Feeding Off the Energy

Returning from the Care Innovation Summit, I left energized by the optimism that coursed through the 1,000+ attendees (another 1,200 viewed it on the Web).

Hosted by CMS, Health Affairs and West Wireless, some wonderful better care models were on display, much of them focused on chronic disease. The Care Delivery|Chronic Disease Innovation Case Study moderated by Atul Gawande highlighted a few such examples: 

• Healthways’ Silver Sneakers program to get seniors to be more physically active
• Health Quality Management’s Community-Based Care Management
• Mary Naylor’s Transition of Care Model focused on the hospital discharge process
• Wellpoint/CareMore’s approach to managing patients with high-cost chronic conditions. 

Each demonstrated success achieving the “Triple Aim” -- improving care, population health and lowering cost; each has an almost decade long-history of operating apart from traditional fee-for-service payment.  

These models have been on the radar for a while. But as they have grown in sophistication, it now feels like the field views them less as exemplary exceptions and more as aspirations for communities across the U.S.

The hope is that payment changes will propel their spread. The primary threat to their success, as identified by their proponents, is not payment, but limitations in how we approach care for patients (due to regulation, our ability to think differently, or behave differently as providers).  

As Tom Lee of One Medical reminds, “Creativity is thinking new things, innovation is doing new things.” Are we up to the challenge?

Notes on Project ECHO

The New Year marks the start of "Better Ideas in Action," a blog that highlights
innovative approaches to chronic disease care. Today's entry about Project ECHO marks the
first post. I look forward to your comments, and to learning about your better ideas in
action.

Having returned from a visit to Project ECHO in the wide open spaces of New Mexico, I
came away with the impression that it’s not the technology that’s transformative, but the
relationships it supports.

Developed by Dr. Sanjeev Arora and colleagues at the University of New Mexico (UNM), the
ECHO (Extension for Community Healthcare Outcomes) model is an Internet/telemedicine-
based method of providing specialty support to primary care practices. The goal is to
increase the ability of primary care providers to act as local specialists by creating a
“virtual practice community.”

How are they doing things differently?  

• Learning is not didactic, but through the co-management of specific patients in these primary care practices (case-based learning).
• In exchange for co-management support, primary providers are expected to become the local specialists for these conditions in their community (and also receive free CME). 
• The specialty interdisciplinary team (e.g., pharmacist, psychiatrist, hepatologist) virtually “rounds” with the primary practices, so that all practitioners simultaneously learn best practices (as they implement them) and become a practice ‘community.’ 
• Clinical outcomes are centrally captured and shared.

Key requirements: 

• The “de-monopolization” of specialty expertise-- finding specialists (and subspecialists) who inherently believe that complex conditions can be managed in the primary care setting.
• Interested primary care providers willing to spend the extra time (2 hours weekly) to participate in an ECHO and provide consultations to other local providers.
• The condition should be common, require complex management, with evolving treatments/medications, high societal impact (health and economic), serious outcomes of untreated disease, and ability to significantly improve outcomes with disease management.
• Initial outcomes are promising, as evidenced by their recent NEJM article, which demonstrated similar Hepatitis C treatment outcomes in the community when compared to the tertiary care center (almost unheard of).

The model is being spread to: addiction management (via buprenorphine), rheumatology,

pain management, diabetes care, severe hypertension, chronic kidney disease management,
and CHF.  It also has been used to also train medical assistants, peer support staff; and,  the infrastructure, once in place, can be used for rapid dissemination of information (e.g., H1N1 information).

The most aggressive adopters are the VHA and DoD.Most replication sites are rural, but the University of Chicago is using the model with local federally qualified health centers (FQHCs) to support hypertension care.Even UNM is using ECHO to better support care in their local FQHCs and feel that they are now much more effective at triaging patients into specialty care visits.

To date, however, the model seems to be implemented in settings where specialists are salaried and play an active role as educators.