Project ECHOTM Model of Care for HIV-HCV

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Jemima McLaughlin
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1 Access to Specialty Care Insurance status Project ECHO CHCI: Enhancing and Expanding HIV/HCV Treatment and Care Through Telemedicine TM Marwan Haddad, MD, MPH, AAHIVS Community Health Center, Inc. Connec<cut December 7, 2012 Public health insurance: 68% Uninsured: 22% Current model: Specialist Specialist Hepatitis C 1,500 patients 3.2 million people nationwide HIV 600 patients 1 million people nationwide Pa<ent Specialist Specialist 60% of patients never make it to the specialist Source: WHO 2000 Project ECHOTM Learning Objectives Mission: The mission of Project ECHO is to develop the capacity to safely and effectively treat chronic, common and complex diseases in rural and underserved areas and to monitor outcomes. To review and understand what the Project ECHOTM model is, highlighting the place for telehealth in HIV/HCV care. To review the implementation process of Project ECHO CHC and enumerate the steps required for replication of the model. To understand the benefits of and barriers to implementing a telehealth model of care for HIV/HCV in the primary care setting. Dr. Sanjeev Arora, University of New Mexico Source: echo.unm.edu

2 million people nationwide HIV 600 patients 1 million people nationwide Pa<ent Specialist Specialist 60% of patients never make it to the specialist Source: WHO 2000 Project ECHOTM Learning

2 Project ECHO Adapted from the Extension for Community Healthcare Outcomes (ECHO) model developed by University of New Mexico (UNM) Prospective cohort study comparing HCV Rx at UNM with Rx by primary care clinicians at 21 ECHO sites in rural areas and prisons in NM. Total of 407 patients with no previous treatment were enrolled. Primary endpoint was SVR. 57.5% at UNM and 58.2% at ECHO sites achieved SVR. With HCV Genotype 1, 45.8% at UNM and 49.7% at ECHO sites achieved SVR. Serious adverse events occurred in 13.7% at UNM and 6.9% at ECHO sites. Arora et al. Outcomes of Treatment for Hepatitis C Virus Infection by Primary Care Providers. NEJM 2011; 364: CT HCV Sta<s<cs HCV prevalence rate: 62.1/100,000 person years Highest case burden among baby boomers (born ) As of 2010: 1,019,049 baby boomers in CT (28.5% of total popula<on) As of 2012: 36,000 CT baby boomers es<mated to have HCV infec<on CT Registry: only 22,500 (63%) have been iden<fied Potential Benefits & Expected Outcomes of Implementation of Project ECHO For Patients Increased access to treatment options for underserved patients More patients initiating treatments More patients completing treatments Cost effective care avoid excessive testing and travel Prevent cost of untreated disease More treatment options at their medical home For Providers Self-efficacy increases Improving profession satisfaction and retention Workforce training and force multiplier Integration of public health into treatment paradigm HCV in Baby Boomers at CHCI 16,116 pa<ents across the agency born between (Baby Boomers) 4,230 have been screened for HCV an<body (26.25%) 745 of those HCV an<body tests reac<ve/posi<ve (17.6% of those screened) HCV and HIV Burden CHCI and Connec<cut

2% at ECHO sites achieved SVR. With HCV Genotype 1, 45.8% at UNM and 49.7% at ECHO sites achieved SVR. Serious adverse events occurred in 13.7% at UNM and 6.9% at ECHO sites. Arora et al.

3 Steps in Organizational Change Toward Healthcare Integration OST Communication HIV 1 o care MH Coordination HCV OST MH 1 o care HIV HCV OST MH 1 o care HIV HCV 1 o care/ HIV/ HCV/ MH/ OST Separate Sites Co-Located Services Partial Integration Complete Integration HIV at CHCI Integrated Primary Care Model ADVANTAGES: DISADVANTAGES: 600 total HIV/AIDS pa<ents receiving primary care at CHCI 325 of 600 receiving both HIV and primary care 110 of 207 PLWH in Meriden 75 of 157 PLWH in Middletown 140 of 397 PLWH in New Britain Each provider provides fully integrated care ; one stop shop No need for expensive, on-site specialists Increased trust to link adherence to ART/HCV regimens and BPN simultaneously May improve attitude towards substance abuse by HIV/HCV provider Modified hybrid models can be used Improved treatment outcomes The workload for a single provider is high (in treating patients and in training) Lots of control is concentrated in 1 provider s hands, leading to potential concerns about patient autonomy Specialists/backup care providers are needed to answer questions and to cover leaves of absence Integrated Healthcare Models CHC Model of Specialty Integration into Primary Care

of 600 receiving both HIV and primary care 110 of 207 PLWH in Meriden 75 of 157 PLWH in Middletown 140 of 397 PLWH in New Britain Each provider provides fully integrated care ; one stop shop No need

4 HIV Care at CHCI 3 of 13 sites across CT HIV Team Project ECHO at CHCI Meriden Project Director Middletown Medical Director New Britain HIV Primary Care APRN Ancillary CHCI Services Nurse Care Coordinator Pharmacy Program/Medical Assistant Mental Health Case Manager/Outreach Dental HIV providers (MD/APRN) Nutri<on/CDE =HCV team Podiatry Emerging Roles of the HIV Specialist CHC Project ECHO Goals: Expand scope of services to CHC patients at all sites Offer evidence-based, top quality HCV and HIV treatment to CHC patients who do not or cannot have access to local specialists prefer to receive treatment from CHC Improve health outcomes for our patients Integrated care from one site (PCMH) proven to improve outcomes Patients better engaged through primary care than specialist clinics and more likely to follow up Primary Care/HCV Mental Health /Addiction Pharmacology Prevention/Adherence Counseling Multi-disciplinary Team Approach Primary Care Team Pod System Medical Provider (MD/APRN) Nurse Medical Assistant Behavioral Health Additional Services Dental Nutrition CDE Podiatry Pharmacy Implementa<on Process HIV/HCV Care Team Pod System HIV Primary Care Provider (MD/APRN) Nurse/Adherence Counselor Medical Assistant Care coordinator/ Outreach Behavioral Health Additional Services Dental/Nutrition/CDE /Podiatry/Pharmacy Faculty Specialist Recruitment Replica<on Visit Joining Project ECHO New Mexico Technical Capability PCP recruitment Administra<ve Support Funding

Goals: Expand scope of services to CHC patients at all sites Offer evidence-based, top quality HCV and HIV treatment to CHC patients who do not or cannot have access to local specialists prefer to

5 Faculty Specialist Recruitment Internal pre- exis<ng medical and nursing exper<se at CHCI Recruitment for pharmacy and mental health What if internal exper<se doesn t exist in your agency? Replica<on Visit/Joining Project ECHO New Mexico Selected members of CHC ECHO team visited New Mexico to learn about the model Par<cipa<on with Project ECHO x 6 months Ac<vely presented pa<ents All recruited faculty members par<cipated Seek out opportuni<es to get involved with UNM or other ECHO models around the country Technological Infrastructure Video conferencing system for ECHO team Mobile teleconferencing platform (Vidyo ) Webcam/ipad/ smart phone for end-users iecho tracking system EHR PCP Recruitment Agency- wide HIV/HCV educa<on done regularly (Grand Rounds, updates) Personal outreach to PCPs known to have interest in HIV/HCV 1 provider/site Benefits of being an ECHO- ist Gain exper<se Improved pa<ent care Job sa<sfac<on Reten<on CME Administra<ve Support Senior Leadership Buy in from CEO, VP of Clinical Services, CMO, CQO Administra<ve support HIV/HCV Program Director Grant wri<ng Organiza<on Policy development and workflow Designated ECHO coordinator for scheduling, IT issues AmeriCorps volunteer Data collec<on Funding No well established model for financing telehealth Current system based on face- to- face encounters Costs Lost produc<vity for clinicians and faculty 2 hours/week IT infrastructure

recruited faculty members par<cipated Seek out opportuni<es to get involved with UNM or other ECHO models around the country Technological Infrastructure Video conferencing system for ECHO team

6 Poten<al Funding Sources Structural Features CHC expert team: Aﬀordable Care Act: Increased scope of health informa<on technology Grants CT Public Health Act allows for cost reimbursment for telemedicine services to Medicaid pa<ents star<ng 2013 Pharmaceu<cal Industry 3 PCP specialists 2 PharmD s Case management RN Psych APRN Project coordinator Participants: 7 sites, one PCP at each Health for the Homeless Program NP Residents Patient Referral Process Identify patients with new or previously known HCV or HIV infection in PCP panel Patient lists with HCV/HIV sent out to individual providers Discuss with patient the new ECHO service for Hep C and HIV treatment Evidence based; top quality; easy access to CHC HIV/HCV specialists; delivered at their CHC site; regardless of insurance Encourage non-echo providers to refer to their local ECHOists. CHC Project ECHO Preliminary Program Outcomes Launched January 20, 2012 Format Video conferencing Fridays 12:30 to 2:30 pm Case presentations +/- Didactic lectures Multi-disciplinary faculty (Medical, BH, Pharm, Nursing, Outreach) Primary care providers with interest; no previous knowledge required HCV and HIV Sessions, alternating weeks Pa<ent- related Provider- related

Health for the Homeless Program NP Residents Patient Referral Process Identify patients with new or previously known HCV or HIV infection in PCP panel Patient lists with HCV/HIV sent out to

7 Pa<ent- related Outcomes Provider- related Outcomes Baseline Surveys HIV/HCV Treatment All HIV pa<ents are on ARVs 83% stable on ARVs upon presenta<on 10% required ARV changes 7% new ARV starts (new diagnoses) HCV pa<ents 9% started HCV treatment

stable on ARVs upon presenta<on 10% required ARV changes 7%

8 Provider- related Outcomes 6 month Surveys ECHO Session Data Jan- 12 Feb- 12 Mar- 12Apr- 12May- 12 Jun- 12 Jul- 12 Aug- 12 To date Unique sessions HIV HCV Combined clinic Total cases presented Unique pa<ents presented HIV HCV Follow up pa<ents presented Average presentacons/clinic PCP ECHO ParCcipants Presenters Average cases/presenter DidacCc presentacons CHALLENGES

73 HIV 2 7 4 2 1 5 6 1 27 HCV 7 8 9 10 4 6 2 4 46 Follow up pa<ents presented 0 0 9 6 9 5 7 7 36 Average presentacons/clinic 4.5 3.8 5.5 4.5 3.5 3.2 5.0 1 4.

9 Challenges: Recruitment Challenges: Administra<ve Providers High turnover New recruitment Provider Time Lateness (Faculty and ECHOists) Timeliness of case referrals Provider Produc<vity Lack of reimbursement/loss of revenue IT Connec<vity issues Challenges: Recruitment Challenges: Administra<ve Pa<ents Recruitment of pa<ents In- house Case- finding within current ECHOist panels Case- finding and referrals from local non ECHO providers Outreach Becoming established as HIV/HCV treatment sites» Community- based organiza<ons» Word of mouth Scheduling Blocking of schedules Con<nued Buy- in of Senior Leadership Challenges: Recruitment Challenges: Pa<ent Management HCV/HIV pa<ent recruitment More HCV pa<ents than HIV pa<ents in general Building trust as a clinic in pa<ents and community HIV more difficult Pa<ent- Provider rela<onship Trust more of a challenge with HIV Concerns of competence Turnover of providers Provider readiness to treat HIV Lack of confidence re: ARV knowledge and resistance Yet, 100% of ECHO pa<ents on ARVs HCV More confidence re: HCV treatment Yet, few pa<ents started on treatment Pa<ent readiness Ancillary Services

finding and referrals from local non ECHO providers Outreach Becoming established as HIV/HCV treatment sites» Community- based organiza<ons» Word of mouth Scheduling Blocking of schedules Con<nued

10 Challenges: Provider Feedback How to get it? When to get it and how open? Who should get it? Provider Feedback Posi<ve Increased learning Increased confidence Protected <me Enjoyment Construc<ve cri<cism Beqer networking with fellow ECHOists Level of didac<cs too high Referral process too cumbersome Next Steps: Expansion v More ECHO clinics: Buprenorphine services Care coordination Pain management v External clinics to CHC

cri<cism Beqer networking with fellow ECHOists Level of didac<cs too high Referral process too cumbersome

Project ECHO - A Network Marketing Model for Primary Care Solutions

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