The Problem. Hepatitis C, which causes cirrhosis of the liver, liver cancer and liver failure if untreated, is a major health problem in New Mexico. The state's cirrhosis rate is twice the national average and deaths from liver failure are above average.
Many cases of hepatitis C (between 45% and 75%) are curable with treatment. But the treatment is complex and requires specialized expertise, which has been available only in Albuquerque.
Sanjeev Arora, MD, runs the hepatitis C clinic at the University of New Mexico School of Medicine in Albuquerque. "There was an eight-month wait to see me. Patients would have to drive, sometimes 250 miles, from remote parts of New Mexico," said Arora, who is a professor and vice chairman of the Department of Internal Medicine and chief of clinical operations for the Department of Medicine.
Many people with hepatitis C have no health insurance. Some are too poor to make the monthly trips to Albuquerque from their rural communities for the yearlong treatment. In 2004, fewer than 5 percent of patients with hepatitis C in New Mexico were treated.
Bringing specialist-level care to rural communities. Arora started Project ECHO (Extension for Community Healthcare Outcomes) in 2004 to leverage scarce specialist resources and expand access to treatment for patients with hepatitis C throughout New Mexico.
Through use of a secure, Internet-based audiovisual network, best practice protocols and case-based learning, primary care providers receive the training and support they need to deliver best practice care. Most of these providers work in federally qualified health centers and other practices that serve Medicaid patients and other underserved populations.
After diagnosing a patient with hepatitis C, a primary care provider presents the case during a video or telephone conference so that specialists can help provide a treatment plan. The primary care provider then treats the patient and presents status reports and issues during follow-up conferences.
"Project ECHO, through the knowledge networks, can expand access to specialists' input for these patients and make it available at the right time, quickly, and enable their primary care physicians to provide best practice care in their home environment," said Arora, who started Project ECHO with funding from the Agency for Healthcare Research and Quality. Since 2006, the New Mexico legislature also has been providing funding.
About 40 percent of inmates in New Mexico have hepatitis C. Project ECHO has a separate hepatitis C clinic for inmates, in collaboration with the New Mexico Department of Corrections. Arora also set up a peer education program in which inmates help other inmates prevent the spread of hepatitis C, HIV and sexually transmitted diseases and discourage drug use. After completing a 40-hour training program, the peer educators deliver a 10-hour curriculum to every prisoner.
By 2007, Arora had expanded Project ECHO to include clinics for rheumatology, substance use and mental health disorders. That year, Project ECHO won the Changemakers competition for projects offering new ways to deliver health care services. The Robert Wood Johnson Foundation (RWJF) co-sponsors the competition with the Arlington, Va.-based Ashoka Foundation, which supports the work of social entrepreneurs (who use business approaches to have a social impact).
Over the next two years, Project ECHO expanded to 16 clinics, ranging from asthma and diabetes to cardiac risk reduction, chronic pain and headache and pediatric obesity.
RWJF promotes further expansion. In 2009, RWJF awarded Project ECHO a grant (ID# 063945) to expand and replicate its programs.
Under the grant, Project ECHO is taking six of the clinics—asthma, diabetes, chronic pain and headache, high-risk pregnancy, integrated addictions and psychiatry and rheumatology—to "industrial strength," said Arora. That includes working with primary care providers in 29 of New Mexico's 33 counties. In the diabetes clinics, Project ECHO also is training community health workers, who help patients manage their chronic diseases.
Through Project ECHO, tens of thousands of patients have received care they would not otherwise have had access to, and thousands of doctors in rural communities have been trained to provide specialty care for complex diseases. Project ECHO has proven that "rural doctors can provide the same level of care as a university," said Arora, "You don't have to sacrifice quality when a primary care physician provides specialist care as long as he's [or she's] hooked to a knowledge network where he [or she] can get support."
Linking to the Medical Leadership Institute. The same year it funded Project ECHO, RWJF also launched the Medicaid Leadership Institute, a fellowship program to enhance the leadership capacity of state Medicaid directors. Special advisor for program development Nancy Barrand, the initial program officer, introduced Arora to Carolyn Ingram, New Mexico's Medicaid director and a fellow in the first class (2010) of the Medicaid Leadership Institute. Despite their overlapping interests, Ingram had never met Arora nor heard about Project ECHO.
"I gave her a presentation on ECHO, and she was immediately able to see that this kind of model could be very helpful to her rural patients," said Arora, "It could enhance quality and reduce costs for Medicaid." Ingram helped Project ECHO get a Medicaid administrative match for some of the RWJF funding.
"Medicaid is getting care for these individuals, and a bigger bang for the buck, because we don't have to pay to transfer clients to Albuquerque for treatment," said Ingram, "The patients are staying in their community, so they're happier."
An impact beyond New Mexico. Arora is working with the University of Washington to replicate Project ECHO in Washington State. So far, the university has established a hepatitis C clinic (with funding from RWJF, passed through Project ECHO) and chronic pain and substance use disorders clinics (with other funding). Washington State also is exploring the possibility of a grant through Medicaid.
Project ECHO has developed a site visit program and a replication kit to help others follow the model. Other states have expressed interest in Project ECHO, as have other countries, such as India and Egypt.
The Medicaid Leadership Institute also is helping spread the word about Project ECHO and its role in helping Medicaid provide better care for beneficiaries. For example, the Center for Health Care Strategies, the national program office for the Medicaid Leadership Institute, has introduced Arora to its Medicaid Users Group, composed of senior leaders in Medicaid state programs, health plans and research organizations. The group provides input and guidance to the center on issues related to population management, and it shares information and strategies for identifying/managing high-risk members. For more information on the institute, read the Progress Report.