Project ECHO at Penn State Implementation Profile

Project ECHO came to the attention of the Penn State College of Medicine when Thomas Ma, MD, became chair of the Department of Medicine. Ma had been the chief of the Division of Gastroenterology and Hepatology at the University of New Mexico—the division home for Sajeev Arora, MD, who founded Project ECHO. Jennifer Kraschnewski, MD, said that when Ma joined Penn State, he looked around and said, “You know, central Pennsylvania looks a lot like New Mexico. Where’s your Project ECHO?” With Ma’s support, Kraschnewski made a one-day visit to the ECHO Institute and shortly afterward Arora was a grand rounds speaker at the Penn State College of Medicine. Kraschnewski said, “After that, I was hooked on the potential for this model and the good work that we could do.” Early adoption was also championed by Sarah Kawasaki, MD, who had previous experience with an intervention modeled after Project ECHO through Johns Hopkins University (JHU) while working at a Federally Qualified Health Center in Baltimore City. Kawasaki described her experience with JHU as “feeling connected to a team of experts that I could reach out to.” Kawasaki was sold on Project ECHO and worked with Ma to “sell it to other clinicians who were thinking about doing their own ECHO for their own disease processes.” Adoption was a “directive from the top down” and “there was no resistance” from clinicians. More than a dozen faculty and staff from Penn State attended the three-day immersion training at the ECHO Institute.

Kraschnewski was the executive director and clinician lead for Project ECHO at Penn State. When initiating the program, Kraschnewski spoke with Penn State leadership and asked for and received startup funds, a teleconference room for Project ECHO, and technology support. Startup funds were sufficient to hire two positions from the start. One position was for a project director because, as Kraschnewski commented, “there’s a need for someone to support ECHO’s day to day operations.” She also wanted a marketing manager because “I needed someone who can get the word out.” The Project ECHO team at Penn State had grown to include about a dozen staff. At the time of this interview, Project ECHO at Penn State was located within the Penn State College of Medicine.

Medication for Opioid Use Disorder (MOUD) ECHO Program

The MOUD ECHO was the initial ECHO program offered by Penn State. It was enthusiastically endorsed by Kawasaki, who said, “We can easily do an ECHO for medications for opioid use disorder. Let’s do it. I’ll be the champion.”  Kawasaki had previously been involved in an ECHO-like project and saw “only success” in adopting the model at Penn State. The MOUD ECHO was part of a larger grant that Penn State College of Medicine had with the Substance Abuse and Mental Health Services Administration (SAMHSA), which included funding for clinical and treatment services. The MOUD ECHO leveraged an existing state program to attract spoke providers and clinics. The PacMAT—Pennsylvania Coordinated Medication Assisted Treatment—program served as a physical hub-and-spoke model where an addiction specialist physician provided expert guidance and support to primary care physicians in rural and underserved areas of the state. The MOUD ECHO was used to “foster communication with the PacMAT programs” and PacMAT spokes were recruited to join the ECHO program. Kawasaki shared that state funding for PacMAT programs helped fuel the MOUD ECHO. This series has been offered four times and included providers and case managers from clinics and treatment facilities throughout Pennsylvania.

Boy Scouts Summer Camp Revamped (Boy Scouts Summer Camp) ECHO Program

This unique ECHO program was based on a pre-existing program at PRO (Prevention, Research and Outreach) Wellness, a nonprofit center within the Department of Pediatrics at Penn State College of Medicine. The program was sponsored by a local philanthropist who wanted to see improvements in the Boy Scouts camp environment. The program was led by Kara Bowers, a dietitian and project manager, and Erica Francis, program director for Penn State Project ECHO, who initially visited local Boy Scouts camps to “help them find unique ways to improve their camp environment. Around nutrition, but a little bit with physical activity.” By the second year, Bowers and Francis had branched out to camps across Pennsylvania, in Georgia, and in Arizona. By the third year they were reaching out across the country. They were “traveling a lot and it became really expensive. We also found that at some camps, the Scouts executive would be on board but not the kitchen staff. For those camps, the program worked better if they could connect with a camp that had already been successful.” When Bowers heard about ECHO, she saw a way to reduce travel time and costs, and a way to encourage peer-to-peer learning. Bowers eventually joined the larger Penn State Project ECHO team.

The Boy Scouts Summer Camp ECHO program attracted spokes from across the country. Participants varied from large, well-funded adventure camps to rural “mom-and-pop camps that could have gone out of business years ago.” The hub faculty reviewed menus; and as registered dietitians, this review was used as part of a national requirement—this complimentary review could save camps up to $500 each year.

The ECHO Model seeks to build a learning community based on “all teach, all learn.”  This is done by leveraging technology, by sharing best practices, through case-based learning, and using data. We asked respondents to tell us what “all teach, all learn” (ATAL) meant to them. One dimension of ATAL shared across the hub and programs was that knowledge was distributed. This dimension was summed up in a comment shared by Jackie Sabol, education program specialist: “We are a community of learners and a community of teachers. We all ask questions. We all have answers.” Kraschnewski provided an example of how this distribution looked in practice. During a case discussion, a spoke provided a recommendation to which two “very seasoned” experts said, “Oh, I never even thought of doing that.” Some programs were using former spokes as experts.

ATAL “puts the participants at the center,” shared Abbey Fisher, research project manager. And it’s not just the participants; patients are also at the center of ATAL. Kawasaki said that when a spoke presented a case, “They are bringing a unique person, with a unique set of experiences with the medical community. The case is a teaching tool for everyone participating, even to the expert team because every patient is different.” The theme of uniqueness and difference was expressed by Jessica Beiler, project manager, who said, “We have different lived experiences. ‘All teach, all learn’ gives space for everyone’s voice to be heard, to share those differing experiences.”

Adding to this definition was a perspective shared by Kraschnewski where ATAL was a “super powerful” way to recognize and reassure clinicians that they are experts in what they need to do for patients and that “sometimes we just don’t have all the answers in medicine.”

Case presentation and discussion fostered an ATAL environment at Penn State. In part, this was due to expanding or redefining the term “case” and thereby making case presentations less “intimidating.” Penn State Project ECHO was “keeping the term ‘case,’ but we’re doing more to explain what a case actually is or might mean to the spoke.” They were “softening the language” and participants were asked if they “have a case, a question, an example, a challenge” to initiate a case-based discussion. In the MOUD ECHO, participants were reminded that “a case can be anything that you’re dealing with. It could be a patient, it could be a general question, it could be a challenge that you’re seeing across multiple patients in your clinic.”  In the Boy Scouts Summer Camp ECHO, the term “cases” was intimidating to participants and the phrase “real-life camp examples” was used to initiate a case-based discussion. The case template they used stated, “If you have a real-life camp example or question that you’d like to discuss, fill out this survey form.”

In addition to cases, both ECHO programs featured didactics. The Boy Scouts Summer Camp ECHO started off with a case and then shifted to a short didactic “followed by questions and more discussion; because participants know each other, they ask questions of each other.” This ECHO had six themes that “all camps should know” and were led by a dietitian and project manager. The Boy Scouts Summer Camp ECHO also had a series of videos and support materials that were available to all participants. The MOUD ECHO featured different speakers for their didactics. Kawasaki said that they’re “lucky to be based at a large academic institution. We have our pick of specialists to speak on various topics.” Session topics were set in advance and over time they developed a set curriculum for the MOUD ECHO.

Evaluation, another aspect of the ECHO Model, was core to both programs. The MOUD ECHO provided an evaluation form at the end of each session, though the feedback was not extensive. Series evaluations were also sent to participants at the conclusion of the MOUD ECHO program. The Boy Scouts Summer Camp ECHO collected information during registration such as “How big is your camp? What have you tried? What worked? What hasn’t worked?” This information was used to initiate conversations and shape didactics. This ECHO program also collected feedback at the end of the series and conducted a final evaluation at the end of the summer asking participants, “What did you actually implement at camp? What worked?”

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. Below, we identify factors that emerged during interviews which influence how Project ECHO at Penn State and the MOUD and Boy Scouts Summer Camp Revamped ECHOs were implemented.

Organizational Staffing

The Project ECHO team at Penn State had doubled in size in 18 months and included about a dozen members. The team was cohesive with respondents describing their team as a “well-oiled machine” and repeatedly talked about feeling “welcomed” and “lucky” to be on the “best team at Penn State.”  This well-oiled machine was built on a solid understanding of ECHO gained through more than 12 people attending immersion training at the ECHO Institute as a group and through a well-developed internal training program. Training emphasized fidelity to the model and ensuring that standard procedures— such as evaluation and feedback—were consistently followed.

Leadership

As one respondent noted, Project ECHO at Penn State started was a top-down initiative when Ma became chair of the Department of Medicine at the Penn State College of Medicine and asked, “Where’s your Project ECHO?” The dean of the School of Medicine was also supportive, providing startup funds to hire staff and technical support. Kraschnewski provided leadership and guidance for ECHO. Her team described her as a “champion,” as having a “great working relationships on campus” and as a “rock star at getting interesting projects and funding.” She said her approach to leadership was to “do good work and people will see, but you also need to do a good job promoting that work.” Kraschnewski promoted the ECHO work and encouraged continued engagement from the dean through reports and presentations at department and division meetings to “raise awareness and engage people who might think ECHO is a good fit for what they do.”   

Policy/Service Environment

ECHO programs can be sensitive to policy issues. For the Boy Scouts Summer Camp ECHO, participants were from different states. When talking about food safety guidelines with COVID, the hub leads referred to CDC guidance but “constantly refer participants back to their own state health guidelines because they all had different standards.” In addition, the Boy Scouts Summer Camp ECHO program had to comply with the national standards set by the Boy Scouts of America.

Pennsylvania is a Commonwealth State where counties and regions had much autonomy to make and interpret policies and to set budgets. Kawasaki shared that the MOUD ECHO spent a great deal of time building a network that crosses boundaries so that peers can positively influence each other.

Funding

Penn State Project ECHO had startup funds from the dean used to support the hiring of staff and launching several ECHO programs. Most of the funding for ECHO work at Penn State, however, came from external grants with more than 15 proposals being submitted in a one-year period. Some startup funds remained and they were used to pilot new ECHO programs. The budget was managed by the Department of Medicine, but the core team had spreadsheets that tracked time and money. ECHO programs also had pre-determined cost estimates based on the size of the ECHO, and these estimates were used to create budgets for proposals. Penn State physicians who offered didactics or facilitated ECHO sessions were compensated for their time. As Kraschnewski indicated, “If docs and academics aren’t seeing patients, they are expected to cover their time. Everybody likes to volunteer, but that only goes so far.” 

Penn State Project ECHO had been successful in their proposals and the MOUD ECHO was secure in their future funding given state priorities and a multi-year SAMHSA grant. The Boy Scouts Summer Camp Revamped ECHO, however, had less certainty. The Boy Scouts Summer Camp program was originally supported by a single donor who previously served on the Boy Scouts of America National Board. Nutrition was an area of particular concern for her. She provided support for the initial two years of the program. The team was able to stretch those initial funds for an additional four years. The team hoped to sustain the program through support from the National Office of the Boy Scouts of America but competing priorities took precedence.

Partnerships and Networks

ECHO work at Penn State took place within a dense network of relationships within and beyond the College of Medicine. Kraschnewski and Kawasaki engaged with state departments and networks to strengthen support for ECHO. The MOUD ECHO used existing relationships formed through another initiative—PacMAT—to reach participants and market their work. The MOUD ECHO was also strengthening networks across counties which, Kawasaki said, “is helping to change the culture of treatment . . . to the point where people are more accepting of science.”  Thus, MOUD ECHO was both drawing from and strengthening networks and partnerships.

Training

In-house training for hub members and expert presenters was well developed and included a discussion about what ECHO was and what it was not, as well as “why we are doing things the way we do.” The training included a “staged 10-minute video of the perfect case discussion that participants watch before they come to the training.” During the training, participants practiced a mock ECHO case discussion and debrief. The hub team also shared a best practice facilitation guide with the facilitator. All hub/program experts were required to go through training—in-house and/or immersion training at the ECHO Institute. The result was a standardization of ECHO implementation.

Respondents were thinking about and planning for the future. Penn State Project ECHO had a five-year plan when they started and “hit everything in the first two and half years.” The Penn State ECHO team came to Kraschnewski and said, “We started a strategic planning process.” Her response was, “This is the best team ever—they are already thinking about and planning for the future.”

Sabol would like to see ECHO “become a standing unit, not a grant-funded unit, but a unit like an IT department. You have to have an IT department; you have to have an ECHO department.” The future infrastructure of Project ECHO was a question on Kraschnewski’s mind as well, commenting that as they grow, they needed an infrastructure that supported them and encouraged continued growth. Similarly, Abbey Fisher, research project manager, noted that the ECHO team had doubled in size and they were “getting a lot of interest and a lot of projects. We’re looking at how we manage this growth.” 

This more expansive structure fit with a more expansive vision of ECHO work. For example, Kraschnewski said she has a “bigger vision” of ECHO that “leverages the focus of ECHO on health disparities to really make a difference” and to “start demonstrating the impact of ECHO.” This thought was also expressed by Sabol, who talked about “looking at the next level of impact of ECHO” and leading that effort at Penn State and within the ECHO movement.

Building partnerships was a vision shared by several respondents. Beiler would like to see ECHO build “better relationships with the State. There are a lot of departments with which we could work.” This theme was shared with the MOUD ECHO program. Kawasaki’s vision of the MOUD ECHO program was “working with detox facilities and getting them to participate. I’d love to see participation from law enforcement and politicians as well.”

Bowers would like to see the Boy Scouts Summer Camp ECHO continue “because this is a group of people that lack support and peer mentorship.” The hub leads would like to have more cohorts and reach more summer camps, but that goal was contingent on funding and it wasn’t clear that the funding was forthcoming. This ECHO may need to take a pause.

Jessica Beiler, MPH
Project Manager
Penn State Project ECHO

Kara Shifler Bowers, RD, MPA
Project Manager and Content Expert
Penn State Project ECHO

Abbey Fisher, MPA
Research Project Manager
Penn State Project ECHO

Erica Francis, MS
Program Director
Penn State Project ECHO

Sarah Kawasaki, MD
Director of Addiction Services, Pennsylvania Psychiatric Institute
Assistant Professor of Psychiatry and Behavioral Health

Jennifer L. Kraschnewski, MD, MPH
Professor of Medicine and Public Health Sciences
Director, Penn State Project ECHO

Jackie Sabol, M.Ed.
Education Program Specialist
Penn State Project ECHO

Larson, R. S. (2022). Project ECHO at Penn State Implementation Profile. Diffusion Associates. https://www.diffusionassociates.com/echo.