Abstract
Introduction:
The Veteran Integrated Service Network (VISN) 20 Veterans Affairs-Extension for Community Healthcare Outcomes (VA-ECHO) program connects specialty and primary care providers (PCPs) across large geographic areas, utilizing video-teleconferencing with the intention of increasing access to care among underserved and isolated populations. No previously published work describes participation patterns of a multispecialty ECHO program. We describe the development of VISN 20 VA-ECHO program to inform the design and evaluation of ECHO programs.
Methods:
The participant cohort included VA-affiliated licensed health care professionals, including trainees, who attended at least one VISN 20 VA-ECHO session between April 2012 and December 2018. Participant characteristics reported include gender, clinical location, clinical specialty, discipline, and rurality.
Results:
Over the 6-year time frame, VISN 20 VA-ECHO offered 945 sessions in 14 clinical specialties and recorded 17,893 hours of attendance. The cohort included 1,346 participants, 74.3% of whom were female, 85.2% employed in medical centers, and 40.7% affiliated with primary care. Most participants (62.3%) attended one specialty exclusively; among all participants, 40% attended five or more sessions.
Discussion:
Although VA-ECHO was implemented to develop single specialty expertise among PCPs, our participant cohort represented a more diverse audience from a range of disciplines and specialties. Our experience may be valuable to other teams implementing ECHO programs.
Conclusions:
Through adaptability and strategies that actively promoted inclusion of a diverse audience, VISN 20 VA-ECHO expanded to include multiple clinical specialties and successfully engaged an audience across a large geographic area and beyond PCPs.
Background
Project Extension for Community Healthcare Outcomes (ECHO) was first implemented in 2003 to treat patients with hepatitis C living in underserved communities. 1 ECHO connects specialty and primary care providers (PCPs) across large geographic areas utilizing video-teleconferencing.
ECHO is intended to increase access to care among underserved and isolated populations through the de-monopolization of specialty knowledge and the development of specialty expertise among PCPs, thus extending specialty care outreach and impact. ECHO participants report utilizing expanded specialty knowledge and skills to care for their patients as well as sharing knowledge with colleagues (force multiplication). 2 Hepatitis C antiviral treatment delivered by ECHO-engaged PCPs has been found to be as safe and effective as treatment provided by tertiary-center based specialists, 3 with reported increased knowledge, self-efficacy, and job satisfaction. 4 For patients who live a significant distance from specialty care, ECHO may also reduce travel costs. 5
Introduction
The Veterans Health Administration (VHA) serves 9 million Veteran enrollees annually at 171 medical centers and 1,112 outpatient sites. 6 Veterans enrolled in VHA health care are disproportionately rural; 58% of rural Veterans eligible for VHA care are enrolled in VHA health care compared with 37% of their urban counterparts. 7
In 2011, VHA introduced 11 Veterans Affairs-ECHO (VA-ECHO) programs nationwide 8 with the objective of increasing access to specialty care for rural and geographically isolated Veterans. 9 The Veteran Integrated Service Network (VISN) 20, which includes 8 VHA medical centers/health care systems and 47 community clinics in Alaska, Idaho, Oregon, Washington, and western Montana, and encompasses the largest geographic area among the 18 VHA networks, 10 implemented a regional multispecialty program (VISN 20 VA-ECHO).
VISN 20 VA-ECHO initially focused on five specific complex chronic conditions: human immunodeficiency virus, suspected lung cancer, chronic hepatitis C, heart failure, and chronic kidney disease. Over time, most VISN 20 VA-ECHO specialties broadened in scope to include general content (e.g., hepatitis C specialty expanded to cover general hepatology and gastroenterology). By 2018, VISN 20 VA-ECHO had offered sessions in 14 specialties (Supplementary Appendix Table SA1). Between April 2012 and December 2018, VISN 20 VA-ECHO recorded 17,893 hours of attendance over 945 sessions.
No previously published work describes participation patterns of a multispecialty ECHO program. We report on the development of VISN 20 VA-ECHO over ∼7 years with the intent to inform the design and evaluation of ECHO programs in other large, geographically expansive health care systems.
Methods
The VISN 20 VA-ECHO participant cohort included VHA-affiliated licensed health care professionals, including trainees, who attended at least one session between April 2012 and December 2018. The following participants were excluded: (1) those without VHA affiliation, (2) those without clinical licensure including non-clinical staff, program support staff, and pre-licensure trainees, and (3) speakers who presented didactic material but did not attend additional sessions as a learner.
Incentives for attendance differed by year, location, and VA-ECHO specialty. The most common incentive was continuing education (CE) credit. Other incentives included clinical reference material and nominal salary support from the Office of Rural Health (ORH) disbursed to the participants' employing facility. Participants did not receive monetary compensation or performance-based incentives.
DETERMINING PARTICIPANT ATTRIBUTES
Participant characteristics, including clinical location, discipline, and clinical specialty(ies), were determined by both self-report and online sources, including academic affiliate faculty directories and the National Provider Identifier Database.
Participants were assigned to clinical discipline based on the National Uniform Claim Committee (NUCC) provider taxonomy 11 and to clinical specialties based on the Centers for Medicare and Medicaid Services (CMS) physician specialty codes. 12 Health care trainees were not assigned to specialties. Whenever possible, we accounted for changes in location or professional role; however, there are limitations to tracking changes over time. Participants' most recently known attributes were utilized for the analysis.
Participants were designated as “rural” based on VHA Support Service Center (VSSC) data. Participants were considered rural if they practiced at a location based in a rural or insular island community based on the Rural Urban Commuting Area (RUCA) designation as determined by the United States (U.S.) Department of Agriculture, 13 or if their clinical site served a majority rural patient population.
PARTICIPANT TRACKING
VISN 20 VA-ECHO staff recorded participation into a Microsoft Access database. Regular quality control processes were applied to ensure accuracy. All statistical analyses were performed by using SAS version 9.4 (Cary, NC).
QUALITY IMPROVEMENT STATUS
This approved quality improvement initiative was conducted under the auspices of the VA Office of Specialty Care and the ORH. In accordance with VHA Handbook 1058.05, we obtained approval of non-research status from the VA program office. This approval constitutes an IRB waiver. In addition, we secured written concurrence of non-research status from VA Puget Sound's Director of Human Research Protection Program, Associate Chief of Staff for Research and Development, and Director of Quality, Safety and Values. As a designated quality improvement (non-research) project, informed consent was not obtained. Informed consent was waived, as this project was approved before implementation as a non-research (quality improvement) initiative and therefore informed consent was not required.
Results
SESSIONS AND SPECIALTIES OFFERED
Between April 2012 and December 2018, VISN 20 VA-ECHO offered 945 sessions. The number of sessions, specialties, hours of attendance, and unique participants increased annually ( Figs. 1 and 2 ). Participants represented 207 VHA clinical sites in 48 states and 1 U.S. territory (Fig. 3). Fifty sites (24%) were in rural communities. The number of sites participating increased over the evaluation period (Fig. 4).
VISN 20 VA-ECHO: number of sessions and specialties offered per year (2012–2018). The number of program sessions and program specialties increased over time. Each bar reflects the number of sessions. Each diamond represents the number of specialties. VA-ECHO, Veterans Affairs-Extension for Community Healthcare Outcomes; VISN, Veteran Integrated Service Network.
VISN 20 VA-ECHO: hours attended and unique participants per year (2012–2018). The number of unique participants increased over time, which is depicted by the line. Bars represent the number of hours attended, which also increased over time.
VISN 20 VA-ECHO: new participating clinical sites by year (2012–2018). The number of new participating clinical sites per year is represented in the bar chart with light gray corresponding with new urban sites and dark gray corresponding with new rural sites.
PARTICIPANTS
Over the 6-year period, 1,346 participants attended at least one VA-ECHO session (Table 1). The majority of participants were female (74.3% [n = 1,000]), based at urban clinical sites (85.2% [n = 1,147]), and employed in medical centers (77.5% [n = 1,043]) as opposed to community-based clinics (21.5% [n = 290]). Overall, most participants were not affiliated with primary care (59.3% [n = 798]); however, the majority of rural participants were primary care-affiliated (73.9% [n = 147]).
Veteran Integrated Service Network 20 Veterans Affairs-Extension for Community Health Care Outcomes Participant Demographics by Rurality
Includes one participant from Guam (insular island per RUCA).
One participant with gender unknown.
Defined as providing at least two categories of care (outpatient, inpatient, residential, institutional extended care).
Includes CBOCs; multispecialty CBOCs, which may provide ambulatory surgery and/or invasive procedures, but which are not designated medical centers (HCCs); and OOS designated sites. Mobile medical units are not included.
Includes those sites where services are limited to extended care (e.g., nursing home care and respite care); participants from medical center based extended care settings are included as medical center based participants.
CBOCs, community-based outpatient clinics; HCCs, Health Care Centers; OOS, Other Outpatient Services; RUCA, Rural Urban Commuting Area.
Registered nurses (RNs) comprised the largest group of participants by clinical discipline (22.1% of participants), of whom 81.9% (n = 244) worked in urban settings (Table 2). The next largest group were physicians (18.9%); 88.8% of whom were medical doctors (MDs). As with the RNs, the majority of physicians (85.0%) worked in urban settings. Other disciplines with significant participation included pharmacists (15.3%) and advanced practice nurses (13.5%).
Veteran Integrated Service Network 20 Veterans Affairs-Extension for Community Health Care Outcomes Participants by Clinical Discipline
It was not possible to ascertain clinical discipline for one participant (urban).
Includes one participant from Guam (insular island per RUCA).
Observations where rurality could not be determined (null rurality) are excluded.
Includes MD, DO, DPM and/or MB BS.
May include CPS and PharmD.
Includes ARNP and CNS.
Includes resident physicians, pharmacy residents, nurse practitioner residents, graduate nurse trainee, nurse practitioner student, and dental residents.
Includes social workers (e.g., LICSW, MSW); health behavior coordinators and LPMHC.
Includes RRT, PT, OT, speech language pathologists, sleep technicians and pulmonary function technologists.
Includes PhD and PsyD.
Includes LPN and LVN.
Includes RD and dieticians.
Includes health technician, medical assistant, medical support assistant, RDMS, medical instrument technician in addition to other technicians.
ARNP, advanced registered nurse practitioner; CNS, clinical nurse specialist; CPS, clinical pharmacy specialist; DO, doctor of osteopathy; DPM, doctor of podiatric medicine; LICSW, licensed independent clinical social worker; LPMHC, licensed professional mental health counselor; LPN, licensed practical nurse; LVN, licensed vocational nurse; MB BS, Bachelor of Medicine/Bachelor of Surgery; MD, medical doctor; MSW, master of social work; OT, occupational therapist; PharmD, doctor of pharmacy; PhD, doctor of philosophy; PsyD, doctor of psychology; PT, physical therapist; RD, registered dietitian; RDMS, registered diagnostic medical sonographer; RN, registered nurse; RRT, registered respiratory therapist.
Additional disciplines represented included physician assistants; respiratory, rehabilitation, and restorative care providers; licensed practical/vocational nurses; and behavioral health and social service providers. Post-licensure health care trainees represented 9.1% of participants, the majority of whom were resident physicians (57.7% or n = 71).
LONGITUDINAL ATTENDANCE PATTERNS
Individual participants attended 1–258 sessions (mean 12.5; median 3) (Table 3). Nearly 40% (38.5% [n = 518]) demonstrated “high participation,” attending five or more sessions. Approximately one third of participants (n = 368 [27.3%]) attended two to four sessions (defined as “intermediate participation”), and one third (n = 460 [34.2%]) attended a single session (defined as “low participation”).
Veteran Integrated Service Network 20 Veterans Affairs-Extension for Community Health Care Outcomes Attendance Patterns (2012–2018) (n = 1,346)
SD, standard deviation.
The extent of specialty focus varied, with most participants attending one specialty exclusively (62.3% [n = 839]) and another 25.1% (n = 338) attending 2–3 of the 14 specialties offered (“narrow focus”). A minority (5.1%) attended sessions in 6–10 specialties (“broad focus”).
Discussion
From the first full year of data (2013) to 2018, the program reach expanded with respect to unique participants attending, clinical sites engaged, and number of specialties offered. This occurred despite ongoing and widespread clinical and administrative demands on all VHA clinicians, including the increased organizational emphasis on improving access to care and without directly compensating clinical sites with regular participation, in contrast to the Arora model. 14
More than one third (34.2%) of participants attended only one session. In a prior evaluation of a VA-ECHO program, participants and invitees who attended zero to two sessions reported that it was the specific day and time that limited participation, suggesting that changing curriculum or modality may not significantly improve retention or recruitment. 15 Recognition of this pattern is valuable when developing and implementing ECHO-based programs. ECHO programs may choose to work to improve engagement among these individuals or accept that a percentage will not return and direct focus on meeting the needs of participants who attend regularly.
Previous reports suggest that VA-ECHO participants who participated for 1 year or longer were significantly more likely than those with a shorter duration of participation to self-report that VA-ECHO improved patient access to care, resulted in higher quality care, increased knowledge and competencies, and improved integration into a broader clinical team. 16 The mean duration of participation in our cohort is 11.5 months (median 2.3; range 0–81.2 [6.75 years]), despite a third of participants engaging for only a single session. Appreciating that many participants attend briefly or for a limited number of sessions can guide curriculum development (and repetition), advertising, outreach, and program evaluation.
Project ECHO was initially conceived as a means to develop specialty expertise among physicians, nurse practitioners, and physician assistants working in geographically isolated and rural primary care settings. 1 VA-ECHO, when initially proposed in 2011, shared this intention 8 ; however, the VISN 20 VA-ECHO audience has emerged as more diverse in discipline, specialty, and location than only rural PCPs. Between 2012 and 2018, almost 60% of VISN 20 VA-ECHO participants were not affiliated with primary care and 58% were not physicians, nurse practitioners, or physician assistants. In fact, only 203 (15.1%) of the 1,346 participants were PCPs and of those, 58 (or 4%) of all participants were rural PCPs.
Although we hoped for consistent high levels of engagement from rural PCPs (and PCPs in general), there were barriers to their participation, in part related to recruitment logistics and program design. Targeted recruitment of rural PCPs was not possible, as there is no directory of rural providers or rural managers and leaders. Recruitment was attempted through other mechanisms, including the VHA ORH Community of Practice, in-person visits to rural sites, and e-mail-based advertising to rural site leadership and management (when possible to determine based on site rurality) and/or leadership and management at (urban) parent stations. Inability to provide consistent salary support for PCP involvement also limited participation, compounded by the fact that VA-ECHO-based clinical care did not generate revenue-producing clinical workload.
With respect to program growth, VISN 20 VA-ECHO initially focused on regional expansion in four northwestern states. Over time, some specialties took steps to engage a more clinically diverse audience beyond PCPs by discussing multidisciplinary aspects of care, expanding the types of CE offered, adding multidisciplinary team members to curriculum planning and faculty, and conducting outreach to new potential participant groups. As the audience diversified, evaluation results, needs assessments, and, thus, curriculum development reflected the new participants, resulting in a positive feedback cycle promoting expansion.
Although VA-ECHO was implemented to develop single specialty expert PCPs, including MDs, ARNPs, and PA-Cs, ultimately participants represented a more diverse range of disciplines and specialties. Awareness of the potential diversity of participants guides ECHO-based program implementation and expansion. Strategies to ensure program inclusivity, if a programmatic objective, are: Ensuring initial program planning addresses potential for audience diversity, including integration into planning documents including initial program checklist. Early recruitment and involvement of multidisciplinary faculty and planning committee members. Offering multiple types of CE accreditations. Development of didactic content relevant to a broad audience. Utilization of terminology and language inclusive of multidisciplinary care in program outreach and announcements (“branding”). For example, the session title “Care of patients with COPD” is more inclusive than “Medical Management of COPD.” Explicit acknowledgment of the role of rurality and specific clinical settings during care delivery. For example, didactic content, case presentation, and clinical recommendations should recognize resource limitations and geographic considerations experienced by all participants. Faculty, who are often specialists in urban, tertiary medical centers, can promote a community of practice and inclusivity by acknowledging barriers experienced by geographically isolated providers and those working in health care shortage areas by avoiding statements that imply and overly value unfettered access to other specialists (e.g., avoiding statements like “if you see this pattern, I recommend you just walk downstairs and talk to the specialty radiologist”). Selection of faculty who are philosophically aligned with de-monopolization of specialty knowledge, value team-based and patient-centered care (and consistently demonstrate this in their professional interactions), and who genuinely welcome questions and dialogue during and outside of session from all participants, including those without recent and/or advanced education related to the didactic content. Development of clear guidelines for faculty and other team members regarding program operations and mission. Engagement of rural sites and providers through site visits, in-services and needs assessments. Development of program evaluation tools with attention to participant diversity. Analyzing participant self-report of knowledge and skills acquisition is a common ECHO program evaluation strategy,
5,15,17
–19
but this strategy may risk focusing on the practice of medicine (e.g., assessing new knowledge regarding “prescribing medications”). Evaluations focused solely on medical practice may fail to adequately describe the impact of VA-ECHO program across more diverse audiences.
Arora envisioned Project ECHO to care for patients with hepatitis C with limited access to specialty care. He was able to successfully engage PCPs, develop a mechanism for ECHO consultations, and provide an educational setting with a multidisciplinary team. In practice, VISN 20 VA-ECHO has successfully expanded and met participants' needs despite deviation from the original model by including a more diverse audience, including non-referring participants, and addressing a wider range of clinical conditions.
The VHA has several advantages compared with non-VHA health care systems with respect to program implementation. Specifically, the VHA system is technologically integrated. All VHA employees have access to the same virtual teleconferencing/meeting applications, email and calendar system, and electronic health record. Program teams have access to large national email distribution lists, national leadership, policy guidelines, and pharmacy formularies. The VHA providers also share a common culture, providing a preexisting sense of community and mission, an emphasis on provision of care to rural Veterans, and a model of care not directly tied to revenue generation.
Specifically, VA-ECHO is deliberately aligned with the core organizational priorities of access to care and equity between rural and urban sites. Further, VHA programs have access to patient-level outcomes and national, regional, and local data sets regarding referral patterns, deficits in specialty care, and performance metrics. This permits both targeted outreach and development, as well as outcome evaluation at the patient level.
Conclusions
VISN 20 VA-ECHO will continue to adapt to the needs of the Veterans receiving care in the VHA health care system and the health care professionals who serve them. A consistent focus on data collection and quality improvement has allowed VISN 20 VA-ECHO to adapt to meet the expressed needs and goals of VHA practitioners and leadership. The program attracts a diverse and growing community of learners dedicated to working together to improve care for our nation's Veterans.
Footnotes
Acknowledgments
The authors thank Drs. David Au and Bessie Young for their assistance with funding procurement for the VISN 20 VA-ECHO T-21 grant and Dr. Young and Kathryn Todd, RN for their early involvement in study design and article development.
Disclaimer
The contents, views, or opinions expressed in this presentation are those of the author(s) and do not necessarily reflect the official policy or position of the Department of Veterans Affairs.
Disclosure Statement
No competing financial interests exist.
Funding Information
This work was supported in part through funding by the U.S. Department of Veterans Affairs VHA Office of Patient Care Services (Specialty Care Services); the VHA ORH; the VA Northwest Health Network (VISN 20); and with resources and use of the facilities at VA Puget Sound Health Care System (Seattle, WA), VA Portland Health Care System (Portland, OR), and the Boise VA Medical Center (Boise, ID).
Supplementary Material
Supplementary Appendix Table SA1
References
Supplementary Material
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