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Project ECHO: An Effective Means of Increasing Palliative Care Capacity
Sanjeev Arora, MD; Tracy Smith, BS; Jennifer Snead, PhD; Sarah Zalud-Cerrato, MPH; Lisa Marr, MD; Max Watson, MBChB; Sriram Yennu, MD; Amy Bruce, MPP; Chris Piromalli, DO; Stacy Kelley, MPH; Nandini V
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Project ECHO: An Effective Means of Increasing Palliative Care Capacity

Sanjeev Arora, MD; Tracy Smith, BS; Jennifer Snead, PhD; Sarah Zalud-Cerrato, MPH; Lisa Marr, MD; Max Watson, MBChB; Sriram Yennu, MD; Amy Bruce, MPP; Chris Piromalli, DO; Stacy Kelley, MPH; Nandini V
This article provides insight on the work of 7 of Project ECHO’s replicating partners from around the world who are implementing the ECHO model to address the knowledge gap that underlies integrated palliative care crisis.
Globally, the need for integrated palliative care has never been greater. Populations are aging, and rates of terminal non-communicable diseases continue to progress. Approximately half of all patients with cancer, for example, will eventually succumb to their disease—nearly one-third of cancer deaths happen within 6 months of diagnosis.1 Organizations, such as the National Academies of Science, Engineering, and Medicine (formerly Institute of Medicine) and the American Society of Clinical Oncology, recommend full integration of palliative care as a routine component of comprehensive cancer care.2 Integrated palliative care—which encompasses coordination of care for multiple severe, complex conditions; behavioral health concerns; and end-of-life care—can provide symptom control, psychosocial support, and coordinated transitions of care for patients and their families.3-5

Yet, as Atul Gawande, MD, MPH, documented in his 2010 book, Being Mortal, best practices and innovations in creating or maintaining quality of life (QOL) for individuals nearing the end of their lives, or faced with life-threatening conditions, are not readily accessible to those who need them most.6

Despite ongoing efforts to incorporate palliative care concepts and training in medical and nursing education,7 barriers to access persist, and palliative care remains an insufficiently researched topic.8 The World Health Organization estimates that 19 million adults across the world are in need of palliative care, the majority in low- and middle-income countries, but that in many areas, the level of palliative care provision and access to services remain extremely limited and clinicians often lack the capacity to provide care to all in need.9

In the United States, large regional disparities in access to palliative care exist, especially in rural areas and among medically underserved populations.10 The number of palliative care specialists falls far short of demand, exacerbating geographic, racial, and economic disparities in access.11,12 Culture- and country-specific assumptions, perceptions, and laws about palliation, pain relief, and drug prescription/use are also significant impediments to effective palliative treatments.13

To overcome the gap between the growing need and the limited resources for palliative care around the globe, a transformative educational intervention is necessary. Such an innovation must effectively disseminate the principles, best practices, and applications of palliative care concepts for the frontline healthcare practitioners who serve communities most in need of that care. For the past 14 years, Project ECHO (Extension for Community Health Outcomes) has leveraged its innovative technology-enabled model for healthcare education to address global disparities in healthcare access for complex chronic conditions such as hepatitis C, HIV, tuberculosis (TB), and opioid use disorder. The ECHO model, which fosters and sustains communities of practice that bring together primary care clinicians with interdisciplinary specialist teams for ongoing case-based learning, mentoring, and sharing of best practices, also has the potential to tip the scales of the world’s integrated palliative care crisis. This article describes the work of 7 of Project ECHO’s replicating partners from around the world who are implementing the ECHO model to address the knowledge gap that underlies this crisis.

Project ECHO
Project ECHO improves healthcare workforce capacity and increases access to specialty care for the world’s rural and underserved populations. A low-cost, high-impact intervention, Project ECHO links expert multidisciplinary specialist teams with frontline community healthcare providers via ongoing videoconference-enabled sessions. In these teleECHO clinics, specialists share their expertise and community providers share their experience with individual patients via case-based learning and telementoring. Overall knowledge is enhanced as cutting-edge research, treatments, and best practices from academic and research centers are tested and refined through ongoing discussion and application within community- and culturally-specific contexts on the ground. Participating community providers do not need any additional equipment to participate other than a laptop enabled with internet and a videocamera. The ECHO model builds and strengthens communities of practice through latitudinal learning and the free exchange of knowledge: all participants teach, and all participants learn from one another. Community providers develop the capacity to care for patients with complex conditions where they live.

Project ECHO benefits not only patients in need of care, but also the providers who care for them. The communities of practice built through regular teleECHO clinics reduce professional isolation for providers located in rural areas, building networks and new opportunities for collaboration.14-17 These additional resources and opportunities support clinic staff retention and increase professional satisfaction.18-21 The peer support and mentorship that teleECHO clinics provide enable critical incident stress debriefing and self-care strategies, reducing provider burnout.

Project ECHO moves knowledge, not patients (Figure 1). It provides increased access to high-quality healthcare and reduces travel to, and wait times at, centers of medical expertise. The ECHO model, originally designed and implemented in 2003, addressed the lack of hepatitis C care across rural New Mexico. Within 18 months of establishing the first teleECHO clinic sessions, which connected primary care providers and community health workers around the state with a multidisciplinary specialist team at the University of New Mexico (UNM), wait times at the UNM hepatitis C clinic had dropped from 8 months to 2 weeks. Rural providers reported a greater sense of self-efficacy and confidence in treating hepatitis C patients in their own communities. Subsequent research demonstrated that the cure rate of those providers was the same as that in the UNM hepatitis C specialty clinic.14

Fourteen years later, Project ECHO has grown from 1 program serving rural New Mexico to over 110 partners in over 20 countries addressing over 55 conditions. The ECHO model has proved effective for hepatitis C treatment in the US Department of Veterans Affairs,15 for training primary care providers in the provision of buprenorphine for treatment of patients with opiate use disorder,16 and improvements in clinician geriatric mental healthcare knowledge/treatment and decreases in emergency room costs for their patients with mental health diagnoses.17 Providers participating in teleECHO clinics regularly report increased professional satisfaction and a reduced sense of isolation, along with improved self-efficacy and capacity to care for their patients.19-21 Globally, the ECHO model is being deployed in Europe, Asia, Africa, and India to expand frontline health workers’ capacity to care for underserved populations across complex chronic conditions like HIV, cancer, hepatitis C, multidrug-resistant TB, and behavioral health.

Project ECHO provides a unique model to address global disparities in access to palliative care. The ECHO model has been replicated by early adopters to expand, support, and disseminate knowledge of primary palliative care to providers working with rural and underserved populations, enabling them to address the complex needs of their patients with advanced serious illness. In its focus on ongoing mentorship and development of multidisciplinary communities of practice, the ECHO model is particularly suited to palliative care, which at its best involves care teams supporting patients and their families in the transition from medical support for a specific condition to a focus on overall QOL. Each of the brief narratives below recounts the experience of implementing ECHO for palliative care from the perspective of 7 of our replicating partners (also, see Table).

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