“This ECHO was created as a way “to give facilities, their staff, a space to be together and share common challenges, along with trying to find common ground and common solutions.”
The Oregon ECHO Network hub and two of its programs, the Hepatitis C: Treatment and Elimination ECHO and the Nursing Facility Behavioral Health 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.
Maggie McLain McDonnell, director of the Oregon ECHO Network, was one of 10 implementation fellows in 2020, and worked alongside Diffusion Associates in this study. Troy Jorgensen, senior program manager, Project ECHO-Nevada and a 2020 implementation fellow, and Nagesh Rao, PhD, professor at Ohio University, conducted interviews in September and October 2020 that were the basis of this profile.
We begin this profile by sharing unique implementation insights from the Oregon ECHO Network (OEN) and the Hepatitis C: Treatment and Elimination (HepC) ECHO and the Nursing Facility Behavioral Health ECHO.
ECHO Implementation Insights
The ECHO Hub as a Service Center
The Oregon ECHO Network (OEN) was organized as a statewide resource for ECHO programs and services. The OEN worked with organizations to develop and implement ECHO programs so that the other organizations did not need to reinvent the wheel. The OEN created a scope of work for each project so that it was clear which elements were going to be provided by OEN and which were to be provided by the outside organization. The OEN benefited from a strong relationship with ECHO Colorado and licensed the ECHO Colorado participant portal.
Advisory Board Representation
The OEN’s relationship with insurers and health systems had considerable influence on implementation. An OEN advisory board brought these outside stakeholders together to advise OEN. Board members recruited participants for programs, in part because they saw that engagement could lead to improved quality metrics and to reduce the need to provide separate CME for these topics.
Partnerships and Programmatic Funding
While multiple organizational partnerships have helped the OEN mission, the connection with the OHSU Addiction Medicine division was particularly important. SAMHSA funds allocated by the State Targeted Response to the Opioid Crisis paid for the delivery of programs to develop the skills and knowledge of ECHO participants about addiction medicine, and provided important seed funding and ongoing funding, for the development of the OEN.
Continuous Quality Improvement
Continuous quality improvement was built into the activities of Oregon ECHO Network programs. The mid-program evaluation process, per-session survey feedback to expert teams, and the post-session debrief sessions were three of the primary ways that Oregon maintained high quality and fidelity to the ECHO Model.
ECHO Model Adoption
Oregon ECHO Network
Ron Stock, MD, was instrumental in bringing the ECHO Model to Oregon. He initially heard about ECHO while serving as director of clinical innovation for the Oregon Health Authority Transformation Center. This center was developed in 2012 as an entity within the state health department and dedicated to “bringing best practices to the state and helping the clinicians across the state reform their practices and address some incentive measures or pay for performance measures” in response to statewide Medicaid reform efforts. Project ECHO was identified as an innovative model that could address the challenge of supporting organizations to share best practices and disseminate quality improvement programming most effectively. In 2013, the Oregon Health Authority Transformation Center hired the Providence Health Care’s Center for Outcomes Research and Education (CORE) to conduct a study of ECHO. The study had two parts. First, it was a scan – a collection of what was known about ECHO at that time. Second, it included options on how ECHO could be developed within the state. In addition, a meeting was held that included Oregon stakeholders, including insurers and hospital associations, and representatives from the ECHO Institute. Shortly after this meeting, an ECHO pilot was initiated and it was “highly successful.” The Oregon Health Authority decided to adopt ECHO.
In 2016, the Oregon Health Authority Transformation Center funded the Oregon Rural Practice-based Research Network (ORPRN) at OHSU to develop a business model for offering Project ECHO throughout the state. ORPRN was chosen because of its connections with rural practices and experience with primary care research. They conducted a nine-month needs assessment that included interviews with leaders at ECHO hubs across the U.S. about best practices and challenges of building ECHO networks, a survey of primary care clinicians to assess which ECHO topics were of greatest interest, and implementing a pilot ECHO program about primary care behavioral health integration. According to McDonnell, the most important part of the needs assessment and business model planning was a steering committee composed of leaders from insurers, medical associations, academic medical centers, and other organizations who participated in three meetings to discuss the merits of creating a statewide Project ECHO.
In summer 2017, five organizations that had participated in the steering committee committed funds to launch the Oregon ECHO Network (OEN). The OEN contracted with experts or worked with organizations or departments at OHSU to provide specialist expertise, including curriculum and case support. ECHO experts were selected either from OHSU or other health systems throughout the state. Most OEN programs were delivered cohort style in which a program consisted of a set number of sessions all of which participants were expected to attend. Evaluation was a standard component of OEN programs, with per-session surveys, pre- and post-program surveys, and focus groups or structured interviews common evaluation methods. Stock, a geriatrician by training, was expert in quality improvement methodology. He had participated in Institute for Healthcare Improvement training and Advanced Training in QI at Intermountain Healthcare. McDonnell drew upon her experience in public health, project management, and facilitation as key factors in developing the network.
The OEN partnership with ORPRN and OHSU was strong. The ECHO operation benefited from the stability provided by being housed at an academic medical center, with human resource and grant management support, as well as from OHSU’s brand. OHSU was one of the eight sponsoring organizations that formed the Oregon ECHO Network advisory board, along with six Medicaid insurers in Oregon, and Providence Health Plan (a vertically integrated health system). The sponsoring organizations provided about one-third of OEN’s funding. The remainder of the funding came from grants from the state and foundations, and units at OHSU. Funding had grown from approximately $300,000 annually to about $1.5 million in 2020.
Hepatitis C: Treatment and Elimination (HepC) ECHO Program
The HepC program was started by Atif Zaman, MD, hepatologist, and Lauren Myers, PA. Zaman initially heard about ECHO through professional relationships and thought it would be a good option for improving access to care in Oregon. They benefited from the immersion training provided by the ECHO Institute. The HepC program was designed to build the capacity of primary care providers and their teams to treat hepatitis C from an integrated approach that included substance use disorder treatment and harm reduction. The HepC ECHO included the traditional ECHO knowledge and skill building activities for diagnosis and treatment, as well as additional program development components to support the primary care clinics’ own development of hepatitis C elimination programs.
The program was initially funded by OHSU via the 340b pharmacy program. At the time of the first cohort, the program was a general hepatitis C diagnosis and treatment ECHO. After that, the program focus changed to consider how substance use affects the diagnosis and treatment of hepatitis C. Given this change in program focus, the next two cohorts were sponsored through the State Targeted Response for the Opioid Crisis and State Opioid Response funding from SAMHSA that flowed through the Oregon Health Authority.
Nursing Facility Behavioral Health ECHO Program
Nirmala Dhar, an older adult behavioral health coordinator for the Oregon Health Authority, learned about the ECHO Model by participating in the University of Rochester’s nursing facility behavioral health ECHO. An assessment completed by the Oregon Health Authority had demonstrated the lack of access to behavioral health services in skilled nursing facilities. Dhar was aware of the Centers for Medicare & Medicaid Services (CMS) civil money penalty funds and worked with the Oregon Department of Human Services and ORPRN to access funds for the Oregon ECHO Network. the Nursing Facility Behavioral Health ECHO was designed for frontline skilled nursing facility staff working in rural and underserved facilities in Oregon to gain increased access to behavioral health specialists. Most learners for this ECHO were skilled nursing facility administrators and directors of nursing who were trained as nurses. This ECHO was created as a way “to give facilities, their staff, a space to be together and share common challenges, along with trying to find common ground and common solutions.” Two cohorts of the Nursing Facility Behavioral Health ECHO were funded through CMS civil money penalty funds.
The decisions to adopt ECHO for hepatitis C and nursing facility behavioral health initiatives were similar in terms of how they leveraged administrative support (e.g., project management, recruitment, evaluation, IT support) provided by the Oregon ECHO Network. Both programs sent facilitators to ECHO Institute immersion training and benefited from additional training and support from the Oregon ECHO Network. Both programs prioritized recruiting underserved communities. A key difference between the programs was that the HepC ECHO focused on primary care clinicians and their teams and the Facility Behavioral Health ECHO focused on front line skilled nursing facility employees.
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 discussed the importance of participants as experts in their own communities and how critical their active participation was to the success of ECHO. When talking about “all teach, all learn,” Stock said, “It’s an attitude. It’s a personal thing, but it’s also a cultural thing. You need to create a culture in which that is just the way the work is done . . . I’m very proud of our team in that they’ve really embraced this. It really flattens out the hierarchy within an organization and within the team. It promotes team-based behavior and attitudes. And you have better outcomes.” McDonnell, OEN director, said they baked “all teach, all learn” into each program’s ground rules. By including “all teach, all learn” in the ground rules “it creates respect and a willingness for people to speak up and make the sessions really valuable.” Similarly, the Nursing Facility Behavioral Health ECHO emphasized ground rules at the start of sessions, “Everybody speaks up and shares thoughts or questions or ideas.”
The HepC ECHO offered optional community of practice sessions every other week between ECHO sessions. These community of practice sessions were 90 percent case discussion and featured a three- to five-minute didactic lecture designed to help practices develop their hepatitis C elimination program. The HepC ECHO team had been especially successful in recruiting participants to present cases and reported that every session had a case discussion. This ECHO team had two different case forms available and gave participants the option to present a more traditional patient-oriented case, or a systems challenge. Some of the strategies the ECHO team used to recruit cases included calling for case volunteers at the beginning and end of sessions, direct emails to participants, and asking participants to present a follow-up report from a previously presented case.
The Nursing Facility Behavioral Health ECHO enhanced participation through a live kickoff event prior to the beginning of the ECHO sessions. The kickoff event included a breakfast and mock ECHO sessions where participants could practice the ECHO case format. The event introduced participants to each other and “people came to the table with ideas.” These sessions helped build trust among the participants and helped them feel connected to each other. In addition, Tuesday Graham, lead project manager, visited each facility in-person prior to the kickoff event to orient the nursing facility staff to the project. Graham drove hundreds of miles to complete these orientation sessions. She also set up webcams and speakerphones, further reducing barriers to participation. The in-person orientation sessions were an opportunity for Graham to ask facility leaders their goals for participating in the ECHO and ensure that the participants understood the program objectives. Graham also used the in-person orientation site visit as a time to recruit case presentations. She framed the process as the facility’s opportunity to pick a date to present their case, rather than asking for volunteers to present a case.
Factors Influencing Implementation
Studies of program implementation identify outer and internal contexts that can shape program implementation. Factors in the outer context that can influence program implementation include external leaders or champions, state and federal policies, external funding, and external partnerships or collaborations. The inner context refers to characteristics within an organization such as internal structures and processes, leadership within the organization, monitoring for quality and fidelity, and staffing—including how people are 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. Below, we identify factors that emerged during interviews which influenced how the Oregon ECHO Network and its programs took shape.
Service Environment and Funding
Local, state, and federal policies created unique funding mechanisms crucial to the development of the Oregon ECHO Network and the HepC and Nursing Facility Behavioral Health programs. In 2017, when the Oregon ECHO Network was being developed, the state received a large influx of funds from SAMHSA focused on opioid misuse. These funds supported the initial Addiction Medicine ECHO programs, which were the first large projects organized by the Oregon ECHO Network. These funds continued as the epidemic worsened. The Nursing Facility Behavioral Health ECHO was funded from penalty dollars that nursing facilities pay when they do not meet regulations. The penalty dollars were collected by CMS and went into a fund that had to be used for education purposes. The Oregon ECHO Network also received a considerable proportion of its funds from subscribers, comprised of insurers and two large health systems. The subscribers voted on a yearly basis to fund several ECHO programs.
Inter-Organizational Environment and Networks
A faculty member at OHSU, Andrew Seaman, MD, conducted research documenting the limited access to hepatitis C treatment in rural areas. This research was shared with the OEN and led to the creation of the HepC ECHO program. The relationships of OEN with the Oregon Department of Human Services, Aging and People with Disabilities Division and Nirmala Dhar, the program’s Oregon Health Authority champion, were key for the development of the Nursing Facility Behavioral Health ECHO. Through these relationships, the Oregon ECHO Network found out about the CMS penalty dollars that were used to fund the program. Dhar’s relationship with the older adult behavioral health specialists and knowledge of the corporate nursing facility leadership facilitated the recruitment of nursing facilities to participate in the program.
Leadership was a key inner context factor in the creation of the OEN and its programs. Stock’s interest in ECHO, stemming back to 2012, and relationships with leaders in the state, including the governor’s health advisor, were leveraged to build OEN. Similarly, Seaman’s desire to serve HepC patients was a catalyst for developing an elimination program. “You can’t do this work without passion,” Seaman said. “You can treat people, but you can’t build a whole program unless you really care about that. ECHO [allows us] to share the joy of doing this work and to share our passion in doing this work.”
Quality and Fidelity Monitoring/Support
Fidelity to the ECHO Model and the frequent use of survey feedback was emphasized by all respondents. Model fidelity was reinforced through training. Stock, McDonnell, and other key Oregon ECHO Network staff were trained at the ECHO Institute, and most of OEN’s lead faculty attended immersion training. The OEN team instituted Mid-Program Evaluation in 2020 where two observers watch one or two sessions within an ECHO series and complete a structured observation form. After the session, the observers share their feedback with the ECHO expert team. This feedback augmented the standard OEN surveys that follow each program session, the de-identified results of which are sent to each expert team for reflection. ECHO teams also commonly debriefed after each ECHO session. Seaman, facilitator of the Hepatitis C ECHO, noted that his team met for 15-20 minutes after each session to complete a “semi-structured review of the session.” Similarly, Sue Rose, PhD, NP, facilitator of the Nursing Facility Behavioral Health ECHO, noted that the feedback from the previous sessions was used to adjust the program and make improvements.
Since 2017, the OEN has been a statewide utility for ECHO programs and services. OEN provided administrative functions such as recruitment, IT support, evaluation, and project management support, with the division or external organization providing the specialist, the curriculum support, and the case support. OEN expanded to 10 staff with 8.0 FTE. The ECHO program development process was honed over time with a program manager developing a program (e.g., creating program objectives, curriculum development) and implementation support provided by a project coordinator (e.g., taking attendance, supporting participants). Project coordinators in both ECHO programs were lauded for how they guided the program and encouraged participants to share comments and actively participate.
ECHO Vision and Sustainability
When asked about the vision for the hub in the next several years, McDonnell said they would continue to focus on the needs and interests of participants. In the future, they may collaborate with participant groups beyond primary care. OEN was also finding the right size for the organization as it had grown quickly over the past three years. Stock believed that the organization was on the right track and wanted a closer connection to the state and the legislative process.
Better relations with rural and underserved areas as well as a stronger focus on health equity were mentioned as important to OEN’s future. Ideas for improving health equity and diversity included examining how ECHO experts were selected, facilitating discussions with ECHO faculty to challenge their thinking about health equity and disparities in existing programs, recruiting more diverse ECHO participants and ECHO team members, and developing an ECHO program focused on health equity.
Maggie McLain McDonnell, MPH
Director, Oregon ECHO Network
Lead Project Manager, Oregon ECHO Network
Ron Stock, MD, MA
Clinical Advisor, Oregon ECHO Network
Andrew Seaman, MD
ECHO Lead, Hepatitis C: Treatment and Elimination Program
Sue Rose, PhD, NP
ECHO Lead, Nursing Facility Behavioral Health ECHO Program
McDonnell, M., & Rao, N. (2022). Oregon ECHO Network Implementation Profile. Diffusion Associates. http://www.diffusionassociates.com/echo.