to leverage scarce healthcare resources, and the specialists at academic medical centers (AMCs) are better able to attend the most complex, high-risk patients. The ECHO model™ is not “telemedicine” where the specialist assumes the care of the patient, but instead a guided practice model where the primary care clinician retains responsibility for managing the patient, operating with increasing independence as their skills and self-efficacy grow.
Developed as a platform for both healthcare service delivery and research in June 2003, the ECHO model develops knowledge and capacity among community clinicians through: a) case-based learning, b) knowledge networks, and c) learning loops. The knowledge networks consist of regularly scheduled teleECHO clinics that bring together expert inter-disciplinary specialists and community-based partners. These partners learn best practices through learning loops in which they co-manage diverse patients in real world situations and practice. Over time, these learning loops create deep knowledge, skills and self-efficacy.
EVALUATION & IMPACT
From 2003 to 2011, the effectiveness of the ECHO model was evaluated by assessing the impact on rural clinicians participating in teleECHO clinics. Impact measurements included effect on treatment rates, self-efficacy and overall professional satisfaction. The results of this research were first published in Hepatology in September 2010. This article illustrated the ECHO model’s impact to the current healthcare system in three major areas: 1) access to specialty healthcare, 2) expanded delivery of evidence-based best practice care, and 3) a new paradigm for team based interdisciplinary professional development.
Patient outcomes were also evaluated via a prospective cohort study, demonstrating that treatment for hepatitis C virus (HCV) using the ECHO model is as safe and effective as treatment at an Academic Medical Center (AMC), was published in the New England Journal of Medicine in June 2011. The study compared treatment of HCV at the University of New Mexico Health Sciences Center (UNMHSC) HCV clinic to treatment by primary care clinicians at Project ECHO partner sites in rural New Mexico.
The demonstration project expanded the ECHO model to six additional complex health issues as well as the University of Washington for HCV care. Each of these new Project ECHO arms demonstrated the need, effectiveness and impact of the ECHO model. In addition to HCV, Project ECHO currently conducts teleECHO clinics for other chronic conditions such as: chronic pain, integrated addictions and psychiatry, rheumatology, HIV/AIDS, dementia, complex care, palliative care, women’s health/genomics, as well as endocrinology.
Since its initial expansion project, the ECHO model has been successfully replicated across the United States and around the globe and these new efforts will help determine the broader applicability of the model.
Project ECHO was able to effectively implement a robust expansion of the model to establish its effectiveness, through support from the Robert Wood Johnson Foundation (RWJF). The demonstration project expanded the ECHO model to six additional complex health issues as well as the University of Washington for HCV care. Each of these new Project ECHO arms demonstrated the need, effectiveness and impact of the ECHO model. In addition to HCV, Project ECHO currently conducts teleECHO clinics for other chronic conditions such as: chronic pain, integrated addictions and psychiatry, rheumatology, HIV/AIDS, dementia, complex care, palliative care, women’s health/genomics, as well as endocrinology.
Replication of the ECHO model is achieved through the creation of ECHO “hubs” or regional centers, in which partner sites or “spokes” connect through teleECHO clinics, gaining specialty expertise and knowledge. Project ECHO demonstrates its ability to be a leader in integration and utilization of aggregated patient data to improve outcomes and reduce costs, while making healthcare delivery more effective and efficient. Since its initial expansion project, the ECHO model has been successfully replicated across the United States and around the globe and these new efforts will help determine the broader applicability of the model.
Today, Project ECHO has 43 hub replication partners globally, 36 sites in the U.S. with an additional 8 programs operating in 5 countries, covering 39 distinct disease focus areas with an estimated 2,800-3,000 spoke sites.
VISION FOR ECHO IN INDIA
Our experiences in New Mexico and with replication projects throughout the United States and around the world demonstrate that the ECHO model offers great capacity to expand patient access to desperately needed specialty expertise in a cost-effective way. Given the urgent need for adequate medical care throughout India, Project ECHO has two central goals:
1) To build a self-sufficient ECHO India replication office to provide technical assistance for ECHO projects throughout India. ECHO India, our first global “SuperHub” was officially launched in January of 2015, and will be fully operational and training India ECHO hubs on their own by the end of the year.
2) To develop and expand innovative ECHO projects in India. The purpose of these projects is both to expand access to care and to demonstrate to the government of India and regional state governments the utility of adopting the ECHO model as a cost-effective way to expand access to underserved populations.
India provides an exciting environment for Project ECHO to expand its activities for a number of reasons. First, there is an immediate and overwhelming need for expanded access to services in the currently targeted areas (HIV/AIDS, autism, Hepatitis B and C, and mental health services), among many others. Second, Project ECHO has already established relationships with partners and medical experts in each of these fields who are eager to use the ECHO model and partner with us. Finally, India provides an environment with a high level of technical sophistication. Needed infrastructure such as access to the Internet, broadband services and video conferencing are widely available. As a result, our India partners provide a ready pilot to demonstrate how Project ECHO can assist countries that have both great technical and human capital resources and significant segments of the population who have difficulty accessing basic health services.
In order to develop the groundwork and infrastructure in India for the ECHO model to spread and flourish, the ECHO Institute will continue to build and support new hubs around the world, but India’s replication will be increasingly managed by the ECHO India Office, located in New Delhi. We hope to have 30 or more ECHO projects operating across India within the next five years.
Current ECHO India Initiatives:
1. Fully train and empower the newly-established ECHO India Replication Office as an ECHO “SuperHub” to provide technical assistance and support to ECHO projects throughout India, build and train new ECHO hubs and grow the ECHO movement across the country. This ECHO India office was launched in the fall of 2014. They are already providing technical assistance to existing ECHO hubs in India, and have recruited and signed partnership documents with two new ECHO replication partners. We expect them to be fully staffed, trained and operating at a very high level as a super-hub by the end of 2015.
2. In the mid-2000s the national government began a more aggressive strategy to expand access to antiretroviral treatment and reduce the rate of spread of the HIV/AIDS and intervene in the growing Indian AIDS epidemic. To accomplish this goal, the National AIDS Control Organization (NACO) established a network of antiretroviral treatment (ART) centers throughout the country.
This network has done much to reduce the rate of transmission of the AIDS virus in India. A central limitation, however, is the ability to easily train partners in this network and maintain a mechanism for on-going mentorship and learning. The DISHA-ECHO projects are designed to meet this need by working to expand and enhance patient care, teaching, and research activities at the antiretroviral treatment (ART) centers through ongoing mentoring via use of the ECHO model. Project DISHA-ECHO is derived from the concept of DISHA (Decentralizing and Intensifying Services for High quality ART) and Project ECHO’s model to expand access to specialized care for vulnerable populations and underserved areas through the state of the art telehealth technology and clinical management tools. After trial runs proved successful, the first project officially took off in July 2010. The DISHA-ECHO project is a joint collaboration between Maulana Azad Medical College, the ECHO Institute and the Department of AIDS Control / National AIDS Control Organization (NACO), Ministry of Health and Family Welfare, Govt. of India.
The hub at Maulana Azad Medical College, New Delhi is currently linked to 14 ART Spokes: Lok Nayak Hospital, AIIMS, RML Hospital, Baba Saheb Ambedkar Hospital, DDU Hospital, LRS Hospital, Safdarjang Hospital, Guru Teg Bahadur Hospital, SMS Jaipur, Medical College Aligarh, Medical College Dehradun, District Hospital Haldwani, Medical College Bhopal, and LLRM Medical College Meerut through teleECHO sessions.
3. The second DISHA-ECHO project at B.J.Medical College launched in mid-2014. This is an HIV-focused ECHO at a large medical college. The hub is connected to the various hospitals in the state of Gujarat. Equipment has been provided to connect 20 spokes to the hub at the medical college. They are holding clinics every month and currently 17 spokes are connected.
4. Availability of treatment of Substance Use Disorders (SUDs) is severely limited in India and is concentrated primarily at academic medical centers located in urban settings.
A few facilities do offer similar SUDs treatment, but they are also located in cities and are extremely costly, making them inaccessible to the general population. One reason for the growing gap between need and availability of SUDs treatment services is a lack of training for PCPs. Many physicians and other healthcare providers are reluctant to provide care, and often SUDs related issues are not addressed even in hospitalized patients. Further complicating matters is the stigma and cost that are associated with visiting a mental health or SUDs service center, which can lead to decrease treatment acceptance.
Project ECHO and the National Institute of Mental Health and Neurosciences (NIMHANS) in Bangalore, India have launched a teleECHO clinic based at NIMHANS in Bangalore, India. This project will increase access to SUDs treatment services in India by training Primary Care Providers (PCPs) to deliver care, and will help develop a model for expanding high quality chronic disease care more generally in India. Currently 40-60-community provider “spokes” are joining the weekly NIMHANS teleECHO clinics.
5. In 2007, a school for children with Autism and special needs in Lucknow, India (PYSSUM) came in contact with the UNM Center for Development & Disability (CDD) and ENVISION NM through Project ECHO and have since been collaborating to organize free training workshops for teachers working with special-needs students. These workshops have also been extended to HR heads to oversee the employability of adults with autism. The objective of the India Autism ECHO Project (IAEP) is to establish a broader network of teleECHO sites in India for training teachers, pediatricians, therapists and psychologists to improve their knowledge and skills in working with children with autism and other developmental disabilities.
This collaboration has spread to cities such as Chandigarh and Bombay to conduct training programs on autism. The specially designed training programs utilizing the Project ECHO model have been received with great enthusiasm in special education and rehabilitation circles in these cities.
These three participating IAEP sites will be developed as fully independent hubs, each connected to a network of multiple schools and care organizations working with autistic children and adults. The PYSSUM team will travel to the ECHO Institute in January for training as a new ECHO autism hub.
6. New partnerships and initiatives: since its inception in mid-2014, the ECHO India Office has been engaged in actively disseminating the ECHO model via education and outreach to government, academic, medical and philanthropic organizations. These efforts have resulted in recruiting and signing (as fully authorized ECHO replication partners) two additional organizations with large capacity as hubs and with the financial means to not only support their own ECHO activities but with the potential to become supporters of the broader ECHO India activities. These partners are Jindal Steel and Power Limited Foundation and the Karuna Trust. Teams from these two organizations will travel to the ECHO Institute in January for training as ECHO replication hubs.
Project ECHO maintains a growing database of curriculum materials, surveys and templates that will be available to all Indian participants. Particularly in the field of substance abuse, Project ECHO has considerable experience and a wealth of training tools to share with our Indian counterparts.
In addition to existing materials, expansion in India and to new subject fields such as autism will require significant work with our partners to develop new curriculum materials that are appropriate for the Indian context. Once these materials have been developed, they too will become part of the ever growing database of materials made available to ECHO partners interested in starting new teleECHO clinics in India or elsewhere.
Director of Project ECHO, Sanjeev Arora, MD, FACP is the Director and Founder of Project ECHO. He is a Distinguished Professor of Medicine n the Department of Internal Medicine at UNMHSC. He has been involved in management of viral hepatitis for over 20 years and helped to develop and implement the Hepatitis C Disease Management Program at UNMHSC. While he was pleased with the success of the program he was also frustrated by his inability to see all patients afflicted with the disease, due to the sheer volume. As a solution to the need for new and improved ways to serve patients in need of specialized care, he developed the innovative Project ECHO model to share his medical knowledge and broaden healthcare access.
Nick Shroff, MD
Chair AAPI Charitable Foundation 2012-2014