Sanjeev Arora M.D. Professor of Medicine (Gastroenterology/Hepatology) Director Project ECHO Executive Vice Chairm

1. Sanjeev Arora M.D. Professor of Medicine (Gastroenterology/Hepatology) Director Project ECHO Executive Vice Chairman Department of Medicine University of New Mexico Health Sciences Center, Tel: 505-272-2808 Fax: 505-272-4628 sarora@salud.unm.edu

2. MISSION MISSION The mission of Project ECHO is to develop the capacity to safely and effectively treat chronic, common and complex diseases in rural and underserved areas and to monitor outcomes. Supported by Agency for Health Research and Quality HIT grant 1 UC1 HS015135-04, and MRISP, R24HS16510-02 and the New Mexico Legislature, Robert Wood Johnson Foundation

3. Hepatitis C: A Global Health Problem 170 Million Carriers Worldwide, 3-4 MM new cases/year EAST MEDITERRANEAN 20M WEST EUROPE 9 M FAR EAST ASIA 60 M U.S.A. 4 M SOUTH EAST ASIA 30 M AFRICA 32 M SOUTH AMERICA 10 M AUSTRALIA 0.2 M Source: WHO 1999

4. AASLD Practice Guidelines: Diagnosis, Management, and Treatment of Hepatitis C • AASLD guidelines a key reference on best practices for care of hepatitis C patients • Previous guidelines issued in 2004, • 2009 guidelines recently published • Evidence-based recommendations approved by the AASLD, the Infectious Diseases Society of America, and the American College of Gastroenterology Ghany MG, et al. Hepatology. 2009;49:1335-1374.

5. Grading System for Quality of AASLD Diagnostic/Treatment Recommendations • Classification • Class I: evidence that diagnostic/treatment is beneficial, useful, and effective • Class II: conflicting evidence/divergence of opinion about usefulness/efficacy of diagnostic/treatment • Class IIa: evidence/opinion in favor of usefulness/efficacy • Class IIb: usefulness/efficacy less well established by evidence/opinion • Class III: evidence/general agreement that diagnostic/treatment is not useful/effective and may be harmful in some cases • Evidence level • Level A: data derived from multiple RCTs or meta-analyses • Level B: data derived from single RCT or nonrandomized studies • Level C: only consensus opinion of experts, case studies, or SOC Ghany MG, et al. Hepatology. 2009;49:1335-1374.

6. AASLD Guideline Recommendations for Screening and Counseling 1. As part of a comprehensive health evaluation, all persons should be screened for behaviors that place them at high risk for HCV infection (Class I, level B). 2. Persons who are at risk should be tested for the presence of HCV infection (Class I, level B). 3. Persons infected with HCV should be counseled on how to avoid HCV transmission to others (Class I, level C). Ghany MG, et al. Hepatology. 2009;49:1335-1374.

7. AASLD Guideline Recommendations for Screening and Counseling 4. Patients suspected of having acute or chronic HCV infection should first be tested for anti-HCV (Class I, Level B). 5. HCV RNA testing should be performed in: - Patients for whom antiviral treatment is being considered, using a sensitive quantitative assay (Class I, Level A) - Patients with a positive anti-HCV test (Class I, Level B) - Patients with unexplained liver disease whose anti-HCV test is negative and who are immunocompromised or suspected of having acute HCV infection (Class I, Level B). Ghany MG, et al. Hepatology. 2009;49:1335-1374.

8. Topics Why screen for HCV How to screen for HCV Who should be tested for HCV What laboratory tests should be used to test for HCV How to counsel HCV-infected patients

9. HCV Screening Why screen for HCV How to screen for HCV Who should be tested for HCV What laboratory tests should be used to test for HCV How to counsel HCV-infected patients

10. Guidelines Recommend Risk Factor Screening in All Patients • Potential for harm reduction • Alcohol intake, vaccinations, secondary transmission, treatment • Treatment reduces long-term adverse outcomes • Treatment benefit will improve further as SVR rates increase Ghany MG, et al. Hepatology. 2009;49:1335-1374.

11. HCV Testing and Counseling Why screen for HCV How to screen for HCV Who should be tested for HCV What laboratory tests should be used to test for HCV How to counsel HCV-infected patients

12. Risk Factors in 3 Domains Significantly Associated With HCV Infection Domain Odds Ratio (95% CI) 2.92 Medical history: blood transfusions, dialysis, elevated liver function tests results 5.92 Exposure: any blood contact 1.16 Work: job with high risk of HCV exposure 1.63 Personal history: sharing toothbrushes, receiving tattoos or piercings, acupuncture 8.15 Social history: illicit drug use, incarceration, past and current sexual activity 0.01 1.00 15.00 1000 randomly selected patients questioned about risk factors in 5 domains 83 were anti-HCV positive; 63 had at least one positive response McGinn T, et al. Arch Intern Med. 2008;168:2009-2013.

13. HCV Screening Begins With Risk Factor Assessment Ghany MG, et al. Hepatology. 2009;49:1335-1374. 1. Shehab TM, et al. Viral Hepat. 2001;8:377-383. 2. Kim WR. Hepatology. 2002;36:S30-S34. • Recommendation: Universal risk screening and focused testing (ref 1) • Survey of 4000 primary care physicians[2] • 59% of 1412 respondents asked all patients about HCV risk factors • As few as 25% of HCV infections are recognized[3]

14. Practical Models of HCV Screening • Include list of HCV risk factors in patient intake form • Have non physician review risk • Build risk screening into quality assurance • Veterans Affairs Medical Center example • 36,422 patients screened for HCV risk factors from January 2000 - December 2001 • 12,485 patients (34%) at risk received anti-HCV testing • Anti-HCV was detected in 681 (5.4%) Groom H, et al. J Clin Gastroenterol. 2008;42:97-106

15. HCV Testing and Counseling Why screen for HCV How to screen for HCV Who should be tested for HCV What laboratory tests should be used to test for HCV How to counsel HCV-infected patients

16. Groups Recommended for HCV Testing by AASLD and USPHS Ghany MG, et al. Hepatology. 2009;49:1335-1374. Centers for Disease Control and Prevention. MMWR Recomm Rep. 1998;47:1-39. • Recent/past injection drug users—even if only used once • Groups with high HCV prevalence • HIV-infected individuals • Hemophiliacs treated with clotting factor concentrates before 1987 • Hemodialysis recipients • Patients with unexplained aminotransferase abnormalities • Recipients of transfusion or transplantation before July 1992 • Children born to women infected with HCV • Healthcare, public safety, and emergency medical personnel following needle injury or mucosal exposure to HCV-infected blood • Current sexual partners of individuals infected with HCV • Persons who have used illicit drugs by noninjection routes

17. HCV Antibody Testing Is Recommended for Initial Detection of HCV Infection HCV antibody testing is sensitive and inexpensive Positive results should be confirmed with repeat antibody test Signal-to-cutoff ratio may be used to confirm that test is a true positive Positive test results are often reportable Ghany MG, et al. Hepatology. 2009;49:1335-1374.

18. HEPATITIS C IN NEW MEXICO HEPATITIS C IN NEW MEXICO • Estimated number is greater than 28,000 • In 2004 Less than 5% had been treated • Without treatment 8,000 patients will develop cirrhosis between 2010-2015 with several thousand deaths • 2300 prisoners diagnosed in corrections system (expected number is greater than 2400) - None treated • Highest rate of chronic liver disease/cirrhosis deaths in the nation

19. Sustained Viral Response (Cure) Rates with PegIFN/RBV According to Genotype 76%-82% 42%-46% Genotype Non-1 Genotype 1 Adapted from Strader DB et al. Hepatology. 2004;39:1147-1171.

20. HEPATITIS C TREATMENT Good News: Curable in 45-81% of cases Bad News: Severe side effects – anemia (100%), neutropenia >35%, depression >25%

21. Rural New Mexico RURAL NEW MEXICO • Underserved Area for Healthcare Services • 32 of 33 New Mexico counties are listed as Medically Underserved Areas (MUA’s) • 14 counties designated as Health Professional Shortage Areas (HPSA’s) • 121,356 sq miles • 1.83 million people • 42.1% Hispanic • 9.5% Native American • 17.7% poverty rate compared to 11.7% nationally • >22% lack health insurance

22. HEALTH CARE IN NEW MEXICO HEALTHCARE IN NEW MEXICO • 20% practice in rural or frontier areas New Mexico Physician Survey 2001

23. GOALS GOALS • Develop capacity to safely and effectively treat Hepatitis C in all areas of New Mexico and to monitor outcomes • Develop a model to treat complex diseases in rural locations and developing countries

24. PARTNERS PROJECT ECHO • University of New Mexico School of Medicine Dept of Medicine, Telemedicine and CME • NM Department of Corrections • NM State Health Department • Indian Health Service • Community Clinicians with interest in Hepatitis C and Primary Care Association

25. METHOD METHOD • Use Technology (telemedicine and internet) to leverage scarce healthcare resources • Disease Management Model focused on improving outcomes by reducing variation in processes of care and sharing “best practices” • Case based learning: Co-management of patients with UNMHSC specialists • Centralized database HIPAA compliant to monitor outcomes

26. STEPS STEPS • Train physicians, nurses, pharmacists, educators in Hepatitis C • Train to use web based software “ihealth” • Conduct telemedicine clinics – “Knowledge Network” • Initiate co-management – “Learning loops” • Collect data and monitor outcomes centrally • Assess cost and effectiveness of programs

27. BENEFITS TO RURAL CLINICIANS COMMUNITY PARTNERS • No cost CME’s and Nursing CEU’s • Professional interaction with colleagues with similar interest – Less isolation with improved recruitment and retention • A mix of work and learning • Obtain HCV certification • Access to specialty consultation with GI, hepatology, psychiatry, infectious diseases, addiction specialist, pharmacist, patient educator

30. Technology METHOD • Videoconferencing Bridge (Polycom RMX 2000) • Videoconferencing Recording Device (Polycom RSS 2000) • You Tube like Website (Polycom VMC 1000) • Webcam Interfacing Capacity (Polycom CMA 5000) • iHealth • Webinar • Customer Relation Management Solution • Software for Online Classes

31. DISEASE SELECTION DISEASE SELECTION • Common diseases • Management is complex • Evolving treatments and medicines • High societal impact (health and economic) • Serious outcomes of untreated disease • Improved outcomes with disease management

32. BUILDING BRIDGES HEALTHCARE IN NEW MEXICO BUILDING BRIDGES PARETTO’S PRINCIPLE State Health Dept Community Health Centers Private Practice UNM HSC Hepatitis C Asthma and COPD Substance Use and Mental Health Disorders

33. KNOWLEDGE IMPORTANT - NOT TITLE FORCE MULTIPLIER HEALTHCARE IN NEW MEXICO Use Existing Community Clinicians Primary Care Nurse Practitioners Physician Assistants Specialists Hepatitis C Asthma and COPD Substance Use and Mental Health Disorders

34. KNOWLEDGE IMPORTANT - NOT TITLE FORCE MULTIPLIER HEALTHCARE IN NEW MEXICO Chronic Disease Management is a Team Sport Community Health Worker Medical Assistant Primary Care Nurse Hepatitis C Asthma and COPD Substance Use and Mental Health Disorders

35. Changes in HbA1c with CHW as sole Diabetes Educator % Change from Baseline 20 15 10 5 0 –5 –10 –15 –20 20 15 10 5 0 –5 –10 –15 –20 FullParticipation Full Participation Partial Participation Partial Participation 6 Months 12 Months Culica JH. Care for the Poor & Underserved. 2008;19:1076-1095.

36. Community Based Care for Cardiac Risk Factor Reduction was More Effective than Enhanced Primary Care Becker Circulation. 2005;111:1298-1304.

37. Why is a CHW Intervention Effective? DISEASE SELECTION • Live in Community • Understand Culture • “Have Walked Two Moons in The Patient’s Moccasins” • Appreciate Economic Limitations of Patient and Know Community Resources Available to Patient • Often Know Family and can engage other Social Resources for Patient • Spend More Time with Patient

38. CHW Training – TWO TRACKS DISEASE SELECTION • CHW Specialist Training • Diabetes, Obesity, Hypertension, Cholesterol, Smoking Cessation, Exercise Physiology • Substance Use Disorders • Hepatitis C • CHW Basic Training • Computer Use, Human Behavior and Social Environment, Healthcare Delivery Systems, Payment Systems, Ethics, HIPAA • Medical Terminology, Human Anatomy, Patient Care Skills, Medical Record Keeping, Interpersonal Communication, Client Advocacy, Cultural Competence, Stages of Change Motivational Interviewing, Understanding Poverty, Family Dynamics and Family Systems Theories, Nutrition and Healthy Eating, Tobacco Risks and Cessation, Substance Abuse and Healthcare

39. Specialty CHW Program DISEASE SELECTION • Use Low Cost Technology to Take Specialty Training to the CHWs, Promotoras, CHRs, Medical Assistants Where They Live • Narrow Focus- Deep Knowledge • Standardized Curriculum • Ongoing Support via Knowledge Networks • Part of Disease Management Team • Warm Handoff

40. Basic CHW Training DISEASE SELECTION • Use Low Cost Technology to Take Basic Training to Individuals Where They Live • Standardized Curriculum • Ongoing Support via Knowledge Networks • Develop a Certification Program in Collaboration with DOH and Organizations that Represent CHWs • Collaborate with DOH and CHW Organization to Develop a Process and Criteria to Grandfather Existing CHWs

41. Why Do We Need An Army of CHWs? DISEASE SELECTION • The Baby Boomers Are Aging • There will be a Tsunami of Chronic Disease • They Have a High Expectation for Service • There is a Severe Shortage of Primary Care Clinicians with No Visible Solutions in the Short Term • Primary Care Clinicians Need Support

42. ECHO Model Overcomes Many Barriers for Training & Development KNOWLEDGE MODEL • Existing Methodologies for Training and Development of Widely Distributed Learners Have Significant Limitations • Expensive • Out of Sight-Out of Mind • Applying Knowledge is a Whole New Thing • Employee Turnover • Knowledge Becomes Obsolete

43. Community Health Workers in PrisonThe New Mexico Peer Education ProgramPilot training cohort, CNMCF Level II, July 27-30, 2009 First day of peer educator training Photo consents on file with Project ECHO and CNMCF

44. Graduation Ceremony of First CohortThe New Mexico Peer Education ProgramPilot training cohort, CNMCF Level II, July 27-30, 2009 Graduation as Peer Educators Photo consents on file with Project ECHO and CNMCF

45. Successful Expansion Into Multiple Diseases VISION FOR THE FUTURE 28

47. How well has model worked for Hepatitis C ? • 375 HCV Telehealth Clinics have been conducted • 3534 patients entered HCV disease management program • CME’s/CE’s issued: • 5100 CME/CE hours issued to ECHO Clinicians for Hep C. Total CME hours 8500 at no cost • 237 hours of HCV Training conducted at rural sites • National Recognition as Model for Complex Disease Care

48. Project ECHO Clinicians HCV Knowledge Skills and Abilities (Self-Efficacy)scale: 1 = none or no skill at all 7= expert-can teach others

49. Project ECHO Clinicians HCV Knowledge Skills and Abilities (Self-Efficacy)

50. Project ECHO Clinicians HCV Knowledge Skills and Abilities (Self-Efficacy) Cronbach’s alpha for the BEFORE ratings = 0.92 and Cronbach’s alpha for the TODAY ratings = 0.86 indicating a high degree of consistency in the ratings on the 9 items