Starting and sustaining a movement in healthcare is tough business, unless there is a plan and resources for dissemination. The movement to integrate behavioral health services into primary care began in diverse places, but now appears to have serious momentum. The challenges facing integration today are many and include the following big two: workforce development and variation. The first is a constant requirement for the health care ecosystem and a major determination for how fast a system can integrate. The second is a natural result of the germination of integration across many spots of land, some good and some poor. Variation is good for gene pools and music playlists, but not for disseminating best practice in primary care. Variation means everyone is NOT on the same page. It is a major impediment for research and dissemination. Closed systems seem to have the least amount of variation (see Kaiser, Cherokee, and the VA system) and often boast the most outcome data. The bad news is that many rural and remote clinics operate outside closed systems and lack access to info on best practices.
One possible solution for addressing these issues of variation, access, and even workforce development is Project ECHO (Extension for Community Healthcare Outcomes). Some of you are probably familiar with ECHO especially when it comes to liver disease management, HIV treatment, or psychiatry in primary care. ECHO is basically a marriage of professional education and care management that enhances primary care treatment. For those of you with behavioral health training backgrounds, it is very similar to group peer supervision (shout out to Dr. Springer, my favorite group supervisor). ECHO works to broadly share knowledge and build capacity among primary care workers, all in an effort to reduce disparities between urban centers and rural communities. For additional bonus points, ECHO also seems to reduce variation in practice and develop the workforce. The research is impressive. One recent article on ECHO for integrated primary care reports increased provider knowledge and self-efficacy and reduced feelings of isolation.
Short side story here: When I was a kid growing up in New York, my family did not have cable television. We had a big antenna on our roof and picked up major network channels and public television. I enjoyed the popular kid shows at the time, even though most of them were just 30-minute advertisements (GI Joe and Transformers, I’m looking at you). The only daytime option for television was the Public Broadcasting Station (PBS) channel. My three brothers, three sisters, and I (yes, big family) enjoyed watching classic PBS shows like Reading Rainbow, Sesame Street, and 3-2-1 Contact. I can sing the theme songs of most of these shows. These shows were ad-free, high quality, and funded by public and private payers. Project ECHO is like your local PBS channel, allowing everyone access to quality content.
Nothing compares to PBS. Those television programs have impacted millions of children in the US and continue to do so today. Beyond public education and public libraries, it is one of the most effective ways for sharing education with a wide audience. In healthcare, I believe that ECHO is one of the best strategies for making expert knowledge of integration as widely and freely accessible as possible. Imagine the small rural practice in Wyoming that wants to integrate, but has no access to an academic hub or enough funds for a consultant. That rural practice can join an ECHO group, connect with other similar clinics, and begin learning best practices immediately. All for free. The major challenge for most ECHO hubs (a hub is the collection of experts that work with the local sites, called spokes), just like PBS, is securing funding, often through sponsorship.
We have published previous blog posts on ECHO (here, here). I mention it again now because of recent developments by large organizations to develop ECHO hubs specifically for behavioral health integration. There are many hubs on opioid addiction and psychiatry, but none that focus specifically on integrating behavioral health providers into primary care. Some recent examples include ECHO Colorado and Arizona State University. The former is focused on patient treatment, the latter on practice transformation and management strategies. Despite the benefits of ECHO, there are challenges. I already mentioned funding, a common one because the founders of ECHO at the University of New Mexico require all hubs to make ECHO services free and accessible to primary care clinics. Another challenge is the struggle to measure practice transformation within spokes that participate in ECHO. Most studies that I see measure knowledge and self-efficacy. It’s difficult gaining access to multiple EMRs without major funding and expertise.
But those challenges are surmountable. Project ECHO is really a project of the willing. The people who stand to benefit the most from integrated care are those living in rural, remote, and underserved areas. Those clinics often lack access to expert knowledge. ECHO reduces this disparity just like Elmo from Sesame Street. But it requires self-motivated individuals who are willing to invest time and resources upfront before funding is later available. That is a tough pitch to make to your CEO. My advice is to just ask your CEO if he or she grew up watching PBS.