“. . . boots on the ground that inform education, inform research, inform advancement, and what should be explored within the knowledge base and within the evidence base.”
Indiana University Purdue University at Indianapolis (IUPUI) ECHO Center at the Indiana University (IU) Richard M. Fairbanks School of Public Health (IUPUI ECHO Center) and two of its programs, the Integrated Pain Management ECHO and the Indiana Peer Education Program ECHO, 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.
Andrea Janota, director, IUPUI ECHO Center, was a 2021 implementation fellow and joined 14 other fellows alongside Diffusion Associates to conduct research for this study. This profile is based on interviews conducted in August 2021 by R. Sam Larson, director of Diffusion Associates, and Sara Dugan, PharmD, director of interprofessional development at Northeast Ohio Medical University and a 2021 implementation fellow.
We begin this profile by sharing unique implementation insights from the IUPUI ECHO Center and the Integrated Pain Management (IPM) and the Indiana Peer Education Program (INPEP) ECHO programs.
ECHO Implementation Insights
“Plus ECHO” Program
The Indiana Peer Education Program ECHO was closely modeled on a program in New Mexico. It included an in-person 40-hour workshop, monthly site visits, and monthly ECHO sessions. Content deemed essential for the program was the focus of the workshop, which allowed the ECHO sessions to be responsive to emerging challenges and opportunities. ECHO sessions can be paired with other training and development activities.
Build from What Works
The Integrated Pain Management ECHO built from an existing multidisciplinary Interprofessional Education Program’s comprehensive pain assessment clinic. The IPM ECHO started by building from existing relationships and then “identified bright spots around the space” to add to the team. Similarly, the INPEP ECHO was a replication of a program developed in New Mexico. The INPEP staff made a site visit to participate as observers in the New Mexico peer workshop. They also had a staff member from the New Mexico program attend their first two trainings and provide consultation and guidance from the peer perspective. Partnering with Step-Up, Inc., a community nonprofit organization, was another way to build from what already works. Step-Up, Inc. had a proven track record in working with those incarcerated or recently released.
Finding the Fit
The ECHO Center fit well within the IU Richard M. Fairbanks School of Public Health and had institutional leadership support. The ECHO Center leaders were looking to expand and grow their footprint in the university by certifying their center status, joining an academic department, and/or partnering with the Clinical and Translational Science Institute at IU. Organizational fit can change over time.
ECHO as Open Source
ECHO was described as an “open source” model—anyone could adopt, modify, and share it as it was publicly accessible. The IUPUI ECHO Center “can’t say we’re the only people who could do ECHO. And that’s not the approach, the spirit of ECHO.” Still, this can create a “dynamic tension” that had to be navigated and begged the question, “Does it always make the most sense to have various iterations of ECHOs? If there’s an ECHO Center, would it not just make sense to pull resources and not duplicate positions?” This dynamic tension was managed by working collaboratively.
ECHO Model Adoption
IUPUI ECHO Center
The ECHO history at IUPUI begins with an HIV outbreak in Scott County, Indiana, in late 2014. Will Cooke, MD, a family physician, attended an HIV ECHO offered by the Weitzman Institute to learn more about treating patients with HIV. He shared his experience with Joan Duwve, MD, who was the associate dean for public health practice at the IUPUI Richard M. Fairbanks School of Public Health. Upon learning about Project ECHO, Duwve attended a MetaECHO conference and met Sanjeev Arora, MD, the founder of Project ECHO. Duwve introduced ECHO to Andrea Janota, MPH, then a program coordinator, who attended immersion training in New Mexico in November 2017. Duwve and Janota launched two ECHO programs in 2018 and three more in 2019. As ECHO programs were added, the IUPUI ECHO Center was established in 2018 with Duwve as its director.
Duwve left the IU Fairbanks School of Public Health in 2020. Her departure, along with the continued expansion of ECHO programs, led to changes in staffing. Janota was promoted to director of the IUPUI ECHO Center. She partnered with Gerardo Maupome, PhD, associate dean of research, and the acting associate dean for public health practice. Maupome learned of the ECHO Model while working at the Fairbanks School of Public Health. He described ECHO as “aligning very well with how practical, real-life, real-world issues are addressed by” the Fairbanks School of Public Health. He was the chief innovation officer for the IUPUI ECHO Center, which was, he said, an advisory role to Andrea.
Integrated Pain Management ECHO
Deanna Willis, MD, the Otis R. Bowen professor of Family Medicine at the Indiana University School of Medicine, initiated the Integrated Pain Management ECHO with the help of Duwve and Janota. Willis shared that the three had met to discuss how “we could collaborate on interprofessional education. Duwve was talking about how she had funding for different ECHO offerings and so we began talking about what we could do to start up an ECHO that had an interprofessional education or professional practice component.” This was the first that Willis had heard about ECHO and “it was such a natural, logical decision that I was surprised it hadn’t happened before.”
Jeremy Hooker, PharmD, manager of the Clinical Pharmacy Program at the Richard L. Roudebush Veterans Affairs Medical Center, had been involved with the Integrated Pain Management ECHO since it launched. He heard about ECHO via the Veterans Administration where they had ECHO programs but he “didn’t have a full understanding of ECHO” until he began working with the IPM ECHO. Kaley Liang, MPH, an ECHO program management specialist at the IUPUI ECHO Center, provided support to the IPM ECHO. She had been looking for an internship and “came upon ECHO. I read a little bit about it and watched a couple of ECHO videos. I said, ’This is very cool’ I wanted to learn more about ECHO.” Her engagement “took off from there” and she joined the IUPUI ECHO Center as a staff member and became an assistant director.
The IPM ECHO met twice a month to advance best practices among health care professionals. Willis and Hooker worked on interdisciplinary teams prior to the IPM ECHO and drew on those experiences when developing the program. Willis attended immersion training as well, and Liang attended the virtual immersion training program offered by the ECHO Institute.
Peer Education ECHO
Deborah Nichols, MPH, then the director of Viral Hepatitis & Harm Reduction at the Indiana Department of Health, first learned about Project ECHO from a staff member who was working with corrections and had attended the National Viral Hepatitis and Corrections Network Meeting. The staff member attended a presentation by the New Mexico Peer Education Project (NMPEP) ECHO. She came back from that training “really excited and told me about the program in New Mexico. So, I learned more about it. It took about two minutes to get interested and to know that we wanted to do this!” Nichols was aware of IUPUI’s expertise in ECHO. Nichols met with her division director at the Department of Health “who came on board and told me to reach out to Step-Up.” Step-Up, Inc., was a community nonprofit organization that provided prevention, education, care coordination, and counseling to vulnerable populations. Nichols said that within five minutes of discussing Project ECHO with the leader at Step-Up, he said, “Yep, we’re in.” The INPEP ECHO was a shared program operationalized collectively by the three agencies with dedicated staff from the Indiana Department of Health, the IUPUI ECHO Center, and Step-Up, Inc.
Abby Carr, MPH, was the INPEP (Indiana Peer Education Program) ECHO manager (and later became the director of Reentry Services at Step-Up). She became aware of ECHO shortly after Nichols met with Step-Up, Inc. In spring 2018, NMPEP ECHO staff invited the Indiana team to participate in their monthly teleECHOs. The Indiana team spoke directly to the peer educators and received advice on how to plan a program in Indiana. In summer 2018, the ECHO Institute hosted a two-day training specific to NMPEP replication. Carr and Nichols, along with other team members, attended this and the traditional three-day ECHO immersion training. The NMPEP experience included visiting two facilities in New Mexico where attendees observed a 40-hour training taught by NMPEP staff and a 10-hour workshop taught by peer educators. It was a “fantastic introduction to how all of this works.” The team built a meaningful relationship with the NMPEP ECHO staff and asked to visit New Mexico a second time to observe a 40-hour workshop at a prison. The NMPEP ECHO team agreed, with the caveat that the Indiana staff co-facilitate the training. Carr said, “I was presenting by 11:00 on the first day! That’s how they went about training us. It was fun and challenging and a great learning experience.” Still, they were feeling a “little apprehensive about making sure we did the program justice” so they invited one of the NMPEP ECHO staff, a former peer educator, to Indiana to co-host the first two initial INPEP ECHO 40-hour trainings.
INPEP ECHO became part of a larger training program that included an in-person 40-hour training module, monthly in-person site visits at each location, and monthly virtual ECHO sessions. The purpose of the INPEP was to train spokes as health educators who would then work with their peers on non-medical health interventions. The INPEP spokes were incarcerated individuals with no background in medical care. Those participating in the INPEP ECHO were in prisons.
In addition to the extensive ECHO training, Carr and Nichols drew on their professional training to make the program work. Carr had been a case manager and her master’s in public health focused on health disparities. Nichols was an epidemiologist by training and an adult educator whose classes included previously incarcerated students.
ECHO Model Implementation
The ECHO Model seeks to build a learning community where “all teach, all learn” (ATAL). This is done by leveraging technology, by sharing best practices, through case-based learning, and using data. We asked respondents affiliated with the IUPUI ECHO Center to tell us what ATAL meant to them. Willis summarized a central theme shared across interviews: “It really is about an equal playing field where everybody brings different perspectives, different experiences. We all have something to contribute. We all have something to take.”
Maupome described ECHO participants as coming to a session and sharing: “I have these challenges, and this is the toolbox I have. What do you think? What would you do if you were in my shoes?” Similarly, Hooker described participation in the IPM ECHO as stemming “from an inability to do something that they [participants] want to do, need to do. It helps them feel good.” The willingness to seek advice comes from creating a safe place where professionals can collaborate collegially.
ATAL was also described as a space where “research evidence gets out of its ivory tower and into communities” and “bridging the gap” between those with and without resources. Janota shared that there was a substantial disconnect between those who work in urban settings and academic institutions, including academic health centers, and what was happening in rural and underserved areas. She described ECHO as moving knowledge between practice and research. She talked about getting “boots on the ground that inform education, inform research, inform advancement, and what should be explored within the knowledge base and within the evidence base.”
ATAL extends to those on the multidisciplinary IPM panel where hub team members learn from each other. Hooker described an event where specialists with different disciplinary backgrounds were sharing ideas. Hooker said that they did not “fight against each other” but complemented each other, and all team members were learning. Nichols with the INPEP ECHO also described “learning from our other hub members. We all have expertise in different areas. We’re learning from others while the peers are learning.”
Respondents at both IUPUI ECHO programs talked about ATAL at a personal and relational level as well. An IPM ECHO respondent talked about “an understanding or an opportunity for learning where people are and what barriers they face, and a shared experience.” Carr with the INPEP ECHO defined ATAL as, “Being in a moment together. We’re crying, we’re laughing, we’re learning from each other, sharing our experiences . . . the sense of humanity and the inherent goodness of people.”
Didactics and cases help to build ATAL. In the IPM ECHO, didactics were “intentionally multidisciplinary to ensure that we’re not creating this sense that the first thing we need to take care of is medication.” The hub team IPM experts convened at the end of a program and prior to the start of a new program to discuss goals and review past topics and sessions. From there they would build out a schedule. Presenters received guidelines that walked them through each step of ECHO and what they should expect. They were also invited to attend a session in advance to “get a feel for what ECHO is.” Didactics were placed in a learning management platform so that participants could access them.
The teleECHO was part of a larger INPEP program that included 40 hours of in-person training. The teleECHO didactic topics were identified in several ways. For one, participants completed session evaluation forms where they identified future topics. In addition, the INPEP team drew on site visits where they identified topics through conversation and observation. Finally, the chief medical officer at the facilities sometimes identified topics. The INPEP team tapped into their network to find presenters and offered guidance via an email template that provided an overview of ECHO.
Getting cases was challenging during the first couple of IPM ECHO sessions but got easier later in the program. Participants often volunteered in advance and some case presenters provided updates on previous cases. Participants who shared three or more cases and attended twelve ECHO sessions received an ECHO certificate. Cases followed a template that included a medical history and financial background and social background that factor in a case. If they didn’t have a participant case, a hub panel member provided one. Cases in the IPM ECHO were described as “opening the conversations to show that populations and providers may not have the same access to resources.”
In the INPEP ECHO, cases were led by peer educators who were the “experts on what it’s like to educate others in corrections. Peer educators walk through different scenarios that they’re facing with the hub team, and, honestly, probably of more help are the peer educators at other facilities.” INPEP cases were often built around a challenge a peer educator faced in their facility. Participants completed a case presentation template in advance, which was shared on the screen during the session; this helped the visual learners follow along. The template included: “What the issue is, what you’ve done to try to solve it, what the benefit of getting the issue fixed would be, who’s going to take the lead on fixing it, and then space for the top three questions for the council.”
Factors Influencing Implementation
Studies of program implementation identify contextual factors that can shape how a program was implemented. These factors include leaders and champions, state and federal policies, funding, partnerships, and internal organizational structures and processes, monitoring for quality and fidelity, and staffing—including how people were trained and the characteristics of the people leading and supporting the program.
Not all of these factors play a role in how ECHO was implemented here or elsewhere, and some factors were more important than others. Below, we identify factors that emerged during interviews that influenced how the IUPUI ECHO Center, the Integrated Pain Management (IPM) ECHO, and Indiana Peer Education Program (INPEP) ECHO were implemented.
The IU Richard M. Fairbanks School of Public Health was described as “making sure that everything that we do was well-positioned to make differences in the lives of people, real people in Indiana,” as well as contributing to research and major federal initiatives. Maupome commented, “The great success of ECHO comes from what Fairbanks is really good at—and that is down to earth solutions to public health challenges. A lot of the work we do is rather practical and well-grounded on realities.” Leadership recognized this fit, though Janota commented that it took some time for people to buy in. Now, she said, “There is great support for ECHO and that certainly extends to the leadership level of the Fairbanks School of Public Health.”
Quality and Fidelity Monitoring
The IUPUI ECHO Center maintained fidelity to the ECHO Model through training, guidelines for didactic speakers, a consistent use of case templates, evaluation, and by modeling “all teach, all learn.” The staff at the center and many of the panel members had attended ECHO immersion training and training was an on-going practice. As described earlier, the INPEP ECHO staff had in-depth training with a similar program in New Mexico. IUPUI ECHO programs provided guidance to speakers. Liang, with the IPM ECHO, described reaching out to speakers to “explain what ECHO is, what we do, and then what we’re looking for in a presentation. I created a presenter guideline that walks through each step of ECHO and what they should expect. I also invite them to a session or two before the presentation if they’re interested, so they can sit and get a feel for what ECHO is.” Speakers for the INPEP program received an email template that provided an overview of INPEP and included some things to consider about the population such as not having access to internet. Both programs consistently used case presentation forms tailored to their programs.
Evaluation was integral to both programs. The IPM ECHO had a “post session survey that we have participants fill out, asking them what they learned as well as any improvements we can make.” INPEP evaluated each ECHO session. In addition, a doctoral student was working with them to develop new evaluation tools and deepen their measurement of ECHO outcomes. Feedback was a “driver” of the INPEP ECHO. Staff provided interpersonal feedback by modeling how to give feedback. Carr said, “From day one, we’re modeling to our peer educators how to give feedback. After a presentation, the peer educators stand in front of the class and say, ’What did you like about my presentation?’ And you can raise your hand and give any type of feedback, and we give a lot of feedback. Then they have to say what could be improved or what could be made better. And we do the same thing.”
ECHO operations at IUPUI ECHO Center were funded through soft money. Maupome stated: “We are fully funded by our wits and effort. That’s very much to the credit of the team and, particularly, Andrea.” Funds were described “as project specific. So that leaves vulnerabilities when there’s a program that’s a hard sell.” Funds for the IUPUI ECHO Center came primarily from the university and federal pass-through grants. The university funds were part of an IU Grand Challenges that paired faculty, staff, and students from all disciplines in partnership with community and business leaders to address problems impacting Indiana and the world. One of the Grand Challenges was “Responding to the Addictions Crisis” and funds from this challenge supported the establishment of the center and several ECHO programs. In addition, the center was working with three different divisions within the Department of Health; the center also received some foundation grants, and modest support from the American Cancer Society and the Indiana Immunization Coalition.
Funding was described as relatively secure for the IPM ECHO. Initially funded by CDC via pass-through funds, it then received Grand Challenge funds. At least two more years of funding were available through the CDC via the Indiana Division of Injury and Trauma Prevention. Hub team members’ time was covered by the IUPUI ECHO Center either through supplemental pay or by supporting effort allocations.
The Indiana Peer Education Program, which included an ECHO component, received pass-through funds from the CDC. Funding was expected to increase with more funds coming directly from the Department of Corrections to support INPEP ECHO expansion to additional facilities and provide longer-term stability for the program.
Partnerships and Networks
The IUPUI ECHO Center was closely connected to partners in the community such as Eskenazi Health (the state’s largest federally qualified health center), IU Health, Riley’s Children’s Hospital, and the Indiana University School of Medicine. They also worked with local nonprofit organizations such as Step-Up, Inc. (INPEP collaborator). They partnered with the Indiana Academy of Family Physicians to offer Family Physician Prescribed Credits. In addition, the center worked with other ECHO hubs, such as with Project ECHO at West Virginia University as part of the HCV Appalachia Collaborative. Partnerships and collaborations were evident in ECHO programs as well. The IPM ECHO and the INPEP ECHO were founded on collaborative structures. IPM ECHO was a partnership with the center, the IU School of Medicine, the Richard L. Roudebush Veterans Affairs Medical Center, and Eskenazi Health. The INPEP ECHO involved the Indiana Departments of Health and Correction, the nonprofit Step-Up, Inc., and the IUPUI ECHO Center. Both programs had multidisciplinary teams drawn from multiple organizations.
ECHO Vision and Sustainability
When asked about the vision for the IUPUI ECHO Center in the next several years, Janota shared that they wanted to grow and expand their operations and sustain current work. This would require expanding current leadership support of ECHO so that leaders would “promote ECHO because it is on their minds and they will bring it up when they see something that could make a good ECHO.” Janota and Maupome also talked about their operational home and configuration. The ECHO Center was part of the dean’s office. They were a “a small c center. So, we’re not recognized by the IUPUI institution.” They expressed an interest in becoming “a large c center recognized by IUPUI.” This would require an accreditation review at IUPUI on which they were working. In addition, they did not have a departmental affiliation. Having such an affiliation would make it easier to manage research grants and tie their work more closely to the academic core as implementation scientists who contributed to the evidence and research base. An additional vision expressed was to be thinking more rigorously about community impact.
One challenge to the overall vision was funding. Maupome discussed hiring a development officer to generate more funding opportunities. He and Janota shared they were “starting conversations to see if we can get more of a stable relationship with CTSI, the Clinical and Translational Sciences Institute, because it was coming up for reapplication for another five years of funding.” In addition to finding ongoing programmatic funding, Maupome expressed an interest in finding funding “for proper research” that included a “more sophisticated level of measurement to see which components of ECHO actually are the ones that deliver the punch.” The IPM and INPEP ECHO programs also shared an interest in expanding their evaluation and research efforts.
Geographic expansion was a future goal for the IPM ECHO. Hooker shared: “There are so many clinicians that would benefit from this type of resources; one that is dynamic and in real time and not just watching a pre-recorded webinar.” He wanted to see the program expand into other regions of the state, especially into the northwest corner. Willis talked about expanding their participant base by bringing in “trainees” or medical students who could gain a “bigger worldview” by participating in the IPM ECHO. Liang wanted to see more providers willing to treat patients with chronic pain in a culturally competent way. A shared theme was the desire to have participants practicing “all teach, all learn” outside of ECHO and encouraging their colleagues to ask other providers from different disciplines for their input and expertise.
The INPEP ECHO wanted to expand into every prison facility in Indiana. Carr said: “We’re constantly told by our peer educators that this program should be in every facility in the Indiana Department of Correction.” The INPEP team discussed expanding their education program into high-risk, non-incarcerated communities and were talking to a “work release facility in Indianapolis about using our peer educators” for this purpose. They also wanted peer educators to become certified community health workers, which would “improve the likelihood that we can bring them in at Step-Up, Inc. or in one of our partner organizations and pay them for their experience and knowledge.” Limiting factors for growth and expansion was the amount of time it takes to run the INPEP program. It required “a lot of work” to host a 40-hour workshop and to manage the paperwork, so staff time was a challenge. Nichols noted that they would need more full-time people and longer-term funding to expand the program.
The INPEP team described a future where peer educators were empowered and in charge. Eventually, Carr would like to see the program “entirely peer led. Literally, my goal is to not have a job with this program anymore” because the peer educators would be the ones supporting and managing the program moving forward. To reach this goal, they need more peer educators who have been released and who would want to continue this work. Nichols shared a similar vision, “I would like to see our peer educators at the table when decisions are being made about what is happening in the facilities, especially regarding providing medical services.”
Abby Carr, MPH
Director of Reentry Services
Jeremy Hooker, PharmD, BCGP
Clinical Pharmacy Program Manager
Richard L. Roudebush Veterans Affairs Medical Center
Andrea Janota, MPH
Director, IUPUP Project ECHO Center
IU Richard M. Fairbanks School of Public Health
Kaley Liang, MS, MPH
ECHO Program Management Specialist
IUPUI ECHO Center
IU Richard M. Fairbanks School of Public Health
Gerardo Maupomé, BDS, MSc, PhD
Associate Dean of Research
IU Richard M. Fairbanks School of Public Health
Deborah Nichols, MPH, MS, CHW
Division of Viral Hepatitis and Harm Reduction
Indiana Department of Health
Deanna Willis, MD, MBA
Otis R. Bowen Professor of Family Medicine
Indiana University School of Medicine
Larson, R. S. & Janota, A. (2022). IUPUI ECHO Center at the IU Richard M. Fairbanks School of Public Health Implementation Profile. Diffusion Associates. https://www.diffusionassociates.com/echo.