“All teach, all learn is non-proprietary. Inclusiveness is an important element in terms of who we ask to present and who we ask to bring cases forward to the group. We try to create an even playing field, to create a learning environment.”
Huther Doyle, an addiction treatment nonprofit located in Rochester, New York, and specifically the Medical Assisted Treatment (MAT) and Care Management ECHO programs, were included in a study led by Diffusion Associates and funded by the Robert Wood Johnson Foundation. The purpose of this study was to document and share how ECHO is adopted, implemented and sustained across ECHO hubs and programs in the United States and Canada. This study was separate from, but endorsed by, the ECHO Institute.
This profile is based on interviews conducted in December 2020 by R. Sam Larson, PhD, director of Diffusion Associates, and Jay Mason, director of Community Programs and Project ECHO, West Virginia University, and 2020 ECHO implementation fellow in this study.
We begin this profile by sharing unique implementation insights from Huther Doyle ECHO.
ECHO Implementation Insights
Building on Existing Work
The Medical Assisted Treatment (MAT) and Care Management ECHO programs had their origins in pre-existing work. The MAT ECHO started elsewhere and was integrated into Huther Doyle primarily because the MAT ECHO lead physician had an appointment with Huther Doyle. In addition, the ECHO Model and philosophy of democratizing knowledge was compatible with the mission of Huther Doyle and this made it easier for the organization to adopt the pre-existing MAT ECHO program even with little or no funding. The Care Management ECHO had its basis in a pre-existing training program for 40 care management agencies. The ECHO Model provided two advantages. First, the use of Zoom meant that training could continue during COVID and they could reach more people. Second, the blending of the didactic information and case presentations was considered a superior learning experience. For both programs, Huther Doyle easily adapted and replaced existing workflows to accommodate the ECHO Model.
Building on a Community Network
Huther Doyle exemplified how a “small but mighty” organization can make an oversized impact by building from a strong network among community-based organizations. Huther Doyle could quickly reach out to and recruit participants from this network. For example, specific to the Care Management ECHO, Huther Doyle and the Health Homes of Upstate New York (HHUNY) Network had “literally hundreds of care managers” which made it “relatively easy” to recruit participants. The network also served as a way to recruit didactic speakers. Because this network was broad, Huther Doyle was able to address issues that come up across their community of providers.
Huther Doyle’s adoption and implementation of ECHO programs provided “some prominence and recognition in medical and human services.” Their involvement in ECHO helped Huther Doyle to “be at the right meetings to network.” The value of this prominence and recognition was expanding and strengthening collaboration with communication partners which lead to access “to an array of services that clients can step right into.”
ECHO Model Adoption
Huther Doylehad provided addiction services in the Rochester, New York, area since 1977. Over time, Huther Doyle moved from a “mom-and-pop-style community-based organization” to a larger, substance use disorder provider and a Medicaid Care Management organization for the Finger Lakes area of Upstate New York, serving people who were affected with multiple substance use, mental health, and medical issues. Huther Doyle, in conjunction with Health Homes of Upstate NY (HHUNY), was the area’s central organization for the “coordination, training, and money flow” for about 40 community-based organizations. The network that Huther Doyle sat within and fostered was a good fit for the ECHO structure. Huther Doyle drew on “networks already developed among substance use providers in this part of the state and a whole lot of community-based organizations working with people with behavioral health issues.”
Huther Doyle traced its association with ECHO to Ann Griepp, MD, a medical director of Excellus Blue Cross Blue Shield. Griepp put together a group of experts, including Huther Doyle leaders, and pursued Health Resources and Services Administration (HRSA) funding for an ECHO program focused on Medication Assisted Treatment (MAT). Craig Johnson, the chief operations officer of Health Homes and New Initiatives at Huther Doyle, noted that there were “other ECHOs around town and Excellus has been involved in several of them.” Led by Excellus and funded by HRSA, the MAT ECHO program was national in scope with participants from across the country. When the HRSA grant ended, Huther Doyle became the lead agency for the MAT ECHO program and the geographic focus narrowed to New York State “and keeping it more regional in scope.” Huther Doyle received funding from the New York Office of Addiction Services and Supports for the MAT EHCO that supported “a point person for ECHO, the moderator, essentially, and then some time for facilitators, as well as the infrastructure basically to put the ECHO on and market it.” As the program shifted to Huther Doyle, Johnson, along with Courtney Caldwell, coordinator, and Mayra Rodriguez, physician assistant and director of medical services and MAT services for Huther Doyle, attended ECHO immersion training in Albuquerque.
Medical Assisted Treatment (MAT) ECHO Program
The history of Huther Doyle’s adoption of the ECHO Model was linked to the MAT ECHO program initiated by Griepp with Excellus Blue Cross Blue Shield. The transition of leadership to Huther Doyle was facilitated by several factors. For one, Tim Weigand, MD, a leading expert for the MAT ECHO, had an appointment as director of toxicology at the University of Rochester Medical Center and was the medical director for Huther Doyle. Second, the ECHO Model was a good fit for Huther Doyle’s community-based approach to service delivery and its network within the region. In addition, ECHO fit the mission and philosophy of Huther Doyle to spread knowledge within the community and improve education for prescribers and those in behavioral health.
The MAT ECHO had a focus on medical-assisted treatment programs and attendees were clinicians and health care providers who were treating patients for pain, addiction, medication-assisted treatment, and substance use disorder.
Health Homes Care Management ECHO Program
Huther Doyle was part of Health Homes of Upstate New York (HHUNY), a Medicaid- funded program that aimed to coordinate those involved in an individual’s care to support better health outcomes. The Care Management ECHO program covered a wide range of topics that captured the entire patient context. Huther Doyle provided training for care managers across more than 40 care management agencies to ensure that “all the objectives are covered for the patient, and to connect the managers with all the care providers.” Usually, care managers were the primary contact for individuals. They coordinated with primary care providers and specialists for behavioral health treatment and to address health disparities. The training of care managers was an ongoing priority at Huther Doyle. After attending immersion training and with the onset of COVID, Huther Doyle decided to shift to an ECHO Model to deliver training and professional development to care managers, case managers, care coordinators, and more.
ECHO Model Implementation
The Echo Model seeks to build a learning community where “all teach, all learn.” This is done by leveraging technology, by sharing best practices, through case-based learning, and using data. We asked Huther Doyle interviewees to tell us what “all teach, all learn” meant to them. “All teach, all learn” (ATAL) was defined as an environment characterized by “no jealousy” where participants “come into this with your ego in check.” Huther Doyle “created a safe space for people to ask what they might consider a dumb question or to say something that’s maybe not popular.” One respondent said, “All teach, all learn is non-proprietary. Inclusiveness is an important element in terms of who we ask to present and who we ask to bring cases forward to the group. We try to create an even playing field, to create a learning environment.” The learning space supported active participation and participants felt “invested in the development process that leads to changes in practice and behavior.” Huther Doyle was successful when “we’re sharing our knowledge, and we’re receiving information from our participants. We’re all learning together.” The MAT and Care Management ECHO programs shared much in common, but there were distinctions between how they express “all teach, all learn.” The Care Management ECHO had “a feeling of people coming together and wanting to participate and learn,” whereas the MAT ECHO “feels a little bit more educational” as “physicians and providers tend to be siloed.”
The MAT ECHO and the Care Management ECHO both reinforced ATAL by focusing on the four principles of the ECHO Model. For example, both used Zoom to bring experts and participants together from across the region, both used didactics to share best practices, and both made use of introductions “so people get to know who’s there” and they overcome their “shyness.” Participation was “key” in both programs as “the model encourages not simply lecturing, but more of an interactive discussion so that people will learn by the questions and by the participation from the audience members, as well as support from the facilitators, guiding people to come to their own thoughts about the case.” Both programs described their didactic presentations as relevant and responsive to participants. Didactics for both ECHO programs were determined by feedback and trends that “impact the whole community of providers.” Leaders in both programs and in the hub shared that didactic content was ever-changing to fit the evolution of the health care environment.
The two programs had unique ways of expressing the ECHO principles. The most striking difference was in the use of cases. In the MAT ECHO program, cases focused on patients with substance use issues and the medications they took. Cases were typically presented by health care providers who focused on treatment for a specific patient. Getting participants to submit cases was a challenge. Initially, sites that were receiving funding from the HRSA grants had to submit at least two cases. With and without HRSA funding, it was a challenge to solicit cases, primarily “because physicians do not have the time to write up a case. People were busy and they have their own cases. Maybe they can think of one, but to actually put it together in case format . . . it comes down to time.” In contrast, Care Management ECHO cases involved “a multitude of conditions and social contributions to disparities in health.” Anyone and everyone were the experts because so much of what care managers have to do for their clients was based on “learned experience.” The Care Management ECHO program had “lots of cases come forward from participants” and had no challenges recruiting cases. Huther Doyle created unique case forms for the MAT ECHO and Care Management ECHO programs to make it easier to document the cases.
The two programs differed in how they evaluated their work. The MAT ECHO surveyed participants every six months and measured the program’s impact on attitudes and behaviors related to content and any potential outcomes for participants’ patients. The MAT ECHO also offered continuing medical education units for providers. The Care Management ECHO planned to survey participants annually to determine future topics, overall satisfaction, and professional development.
The MAT ECHO implementation shifted over time. The HRSA grant initially funded practices that were treating patients with opioid use disorder. Without HRSA funding, the MAT ECHO program became “more of a mentorship-type ECHO where most of the people that were in the audience have training and were looking for specific expertise related to complicated patient management and treatment of addiction. The topics shift as patients become more complex.” Participants were not compensated for their engagement, although continuing medical education credits were available for providers.
The Care Management ECHO built from previous work that had been offered via in-person trainings. COVID was a catalyst for this change, but respondents noted that after attending immersion training, it was clear that ECHO fit the Care Management training model. One respondent commented, “The shift to ECHO is the most effective thing that we have had in a while. We have brought a new crop of care managers up to speed, even as agencies are doing more with less.”
Factors Influencing Implementation
Studies of program implementation identify context factors that can shape how a program was implemented. Such factors include leaders or champions, state and federal policies, funding, partnerships or collaborations, staffing, internal structures and processes, and monitoring for quality and fidelity. Not all of these factors play a role in how EHCO was implemented here or elsewhere. Below, we identify factors that emerged during interviews that appear to influence how ECHO is implemented at Huther Doyle and the MAT and Care Management ECHO programs.
Initially, Huther Doyle had some funding from New York Office of Addiction Services and Supports and HRSA to support the MAT ECHO program, but currently there was no budget supporting this ECHO program. Those working on the MAT ECHO were doing it as part of their regular responsibilities. The physician lead for the MAT ECHO had a joint appointment with Huther Doyle and the University of Rochester. His ECHO work was part of his Huther Doyle responsibilities. The lead for the Care Management ECHO was employed by Huther Doyle and her ECHO work was part of her role, which included overseeing the training for care managers—which she did prior to adopting ECHO for training. Others we interviewed had added ECHO onto their existing workload. One respondent described the ECHO work as coming out of “Saturday afternoons.” Specific to the Care Management ECHO, one respondent said, “We started this off of the rib of Huther Doyle. We’re not a big robust organization, we’re a small- to medium-sized group. But we’re very committed to ECHO.” So why do this work with no additional funding? Because ECHO was “very consistent with our mission and what we do. So, at this point, all of the time that we’re dedicating is really just straight out of operations.” But it was more than that. When asked why people take on this additional uncompensated work, one respondent stated, “Because that’s just the nature of what we do. We’re givers.” Despite limited or no funding, the alignment of ECHO with personal and organizational values was sufficient to continue current ECHO programs.
Unprotected Time of Experts and Spokes
The expert presenters and participants involved in both ECHO programs were not paid to participate in ECHO. Their engagement required freeing up time in their schedules and this was a challenge. For the MAT ECHO, “getting providers to free up their schedule was very difficult. Especially when you’re talking about our target—family practice providers or internal medicine providers or community providers that were in the community practicing.” The MAT ECHO sessions had been “periodically adjusted andshortened” to increase attendance. Free CME was offered as a way to recognize time commitments.
Partnerships and Networks
Huther Doyle reached into community networks to recruit participants, guest speakers, and panel members. Huther Doyle had “networks already developed among the substance use providers in this part of the state and with community-based organizations working with people with behavioral health issues. So, it’s relatively easy to get the word out on either the MAT or Care Management ECHO.” Huther Doyle was prominent in these networks and, in particular, Johnson was described as “knowing most providers in the region.” Huther Doyle credits the network for “robust” programs. Partnerships and networks did not extend to other ECHO hubs and programs beyond the region. The MAT ECHO was already established and the Care Management ECHO had a pre-existing network. Thus, there was no need to reach out or partner with other ECHO programs.
Respondents went through immersion training in New Mexico where they jokingly said they “drank the Kool-Aid” and totally bought into the Echo Model. Immersion training and general discussion with their contact at the ECHO Institute helped respondents to learn the “etiquette of ECHO. Trying and reinforcing someone’s understanding and not to be confrontational. How to present a case and engage the audience and ask questions. To develop a flow in the discussion so it’s not just a free-for-all.” Immersion training was also described as “key to helping understand what the role of ECHO was, the fundamentals of it. And how to really implement it in a way that’s true to the ECHO Model.” Training helped to get everybody involved and “bought-in” to the ECHO principles. Training also extended to professional experiences and training in behavioral health, criminal justice, substance use disorder, and mental health.
ECHO Vision and Sustainability
When discussing the vision and sustainability of ECHO programs at Huther Doyle, two themes emerged, program stability with limited expansion and funding. Huther Doyle envisioned a future that was “fairly constant in five years.” Even without growing program, they could change their impact by having new participants join, or by addressing new challenges in care. They anticipated some expansion and were on the brink of offering a new ECHO. Expansion to new geographic areas was discussed as occurring through collaborations, so that Huther Doyle didn’t necessarily take on more work. They had “enough on our plate right now, but down the road that could change. ECHO has been very helpful for our community in general. So, we want to keep it going as long as we can.” The MAT ECHO would like to “bring in the academic aspect” by working with fellows from the University of Rochester who could “present some cases and participate in the ECHO.” The Care Management ECHO hoped to continue to meet the demands of care managers and perhaps start a “more focused ECHO because the Care Management ECHO is very general. Maybe we take that and we make it smaller . . . Maybe one for clients with HIV/AIDS specifically and the challenges they face.” Growth or the extension of programs would require a new full-time employee, and that would require new or more funding.
Current ECHO work was woven into existing roles and responsibilities at Huther Doyle. This was possible largely because ECHO was highly compatible with the current work, values, and infrastructure of Huther Doyle. Growth of programs, and even longer-term stability of the current programs, would require funding. Additional funding could be used to underwrite existing programs, but also to expand programs. Huther Doyle was writing a proposal to an existing funder for the MAT program. They’d like to apply for more funder for the Care Management ECHO, which would allow for “more dedicated staff time to refine things and to expand to other ECHOs based on other topics.”
ECHO Coordinator for MAT ECHO and Care Management ECHO Programs
Chief Operating Officer
Physician Assistant, Director of Medical Services and MAT Services
Healthy Homes of Upstate New York
Tim Wiegand, MD
Medical Director for Huther Doyle
Director of Toxicology at University of Rochester Medical Center
Larson, R. S. & Walling, B. M., (2022). Huther Doyle ECHO Implementation Profile. Diffusion Associates. https://www.diffusionassociates.com/echo.