Thanks to an innovative program that links subspecialists with primary care professionals, a growing number of New Mexico patients are receiving subspecialty care directly from family physicians.
Having received special training to manage patients with opiate addiction, family physician Leslie Hayes, M.D., in foreground, now uses videoconferencing to consult with FP colleagues in other parts of her home state of New Mexico.
Project ECHO(echo.unm.edu) (Extension for Community Healthcare Outcomes) was launched by Sanjeev Arora, M.D., in 2003 at the University of New Mexico. At the time, Arora, a gastroenterologist specializing in liver disease, worked in one of only two clinics in the state that treated patients with hepatitis C virus (HCV) infection -- a disease that afflicted some 30,000 New Mexicans. Frustrated that he could not treat all the patients who needed care, Arora created Project ECHO as a model for training primary care clinicians to manage HCV disease.
Originally, ECHO linked HCV subspecialist teams with primary care clinicians through "teleECHO" clinics. Today, ECHO clinics are available for a variety of subspecialties and ailments, including endocrinology, rheumatology, addiction, epilepsy and others. Using a videoconferencing tool, subspecialists provide didactic education, mentoring, guidance and feedback to primary care physicians. The goal of this guided practice model is for primary care health professionals to become increasingly independent experts on a particular pathology, thus growing the capacity to safely treat complex diseases throughout the state.
- In New Mexico, Project ECHO (Extension for Community Healthcare Outcomes) is linking subspecialists with primary care physicians to expand provision of subspecialty care in remote areas of the state.
- Using a videoconferencing tool, subspecialists provide didactic education, mentoring, guidance and feedback to family physicians and other primary care clinicians.
- Having received the training themselves, some -- like FP Leslie Hayes, M.D. -- are now "paying it forward" to their family physician colleagues.
To date, more than 4,900 primary care physicians, physician assistants and nurse practitioners in New Mexico have participated in Project ECHO clinics.
"ECHO is a huge resource for us," said New Mexico AFP president Melissa Garcia, M.D., of Albuquerque. "From a statewide perspective, the real value is with rural physicians because the access to specialty care is centralized in Albuquerque, and the wait to get into any subspecialist is really long."
Another plus: Arora is far from unknown to the New Mexico AFP, having interacted extensively with its members during chapter meetings and elsewhere. "Dr. Arora has been a speaker for us for many, many years and had a relationship with the chapter prior to the development of ECHO," said Garcia. "(He is) a consistent part of our CME and speaker pool."
Caring for Patients With HCV Disease
One of the earliest participants in the ECHO clinic that focused on HCV infection was family physician Saverio Sava, M.D., clinical supervisor for First Choice Community Healthcare, a federally qualified health center in rural Edgewood.
"Providers see patients who have hepatitis C, and then they present them to Project ECHO," Sava said. "The team of experts will ask questions about the patient, and they'll come up with recommendations on what to do. The patients never leave their providers' practice. They don't need to make a trip to the university."
Receiving treatment close to home made all the difference to the first patient Sava managed through ECHO in Edgewood. She was a mother of two school-aged children who was also caring for her recently hospitalized husband, he recalled. "She said, 'I would have never been able to get treated if I had to go to the university,'" Sava said. Of the 32 patients with HCV infection he has treated, she is one of 30 who have cleared the virus.
Sava's statistics are compelling, and a study published in the New England Journal of Medicine(www.nejm.org) showed that patients who were treated at a remote center using the ECHO model had outcomes that were comparable to, or even slightly better than, those seen in patients who were treated by experts at academic medical centers in urban areas. Patients often do better when treated at First Choice because they have continuity of care, which contributes to better compliance, Sava said.
Facts About the New Mexico AFP
Chapter executive director: Sara Bittner
Number of chapter members: 875
Year chapter was chartered: 1957
2015 annual meeting: July 16-19, Ruidoso Convention Center/Lodge, Sierra Blanca
"It's very rewarding to see that they can do as good a job as us," Arora said. "We've always known they are amazing physicians. We've shown with the appropriate support system, they can do as good a job as specialists."
About five clinicians provide treatment for HCV infection at First Choice Community Healthcare locations throughout New Mexico, Sava said. And two family doctors at First Choice's North Valley Center in Albuquerque are offering rheumatology care, also through ECHO. "I tell my patients, you can wait eight months to get seen at the university's rheumatology clinic, or you can get in next week at First Choice," Sava said.
Karen Phillips, M.D., current board chair and a past president of the New Mexico AFP, has also participated in teleECHO clinics. Now practicing in Los Lunas, Phillips dialed into the diabetes ECHO clinic when she was working in Mountainair, a town of about 1,000 people. Practicing by herself, she said it was easy to feel isolated.
"ECHO was a structured way to get in touch with other people doing the same thing you're doing," she said. "It was incredibly meaningful support. You stop feeling stupid because you realize everyone has the same questions you have. You know you're doing state-of-the-art medicine."
Helping FPs Curb Patients' Addictions
Currently, said Garcia, many physicians are using the ECHO model to help them manage opiate addiction in their patients. ECHO has trained about 600 health care professionals in the use of buprenorphine to treat this problem and conducts a weekly teleECHO clinic on integrated addictions and psychiatry.
It's a public health threat family physician Leslie Hayes, M.D., knows all too well. Working out of El Centro Family Health's Española Medical Clinic in northern New Mexico's Rio Arriba County, Hayes is on the front lines of the region's heroin epidemic.
From 2008 to 2012, the county saw 67.7 drug overdose deaths(ibis.health.state.nm.us) per 100,000 residents, according to the New Mexico Department of Health. That's the highest overdose death rate in a state that's already known for having one of the worst opiate addiction problems in the nation.
Trying to care for this population was a source for frustration for Hayes, who said in the early and mid-2000s, there was nothing she could do except refer patients to a methadone clinic that had a long wait list and was difficult for patients without reliable transportation to attend.
In 2007, however, Hayes participated in a buprenorphine certification course conducted by ECHO. In addition to becoming certified to dispense the drug to treat opioid addiction, she was also connected with weekly teleconferences with addiction specialists.
"I probably would have up and quit had it not been for ECHO's support," Hayes said.
She was the first physician certified to prescribe buprenorphine in the county and said the support she received during ECHO clinics was invaluable in learning how to use the drug in a medically sound way.
In addition to treating patients' addiction issues, Hayes also provides these previously unseen patients with preventive care and treatment for common health conditions such as diabetes. She also delivers obstetrical care and says women struggling with opiate addiction seek buprenorphine when they discover they are pregnant.
"We used to see a lot of patients come in, and they would have no prenatal care. They'd deliver, be positive for drugs, and we'd call CYFD (the state's child protective services), and they would come in and take the babies away," Hayes said.
But thanks to the special training she received via ECHO, Hayes can provide prenatal care and help these women get drug-free during the same visit. "Now, they're getting good prenatal care and they're not taking drugs during their pregnancy." They're also being monitored for post-delivery relapses, Hayes said, and receiving support to remain drug-free.
Currently, Hayes is practicing up to her 100-patient prescription cap on buprenorphine, and there remains a demand for treatment. To increase the number of clinicians who can treat addiction, she's working with ECHO as a consultant. She's sitting on the other side of the videoconference, so to speak, and she's already helped expand the number of family physicians in the county who provide buprenorphine from just herself to a total of four. Just as Arora expanded the state's capacity to treat HCV disease, she's doing the same for addiction.
"Through Project ECHO, we have more things we can do to make a difference in the community," Hayes said.
Although Project ECHO is based in New Mexico, the model has been replicated worldwide, and clinics are available throughout the country. A listing of all the clinic locations is available online.(echo.unm.edu)