Author: Cathy Shufro
Family nurse practitioner Sarah Marks had been seeing a teenage patient for four years, treating her for GI issues that had developed into an eating disorder. The young woman didn’t tolerate her medications well and frequently requested changes. Recently, she had begun missing appointments at the small-town federally qualified health center where Marks has worked for 15 years. (We are not using Marks’ real name to protect patient confidentiality.)
Marks needed advice.
If you’re a rural primary care provider like Marks, FNP, where do you get advice? That was a quandary for Marks, who works in a small Midwestern town, population 1,550.
Luckily, she’d heard of a Weitzman Institute program that connects rural providers with experts. Just three years into the five-year program, the Telehealth Technology-Enabled Learning Program has, so far, provided “telementoring” to 278 rural primary care providers (PCPs) and other health care professionals in 43 states.
Even though the series on complex pediatrics met on her day off, Marks joined the twice-a-month lunchtime meetings. “It was nice to be with a group of people working with youth, seeing the same issues, struggling with the same things.”
The series follows a model called Project ECHO (for Extension for Community Healthcare Outcomes). Each ECHO is led by subject-matter specialists recruited and guided by Weitzman’s Education team. A moderator opens the hour-long meeting, a specialist gives a short didactic presentation, and then a participating provider presents an anonymized case from their own practice. The whole group discusses how best to care for the patient.
“It’s almost like a live consult,” says Karen Ashley, Ed.D., director of education at the Weitzman Institute. “One of the goals is not only to impart knowledge from specialists to the providers, but also to connect the providers with each other and build that learning community. They can share with their peers what has worked well with their patients.”
Nurse Practitioner Marks got the chance to present a case. At one of the meetings, she described her teenage patient to participants who included fellow advanced practice nurses, physicians, physician assistants, psychologists, and social workers. How should she respond to the skipped appointments? To complaints about medications?
“They asked me to consider if there is something about coming to the clinic that might trigger anxiety around coming,” says Marks. They suggested she consider barriers presented by check-in, or billing, or the drive to the clinic. Someone suggested that five minutes into the appointment, if the patient hadn’t arrived, Marks could call her and offer a phone consultation. The group discussed whether the medications Marks was prescribing would realistically cause the discomfort that the patient reported.
For Marks, “it was very reassuring. I left the meeting being more trusting of my instinct that it’s not the medications.” She took the group’s advice to discuss the situation with the patient’s mental health therapist. “It opened a line of communication,” Marks said.
The ECHO model supports the kind of online interchange that helped Marks see her patient more clearly, says Education Director Ashley. “The goal is not only to impart knowledge from specialists to the providers, but also to connect the providers with each other and build that learning community. They can share with their peers what has worked well with their patients. And the providers know they’re not alone with the challenges they face in providing care for underserved, marginalized, vulnerable, and often minoritized populations,” she said.
Primary care providers in rural areas face pressures that urban practitioners do not. Their patients—the roughly 20% of Americans living in rural settings — have worse health outcomes than do urban dwellers. They have higher rates of mortality from cancer, stroke, suicide and heart and respiratory diseases. On average, their lives are shorter. Many primary care providers practice in regions short on medical professionals of all types. As a result, they frequently treat people with several comorbidities who would, ideally, get care from a specialist.
Weitzman’s telementoring program is geared toward two groups of rural providers: those seeing adults, with a focus on substance-use disorders and mental health; and those caring for pediatric and adolescent patients, with a focus on infectious disease, vaccines, and mental health.
Typically, from 25-90 people attend a given session. The seminars run for 9-12 months, and learners can receive continuing education credits. The five-year program is funded with $2.3 million from the federal Health Resources and Services Administration (HRSA).
"The providers know they're not alone with the challenges they face."
From one course to many
The Weitzman Institute, now a research program of the Moses/Weitzman Health System, has a long history of disseminating ECHOs on a national scale. In 2012, it launched its first, a series for providers treating people infected with both the hepatitis C virus and HIV. Twelve years later, that seminar still meets weekly.
Currently, along with the program for rural PCPs, the Institute is sponsoring eight other ECHOs. Some are geographically focused, such as an ECHO on adult psychiatry and trauma-informed care in Ohio, and another on complex care management for nurses in Connecticut. There are ongoing national programs addressing how PCPs can treat opioid dependence; their role in responding to childhood trauma; and how PCPs, behavioral health providers, and registered dietitians can address patients’ complex health needs related to obesity and weight management. More than 9,000 PCPs and other care professionals have enrolled in Weitzman’s ECHO programs since 2012.
Weitzman’s Education program specialists and instructional designers work closely with the ECHO subject matter experts and provide ideas for keeping meetings engaging. The Weitzman Research team tracks outcomes to ensure that the ECHOs achieve their aims.
The thousands of health care professionals who have participated in Weitzman-sponsored ECHOs so far have used their new knowledge in treating tens of thousands of patients. That is gratifying for Education Director Ashley and her 14-member team. “We’re not the ones making clinical decisions and working with patients directly,” she says, “but because of the education we provide to providers, we have a positive impact on patient care, and ultimately, on the patient’s health.”