Project ECHO Ontario Mental Health Centre for Addiction and Mental Health and University of Toronto Implementation Profile

Ministry representatives traveled to New Mexico with the CAMH and University of Toronto team to learn more about the model, which solidified the Ministry’s ongoing support that continues to provide enviable “evergreen” funding for the ECHO hub and programs.

Project ECHO Ontario Mental Health at the Centre for Addiction and Mental Health (CAMH) and the University of Toronto and two of its ECHO programs—General Mental Health and First Nations, Inuit, and Métis Wellness—were part of 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.

Eva Serhal, PhD, a senior director of the CAMH ECHO and the ECHO Ontario Superhub, was a 2020 implementation fellow and worked with nine other fellows and Diffusion Associates in conducting research for this study. Serhal and James. W. Dearing, PhD, professor at Michigan State University, conducted interviews from October 2020-February 2021 which are the basis of this profile.

We begin this profile by sharing unique implementation insights from Project ECHO Ontario Mental Health at the Centre for Addiction and Mental Health (CAMH) and the University of Toronto and its General Mental Health and First Nations, Inuit, and Métis Wellness ECHO programs.

ECHO Implementation Insights

Remember the Model and Adapt

Maintain fidelity to principles but adapt as necessary to suit the ever-changing needs of your community of practice. This principles-based approach to intervention fidelity—one that allows and even encourages modifications to ensure compatibility with what can be an evolving implementing organizational context—is a key to the ECHO Model’s attractiveness to many potential adopters. ECHO is successful if it is meeting a need, and the needs of spokes can change. For example, the First Nations, Inuit, and Métis Wellness ECHO program was adapted to reflect the cultural context of the project. This included adaptation to processes, the facilitation model, the makeup of the hub and spokes, and the evaluation process. Project ECHO Ontario Mental Health at CAMH and the University of Toronto team refreshed their curricula often, repeatedly obtained and integrated feedback from participants, reviewed the statement of collaboration, and adapted timing and duration of sessions to ensure that it met the needs of most participants.

Plan for Sustainability 

This team kept its funder involved with important decisions and strategy to ensure that ECHO continued to deliver programming in alignment with government priorities which, naturally, increased the likelihood of continued support from government agencies. Additionally, the CAMH ECHO team continued to train new leaders and recruit new members and trainees for each program so that as the operation expanded and grew, and staff turns over, the hub and programs experience continuity. Finally, the team continued to explore new priority areas and reached out to new funding sources so it could expand for greater benefit.

Design for Continuous Quality Improvement

Collect feedback from spokes and use it. Developing an effective community of practice—an “all teach, all learn” ECHO—is at the core of the ECHO Model. Creating a safe and respectful space for people to listen, share, and learn is the point. CAMH ECHO ensured that the community of practice and content delivered was reflective of the needs of providers and continuously gathered feedback and integrated it within a quality improvement process.

People Make the Experience

Recruit the right people. There was a shared ethos required to successfully enact “all teach, all learn.”  This mindset required a vulnerability, and the ability to be both a learner and a teacher within each session. Individuals who thrived in CAMH ECHO programs were comfortable with flattened organizational, disciplinary, and cultural hierarchies. Ensuring that the right people were brought onto the hub that reflected this ethos was crucial to creating the right atmosphere and culture in the programs.

ECHO Model Adoption

Allison Crawford, MD, Sanjeev Sockalingam, MD, Linda Mohri, and Serhal were instrumental in bringing the ECHO Model to Canada. They learned about ECHO from colleagues in Ontario who were planning to implement the model, from conversations with officials at the Ontario Ministry of Health, and from leaders at the ECHO Institute. Later, CAMH personnel participated in MetaECHO conferences and immersion training in Albuquerque.

In 2014-15, after receiving training and signing necessary partnership documents with the ECHO Institute in New Mexico to replicate the ECHO Model, ECHO Ontario Mental Health at CAMH and the University of Toronto was funded for a three-year demonstration project by the Ontario Ministry of Health. The ECHO operation launched in October 2015. In 2017, after a highly successful two years, the operation was expanded to include seven more ECHO mental health programs with sustained annual funding by Ontario’s Ministry of Health. Since then, the operations team has been an incubator for new ECHOs in Ontario. Nationally this hub and its programs supported the implementation of new ECHOs as part of research grants, philanthropic endeavours, and training strategies for associations, including a rapidly implemented Coping with COVID ECHO.

In 2017, CAMH ECHO partnered with ECHO Ontario at University Health Network to become the first ECHO superhub in Canada – ECHO Ontario Superhub. As a large teaching and research hospital with strong leadership advocacy for models like ECHO, CAMH was well positioned to be a superhub. It had resources, including education, IT, research, and public affairs departments that helped to facilitate the implementation and development of ECHO programs. The CAMH ECHO team was trained by the ECHO Institute to be a superhub and in-turn trained staff from 41 new hubs throughout Canada, as well as staff from hubs in Sri Lanka, Brazil, and Australia. The team held an annual ECHO Ontario conference, which brought together ECHO teams from across Canada.

The CAMH ECHO organizational structure included three executive level co-chairs, a senior director, and a manager and centralized operation team that supported the implementation and operations of diverse programs, while ensuring fidelity, accountability, and efficiency. Leadership brought together an advisory committee with representatives from stakeholder groups for input on program development. Each program was supported by co-leads, often with one of the hub co-chairs acting as co-lead, or an executive representative, on each new program. Since launching in 2015, the hub had delivered ECHO programs to more than 3,000 providers representing more than 990 organizations.

General Mental Health ECHO

This was the inaugural program started by CAMH ECHO. The program team went to New Mexico for the MetaECHO conference and immersion training in early 2015 and launched their ECHO shortly after. The ECHO Institute provided feedback and resources to support effective implementation. The team developed the curriculum through a triangulated needs assessment, which included analyzing data about mental health learning needs directly from primary care providers, looking at population health needs articulated in the literature, and seeking expert consensus. Once the curriculum was developed, participants ranked each topic based on interest and learning need, and a curriculum was developed for the 36 two-hour sessions. Session experts included psychiatrists, family physicians, social workers, a librarian, and others, supported by a member of the operations team.

Sessions began with a facilitator welcoming and introducing hub and spoke members. The facilitator would make announcements and introduce didactic presenters. Presenters shared an evidence-based presentation based on the curriculum. Spoke members then posed questions, followed by hub members. After that, cases were presented by spoke members based on a template provided and reviewed by a member of the hub team.

First Nations, Inuit, and Métis Wellness ECHO  

The First Nations, Inuit, and Metis Wellness program was an adaptation of the General Mental Health program based on feedback from Indigenous primary care organization representatives who had participated in the General Mental Health program. During case presentations, the potential for a more culturally relevant approach for First Nations, Inuit, and Métis patients and communities became evident, including considerations for cultural safety and culturally specific resources. Adaptations to the model included altering terms used within ECHO, for example changing the language from “hub” and “spoke,” to “resource team’” and “community member,” respectively. The program was delivered to staff at organizations mandated to support First Nations, Inuit, and/or Métis clients. The facilitation model was adapted with a cultural host coordinating the sessions. Additionally, to ensure that no single community or perspective was exclusively represented, diverse communities were featured each week. Finally, the team did not use a pre- and post- evaluation model, instead they co-developed a sharing circle that prioritized feedback and narratives from participants. The team initially worked to secure philanthropic funding to pilot a year’s worth of sessions. After a successful first year, the funding was included in a larger proposal for expansion to the Ministry of Health in Ontario, and funded on an annual basis. The ECHO Ontario superhub provided training for the ECHO Ontario First Nations, Inuit, and Métis Wellness program members. Additional training outside of ECHO was sought in working across cultures with Indigenous communities and cultural safety training.

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, though case-based learning, and using data. We asked respondents to tell us what “all teach, all learn” meant to them. Respondents tended to define it as a true community of practice where there was mutual, bidirectional teaching and learning; a space that welcomed an admission of vulnerability in order to learn, without hierarchy. The ECHO Model encouraged “all teach, all learn” through a standardized facilitation model that encouraged community of practice members to speak first, and by encouraging interaction by, for example, asking people to raise their physical or virtual hand and ask their question, instead of using chat.

Respondents offered various perspectives on what “all teach, all learn” meant. For example, while some thought it was a place to share best practices, others suggested that “best practice” might actually be antithetical to different people coming together and all teaching and all learning since the term can imply a power hierarchy that some knowledge is better than other knowledge. The First Nations, Inuit, and Métis Wellness ECHO program team often used the term “wise practices” instead, as inclusive of different knowledges, traditions, and practices.

Staff and leaders with CAMH ECHO site used many ways to reinforce the ECHO “all teach, all learn” ethos. They provided rigorous training on the ECHO Model through the superhub that included details on all four components of the ECHO Model, and training on the facilitation model. They conducted needs assessment that triangulated individual participant needs, population health needs, and expert consensus to build a relevant curriculum. They encouraged spokes to participate and present cases through a Statement of Collaboration, and followed a facilitation practice where spoke members were engaged in discussion before asking ‘experts’ for their questions or recommendations. The hub team also provided one-on-one support for individuals in preparing their case presentations, had a librarian conduct a brief literature search to answer remaining questions after each session, and used standardized documents to ensure fidelity to the model via a quality assurance/improvement framework, and meet the accountability requirements set by funders.

Programs had unique ways of reinforcing “all teach, all learn.”  For example, the Project ECHO Ontario Mental Health program used technology such as polling and word clouds to better understand perspectives of the community of practice as a whole. When external presenters were invited to present, they were contacted by a member of the team who provided a brief orientation to the model. To ensure that spokes felt comfortable participating, all registered spokes joined an orientation prior to the first session. This hub was one of the first ECHO sites to ground their research in an educational research model (Moore’s Framework), and staff had evaluated the concept of adaptive expertise. The team assessed the extent to which participants continuously adapted and shared their learning back with the community. They also used simulation during bootcamp trainings.

“All teach, all learn” was also reinforced in the First Nations, Inuit, and Métis Wellness ECHO program. An important consideration in building this ECHO was having a strong community of practice across a culturally diverse group. Participants had distinct and rich identities, yet came together within one group to share knowledge. This required relational work, and cultural humility to understand that one is continually learning about diversity among participants and communities. The team modified their curriculum to include more than biomedical knowledge. The adapted model encouraged participants to consider physical, mental, emotional, and spiritual ways of knowing when discussing cases and presenting didactic lessons, and suggested that family and community aspects of wellness were considered as well as individual wellness. The model equally balanced expertise from the community of practice with biomedical expertise.

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 may play a role in how ECHO was implemented here or elsewhere, and some factors were more important than others. Our intent here is to highlight those factors that stood out to interviewees as they explained the growth and maturation of Project ECHO Ontario Mental Health at CAMH and the University of Toronto.

External Leadership and Champions

The ECHO Institute provided resources and training to facilitate the successful replication and implementation of the model in Ontario. Sanjeev Arora, MD, championed the model and provided evidence that proved compelling to program leadership and funders. The ECHO Institute immersion training in New Mexico also offered team building and visioning opportunities, which helped support program development success.

The strong interest in ECHO by the Ontario Ministry of Health was important for launching and maintaining ECHO operations at CAMH and encouraged involvement of faculty at the University of Toronto. The Ministry saw that the ECHO Model could help to achieve multiple of its strategic objectives. Ministry representatives traveled to New Mexico with the CAMH and University of Toronto team to learn more about the model, which solidified the Ministry’s ongoing support that continues to provide enviable “evergreen” funding for the ECHO hub and programs.

Provincial Policies

Decision makers in the provincial government of Ontario wanted to build the capacity of primary care providers throughout the province. This interest included funding for projects such as the Medical Psychiatry Alliance (which promoted the integration of physical and mental health care), which was another CAMH-aligned project that operated under the same portfolio as ECHO.

While the U.S. Congressional ECHO Act did not directly impact this team in Canada, the U.S. act did add additional clout for the ECHO Model, which helped further solidify confidence in the model in Canada.

External Funding

It is difficult to describe the CAMH ECHO operation without reference to its dedicated annual funding from the provincial government. Hub and program funding started as a three-year demonstration project, with additional long-term funding contingent on demonstrating both a need among healthcare providers, and successful implementation. After both outcomes were demonstrated, the project was funded on an annual basis and was expanded to additional high need specialty areas.

To support the research component of Project ECHO Ontario Mental Health at CAMH and the University of Toronto, a research grant was successfully obtained to measure outcomes relating to ECHO from the Canadian Institute of Health Research (CIHR). While provincial funding supports the majority of ECHO programming within Ontario, philanthropic and federal funding was often sought for pilot programs, or to support programs with a national rather than provincial audience.

External Partnerships

Partnerships with organizations outside of CAMH have been an important means of program development and expansion. A provincial steering committee developed by the Ontario Ministry of Health to inform the growth of ECHO in Ontario included the Ontario College of Family Physicians, Health Quality Ontario (a group that supported quality improvement in healthcare), the Centre for Effective Practice, and members of each ECHO program team. The hub also had an advisory committee made up of stakeholders from academic institutions, primary care associations, healthcare quality improvement organizations, and other healthcare organizations.

Accreditation of curriculum as well as recruitment and marketing were also accomplished through external partnerships. Accreditation was sought from the University of Toronto’s Faculty of Medicine and the Ontario College of Family Physicians. Recruitment and marketing involved professional associations, primary care associations, health associations/organizations, universities, hospitals, and other key stakeholders to support engagement and recruitment of spoke members to the hub’s various programs.

Regional and Cultural Differences

There are vastly different health-related needs in Ontario. The requirements for better mental health among First Nations, Inuit, and Métis populations, Francophone populations, and individuals who need information to support patient gender identity are distinctly different. Additionally, various areas of the province were resourced differently, especially in rural and northern Ontario. Considerations of differences were integral to the planning and implementation of each ECHO.

Organizational Characteristics

CAMH was a teaching hospital affiliated with the University of Toronto, employing respected experts in the field of mental health. The organization was highly suited to implement expansive ECHO projects including perhaps an eventual a national network. Within CAMH, numerous departments supported ECHO, including education, IT, human resources, finance, and project management.


The implementation and expansion of the ECHO Model was supported by a leadership team that included three co-chairs all holding senior roles within the organization. Hub leaders brought preexisting expertise to ECHO such as integrated and collaborative care, virtual care, continuing professional development, education, and research. ECHO had been presented to the hospital’s board of directors and was strongly championed by the organization’s CEO. Additionally, leadership was centralized, which ensured consistency and efficiency among all the ECHO programs as the program continued to expand.

Quality and Fidelity Monitoring/Support

Project ECHO Ontario Mental Health at CAMH and the University of Toronto used a quality assurance and improvement plan to monitor outcomes and support the continual improvement of each program. The hub team evaluated each program regularly through weekly and post-cycle evaluation surveys and quality metrics, and followed a standardized implementation approach to ensure that each new ECHO program was launched with high fidelity to the original ECHO Model. Additionally, funders set benchmarks and expectations, which the ECHO team reported on regularly.

Organizational Staffing Processes

Stable funding from the provincial Ministry of Health ensured sufficient and consistent staffing to support the expanding hub and programs. The team had five information specialists, two research analysts, two research coordinators, one senior project analyst, and one manager to support the ongoing daily operations of 10 ECHO programs.

Training and Orientation

All staff and hub members who participated in ECHO were expected to participate in ECHO Ontario superhub training, and receive additional orientation and training about procedures, facilitation, effective didactics, and how to provide feedback according to ATAL philosophy.

ECHO Vision and Sustainability

Respondents said that their vision for ECHO was to build and expand sustainable communities of practice that continuously adapt to changing needs and support improved health outcomes for patients. To achieve this vision, the teams required sustainable funding and resources, appropriate succession planning and training, advocacy to ensure that spokes had the ability to participate (e.g., funding for professional development, or organizational support for continuing education), and a continuous quality improvement plan. Programs also needed to reflect the community of practice it served by, for example, having indigenous leadership on the First Nations, Inuit and Métis program or having individuals with “lived experience” sitting on various programs. Challenges included the potential of changes in government parties or priorities which might jeopardize the existing allocated funds for ECHO. Additionally, staff turnover on the operations or hub teams could lead to limited resources and reduced expertise to deliver high-quality programs. Finally, lack of support for spoke time and an inability to adapt and advance the curriculum could result in fewer participants from spoke sites.


Allison Crawford, MD, PhD
Associate Professor, Department of Psychiatry
Associate Chief, Virtual Mental Health and Outreach
Centre for Addiction and Mental Health
Toronto, ON, Canada

Sanjeev Sockalingam, MD
Vice-Chair and Professor of Psychiatry
University of Toronto
Vice President, Department of Education
Centre for Addiction and Mental Health
Toronto, ON, Canada

Eva Serhal, PhD,
Senior Director, Virtual Mental Health and Outreach
Project ECHO Ontario Mental Health
Centre for Addiction and Mental Health
Toronto, ON, Canada

Jenny Hardy
Director, Project ECHO Ontario Mental Health
Centre for Addiction and Mental Health
Toronto, ON, Canada

Maurey Nadarajah,
Acting Manager, Project ECHO Ontario Mental Health
Centre for Addiction and Mental Health
Toronto, ON, Canada

Suggested Citation

Serhal, E., & Dearing, J. W. (2022). Project ECHO Ontario Mental Health Centre for Addiction and Mental Health and University of Toronto Implementation Profile. Diffusion Associates.