2016 Public Health Grand Rounds 09/16

PUBLIC HEALTH GRAND ROUNDS Linking Research to Community Health Improvement Jointly sponsored by the Department of Public Health Sciences & URMC Center for Community Health

- [Presenter] Okay, maybe we should get started now.
So welcome everyone to the Pub Health Grand Round.
Which is jointly sponsored by
the Department of Public Health Sciences,
the Center For Community Health at URMC
and the Center for Research.
So today is the kickoff of the grand round
for this academic year, and we're very pleased
to have Dr. Michael Hesselberg here from Psychiatry.
And he will present the Project ECHO
implemented by the UR Medicine.
Dr. Hesselberg is Assistant Professor
of Psychiatry and Clinical Nursing at the University
of Rochester, where he's the Director
of UR Medicine's telepsychiatry program,
the UR Project ECHO.
He is a board-certified Psychiatric Nurse Practitioner
who received his PhD in Prospective Research
from the University of Rochester School of Medicine.
Dr. Hesselberg is also a member of the Academy
of Healthcare Leadership Advancement
through the Healthcare Association of New York State.
He has vast clinical expertise with older adults
in both outpatient and inpatient mental health settings,
as well as the comprehensive psychiatric emergency room.
Dr. Hesselberg also serves as a research
investigator on several federally-funded clinical trials.
So please join me in welcoming Dr. Hesselberg.
(audience applauding)
- Thank you, thank you all for having me.
Thank you for that wonderful introduction.
And what I want to talk to you about today
is kind of near and dear to me.
As you heard, I'm the Director of Telepsychiatry
here at the U of R, and I get asked
a lot to do talks on telepsychiatry.
And actually, I tell folks when I get asked
to do talks on telepsychiatry,
I say you don't want me to talk about telepsychiatry,
that's not very exciting, you want me to talk about ECHO.
And so I'm very excited that I was actually
asked this time to do a talk on ECHO, and what ECHO is.
I have no financial disclosures,
but I do want to acknowledge, I have a lot
of funding support to do with this ECHO model.
The current funders include the Greater
Rochester Health Foundation, and I see some of them in the
room today, and the New York State Health Foundation,
Health Foundation for Central
and West New York, and also HRSA.
So why are we doing this?
We know that five percent of our entire population
in the United States accounts for more
than 50 percent of all healthcare costs.
Looking at this five percent, and we would call
this five percent of folks superutilizers,
these are the ones that are frequently going to the ED,
or are frequently admitted.
What we know about this five percent is 80 percent
of these superutilizers have mental illness,
or a primary psychiatric disorder.
And so we know that, you know, we really need
to help target this population,
not only to improve quality of care for patients
with mental illness, but also, you know,
help for the financial viability of our health system.
So one potential solution is this Project ECHO,
Extension for Community Healthcare Outcomes.
And this gets really, this model gets confused
as being telemedicine.
This is not telemedicine.
And the mothership of ECHO, which I'll talk about,
which is down in New Mexico, the University of New Mexico,
they want to make it clear that this is not telemedicine,
we would call this telementoring, and teleconsultation.
So when I do telemedicine or telepsychiatry,
the great thing about telepsychiatry
is I can get past geographic barriers with my patients.
So I can see a patient here at the U of R who's maybe
in need down in Elmira who can't get up to the U of R.
But the problem with telepsychiatry and telemedicine,
I'm only touching one patient.
There is one patient on the other end of that video screen.
This model allow us to touch lots of patients,
entire case loads of patients.
And the model, like telemedicine,
is based on this concept of a hub and spoke model.
The hub being the academic medical center.
And it's also based on this idea
that academic medical centers, that's where you have a
wealth of specialty expertise and subspecialty expertise.
And out in these community areas
they may or may not have access to specialists.
And how do we de-monopolize subspecialty expertise,
and how do we get it out to the generalists
in the community, so they start to develop
that capacity and have that decision making support
in that specialty area where they can start
better managing their patients within their own community.
The great thing about this model is the technology
is very inexpensive.
We're not talking about very expensive
telemedicine kiosks, polycom, Tamburg hardware.
Only thing that you need to have at the spoke end
to participate in an ECHO session
is internet access, a webcam, a microphone, a speaker.
You know, we all have smartphones these days,
we have lots of participants that join
into this model on their iPhone, on their
Samsung smartphone, tablets, iPads, laptops.
The way this model works is we hold biweekly,
what we call tele-ECHO clinics.
And what these tele-ECHO clinics are
is at the academic medical center,
you have a multi-disciplinary team
of specialists who sits around a boardroom table.
This team consists of medicine, social work,
nursing, pharmacy, psychology,
even non-medical community based resource experts.
They sit around this table, and all of these spoke sites,
these primary care docs or community based
generalist clinicians, they video conference
into this room on these bi-weekly clinics.
The cool thing about the model is you can see
all the specialists sitting around that table
if you're a rural primary care doc,
but you also get to see all of the other primary
care docs that are in clinic also on video.
So essentially what you start doing
is you're forming these communities of practice.
Within the model the way this works
is the generalists or the primary care docs,
they present cases to this specialist team,
but the cases are de-identified, no patient names,
no birthdates, just enough patient information for the
specialists to have a good conversation about the case,
provide recommendations back verbally.
We also send recommendations back in a written format,
within a week of when this generalist presented to us.
But we also encourage all of these
other primary care providers online to give
their thoughts and their recommendations,
what are their best evidence based
practices in their community?
And so we build that into the recommendations.
Once we get through the first case,
what we typically do is we do 15 minutes
of evidence based didactics.
So one of the specialists around our table will
do a 15 minute PowerPoint in that sub-specialty area.
And most of the times our didactics
are really focused on the quality metrics,
the hedist measures that primary care practices are going to
need to meet in value based population health management.
For nursing homes, we do it in nursing homes,
we really focus on MDS quality indicators,
which again, these are the quality indicators
that are tied to Medicaid reimbursement for these homes.
Once we get through that 15 minutes of didactics,
we go back to case presentations.
We try to get through as many cases as we can
in this 90 minute tele-ECHO clinic.
So there are a few different learning theories
that we suspect of how this is actually working,
and how this knowledge is being transferred,
the first being what we call learning loops.
So if you're a generalist in the community,
you have an opportunity to present a difficult case
to this multi-disciplinary specialist team.
The specialist team will provide you recommendations back,
and you have an opportunity to then go
implement those recommendations.
You have a chance to see what works and what doesn't work.
If things don't work, you have another opportunity
to re-present that case, so kind of
this double learning loop, back to that specialist team.
The other kind of thing that we think is going on
with this model is what we call these knowledge networks.
So as you can see, all of the other primary care
providers online, this community of practice starts to form,
where these generalists start to become sub-specialists
in an area, and they start to serve as a resource.
They serve as a resource for
the other primary care providers within
their primary care practice if it's large practice.
They start to serve as a resource for that entire region.
And then all the other primary care providers
who are participating in this community of practice,
they start off clinic hours referring cases to each other,
touching base with each other.
And these may be practices that had really
no communication or weren't even realizing
what the other practice down the street was doing
until they saw each other in this kind of forum.
And again, the last important piece of this
is those didactics, and kind of content knowledge.
And those didactics, like I said are really,
we focus on the quality metrics of these facilities
and practices need to meet, but the other thing
that's really important is, as we move
into population health, we always hear about
team based care, multi-disciplinary based care.
It's hard to do in your own practice,
we're still siloed out.
You've got the physician who writes the order,
you've got the nurse who takes the order off,
you know, you have maybe the nursing aides
that is implementing the order,
the nurse who implements the order.
We don't want that system of care to continue happening,
because we think it's ineffective.
So what we try to do, we have this multi-disciplinary
team sitting around the table,
is showing how you can attack a single problem
that's presented to you from multiple
different disciplines' lenses.
And we show how you can work through issues
from this multi-disciplinary team approach.
And on the other end, we encourage these practices to not
just be the physician who comes to these things.
We encourage them to bring their nurses,
their social workers, their physical therapists,
their psychologists.
And we want to model to them how
multi-disciplinary teams function.
So where did this all start?
We did not invent this model here
at the University of Rochester.
So this model started about, you know,
12 years ago at this point in the state of New Mexico,
at the University of New Mexico.
So essentially what was happening in
that state about 12 years ago, if you were a patient
with hepatitis C, the only place
that you could get care was by a few hepatitis specialists
at the academic medical center.
The great thing about hepatitis C
is it's treatable, and most cases curable.
But 12, 10 years ago the medications we used
to treat hepatitis C were quite dangerous,
and the primary care docs in that state didn't feel
comfortable prescribing these medications.
So this hepatitis specialist, Dr. Sanjeev Aurora
said you know, how can I reach more patients?
Essentially, these patients are dying off
and I can't see enough patients at my practice.
How do I support these primary care providers
in this state to feel comfortable,
to treat these folks, and prescribe these meds?
So he's the one who created this model and started it
in hepatitis C care at the University of New Mexico.
The great thing that Sanjeev Aurora had
was he applied for a very large multi-million dollar
Robert Wood Johnson Foundation grant,
which was funded to actually evaluate
the efficacy of this model.
And what he looked at was,
he looked at patients with hepatitis C
who were going to get care from their primary care providers
who were participating in ECHO,
and he compared that to the group of patients
with hepatitis C who were seeing the hep specialists
at the academic medical center,
and the outcome they were looking
at was sustained viral loads.
And what they found was there was no significant
difference between these two groups,
which suggests that the primary care docs
were providing just as good of care to these patients
as the specialists were in person.
That finding was published in the New England Journal
of Medicine back in 2011, and we all know that the
New England Journal of Medicine is one of the journals.
It's a very high-impact journal,
and when you publish in the New England Journal of Medicine
things take off, things just start to kind of disseminate.
And that's what happened, where actually
at New Mexico they built a Project ECHO building.
And every single day of the week, well except weekends,
and almost every hour of the day
they are running a different ECHO in a different disease
population to support that state.
At this point in time, they're up
to about 30 different ECHOs that they're
running out of their academic medical center.
The model didn't just stay in New Mexico,
it started to slowly come out to the rest of the country,
where at this point in time,
it's in over 30 different states in the United States,
and it's actually in 15 different countries.
Up until about three years ago,
yeah about three years ago at this point,
the model had not yet come to New York State.
And this was right around the time
of the New England Journal of Medicine publication,
not too far after that, so it really hadn't started
disseminating as diffusely across the United States,
but three, four years ago it had not come to New York State.
And right around that time, a few years prior to that,
I had joined faculty in the Department of Psychiatry,
and kind of my background as a clinician,
you know, geriatric psychiatry is what I do.
My PhD work was actually in clinical trial work,
I did pharmacology research for Alzheimer's disease,
biomarker research for Alzheimer's disease.
I loved it.
But my chair, you know, he wasn't so excited about
that Alzheimer's research I was doing.
He said, you know, "I want you to bracket that
"and put that up on the shelf.
"I want you to develop telepsychiatry for our department.
"We don't have telepsychiatry, we need telepsychiatry."
At that point in time, traditional telemedicine,
and it's still today, but it was worse four years ago,
wasn't being reimbursed, and really
the only way you could do it was through grants.
So I wrote a grant to the New York State Health Foundation
to actually do a more traditional telemedicine model.
So we have the geriatric psychiatrist
at the academic medical center.
The older adults arrive to the primary care practice,
we evaluate the older adult,
hand the patient off to the primary care doctor,
who would then manage the patient.
Well the New York State Health Foundation
is who I wrote this grant to.
They loved the idea of integrating geriatric
mental health in to primary care,
but they weren't excited about telemedicine.
Telemedicine has been around in psychiatry,
you know, since the 50s, and you know,
they wanted something different,
and they had heard about this ECHO model,
and had read the New England Journal of Medicine model,
and they wanted to bring this model to New York State.
And they said, "We'll fund you,
"but we'll only fund you if you do Project ECHO."
I knew nothing about ECHO, and I said,
"Great! I'll do ECHO!"
So took the funding, went down to New Mexico.
I got immersed in this model, and U of R signed
a licensure agreement with New Mexico.
It's a proprietary model, but New Mexico
gives it out for free.
And we signed a licensure agreement
to replicate it here in New York State.
There's some good reasons of why ECHO
would fit into the state at that time.
You know, what we know about behavioral health
in our region is folks with psychiatric illness,
the psychiatric diagnosis are in the top three clusters
of patients that frequent REDs in this region.
We also know that these folks,
when they're admitted into the hospital,
they're the most likely to be readmitted
into the hospital after discharge.
So we knew from a patient-wide area
there was a need for this.
The other problem that we have is access
to psychiatrists and psych nurse practitioners,
and to mental health providers.
There's just not enough to go around.
So if you look at 14 counties, Monroe Country
and then 13 counties surrounding it,
11 of those counties are considered health provider
shortage areas, and eight of those
14 counties are specifically
designated mental health provider shortage areas.
Some of these eight counties,
there's not a single psychiatrist
for the entire county, there's not a single psychiatric
nurse practitioner for the entire county.
And then the federally qualified health centers
in New York State have identified specifically psychiatrists
and psychiatric nurse practitioners
are the number one disciplines
that are the most difficult to recruit and to retain.
So again, we knew that there was a need to
kind of de-monopolize this mental health expertise.
Then it gets even more interesting.
So when you talk about older adults,
and again, this is my love, because geriatric
psychiatry is my clinical background.
We know that the older adult population in New York State,
over the next 15 years is going to double.
We know that those with mental illness
are going to grow proportionately with that.
We know that one out of every nine people
over the age of 60 probably has Alzheimer's disease.
That goes up to one out of every three over the age of 80.
When you talk about geriatricians,
there has been some growth, so this dotted line here
is kinda the trend of geriatric medicine,
geriatrician physicians graduating
from school and joining the work force.
So there has been some trend up.
But that solid line is the actual need for geriatricians.
And you see that there's this gap
that we're never gonna close.
When you talk about geriatric psychiatry,
it's 10 times worse.
What a lot of people don't know,
across the entire country, we only graduate 40,
maybe 50 geriatric psychiatrists
for the whole country per year.
So if you're an older adult, if you're lucky enough
to see a psychiatrist or someone in psychiatry,
all likelihood it's probably a general psychiatrist,
and there's a lot of evidence to support
that the general psychiatrists don't feel comfortable
with the older adult population.
Big difference seeing a 30 year old who's on maybe one
medication, versus an 80 year old who's on 25 medications.
So for me, the low-hanging fruit was we'll start
an ECHO in geriatric psychiatry, and you know,
we'll do it for primary care.
And you know, at that time, I was working as
a clinician in our memory care program,
which is an outpatient dementia clinic
where we diagnose Alzheimer's disease
and we manage neuro-psychiatric symptoms,
and I had an eight month wait list to get in to see me.
So I knew okay, that's the low-hanging fruit,
we'll start there in geriatric mental health.
However, I was not at all optimistic that this was
gonna work in New York State, actually very pessimistic.
I said to myself, you know, for a few reasons,
I go, the first thing is is we're
in a fee for service landscape.
How am I gonna convince busy primary care docs
that essentially they get paid by how many patients
they can crank out in an hour,
how am I gonna convince them to leave
that busy practice to come to essentially an educational
experience every two weeks for 90 minutes,
where they're gonna lose that revenue?
And oh yeah, I'm gonna train them to become
experts not only in mental health,
but geriatric mental health where
these patients are complex, they're time-consuming,
and the reimbursement's horrible.
I said I'm not gonna get anybody who's gonna
want to do this.
We were pleasantly surprised.
So we launched our first ECHO in geriatric mental health
and primary care back in 2014.
What you see in this square here,
the big square is our specialist team sitting around
the table, which consists of a geriatric psychiatrist,
a psychiatric pharmacist, geriatrician,
psychiatric nurse practitioner, a geri-psychologist,
and a geriatric social worker.
The four small squares on the side
there are primary care docs.
Actually, at this point in time in the clinic
we have 11 primary care practices up and going.
Those four small squares will rotate out
for whoever kinda talked last,
so everyone gets to see each other.
We can also adjust how many squares
that we have up on the screen on our end.
So we did this project from 2014 to early 2016.
During that time, we held 33 ECHO clinics.
We trained over 500 primary care providers
in geriatric mental health.
We averaged about 16 clinicians per clinic.
We do give free CMEs out, and we gave almost 250 CMEs,
and we got through about 65 case presentations.
The cool thing is the geographic reach of this program.
So we had primary care practices in almost 32 counties
in New York State that participated in this,
with the exception of New York City,
the lower Hudson Valley, and Long Island area.
We had primary care practices that were affiliated
with large health systems, so where you
kinda see the clustering of red,
those are large health systems in our state
that signed up all of their primary care
practices to participate in this.
We had provider owned primary care practices,
we had federally qualified health centers,
some health service corporations.
And interestingly, which was really cool,
some of the kind of county aging services
got interested in this, and we invited them to join.
So the county aging services would video in.
So in terms of our findings, one of the things
that we were really lucky about was right
around the time when I was sent down to New Mexico
to get trained in ECHO, our large HMO
in this region is Excellus, they were
very interested in ECHO.
So actually, their Chief Behavioral Health Officer flew down
with me to get immersed in this model,
and she said, "You know what, we're gonna give you access
"to all of our claims data across the state,
"so you can do an evaluation on this,
"because we want to see if it makes a difference."
We did for several reasons.
We did sub-contract our our evaluation to a third party,
so the New York Academy of Medicine
in New York City did our evaluation,
and partly of why we did that was we didn't want
it to look like there was any bias from us,
because we actually want to get this into
managed care products going forward.
But we were able to look approximately
20,000 Excellus beneficiaries over the age
of 65 across 35 practices that had Excellus beneficiaries.
And the median was about 550 Excellus
beneficiaries per practice.
And what we looked at was we couldn't control for anything,
so there were no control practices,
so we did a pre-post evaluation, we did six months,
we kinda looked at healthcare utilization and cost
of these practices at the practice level,
six months prior to joining ECHO,
and then six months after participation in ECHO.
One of the really kind of cool things was
was we had a trend down for our Excellus beneficiaries
who had psychiatric diagnoses over the age of 65
in most areas of utilization it almost reached
statistical significance for ED utilization.
When we looked at cost, we did reach statistical
significance for ED associated costs
of these beneficiaries that had psychiatric diagnoses.
Again, interpret this data with caution,
because we weren't able to control for anything,
and it was looking only at Excellus beneficiaries.
But this was a very encouraging finding,
not only for us, but the insurers
and the financial leadership here at the University.
Looking at the other group, so patients that were Excellus
beneficiaries who did not have mental illness,
there was actually trend up, increased utilization
of outpatient visits with this group,
and increased cost and prescription cost
for those without psychiatric diagnosis.
And we suspect that that trend had been going on,
we just caught it cross-sectionally
when we did our analyses.
But again, this was not our group of interest.
We were really interested in those with psychiatric illness,
because that's what our intervention was targeting.
So it was even more encouraging where we saw
that this group was trending up,
and we had a trend down with our group of interest.
The other thing we did, which is probably
more rich data of the evaluation,
was a qualitative evaluation of the project.
So New York Academy of Medicine did focus
interviews with our participants,
and you know, we did a theme analysis.
And you know, some of the things
that we heard was they loved the program,
they felt more satisfied, felt more efficacious,
they felt there was knowledge change.
They felt when they implemented the recommendations
on their patients there was improvement.
Some of them identified what we already knew
or what we hypothesized was barriers
to participation was time, and lack of time.
But other kinda cool themes that started coming out
of this evaluation was kind of two things.
The first thing was that the primary care providers
said to me, in their perception,
only a small subset of their practice was of geriatric age.
And they said, even though epidemiology data disagrees
with that, but that's what they perceived.
And they said we would love it if we could have an ECHO
for kind of general psychiatry across the lifespan.
I took that to heart, wrote another grant,
which was funded, and we started up a general
psychiatry ECHO for primary care.
The other theme that started coming out
of this analysis was, you know, the primary care providers,
especially in the rural regions,
they were essentially the hospitalists
in the nursing homes in those communities.
And they said your geriatric mental health ECHO
would be perfect for nursing homes.
And we talked, that would be a great idea,
so we wrote a grant to the Greater Rochester Health
Foundation, which was funded, which allowed us
to take our geriatric mental health ECHO out
of primary care and put it into skilled nursing facilities.
So we launched our ECHO in geriatric mental health
for long term care in December of 2015.
And it's been very, kind of,
cool what we've seen with this ECHO.
We've had, at this point, clinics,
we've had almost 1,600 attendees from these
skilled nursing facilities, so a lot more
engagement from the long term care facilities
than we saw in primary care.
We're averaging, you know,
over 50 attendees per ECHO clinic.
Right now, we have, I want to say, you know,
55 skilled nursing facilities up
and participating in this ECHO across 13 counties.
We actually got so big, we had to start two cohorts
of nursing homes, first cohort 30 nursing homes,
second cohort right now is 25 nursing homes.
They're still biweekly, but they alternate,
so we're essentially running this ECHO every single week.
And we've given out almost 500 CMEs thus far for this ECHO.
This gives you an idea of kinda the geographic reach.
And the Greater Rochester Health Foundation
is really kind of focused in our region,
so this is not a statewide program,
even though we're getting, which I'll talk about
in a little while, lot of recognition
and visibility statewide for this nursing home ECHO.
But this gives you an idea of all
the different nursing homes across the region
that are up and going and participating.
Who comes to these clinics?
It's very cool.
In the primary care model, we got a lot of physicians,
nurse practitioners, and PAs.
Actually in the nursing homes, we get a lot of nurses,
social workers, nursing aides.
We do still get some of the prescribers,
but mostly it's kind of the front end staff
or front line staff that we're getting in this ECHO.
So we launched our general psychiatry ECHO for primary care
in March, and so we're about six months into this ECHO.
We actually have seen more participation.
We're averaging almost 20 primary care
providers per these ECHO clinics.
And we've had about 225 participate
in this six month period of time.
So you know, this one's still kind of in its infancy,
and kind of building up, but we're very excited
about this ECHO, because we think,
and when you talk about population health
and value based care, these are your superutilizers.
And this is where I think there's the most value added,
not only from a patient standpoint,
but also from a financial standpoint for a health system.
So talk about sustainability of this model.
In a fee for service landscape, a volume-based
reimbursement landscape, this model doesn't work.
There is no way of reimbursing for it.
No one wants to pay for somebody else's education.
That being said, as we move to population health,
and as we move to value-based health,
it has a lot of opportunities,
where there's actually right now,
there is an ECHO bill that's in Congress,
because ECHO has gotten so large, really
kind of trying to push the federal government to think about
sustainable reimbursement mechanisms for this model.
There's also a Medicaid learning collaborative
specifically around coming up with innovative
financial mechanisms to support ECHO,
and right now it's in eight states.
We're not one of those states,
but Medicaid is quite invested in this,
looking at the potentials of this model.
So how do we integrate Project Echo
into value-based care here?
The really like serendipity thing
that happened for us was something called DSRIP,
so we were already up and going with Project ECHO,
we were already funded, we had this model going,
and so what DSRIP essentially is
is it's a Medicaid waiver amendment program.
Essentially, Medicaid at the federal level
gave New York State eight billion dollars,
and said over the five years we want you to disseminate
this eight billion dollars across the state,
and we want you to transform the way we provide healthcare.
We want health systems to move from volume to value.
And essentially, what ends up happening in DSRIP is,
this isn't like the U of R just doing this as themselves.
These kind of performing provider systems formed,
where essentially large groups of counties
kind of gathered together, and decided
to kind of write this DSRIP applications,
they joined kind of a league together,
and all of the organizations, including the hospitals,
the primary care practices, the nursing homes,
transportation, housing within these counties
formed these performing provider systems.
Before the performing provider systems even came together,
the great thing was, in the DSRIP toolkit
that went out to these counties to encourage them
to form these performing provider systems,
they actually referenced New Mexico's Project ECHO,
and encouraged these groups to embed Project ECHO
in some way into their DSRIP applications.
So in our region, the performing provider system
is called the Finger Lakes Performing Provider System.
And the cool thing about our performing provider system
is the two big health systems in this region,
UR Medicine, Rochester Regional Health, direct competitors.
And it's a nasty kind of competition
between these two health systems.
But they came together and said we're gonna join forces
and take co-leads of this performing provider system.
And then there are 600 organizations within the PPS
that kind of fall within this.
So we actually, in the state, got a lot of the DSRIP
monies disseminated to our area,
not only because we have a very high Medicaid
population in this region, but our two large health
systems decided that they were gonna work together.
And in other areas of the state the competitive
health systems did not agree to do that.
So there were several DSRIP projects.
One of the DSRIP projects that our performing
provider system elected to participate
in was a project called Behavioral Interventions Paradigm
in Skilled Nursing Facilities.
So this project is really focused
on decreasing Medicaid re-hospitalization.
So patients who are living in nursing homes
get sent to the hospital, get sent back to the nursing home,
and they get sent back to the hospital again.
So they really want to target to decreasing that.
They found that behavioral health
is really kind of driving that.
So the metrics within this DSRIP project are A,
how do we educate both our clinical and non-clinical staff
in nursing homes to become more dementia,
more mental health savvy?
That's where ECHO fits in.
The other is how do we improve access, you know,
how do we embed specifically psychiatric nurse practitioners
into these homes to provide care?
There's not enough psych NPs to go around to meet this need,
so that's kind of where telepsychiatry may fit in.
And then the other is how do we modify our facilities
to be more holistic and kinda dementia capable?
And our ECHO and long-term care,
that the Gray Health Foundation is funding,
actually kind of sits in this DSRIP project.
So all of those nursing homes in
that DSRIP project have an opportunity
to participate in our ECHO.
Then there was another DSRIP project,
project 3.A.I of all about integrating primary
care into behavioral health services.
Same kind of idea of decreasing Medicaid
re-hospitalizations, but really focused on primary care.
RPPS elected to do this project,
and also the Leatherstocking, or Bassett PPS out
in Cooperstown, they also elected
to do this DSRIP project.
And now we're in discussions with not only out PPS,
but also Bassett's PPS, who have both reached out
to us and are interested in our general psychiatry ECHO
being embedded into this DSRIP project.
So ECHO in general, you know, we started
in the Department of Psychiatry, it's just
kind of taken off here at this university,
where we've got this infrastructure,
we've got this great network.
Other departments and schools in the university
started reaching out to me saying they're interested
in starting up ECHOs in their own disciples.
And we've got several ECHOs that are now currently
funded and are going to be launching, or have launched soon.
We've got, you know, ECHOs in hep C, HIV,
and STDs coming out of the CTSI,
eating disorders out of the School of Nursing,
pediatrics is gonna do autism,
geriatric medicine palliative care.
There's an oncology ECHO that's currently
at grants and development, a pediatric epilepsy ECHO,
grant's already been submitted, we're waiting for funding.
And which was really cool is potentially
a hospital medicine ECHO where we can support
our affiliate community hospitals that are joining
kind of the UR Medicine network.
I just want to make a notation
is the Department of Public Health Sciences,
we found out yesterday, Halina Tempora Greener
has just been funded as the PI of a large Donahue grant
to essentially look at performance metrics in nursing homes,
and around behavioral health,
and is interested in potentially looking at the work
that we're doing with ECHO, and seeing does
that make any changes to these performance metrics.
So we just heard that that was funded.
So we're excited, that will increase kind
of the robustness of our Greater Rochester
Health Foundation grant findings.
So recognition of our work, we've got a lot of visibility.
CMS has reached out me, I've done webinars
nationally for CMS on ECHO.
Interestingly, SAMHSA, the Substance Abuse
and Mental Health Service Administration,
they heard about our ECHOs in behavioral health,
they called our department's Office
of Mental Health and said,
"You need to reach out to Rochester
"and find out what they're doing with ECHO."
So OMH called me and said, you know,
what are you doing with ECHO, and I told OMH.
And this went back and ECHO was presented
at a federal briefing, our specific
work here in Rochester with ECHO.
The Department of Health has identified,
they are currently putting out a white paper
around telemedicine, and they're identifying
kind of benchmark organizations.
And they identified six benchmark
organizations for doing telemedicine.
The University of Rochester, we were selected
as one of those benchmark organizations,
and partly for the work that we do with ECHO,
and I see Ken McConnaguhy in the back,
and also the work that he's done
with pediatrics and telemedicine.
We were chosen to be one of these benchmark organizations.
So the Department of Health has come, done a site visit,
they've participated in my ECHO,
so we're looking forward to that white paper going out.
The other thing is the funders love this model.
So we got actually lots and lots of interest for funding.
So it's not a problem of funding this.
But I'm actually not so much interested
in all of these funders, because I don't
want this model to live on grant funding.
I want a sustainable reimbursement mechanism for this.
So I'm actually almost to the point
where I don't want to be funded again.
I'm trying to push our leadership
and push the insurers to invest in this model.
So what are the challenges of that happening?
Well the first is, the long term challenge
is we're still in a fee for service landscape.
Even though that's kind of moving over,
right now we're doing this off of grants,
this cost savings that is being generated
is not all coming back to the U of R.
We have Rochester Regional practices in this,
so it's going to our competitor.
The cost savings of potentially reducing ED costs
is going to the insurer, that actually hurts
the U of R in a fee for service arena,
because we want more people to go
through the ED, not less people.
So you know, kinda the cost is we're not containing it,
so that's an issue.
The other issue about this model is primary care providers,
they're busy folks, and they're asked to do
more and more things, more kind of clicks
that they have to check off to meet meaningful use.
So how many ECHOs can we really offer primary care
providers until they get overwhelmed
and say I'm not participating in this model anymore?
And then the other thing is the misaligned
incentives in a fee for service.
If you're a primary care provider,
why would participate in this?
I'm going to lose volume in my practice.
And then as a health system, why would we invest into ECHO?
Because we're not in value yet, we're in fee for service,
and if this model is showing that it's increasing kinda
high cost procedures and high cost utilization,
that's actually taking away from our bottom line currently.
So they're not really ready to kind of jump in on this yet.
So in terms of reimbursement going forward,
there are several approaches where this model would fit in,
managed care being one of those,
and then accountable care, kind of shared savings.
So let's say we were to do ECHO
in just our accountable health partners.
You know, so the spoke sites were limited
to our own network of primary care practices,
essentially that savings would stay within our network,
and some of the savings should come back
to our ECHO hub to support that infrastructure.
That makes some sense.
Patient-centered medical homes, it makes sense there.
And of course right now we're testing DSRIP.
Other parts of the country, they already
have reimbursement mechanisms for ECHO.
You know, a lot of states already have managed care insurers
that have invested into this, like New Mexico, like Oregon.
In Colorado, their accountable care
collaborative has invested in this.
And there's two of us that are looking
at this through DSRIP.
So in terms of participation and savings,
I mean this model makes a lot of sense.
If we get back to my first slide of those superutilizers,
these are the folks that in a value-based health system,
if we don't get good management
of that top five percent, we're gonna sink.
I mean, we're financially not gonna
be viable in a value-based system.
Who are those superutilizers again?
Those are our psychiatric patients.
We do this intervention of Project ECHO, you know,
what we've seen thus far in our evaluation,
we're improving access to behavioral health expertise,
we're potentially improving treatment compliance,
we're improving provider satisfaction,
they're enjoying participating in that,
and hopefully that will result in shared savings
and reduced costs for our health system.
So the potential benefits in general,
you know the whole idea of this model
is to decrease variations of care.
We don't want this whole region doing
their own thing for certain populations.
We want to make sure that everyone
is providing best evidence-based practices,
and that's what this model is all about,
de-monopolizing expertise and getting everybody
doing best evidence-based care that will ultimately
improve the quality of care of our patients,
we'll have better patient outcomes,
and in turn that should also improve the cost expenditures
that we have here in our region.
So in conclusion, we've found the model
thus far to be pretty robust, and a good effective medium
to reach kind of complex diseases out in our state,
in our region, and especially in underserved areas.
As you saw, it's already quickly expanding
into other disease areas at the university.
Come January 1st, this should be up and going,
and we'll have 10 different ECHOs coming out
of the university across different
schools and different departments.
And we're already looking at sustainability.
Our financial leadership is very interested in this,
they are talking with Excellus about this,
Excellus is interested in it,
our accountable health partners
are all participating in this, they're interesting in it.
So we're working on it.
I mean the issue is this move from volume to value
doesn't happen quickly, and I think everybody
is just kind of dipping their toes in the water
and seeing what's actually gonna happen.
So thank you.
(audience applauding)
Yes?
- [Man] Are these sessions recorded?
- No, it's a very good question.
So the first reason why they're not recorded is,
just speaking about grand rounds,
so think about virtual grand rounds.
In our Department of Psychiatry,
everybody wanted our grand rounds recorded.
They said you know, you have to record
these because I'm gonna watch them later.
We found, we started recording them,
no one ever watched them later.
So what we did, instead of recording initially
was we developed a Blackboard site
that we would just give to our participants
when they asked for it, they could get all of our didactics,
we were thinking about recording
and putting the recordings on the Blackboard site.
We had it open for six months,
and the practices requested it.
Not one person opened the Blackboard site.
And the problem is, these recordings
take up a lot of server space.
So for those reasons, we've elected not to.
Other questions, yes?
(audience member speaking indistinctly)
So we didn't really kinda compare to other patients.
Yeah, so pre-post, this was just
looking at Excellus beneficiaries.
We identified, and it was at a practice level,
so we didn't evaluate at a patient level.
So at the practice level, we looked at all
of the patients in that practice
that were an Excellus beneficiary over the age of 65.
We identified diagnoses in two ways.
Either they were billed for some primary psychiatric
diagnosis in that period of time, or we had a proximal,
because we think the primary care
under-diagnosed a psychiatric diagnoses.
We looked at medication claims.
So if they were on a psychotropic medication,
we used that as a proximal indicator
that this patient has psychiatric illness.
And then we looked at patients,
Excellus beneficiaries over the age of 65,
who weren't on a psychiatric med
or didn't have a psychiatric diagnosis.
But we didn't really compare the two groups, per say.
Yes?
(audience member speaking indistinctly)
Good question.
So one of the things that we were
really nervous about was liability.
And before we even launched this,
we spoke with all of the legal folks here.
And because this is deemed an educational experience,
and everything is de-identified,
our legal counsel felt that our liability was actually low,
and actually would lower the liability
of the primary care providers if they participated in this,
because now they actually have access to specialists.
What we do is we send out a memorandum
of understanding for everybody who
participates in this or sites,
on that memorandum of understanding it clearly states,
and legal put this together,
U of R we don't own these patients,
we don't take on care of these patients.
These patients stay in the purview of the practice.
And then we also, within that memorandum
of understanding is the HIPAA and the de-identification,
that falls on the primary care practice.
So it's their ownership of following HIPAA and not saying.
We have some safeguards.
So when these cases get faxed to us, they get faxed
prior to the sessions to our Project Coordinator.
We ask that the sites de-identify
it on their end before it gets to us.
She gets it at a dedicated fax machine.
She'll go through, and if there's something
that's not de-identified she'll black it out on our end.
The specialists around the table,
we don't see the cases until the site's presenting.
So essentially she'll, the Project Coordinator,
makes copies of these cases, and while it's being
presented it gets passed around the table.
So it's kind of like a curbside consult
that we would do just in general practice.
And thus far, as far as we're aware,
there's never been any legal consequences
or lawsuits associated with ECHO across
the country since it's been up and going.
Yes?
(audience member speaking indistinctly)
Absolutely, so especially with our behavioral health.
So we know behavioral health cuts
across all spectrums of health.
So we have had a lot of interest from other specialty areas
of wanting to participate in our ECHOs
and join and be involved.
And we are starting to allow that to happen.
So what we actually, in our general psychiatry ECHO,
we've several infectious disease doctors kind of join in,
we've have oncology join in.
So it's starting.
We market it to the primary care providers,
because that's kind of what our intent was
of launching the program, and that's
what our funding looked at.
But as the model has started to get visibility,
all of these other specialty services
are saying we would love to participate.
So this is a learning collaborative, so we're open to it.
Yes.
(audience member speaking indistinctly)
I'm not aware of it being used across countries yet.
The countries that it's in right now are typically countries
that have kind of a universal health system already.
So within those ECHOs in those countries,
it's countrywide, but at this point in time I'm not aware
of any ECHOs that are crossing country borders.
And that would actually be kinda difficult too,
I think, because the evidence-based care,
and what is feasible if you have a specialist team
in the United States, some of the recommendations
that we may make in a small country
in Africa may not even be feasible.
So I figure you'll run into some difficulties, potentially.
Yes.
(audience member speaking indistinctly)
Yup, so we use Zoom, Zoom.us.
So Zoom is a web-based video conferencing platform.
You can get it for free and download the app.
The nice thing about Zoom and the
University of Rochester is,
we have a business associate agreement with Zoom,
so that means that Zoom claims to be HIPAA compliant
and protected, and if HIPAA was to be broken,
it would fall on that company, Zoom.
Zoom is also the platform we use
for our traditional telemedicine program,
most of them out of the university.
So it's very secure, and very inexpensive.
Ken?
(audience member speaking indistinctly)
The first barrier, I mean, so if the target audience
is primary care, if you have 20 different ECHOs targeting
the same primary care practices, it will fail.
The primary care folks will get burned out,
they're not going to attend.
The other is, you know, I think from a financial standpoint,
is some of these ECHOs will probably
always live off of grant funding.
There probably will never be a reimbursement
mechanism for, and here's why I say it.
And if Mary Tantillo was in this room,
she would probably argue with me very strongly,
with let's say eating disorders.
Very small sub-set of the population,
not really a high cost sub-set of the population,
so I just don't see an accountable care organization
or a managed care product investing
into running an eating disorders ECHO.
Again, the value added is low, I think, for that population.
Talk about something like autism or behavioral health,
or even you know, potentially HIV or something like
that where these are very high cost patients,
the populations are a little bit higher.
We find that these folks are kind of draining our resources
as a large health system, we become capitated.
I can see the health system investing
in ECHOs in those areas.
So you know, I think it's going to be disease specific,
it's going to be also how many diseases
our primary care folks, if that's gonna
be the target audience, can take on.
And then again, the major barrier
is this transition from fee for service to value-based.
And in reality, our health system does very well
in a fee for service landscape.
I mean we have all the specialists here,
we have all the sub-specialists here.
So you know, we do well by cranking
out orthopedic surgeries, we do well by,
you know, doing high-end neuro surgeries here.
We do well because we have a very busy ED.
In a value-based, all the things that we do well,
we're going to be asked to not do
so much anymore, and that's scary.
So I think for health systems like us, you know,
we're still kind of watching to see if this value happens,
and not quite dipping our toes in yet.
So I think that's a major barrier,
because this model doesn't work in fee for service.
(audience member speaking indistinctly)
Potentially, potentially.
But you know, we already see this kind
of capitation already happening in Medicaid and Medicare,
and I think the train is on the tracks.
I think it's gonna happen.
The train is not gonna go off the track.
So you know, the problem is who's
going to make that decision, and when we're going
to flip the switch on and say okay,
we're going to invest into value and quality,
and we're going to start redeploying our resources
that are really focused onto volume.
And I don't want to be the person for
this health system that makes that decision.
That's a tough decision to make.
But I think it will happen.
So when it's gonna happen, I don't know,
I think the exciting thing for me
is I was invited to present to our board
of directors at URMMC, our Chief Financial Officer knows all
about this model and is talking about this model.
The Chief Financial Officer and CEO
of HP knows all about this model.
People are talking about it, and Excellus
is talking about it.
So like, we're on the radar.
So to me, that I think's a win all in itself.
Yes.
- Great presentation. - Thanks, Steve.
- [Man] Have you looked at like
the amount of patients reached?
Because I saw a project in Nebraska
for epilepsy for Project ECHO,
funded by the epilepsy foundation,
and they were upset because it looked
like the Project ECHO model and telemedicine
only reached like one in two families in the practice.
But what you're reaching, 500 providers,
those providers may be serving 2,000 patients.
- So there some statistical analyses
where you can potentially estimate that.
So you know, you can estimate that a primary care provider
typically has a case load of I think 827 patients,
is what I last read, on average.
And this whole idea of ECHO is called force multiplication.
You train one person, they're going to
be able to manage that large case load.
So we could kind of do those analyses and estimate,
I guess, the larger scale of folks
that were serving with this model.
And I do that when I write my grants,
and say this grant has a potential of reaching
X percentage of patients in these counties,
given this force multiplication idea.
But we're not, we don't really understand,
which is very hard to measure, is how knowledge
is actually transferring in this model
at the practice level, and how it's being disseminated
out to that case load of patients.
So you really kind of need, you know,
to study that and research that.
And no one's done it.
The funding, you would need a lot of money to evaluate that.
Yes.
(audience member speaking indistinctly)
I love that idea, actually.
So when you reframe the video taping of the sessions in
that context, it actually makes a lot of sense,
and has a lot of potential.
And I will kind of rethink about it.
The issue is, these sessions, it actually
takes up a lot of space on the servers.
And to get a server to keep all of these sessions on,
at least that's what my IT person says,
can be expensive and difficult.
But I love the way that you reframed it that way.
(audience member speaking indistinctly)
Absolutely, and if that's an interest area of yours,
I would love to talk to you further about it.
And you know, I think that we probably
would need to get a grant for it.
I think we could get a grant, we could buy
the server space to store this and start evaluating
that type of data, absolutely.
- [Woman] So as someone who grew up in a rural area,
I'm wondering, are there potentially extra
confidentiality concerns, maybe outside
the typical categories that HIPAA outlines,
in that you have a very small patient population,
and a lot of social relationships
that may make some content identifiable
that wouldn't typically be considered identifiable?
- Potentially, yes.
- [Woman] Also because I've heard,
I keyed in on the fact that sometimes
there are non-clinical content experts,
I'm guessing that those could be advocates
or community members with personal experiences.
I'm wondering about that.
- Those, so for example, for long term care
we have an educator from the Alzheimer's Association
that sits at the table.
Not a clinician, but that's what she brings.
But your question is a great question,
and we can't protect all of the HIPAA identifiers.
That's impossible to do.
And if we were to record these sessions,
it would probably, if we were looking at the recordings
for the purview of research, or you know,
how can we generalize this to a larger scale,
in that case yeah, I probably would need to get consent
from my participants that these are going to be recorded
for those reasons, and would pursue that.
I don't think it would be a difficult thing to do, but yes.
(audience member speaking indistinctly)
And that's good to hear, and I'm glad,
Rich, that you were here.
It's not a population that I know.
What I do know from the literature,
that right now it looks like a very small population.
Exactly. Well thank everybody.
(audience applauding)
(audience chattering)
Thank you, thank you for having me, I really enjoyed it.
(woman speaking indistinctly)
Yes, I've read your name.
- And just the possibilities for research here are wonderful
for the postdocs, and for doing global medicine.
- Absolutely, let me turn this off.
- So when you get to that point where
you're thinking about what sort of research,
I'd be happy to just do a quick consult.
- Fantastic, yes, you know for me