“There will always be a need for the ECHO Model.”
The Weitzman Institute is the education, research, and policy arm of the Community Health Center, Inc. (CHC), the largest federally qualified healthcare center (FQHC) in Connecticut. The Weitzman Institute’s ECHO work, and specifically the Complex Care Management (CCM) ECHO and an Alcohol & Smoking (A&S) 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.
Ariel Porto, senior program manager at the Weitzman Institute, was a 2021 implementation fellow and worked with 14 other fellows alongside Diffusion Associates in conducting research for this study. Andrea Janota, director of the IUPUI ECHO Center & Center for Public Health Practice and a 2021 implementation fellow, conducted interviews with CHC and Weitzman Institute staff in July and August 2021, along with R. Sam Larson, PhD, director of Diffusion Associates, which are the basis of this profile.
We begin this profile by sharing unique implementation insights from the Weitzman Institute’s ECHO work, and specifically the Complex Care Management (CCM) and Alcohol & Smoking (A&S) ECHO programs.
ECHO Implementation Insights
ECHO as Professional Development and Continuous Training
At its inception, Weitzman ECHOs were organized by CHC leaders to best meet the needs of their staff. CHC clinicians fulfilled the role of subject matter experts or “faculty” on the ECHO hub teams and serving as an ECHO faculty member was built into the culture of CHC and viewed as a reputable position and distinctive recognition. This was evident in the CCM ECHO that had been offered on a continuous basis since 2015 to nurses across the CHC locations. ECHO was a “journey” and a “personal relationship” where nurses were heard and their needs expressed. The focus was on “transferring competencies, which is different from the original implementation of ECHO, which was to transfer knowledge and build a community of knowledge.”
Fidelity through Choice
The Weitzman Institute had an education division. This division oversaw the creation and implementation of ECHO programs as well as other educational models. ECHO was not the only “tool in the toolbox” when CHC or the Weitzman Institute had need for solution to an education-related problem. Weitzman ECHO was strategic and intentional about distinguishing what was ECHO and what constituted another form of continuing education. While Weitzman had innovated within the ECHO framework, they adhered closely to ECHO’s principles.
Reducing Health Disparities and Inequities in Care
The CCM and A&S ECHOs had a strong and continuous focus on health disparities and inequities. They offered didactics focused on cultural contexts and health disparities. In the CCM ECHO they “talk about these types of issues a lot.” Importantly, they framed this from a pragmatic perspective where “what do you do if you use an incorrect pronoun with a patient. Like how to apologize and really bridge the gap and keep that rapport with the patient? How do you change your language so you’re not calling folks drug addicts? You’re putting the emphasis on the individual being human, just like the rest of us.”
This pragmatic perspective was also used in the A&S ECHO. In states without Medicaid expansion where recommended best standards of care were not be an option or when external factors constrained the provider from implementing the evidence-based practice, the team was prepared to grapple with developing creative solutions and advocating for harm reduction.
Creating a “Deep Bench”
Burnout was a risk for hub team members at many ECHO hubs, especially hubs that offered a large number of programs. Willing and talented experts often became the “go-to” person for a certain specialty area and were repeatedly asked to serve in a role as a hub team member. A respondent shared that ECHO was “always a pleasant experience, but there isn’t a bench, there isn’t a long list of other people that they can go.” Weitzman Institute identified the need to put “conscious effort” into developing a deeper bench. One way to do this was to partner with other agencies and organizations, such as the National Council for Mental Wellbeing, which had networks of skilled practitioners ECHOs could tap into. Through this and additional partnerships, the Weitzman Institute continued to grow its “external faculty network,” composed of subject matter experts representing many primary care topic areas from across the country.
ECHO Model Adoption
The Weitzman Institute was one of the early adopters of the ECHO Model. In 2011, the director of the Weitzman Institute, Daren Anderson, MD, read about Project ECHO in a New England Journal of Medicine publication authored by the ECHO Institute’s founder, Sanjeev Arora, MD, and said, according to Ariel Porto, “This is exactly what CHC needs.” According to Porto, Anderson saw the ECHO Model as a way to reach across all CHC sites to address Hepatitis C and HIV treatment. Anderson met with the CEO of CHC, Mark Masselli, who also thought ECHO was a good fit for CHC. Anderson and a small group from CHC/Weitzman visited the ECHO Institute to learn more about the model.
Initially, the Weitzman Institute sought academic partners to implement Project ECHO in Connecticut; however, finding none, they decided to launch programming on their own, making it the first FQHC to offer ECHOs. The first ECHO programs launched by the CHC/Weitzman Institute were focused internally —on providers at CHC sites across Connecticut and defined based on their needs. Mandy Lamb, director of partnerships and development, said they decided to open these ECHOs because “the Weitzman Institute serves other FQHCs across the country.” When external funding became available to support a Pain ECHO, they partnered with a community health center in Arizona.
Project ECHO was one of several “tools in the medical education toolbox.” ECHO programs were sometimes created in response to requests from external groups as well as to meet CHC needs. Funding was sometimes internal, and other times the work was supported by grants; and the Weitzman Institute was commonly included as a sub-awardee on grants by partners wishing to implement specific topical ECHO programs.
Complex Care Management (CCM) ECHO
The Complex Care Management ECHO was started by Mary Blankson, DNP, chief nursing officer (CNO) for Community Health Center, Inc. Between 2012-2013, Blankson participated in the Weitzman Institute’s first ECHO program, which focused on treating hepatitis C and HIV. When Blankson became CNO in 2014, she designed an ECHO program to support CHC nurses, an internal audience. Blankson recalled that she would spend six months to a year orienting new nurses to the “philosophy of primary care,” a commonly overlooked area of study in many bachelor’s degree nursing curriculums. Blankson saw ECHO as a way to fill knowledge gaps for nurses. She described learning more details about the ECHO Model through published literature and relying on the in-house ECHO experts to assist with the implementation of the CCM ECHO; she also presented at a MetaECHO conference. The CCM ECHO was based in a Knowledge to Action Framework to create a transformational experience in which participants build skills in specific primary care competencies.
Initial funding for the CCM ECHO program came from a three-year Health Resources and Services Administration Nursing Education, Practice, Quality, and Retention grant. After the funding period ended, CHC committed internal resources to continue the program. Costs included the time of Weitzman Institute ECHO– trained staff; however, Blankson constructed the nurses’ schedules “in such a way that blocking them for ECHO doesn’t affect their opportunities for completing billable visits.” At the time of writing, CCM ECHO was supported by Lynsey Grzejszczak, education program specialist.
The CCM ECHO assisted nurses who were practicing at the top of their license with complex patients. The program began in 2015 and was ongoing with no expected end date. Participating CHC nurses met twice a month for 90 minutes to discuss curricular topics set by CHC leadership. Each year of programming included 24 sessions that were reviewed, edited, and updated annually by Mary Blankson, DNP, the ECHO’s lead faculty member and chief nursing officer at CHC.
Alcohol & Smoking ECHO
In 2019, The Weitzman Institute was approached by the National Council for Mental Wellbeing to discuss health needs that could be addressed from a SAMSHA grant awarded to the council. Lamb and Porto indicated that although alcohol and smoking were legal, they were a serious problem. In response, Weitzman ECHO created the Alcohol & Smoking ECHO (A&S ECHO) which was funded entirely by the council. One faculty was Dan Bryant, LPC, the clinical director of Substance Use Disorder Services at the CHC. Bryant began participating in ECHO programs in 2015 as a faculty member for the CCM ECHO and participated on the Weitzman Institute’s Medication Assisted Treatment ECHO, for which he was a hub team expert. Lindsey Lehet, program specialist at the Weitzman Institute, provided operational support for the A&S ECHO. Bryant and Lehet had observed and participated in ECHOs before and received training from the Weitzman Institute.
The A&S ECHO began in February 2019 with a 12-session ECHO with faculty and staff in-person at the Institute but quickly adjusted when COVID made that impossible. The program’s success and demand for it led to a second year of funding. The A&S ECHO came at an opportune time. Smoking could compound the impact of COVID and the team shifted the sessions to “let’s talk about COVID and smoking. If we can help people quit smoking with this model in the face of COVID, that’s great.” This thinking shifted quickly to recognize that alcohol was becoming a pressing concern. Bryant commented, “It became clear that alcohol use was skyrocketing during the pandemic. So that shifted our focus.” The A&S ECHO was “very much in the context of the pandemic.” Still, when Council priorities shifted to new topics the following grant year, the program ended and was replaced with a Childhood Trauma ECHO.
Participants in the Alcohol & Smoking (A&S) ECHO included multidisciplinary primary care and behavioral health providers from across the country. The program promoted integrated care across the healthcare team. The A&S ECHO was cohort-based and a six-month time-limited series. Participants were required to register during the recruitment period and expected to participate in as many sessions as possible.
The decisions to begin the CCM and A&S ECHOs were similar in that the clinical leaders had considerable experience with educational programs and both were familiar with ECHO, having participated in previous ECHO programs. Motivations, however, were different. The A&S ECHO was begun in response to an external agent who had funds to support an educational intervention. In contrast, the CCM ECHO originated internally to meet the training needs of the CHC nursing staff.
ECHO Model Implementation
The ECHO Model seeks to build a learning community where “all teach, all learn.” This is done by leveraging technology, sharing best practices, through case-based learning, and using data. We asked respondents to tell us what “all teach, all learn” meant to them. Respondents described learning that was reciprocal or cyclical—where everyone was learning and teaching each other. Bryant shared that “all teach, all learn” in the ideal had “faculty teaching faculty, you have faculty teaching participants, and you have participants teaching each other. Occasionally you have participants teaching faculty things that they might not know.” Members from the A&S ECHO discussed that when ECHO works well, participants and hub team members collaboratively “work through a challenging and difficult case, and bounce ideas off of one another.”
Interviewees gave many examples of how learning takes place between participants. One respondent gave an example of peer-to-peer learning where a participant shared a question as part of a case study and a second participant used what she previously learned from ECHO to answer her peer’s question. This second participant turned to the ECHO faculty lead to see if the answer was correct and the faculty responded, “You’ve completely answered the question.” Faculty were learning from participants and peers. Porto shared that one faculty commented that he learned just as much from the participants and his peer faculty members as they were learning from him. In another story, a specialist shared that they were implementing new screening services into their day-to-day clinical practice that they learned from an ECHO participant. Faculty and participants were also learning from guest speakers. Bryant shared that a guest speaker shared new content and “their style, their educational talent, was a real blessing.” Weitzman ECHO staff witnessed highly engaged providers transform from ECHO learner to ECHO teachers after years of participating in the program. Participants and faculty also learned from patients. One respondent recounted a time when a patient anonymously (camera off, no name) joined a live ECHO session to share their personal journey with substance use disorder and how the care provided by the participating clinician positively impacted their life. This session was described as “very powerful” and “brought a very human element” to the conversation.
In the CCM ECHO, “all teach, all learn” extended to “supporting self-reflection and introspection.” In one case, a nurse presented a situation in which a patient with a substance use disorder had lied to her in their clinical interaction. The presentation led to a robust conversation among practitioners about the need for self-care, boundary setting, and focusing on the patient’s care process.
Creating a reciprocal learning environment was not without its challenges. When the educational level across participants was “incredibly varied” it required teaching to the least experienced participant’s level. That made for an “interesting dynamic because when you have to make sure everyone’s on the same page, that changes the educational style you choose.”
Both programs adhered closely to the ECHO Model with experts presenting didactics and participants presenting cases. Patient case studies were submitted online and organized for the session by the program’s coordinator. Prior to COVID-19, each program aimed to discuss two patient cases per ECHO session; however, with constraints on provider time, some sessions were reduced to one case presentation. The CCM ECHO was very successful in recruiting cases from participants, perhaps because it was a built-in expectation and had strong cultural support. The A&S ECHO team sent out emails and a sign-up calendar encouraged participants to present cases. On a couple of occasions, they didn’t have a case and they’d “open up questions to the floor. It was like an open forum, which was nice.” The CCM ECHO implemented reflective questions and waterfall chats to increase participant engagement outside of the case-based learning time. Both projects offered an online portal for participants who were registered with the program to view past session recordings, lecture slides, and referenced resources.
Factors Influencing Implementation
Studies of program implementation identify outer and internal contexts that can shape how a program is implemented. 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 Weitzman ECHO implemented these two programs.
The organizational home for ECHO shaped how ECHO programs were implemented. The Weitzman Institute was established by the Community Health Center, Inc. (CHC) in 2007. CHC was a leading independent, nonprofit healthcare provider in the state of Connecticut, providing comprehensive primary care services in medicine, dentistry, and behavioral health to more than 145,000 people. CHC had 19 clinics across Connecticut and provided support to more communities via CHC Mobile Services and school-based health centers. CHC was designated as a FQHC and a patient-centered medical home by HRSA, the Joint Commission, and NCQA.
Lamb describes the Weitzman Institute as CHC’s “incubation center for ideas. Just as we have a human resource department, we have a research, education, and innovation arm.” The Institute’s work focused on research, education, and policy. ECHO was situated within the educational work stream. And it was not alone—ECHO was one of several education models or programs that the Institute supported. ECHO work at Weitzman was, then, embedded within multiple networks. The CHC provider network and a vast external faculty network enabled Weitzman ECHO to create programs designed “by primary care, for primary care.” Weitzman ECHO received evaluation support from the research and evaluation team, marketing support from CHC’s communications department, and worked with internal offices for administrative support with contracts and grants.
Initially, CHC and Weitzman Institute leaders attended immersion training at the ECHO Institute. Since then, the Weitzman Institute had “trained staff members who have trained staff members who’ve trained staff members” to implement the model. The Weitzman Institute had a robust training program for ECHO as well as for other educational initiatives. Lamb said, “We train all of our education team members in the ECHO Model even if they will tangentially touch it, because at some point they might run an ECHO.” The internal training focused on the core principles and drew on the experience of those who attended immersion training and internally developed training materials. The Weitzman Institute had a well-developed facilitator training program. Porto said they took faculty and facilitator training “very seriously.” Faculty training started with reading materials, including a guide on what the sessions were going to look like. They had an ECHO orientation for new faculty where they talked about expectations and how ECHO was different from a webinar. Then, faculty were asked to review an exemplary recorded session. Finally, new faculty did “a dry run, where we’ve already put together the kick-off session agenda.”
Training also drew on what was learned and developed to support other educational programs such as workforce training, residency training, and faculty development. Lamb said the education programs were a cross-collaboration effort and shared practices in educational design. “We’re under one department. Principles of engagement and curriculum design, everything that’s part of an education and learning process, we learn from each other and then adapt that to our own training and how we engage staff in our ECHO programming.”
The ECHO programs at the Weitzman Institute were funded through multiple channels. Some received grants to support programs, such as the A&S ECHO. Some ECHO programs, such as the CCM ECHO, were supported by CHC. The Weitzman Institute also provided ECHO operations for third parties who paid for the support. Weitzman ECHO developed a pricing structure that provided basic coverage for hub team experts and coordinator staff time. ECHO programs without overall grant or contract support operated under a cost-sharing model, where individual health centers or stakeholders such as health plans could pay a fee “per provider, per clinic” for participants to join; however, there was flexibility. “We try to work with the health centers to find a way. We’ve also let them, if they don’t have the funds, to join at no cost, and then review after a year.” CHC sometimes provided a funding backstop should a project temporarily lack financial support to avoid ending long-standing programs. The A&S ECHO was not a long-standing program, and ended when the National Council for Mental Wellbeing worked with the Weitzman Institute to select a new grant focus. Still, Lehet noted that at the Institute “nothing is ever off the table. Nothing is ever out of the question,” so the program could be restarted.
ECHO Vision and Sustainability
When asked about the vision for the hub in the next several years, interviewees said the Weitzman ECHO was focused on growth in meaningful ways. Lamb said, “There will always be a need for the ECHO Model” and growth was likely but they also wanted to be “thoughtful about it.” Lamb and Porto had other educational models to draw on and it would be “interesting to see when we use ECHO versus another intervention.” The future vision for the Weitzman Institute was likely to include determining what was an ECHO and when ECHO was the best solution for a problem. Weitzman ECHO leaders wanted to be less dependent on grant money in the future. They anticipated receiving grants each year “because of what’s out there” but were also looking to third party payers or payer organizations to provide financial support. Blankson would like to see the CCM idea expanded. She described the CCM ECHO program as a model for augmenting nursing education programs. Blankson envisioned “ECHO as a natural part of the educational journey and as part of the growth and experience as a nurse is entering practice.” She wanted to see ECHO recognized as central to bridging the gap between those academic and clinical partnerships and worked into a complementary curriculum. Blankson did not talk about adding more participants to the current ECHO, but about taking ECHO into universities and having it become central to the ongoing training and development of primary care nurses.
A shift in funder priority led to closing down the A&S ECHO. If the program were to relaunch, Bryant would start from the beginning to “find a way to do this as an ongoing program.” The program could extend beyond the 12-session series as participant-reported evaluations supported extending the duration of the programs.
In discussing the future of ECHO, Lamb and Porto looked beyond CHC and the Weitzman Institute to what was happening within the ECHO movement, which was described as being “at a point of change.” They saw situations where the ECHO Model was being evoked but in fact what was being offered was a webinar or a short-term education series without participant-presented cases. Lamb and Porto were looking to the ECHO community to determine “what ECHO means and how ECHO varies from other training programs and education programs.”
Mark Blankson, DNP, APRN, FNP-C, FAAN
Chief Nursing Officer
Dan Bryant, LPC, MSEd
Clinical Director of Substance use Disorder
Behavioral Health Clinician
Lynsey Grzejszczak, MHA
Education Program Specialist
Mandy Lamb, MA
Director of Partnerships and Development
Senior Program Manager, Education
Janota, A. D. & Larson, R. S. (2021). Project ECHO at the Weitzman Institute Implementation Profile. Diffusion Associates. http://www.diffusionassociates.com/echo.