We all know that primary care
doctors have to wear many “hats” in taking care of patients. Unfortunately, with the shortage of mental
health providers and the fact that those with mental illness are living longer
and more often than not, have multiple medical illnesses, it is often left to
the primary doctor to wear the psychiatrist “hat”.

 

As if the shortage of mental health providers
wasn’t difficult enough, there is little time or incentives to seek out more
education or to attend conferences, which often have high registration fees and
involve even higher travel expenses.

What if there was a free, biweekly
mentoring program that you could participate in from the comfort of your
office, which provides advice and education in treating those with mental health
issues as well as provides CME? What’s
the catch, right? There is no catch. The
ECHO^© model was developed by the University of New Mexico to provide best-practice
specialty care and reduce health disparities through tele health.

 

In 2003, Dr. Sanjeev Arora, MD was a liver
doctor at the University of New Mexico, and was frustrated that many people in
the underserved areas were not able to receive treatment for Hepatitis C
because they could not travel to one of two specialized centers in New Mexico
and the primary care doctors didn’t feel comfortable prescribing medications
that often had serious side effects.

 

The solution came to him in the form of
technology. Weekly virtual clinics were
set up to engage primary care doctors in remote areas with specialists at the
academic medical center where they would present de-identified patient cases
and the specialist would provide recommendations. Over time, the hope was that primary care
doctors would learn how to treat these patients on their own, providing better
care for more specialized illnesses in rural areas.

 

The University of New Mexico studied the
providers who participated in the ECHO^© program and discovered that
the viral load of patients who were taken care of by specialists at the
academic medical center were no different from those taken care of by PCPs
involved in the ECHO^© program and a movement was born.

 

The solution came in the form of technology

With the help of the ground breaking
work from University of New Mexico, providers, both nationally and
internationally began to be trained in the ECHO^© model and brought
it back to their institutions. There are
now multiple ECHO^© models in every specialty you can think of all
over the world. Just over 2 years ago,
the University of Rochester became trained in this model and provided geriatric
mental healthcare mentoring to primary care offices as well as nursing
homes.

 

While the participating providers
found the model helpful and supportive, they felt that they needed more help in
learning how to treat the adult population with mental illness and the
University of Rochester Project ECHO^© PSYCH was born.

How
does it work? The ECHO^© Psych team, which consists of a moderator,
psychiatrist, Psych NP, psychiatric social worker, psychiatric pharmacist and a
psychologist sit around a table and listen to cases presented by the primary
care sites. The cases are de-identified
and only include the bare minimum information to generate a useful discussion.

 

Recommendations are made by the treatment team as well as those at other sites
who have recommendations based on their experience and the ideas are collated
and provided in written form. In
addition, there is an evidence-based didactic provided by one of the expert
panel which primary care sites can receive CME credit for. Clinics are
typically biweekly for 90 minutes.

 

The
goal is to not only help the primary care sites with the individual patients
they present in clinic but to educate them on strategies to treat mental health
issues common in primary care practices.
The other hope is that it creates a community of practice where all of
those involved in the program feel supported with difficult cases and where
sites often feel isolated. The team also
hopes to model how to provide team-based care even when there are
disagreements.

What is needed to participate? The beauty of the program is that most people
don’t need to buy any fancy equipment.
The application that our program uses can run on smart phones or any
computer and only requires a basic camera.
Although we encourage video participation, it is also possible to call
in through a phone without video capabilities.

 

Since ECHO Psych was launched in
March of 2016, we have had 12 clinics with over 60 attendees. Most attendees have returned for multiple
clinics. The average attendance per session has been 17 and these attendees
include multiple spoke sites with multiple providers often present at each site. ECHO Psych currently provides telementoring
for psychiatric issues to participants in over 13 counties in New York State,
spanning over 350 miles.

 

The goal is to educate them on strategies to treat mental health issues common in primary care practices 

 

Spoke sites
have presented 20 cases for recommendations, with a number of them presenting
for follow-up recommendations. Twelve
evidence-based didactics have been presented on topics ranging from evaluation
of post-partum depression to identification and behavioral treatment of OCD, to
lessons that have been learned from the STAR^*D trial. An overwhelming number of participants have
graded the didactics as “very good” or “excellent”.

Although it is too early to have
data on ECHO Psych, we have qualitative data derived from 26 interviews from
the Geriatric Mental Health in Primary Care ECHO that ran previously. Most
found that the format was interactive and engaging, but also struggled with
finding time to attend as well as time to present cases.

 

Participants felt they expanded their
knowledge base in all areas including psychopharmacology, non-pharmacologic
treatment modalities and available social supports. Participants also felt they
there was large increase in their confidence in handling older adults with
mental health issues. Overall, Participants felt the ECHO model was highly
beneficial to their practice.

 

So you may be thinking, this sounds
great, how do I get involved in an ECHO program? More information about the University of
Rochester ECHO program can be found at www.urmc.rochester.edu/project-ECHO.Most programs are state
based, so it would be helpful to check the UNM ECHO^© website at http://echo.unm.edu/ to determine what
programs are available in your state.

 

Dr. Richman graduated with a BS from Cornell University and received her medical degree from the University Of Rochester School Of Medicine.  She completed her psychiatry residency at the University of Rochester School of Medicine and Psychosomatic Fellowship training at Georgetown University.  She is currently an Assistant Professor at the University of Rochester and is medical director of ECHO© Psych and Telepsychiatry.  She also runs the psychiatric consultation service at Strong Memorial Hospital and specializes in perinatal psychiatry.