Beyond knowledge and confidence: a mixed methods evaluation of a Project ECHO course on dementia for primary care

ABSTRACT

Primary care clinicians have an important role in the management of dementia and have expressed interest in continuing education. The authors describe a model they used for providing dementia education in primary care, Project ECHO (Extension for Community Healthcare Outcomes), and an overview of its major features. A partnership including academic institutions and a national healthcare association is then outlined, including the unique features of the ECHO model developed through this partnership. A mixed-methods methodology was used for programmatic evaluation. This use of mixed methods adds vital new knowledge and learner perspectives that are key to planning subsequent ECHO courses related to dementia and primary care. The discussion includes an exploration of the significance of these findings for understanding the motivations of primary care providers for participation in the educational program, as well as the limitations of the current study. A final section explores the next steps in the continued development of the model and its implications for geriatrics education in dementia care, especially the supportive role that ECHO courses can play in meeting the challenges of dementia care.

KEYWORDS:

• Primary care providers
• dementia care education
• Project ECHO

Background

Challenges of dementia for primary care

Primary care clinicians have an important role in the management of dementia, given the prevalence and impact of this condition (Manly et al., 2022). They are well-positioned to recognize and discuss dementia through longstanding trust relationships with patients and families (Alzheimer’s Disease Facts and Figures, 2022). In addition, primary care has much to offer dementia management through screening, identification, and management of treatable contributors to cognitive impairment and subsequent care (Sanders et al., 2017). Over the past five years, Medicare reimbursement codes have supported multiple aspects of dementia care, including screening (the annual wellness visit), cognitive assessment, advance care planning, and subsequent care management (Unwin, Loskutova, Knicely, & Wood, 2019).

Unfortunately, several factors hinder the diagnosis and management of dementia in primary care (Bernstein et al., 2019; de Levante Raphael, 2022; Hinton et al., 2007). Generic barriers include crowded schedules and competing demands (Bluestein, Diduk-Smith, Jordan, Persaud, & Hughes, 2017). Dementia-specific barriers include primary care providers’ discomfort and perceived knowledge limitations regarding dementia and nihilism around an “untreatable” condition. Additional difficulties are communicating and coordinating with sub-specialists and community services, and the lack of ready access to interprofessional team members (Arsenault-Lapierre et al., 2022). These challenges are driven by physical separation, a shortage of geriatrics professionals, medical record disconnects, and differences in professional cultures.

As a result, there is great variation in the quality of primary care for dementia (Sivananthan, Puyat, & McGrail, 2013). Delayed diagnosis, non-disclosure of diagnosis, diagnostic errors, and ineffective aftercare are not uncommon events (Alzheimer’s Association Facts & Figures, 2022). Emotional factors also impact care. Management of complex patients, such as those living with dementia, can lead to a high cognitive load (the total amount of mental effort required) and a negative emotional impact (Roskos et al., 2021). Together these factors can result in clinician avoidance and burnout with regard to dementia care.

Educational interventions with primary care

A variety of educational interventions have been developed to address these challenges (Lee, Hillier, Patel, & Weston, 2020). One that holds particular promise is the Extension for Community Healthcare Outcomes (Project ECHO) model (University of New Mexico: Project Echo, 2022). Project ECHO is an innovative telementoring approach linking multi-disciplinary disease specialists and community-based providers who meet regularly via videoconference and engage in case-based learning. In this environment, a community of practice is encouraged, where knowledge and resources are shared freely, learning is multi-directional, and learners increase knowledge and confidence in managing complex, chronic illnesses over time. Unlike lectures and webinars, the ECHO model is based on an “all teach, all learn” philosophy.

The ECHO model was originally developed to overcome barriers of distance and delayed access to sub-specialist care for hepatitis C (Arora et al., 2011). More recently, it has been applied to other complex chronic conditions, including dementia (De Witt Jansen et al., 2018). Initial evaluations of dementia-related ECHO courses focused on specific aspects of dementia care, such as the management of dementia-related behaviors in long-term care (Catic et al., 2014) and pain management in advanced dementia (De Witt Jansen et al., 2018). More recent reports have focused directly on dementia assessment and management in primary care (Haydon et al., 2022).

ECHO dementia interventions have been shown to be effective with primary care teams and to increase their comfort levels for dementia detection and management. For example, a focus group study by Lindauer et al. (2022) found limited time to discuss complex cases, difficulties accessing ECHO materials, and diagnostic ambiguity as problems, but noted the benefit of case discussions and mutual support around clinical challenges. A second dementia-primary care ECHO program noted increased self-efficacy with respect to dementia care and self-reported plans for practice change (Jafari et al., 2020). Similarly, a third report found that 67% of attendees planned to change their practice as a result of ECHO attendance, as well as significant increases in both knowledge and confidence in dementia-specific diagnosis and care (Rhoads, Isenberg, & Schrier, 2021). ECHO courses focusing on dementia primary care are now being used for resident physician education (Bennett et al., 2018), and a dementia ECHO for practicing clinicians has been developed by the Alzheimer’s Association (Lam & Mattke, 2021).

Taken together, these reports document the acceptability of the ECHO model to primary care clinicians and gains in self-reported confidence in, and knowledge of, dementia care. They do not describe the drivers and returns on investment of time and energy that motivated attendees to attend and participate, factors that are crucial to successful ECHO courses.

We examine these elements in this mixed-methods evaluation of a dementia ECHO for primary care clinicians. This approach allows us to identify what attendees valued and found important to their work through ECHO attendance. Understanding what attendees wanted and gained is crucial to tailoring the design of subsequent ECHO programs supporting primary care clinicians in dementia management.

Methods

Program description

The current Project ECHO series is a collaboration between three universities – Johns Hopkins University, the University of Rhode Island, and Virginia Commonwealth University – and the Alzheimer’s Association. Together, this group began meeting in 2021 to discuss the development of a curriculum that could address the diagnosis and management of Alzheimer’s disease and related dementias in the primary care setting. The group utilized a curriculum previously implemented at other sites under Alzheimer’s Association leadership (Lam & Mattke, 2021). The collaboration offered a unique opportunity to pool resources across institutions and serve primary care clinical teams and practice sites across several states. In addition, the inclusion of the Alzheimer’s Association allowed for local resources for patients and caregivers to be included in sessions.

The interprofessional specialty Hub team consisted of a geriatrician, pharmacist, nurse, clinical social worker, and a representative from the Alzheimer’s Association. Each ECHO session also featured a rotating didactic subject matter expert from one of the institutions and included additional physicians, geriatric psychiatrists, social workers, and nurses. Each university aimed to recruit four primary care practices that were familiar with the ECHO model. Of the 13 primary care practices that originally registered, nine participated in the series, with six practices attending 50% or more of sessions and the remaining three practices attending intermittently. No cost continuing education credits were made available for participants.

Primary Care Practice Site and Profession Table

	Average attendance (out of 12 sessions)
Any participant	4
By site
EVMS	3
JHCP-Frederick	4
Beacham Center	6
Hometown Health Center	4
RI PACE	4
JHCP – Sibley	7
Barrington Family Medicine	5
Abingdon Family Medicine	1
Providence Community Health Center	2
By Profession
Physician (MD/DO)	4
Nurse (RN)	3
Advanced Practice Nurse (NP)	7
Social Work (MSW, LSW, LCSW)	3
Other (e.g., MA, Quality Director, CHW)	3

The 12-session series consisted of bi-weekly, hour-long video conferences. Learning objectives were developed for each session (Supplementary Table S1). Each session included a brief, 15-minute didactic lecture presented by a Hub faculty member or guest content expert, followed by real-life, de-identified patient case discussion led by participating learner (Spoke) sites. The case presentations included information about medical history, medications, a review of symptoms related to cognitive status, and psychiatric history, as well as cognitive screening history and related additional testing. The form also provided space to discuss specific provider questions and goals of care for the patient and family. The case discussion format allowed for specialist guidance and mentoring, repeated learning, and all participating clinicians to both learn from and teach each other.

Evaluation design

The study was approved by the University of Rhode Island’s Institutional Review Board. The mixed-methods evaluation consisted of surveys with quantitative and qualitative components, and qualitative interviews. Survey data were collected using Research Electronic Data Capture (REDCap) hosted at a University. REDCap is a secure, web-based application to support data capture for research studies (Harris et al., 2009, 2019).

Pre-series survey

A survey was included in the registration process for the series to document participants’ professions and site characteristics for each Spoke practice. An open-ended question gathered information about what participants hoped to gain from participation in the program, and responses were used to guide the Hub team in final planning for the series.

Individual post-session surveys

Immediately after each session (followed by one reminder request), using an anonymous electronic survey that was not linked to surveys for other sessions, participants were asked their perceptions of the effectiveness of the featured didactic presentation, the case study presentation, the Spoke response to the case, and the Hub response to the case. Effectiveness was ranked on a 5-point Likert scale with 1 = very ineffective and 5 = very effective. In addition, participants indicated the degree to which the didactic topic and case study were practical to their work using a Likert scale ranging from 1 = strongly disagree to 5 = strongly agree. Feedback was reviewed regularly by the Hub team to refine future sessions. Self-reported knowledge gains were assessed using a retrospective pre-post methodology (Colosi & Dunifon, 2006; Lang & Savageau, 2017). For each learning objective for the session, respondents rated their knowledge level before and after the ECHO session on a 4-point Likert scale of 1 = no knowledge to 4= high knowledge. Due to the small sample size, mean pre- and post-knowledge scores across all of the learning objectives were compared using the related samples Wilcoxon signed rank test. This test does not rely on the central limit theorem and therefore is not subjective to the sample size. The level of significance was set as p < .05.

In addition to forced-choice response questions, each session’s evaluation survey included open-ended questions about knowledge gained, intended changes to practice, and suggestions for improvement of the ECHO course. Content analysis was conducted, similar to that described for qualitative interview data below.

Post-series final survey

At the completion of the ECHO series, a final survey was administered to gather feedback on whether the series met the expectations of participants, whether they would recommend the series to other practice teams, what they found to be valuable about the series, their suggestions for improvement, and their attendance and reasons for missing sessions. The survey included questions rated on a 5-point Likert scale ranging from 1 = strongly disagree to 5 = strongly agree and additional open-ended questions.

Post-series qualitative interviews

Upon completion of the ECHO series, a purposive sample (Kuzel, 1999) of individuals who had attended at least six sessions was invited to participate in a 30-minute, recorded, qualitative interview conducted and recorded using the Zoom platform. A question guide was developed to explore participants’ experiences in the course, including assessment of the value of the content and time spent, knowledge gained and practical application of that knowledge, awareness of new resources, interaction with participants in their own and other Spokes, and assessment of course content and components. Interview recordings were professionally transcribed. Transcripts were read and discussed at meetings by coauthors to identify broad themes and patterns in the data. Next, one coauthor (REG) conducted in-depth immersion/crystallization (Borkan, 2022) data analysis by re-reading each transcript while taking detailed notes on content, and comparing content across transcripts to identify patterns and disparities. Lastly, the coauthors discussed these findings to arrive at a final interpretation of the data.

Evaluation results

The clinics were from Maryland, Maine, Rhode Island, Virginia, and Washington DC. Included in this cohort of learners were eight primary care sites, including one older adult-focused clinic, and one PACE (Program of All-Inclusive Care for the Elderly) organization. Two of the participating primary care locations were federally qualified health centers. Primary care teams were encouraged to participate and included physicians, advanced practice clinicians (e.g., nurse practitioners), registered nurses, and social workers.

Quantitative survey findings

Post-session survey results indicate that participants found the featured didactic presentations, the case study presentation, the Spoke response to the case, and the Hub response to the case to be somewhat to very effective (mean scores ranged from 4 to 5) across all sessions. All participants agreed or strongly agreed that the didactic topics and case studies were practical to their work for all sessions.

Evaluation of knowledge gains across all learning objectives (except Session 5 where only 1 participant completed the evaluation so it was excluded from the analysis), indicated that knowledge gains were positive for all objectives, and statistically significant as represented by median = 3.56 (vs. 3.0 pre-session), z = 4.38, p < .001.The highest average knowledge gains were noted for the objectives “Define Medicare reimbursement for care planning for a person with dementia.” and “Identify the role of care management in establishing care plans while integrating other comorbidities with a diagnosis of AD.” The least average knowledge gains were observed for the objectives “Understand the impact of caregiving on the caregiver and the need for continued support.” and “Understand the importance of Advance Care Planning, components involved, and state-specific forms/requirements.”

In the post-series final survey, respondents (N = 9) indicated that: the ECHO series met their expectations (mean 4.67 SD 0.71), the information was valuable to their work (mean 4.67, SD 0.50), they made changes to the way they care for patients based on what they learned (mean 4.33, SD 0.87), they shared information with other staff members in their organization (mean 4.11, SD 1.05), the series expanded access to best-practice care of the patients they serve (mean 4.67, SD 0.50), the ECHO series positively influenced the way they interact with families and caregivers of patients with dementia (mean 4.56, SD 0.73), participating in the ECHO series improved the level of satisfaction they feel in their job (mean 4.33, SD 0.97), and they would recommend the ECHO series to other primary care practice teams (mean 4.56, SD 0.73). When they missed a session, the reason was due to scheduling conflicts (N = 8) or illness (N = 1).

Qualitative interview and open-ended survey question findings

We contacted nine course participants who had attended at least half the sessions and eight chose to be interviewed. All interviewees stated they wanted to attend all the sessions but competing responsibilities and scheduling conflicts made them miss some. The sample included 3 nurse practitioners, 2 primary care physicians, 1 geriatric practice administrator, 1 geriatric nurse-care manager, and 1 graduate nursing student. Three of the interviewees shared they have had immediate family members who were diagnosed with dementia. Where responses to the open-ended survey questions supplement the qualitative interview data, survey data are reported.

Acquisition of knowledge and resources

Respondents to the pre-series survey open-ended questions stated they hoped to gain information on a variety of areas of care for patients with cognitive impairment, including best practices for the care of persons with dementia and other cognitive impairment; how to recognize and screen for early signs; resources, and supports for community and family members for all stages of the disease, and particularly at the early stages; and issues of power of attorney and guardianship.

Participants in the interviews following the completion of the entire series reported they valued hearing from subject experts during the brief lectures that were included in each ECHO session. They placed an equally high value on being exposed to the comments and advice provided by the other participants enrolled in the course. Given the differing experience and professional roles of the participants, they varied in terms of which topics they found the most useful, although all interviewees noted they obtained information on successful care strategies they had not previously considered. Examples include:

While it’s still a possibility, how important that is to include the patient in their planning, taking their opinions into account, and involving them so they feel empowered, and they feel like they’re not being told what to do, but that they’re involved in the process. You generally have better success when they’re involved, and they make their needs known, and they’re being validated and listened to.

People come into my program and say, “I found out that I had this, and they knew I had it for a while, but they never told me.” I was really excited to hear from physicians about how they think it is important to give early detection and the different practices for doing that well. That’s what I got the most out of.

So, it was really wonderful to see how everybody else handles [goals of care conversations] and what resources were available. Because that was, I think, the most valuable piece that I got out of it, a lot of conversation and a lot of resources.

Respondents to the open-ended survey questions reported they experienced significant learning on the following topics: evaluating hearing in patients with dementia; assessing for depression before diagnosing dementia; incorporating family/caregivers on the patient care team and eliciting information from caregivers when assessing the progression of dementia; broad approaches to recognizing triggers for patients’ behaviors and addressing patients’ aggressive behaviors; the importance of speaking directly to the patient rather than about the patient; useful assessment tools; and early intervention strategies including community resources.

In addition, all interviewees said they enrolled in the course anticipating becoming aware of resources and tools they could directly apply in their practice, and their expectations were met. For example, several stated that the AD8 Dementia Screening Interview tool (Galvin et al., 2005) for early detection of cognitive changes and differentiating between normal aging and mild cognitive impairment was new to them, and they had started using it in their practice.

The AD8, and then the Cornell Depression Scale [for Depression in Dementia], those two, as far as having a family observer who can go through it if you have a patient who can’t answer the questions.

Somebody brought up the NIA [National Institute on Aging] has a lot of good resources. I actually went online and ordered some of them to give to families, because they’re dealing with so much, and that was really, really helpful. And they sent me a whole box, so we have them at the clinic. Those are good resources.

Application of learning to practice

All interview participants are engaged in the care of older adults, including patients with Alzheimer’s disease and other forms of dementia. As such, each was interested in learning about cutting-edge care strategies, enhancing their skills in specific areas they find challenging, and/or confirming that their current practices are appropriate and up-to-date.

I do feel that I have more tools in my arsenal to hand out, and just a different perspective. I’m just a little more confident in what I’m recommending, and I hope that continues to evolve and change and grow, of course. I just feel like I’m much more confident and more able to assist people. A lot of it is things you already know, but to be reaffirmed in it, and even expanded on it.

I saw, for example, after we did our case presentation, another patient with a similar kind of situation. And I saw all of us who were in the [ECHO course] processing things a little bit differently, flipping back through our mental Rolodex, so to speak, to find what those resources were and figure out how this fits better into some of the examples that were discussed.

We actually changed part of how we interact with people. If they come in, a patient and their families, we will separate them and talk. While the patient is doing mental status exams and assessments with the social worker, the rest of us will talk with the family members and see a better idea of what resources they need, and answer those questions they might not be comfortable asking in front of the patient. So that shifted a little bit with our experience with ECHO, in a positive way. We had done it before, but we really found discussing it with the ECHO group reinforced the need for that, so now it’s just a part of our standard process.

Similar to some interviewee feedback, respondents to the open-ended survey questions reported they plan to use this ECHO training to implement person-centered care by asking patients and families what is important to them; better educate families about what to expect with advancing dementia; learn from caregivers about each patient’s personality, past activities, and assessment of memory and current abilities; speak directly to patients, even if the patients are not responding; more effectively evaluate cognitive function; implement early screening protocols and train staff about the administration of these tools and what to do after a positive screen; and incorporate the use of the Cornell Scale for Depression and the AD8.

Perspectives on the ECHO course format

All interviewees appreciated hearing from the subject experts in the brief lecture, however, when asked what they liked best about the ECHO course model, all were emphatic about how much they benefited from the case discussions that brought in “the real-world perspective.” They expressed that while preparing a case for the presentation was extra work they became responsible for, it was worth the effort. They learned from working with colleagues at their own organization to put the case presentation together, and they greatly valued the input on their case they received from the other attendees. Interviewees explained how the ECHO model encouraged openness and sharing of personal experiences. Interviewees found some of the input from others as reaffirming what they were already doing in practice, while other comments provided new perspectives. Either way, the ECHO course provided participants with an opportunity to recognize they are “not alone” in struggling with dilemmas in care for older adult patients.

I was hearing the same things that I’m voicing. You know, sometimes you get a little lost in your own practice and you forget that there are others out there doing the same thing, and it’s reassuring.

Interviewees explained that the interdisciplinary nature of the ECHO course was especially useful during the case discussions.

Listening to the different ways social workers might approach a problem one way and nurse practitioners might approach a problem another way, and physicians might approach a problem a different way. Then I also learned that my expectations sort of went out the window as well, because I realized that there were nuances to the way different physicians approached issues that became very interesting to me, too, so just the way people think about problems. It was looking at a macro level about different approaches to individuals’ challenges with these kinds of diagnoses, so it was really powerful.

There are different styles and approaches, and getting a collective of ideas is helpful to understand how people think about situations differently.

I thought that was really helpful, because it was a lot of different ideas from different organizations, so it was nice to get some input from someone I don’t necessarily work with all the time. That was nice, to get that fresh perspective.

Suggestions for improvement of this ECHO course

Respondents to the open-ended survey questions suggested adding topics on caregiver support; more focus on early screening and how to prepare patients and families for the eventuality of dementia; and how to deal with patients or family members who are “poor historians” of the patient’s condition. Allowing more time for case discussion was also suggested.

Interview participants offered suggestions for content, format, and process. Regarding content, interviewees suggested: collating all of the resources mentioned in the course in one place for easy access by participants during and following completion of the course; providing a comprehensive resource packet that attendees can give to their patients; and adding the topic of equity as it impacts patients with Alzheimer’s disease. Regarding format and process, the following was suggested: engaging families in the ECHO case discussions; having attendees collaborate across institutions on case presentations; sending the case to the attendees prior to each session so they are more prepared to offer input and resources; ensuring that each session’s case presentation topic aligns with the lecture topic; and reducing the time devoted to the lecture so more time is available for case discussion. One interviewee’s comment held a sentiment similar to that of others:

I’m not saying I would do away with the didactic, but I would make it shorter, more pointed. And then go to cases, because the cases are when you build the networking, you build the confidence, and in certain individuals, you learn about how they think and all that they know. I found it to be very, very useful and enlightening.

Discussion

This study was an evaluation of an ECHO program aimed at improving dementia care by primary care clinicians. Like several prior efforts in this regard (e.g., De Witt Jansen et al., 2018; Rhoads, Isenberg, & Schrier, 2021), we found increases in attendees’ knowledge of dementia care. In addition, we conducted qualitative interviews with eight program completers that provide a rich understanding of what this group gained from attendance, which can inform further development and refinement of future ECHO initiatives.

Educational outcomes

With regard to educational outcomes, attendees were surveyed as to what they saw as their learning needs. Common responses included learning best practices, learning from peers, early recognition, and provision of support for persons with dementia and their families around conveying the diagnosis. Other specific concerns were related to billing, advance care planning, and treatment. Session elements (presentation, case study reviews) were highly rated regarding effectiveness and relevance (4.69–4.89 on a 1–5 scale). Attendees perceived gains in knowledge of dementia core components and how to make a diagnosis of dementia increased significantly (2.82 to 3.36) on a 1–4 scale. Knowledge of dementia subtypes and presentations increased to a lesser degree (3.09–3.36; 3.00–3.36). Overall, attendees generally felt that their expectations were met.

Attendee perceptions

Knowledge gains were also important to interviewees. Gains included learning about new assessment tools with which they were not familiar. Confidence gains were also valued, for example with regard to challenging tasks, such as de-prescribing and the approach to dementia patients with agitation and behavioral disturbance. High value was placed on information about teaching resources and caregiver support materials, perhaps not surprising given most interviewees’ nursing and case management backgrounds. Several had personal experience as dementia caregivers and supports for family and friends, thus adding to the emphasis on information and resources as coping tools.

Gains in knowledge and confidence were more than ends in themselves. Beyond the cognitive dimensions, knowledge and confidence gains also had a vital affective component as means of support. For example, interviewees noted that knowledge was not just new information, but also a way to validate one’s own knowledge and practices as being comparable to “expert best practices.” Increased confidence also had these affective and supportive dimensions. The importance of the ECHO’s supportive functions was described in suggestions for improvement, namely to shorten the didactic presentation, allow more time for the case presentations, and even have attendees collaborate across practices and institutions as a means of networking and building community.

This intertwining of meeting informational and support needs through ECHO attendance has been observed elsewhere. In an evaluation of an ECHO program focused on dementia in persons with lifelong intellectual disabilities (Clark, Ansello, Helm, & Tanzer, 2023), reported that there were two populations of attendees: those seeking information and those seeking support. This is akin to our experience, with the caveats that knowledge and support needs were engendered in the same individual, and that addressing the support needs seemed the more reinforcing of the two.

Limitations

Several limitations of our work must be recognized. Our ECHO course was delivered during the height of the COVID-19 pandemic “Omicron wave,” which resulted in a smaller sample than we had anticipated. Attendance was also impacted by the number of sessions and a notable dip after the 2021 year-end holidays. We were not able to assess outcomes such as actual changes in practice and whether these changes led to improved quality of care. A limitation perhaps unique to our study is that our participant practices – which included academic settings, university-affiliated interdisciplinary group practices, a PACE program, and federally funded health centers – already provided competent dementia care, largely in urban and suburban areas. The extent to which our findings apply to smaller practices, practices with less dementia expertise, and rural settings remains to be seen.

Lessons learned

ECHO learning programs that engage generalists as active participants can improve the efficiency of sub-specialist input and offer a de facto interprofessional team, especially to primary care practices that lack this resource. The partnership model used for this project helped to provide recruitment opportunities and share the effort of conducting the ECHO across several stakeholders, making implementation less onerous and broadening the range of expertise that could be utilized in the program. Increasing knowledge and confidence were both ends in themselves and, perhaps more importantly, key supportive functions that motivated participants to attend initially, keep coming back, and engage. The take-home point for ECHO planners is that supportive motivators are perhaps more fundamental drivers than knowledge alone for clinicians taking care of dementia and perhaps similar conditions that can exact a personal toll, and should be specifically planned for to achieve the “all-teach all-learn” aspiration of a successful ECHO.

The ECHO sessions were attended predominantly (75%) by nurses, office staff, and other non-physician team members. Participation provided tangible linkages to new resources, allowing for education and support of persons with dementia and their care partners, an issue that was key to most attendees. Moreover, attendance provided staff support with regard to the emotionally challenging demands of dementia care. Staff participation also fostered team building and empowerment as key roles, such as early recognition of incipient dementia cases, patient and family education and support, and case management. These considerations may be important for dementia ECHO planners to emphasize with primary care practice leadership. Benefits may include not only staff enrichment but also engagement, with the potential to translate into improved dementia primary care with attendant enhanced quality and the possibility of reduced costs.

Conclusion

The strength of the ECHO model is in its networking capability. Listening to the experiences of peers who struggle with the same challenges allowed participants to realize they were not alone, incompetent, or to blame for difficult cases. Being able to talk to colleagues who “get it” was noted as an important means of enhancing professional self-care that helped participants cope with the emotional aspects of dementia care, increased their self-efficacy for this care, and reinforced a sense of mission.

Acknowledgements

The authors would like to thank the following members of our Project ECHO Hub team for their contributions to this project: Kim Ivey, Margie Lenz, and Jenni Mathews. We also want to acknowledge our content experts for the ECHO courses.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Supplementary material

Supplemental data for this article can be accessed online at https://doi.org/10.1080/02701960.2023.2278097

Additional information

Funding

This project was supported by grant numbers U1QHP28737, U1QHP28710, and U1QHP28744 from the Health Resources and Services Administration (HRSA) of the US Department of Health and Human Services (HHS). The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement by, HRSA, HHS, or the US Government.