Collaborative health systems ECHO: The use of a tele-education platform to facilitate communication and collaboration with recipients of state targeted response funds in Pennsylvania

Abstract

Background: The opioid epidemic continues to erode communities across Pennsylvania (PA). Federal and PA state programs developed grants to establish Hub and Spoke programs for the expansion of medications for opioid use disorders (MOUD). Employing the telementoring platform Project ECHO (Extension for Community Health Outcomes), Penn State Health engaged the other seven grant awardees in a Collaborative Health Systems (CHS) ECHO. We conducted key informant interviews to better understand impact of the CHS ECHO on health systems collaboration and opioid crisis efforts. Methods: For eight one-hour sessions, each awardee presented their unique strategies, challenges, and opportunities. Using REDCap, program characteristics, such as number of waivered prescribers and number of patients served were collected at baseline. After completion of the sessions, key informant interviews were conducted to assess the impact of CHS ECHO on awardee’s programs. Results: Analysis of key informant interviews revealed important themes to address opioid crisis efforts, including the need for strategic and proactive program reevaluation and the convenience of collaborative peer learning networks. Participants expressed benefits of the CHS ECHO including allowing space for discussion of challenges and best practices and facilitating conversation on collaborative targeted advocacy and systems-level improvements. Participants further reported bolstered motivation and confidence. Conclusions: Utilizing Project ECHO provided a bidirectional platform of learning and support that created important connections between institutions working to combat the opioid epidemic. CHS ECHO was a unique opportunity for productive and convenient peer learning across external partners. Open dialogue developed during CHS ECHO can continue to direct systems-levels improvements that benefit individual and population outcomes.

Keywords:

• Project ECHO
• Hub-and-Spoke systems
• collaborative health systems
• medications for opioid use disorders
• telementoring

Introduction

Opioids are involved in the majority of drug overdose deaths in the United States. Over 70,000 people died from a drug overdose in 2019, with 70.6% of these deaths attributed to an opioid. ¹ These deaths, along with other opioid-related consequences such as non-fatal overdoses, infectious diseases, and crime have cost the nation $560 billion over the past ten years.² In the last decade, Pennsylvania (PA) has experienced increased drug overdose deaths, many of which were due to opioids.³

In July 2017, PA received $26 million in federal funding through the Substance Abuse and Mental Health Services Administration (SAMHSA) to combat the opioid crisis in state-targeted response funds. Under the leadership of PA Department of Health (DOH) Secretary, Rachel Levine, PA DOH created Pennsylvania Coordinated Medication Assisted Treatment (PACMAT) grants, using part of those funds. The PACMAT grants financed development of Hub and Spoke systems to expand access to Medications for Opioid Use Disorders (MOUD). Despite its effectiveness, MOUD remains underutilized due to stigma surrounding patients and the medications themselves, disparate treatment access, and lack of provider education on best practices. Less than half of private treatment programs have adopted MOUD.^4–8 Within programs offering MOUD, only an estimated one-third of eligible patients receive MOUD.^4,9 Additionally, treatment providers lack financial resources needed to support long-term patient engagement.^10,11 Continuity is challenging when individuals are often treated at safety-net community-health clinics, which frequently lack electronic health record (EHR) functionality for data communication or aggregation ability.¹²

A Hub and Spoke model of care represents a continuum of care ranging from primary medical services to specialty care, with systems in place to ensure that individuals with a specific health condition continue to receive life-saving medical services. The PACMAT Hub and Spoke systems were modeled on the success of the Vermont (VT) and Rhode Island (RI) programs,^13,14 but operationalized differently. VT’s Hub and Spoke systems were entirely state funded and provided uniform services including standardized intake and transfer procedures; use of methadone, buprenorphine-naloxone, and vivitrol; and VT government employed supportive nursing and therapy staff per 100 Medicaid patients. RI created centers of excellence, which integrated peer recovery, counseling, and vocational support with all forms of MOUD. By contrast, PA hubs were heterogenous beyond a few guiding principles. All PACMAT recipients focused on access expansion, patient enrollment, sustained recovery, and reduction of overdose deaths. All hubs recruited spoke clinic sites, from within or outside the hub’s health system, with the ability to initiate and continue treatment with buprenorphine and extended-release naltrexone. To obtain funds, grantees were required to develop payment and sustainability plans through individual arrangements or collective advocacy. Beyond these guidelines, each PA Hub and Spoke system employed very different strategies, scales, and scopes of practice. Unlike VT and RI, PA hubs were not required to have all forms of MOUD or to provide treatment in a central location. Some hubs served as linkage to community-based care centers, while others were active opioid treatment programs and previously designated PA Opiate Centers of Excellence. As a result, the PACMAT grants formed a heterogeneous network of Hubs and Spokes across multiple health care delivery systems.

In May 2019, the Penn State Health PACMAT utilized supplementary funds to leverage a collective virtual partnership among the eight PACMAT grantees using Project ECHO (Extension for Community Health Outcomes). Penn State had previously utilized Project ECHO to connect primary care providers with a goal to increase access to MOUD; this model has been shown to achieve this goal by increasing the number of primary care providers waivered to prescribe and improving healthcare provider preparedness to treat OUD, specifically through advances in provider knowledge and self-efficacy.^15–18 Project ECHO provided a platform for PACMAT leadership to share their unique Hub and Spokes operations and practices. Because each PACMAT operates in a different geographic area of PA and uses diverse strategies personnel and electronic health records, Project ECHO fostered a collaborative learning environment to share best practices, discuss unique challenges, and brainstorm collective solutions. The purpose of this paper is to describe the use of Project ECHO to integrate and coordinate opioid crisis efforts across PA. Collectively, this series aimed to augment our collective influence with the PA DOH and other regulatory and financing stakeholders; to contextualize and strengthen individual and collective health systems efforts; and to design collective and empowering strategies to overcome obstacles to care, data collection, and financial sustainability.

Material and methods

Pennsylvania PACMAT

The PACMAT grants directly funded seven Hub and Spoke systems and partnered with the UPMC Health Plan who were awarded a separate but similar SAMHSA grant to its own Hub and Spoke system.¹⁹ Therefore, eight programs were funded in 2017 and 2018 (Table 1). Leadership for each system met monthly with state personnel via telephone conference and quarterly at in-person meetings in Harrisburg, PA to share updates on their programs. Although these meetings were largely interactive, these networking meetings focused primarily on updating the state agency, rather than on collective, cross-organizational problem solving.

Table 1. PACMAT demographics.

PACMAT	Academic Affiliation	Uniform EHR	Number of Hubs	Number of spokes	Number of providers	Number of patients treated total
Wellspan	No	No	1	23	30	633
Penn State	Yes	No	1	12	30	1920
UPMC Health Plan	No	No	4	32	282	2425
UPMC Pinnacle	Yes	No	1	8	10	576
Temple University	Yes	No	1	10	33	627
Geisinger	Yes	Yes	4	10	26	2574
Allegheny Health Network	No	No	1	8	18	554
The Wright Center	Yes	No	1	9	24	609
		Total	14	112	453	9918

Project ECHO

Project ECHO is a telementoring model that uses videoconferencing technology (Zoom) to create a real time “all teach, all learn” knowledge exchange that bolsters provider capacity to deliver best-practice care to underserved populations with increased self-efficacy, skills, and confidence.^16,20 The ECHO model has four core principles, (1) use technology to leverage scarce resources, (2) share best practices to reduce disparities, (3) employ case-based learning to master complexity, and (4) monitor outcomes to ensure benefit. This model was chosen because unlike traditional learning, Project ECHO facilitates rapid dissemination of medical knowledge and increased capacity to deliver best-practice care by utilizing case-based, collaborative learning to support discussion of learners’ challenges and barriers to guideline implementation. 

After launching our PACMAT program in November 2017, Penn State College of Medicine launched a separate SAMHSA funded Project ECHO initiative on MOUD in 2018 (grant TI081432) to build self-efficacy of providers to diagnose and treat OUD across PA.²¹ Leveraging our existing ECHO infrastructure, we created a new learning platform with participation from PACMAT hub leadership, called the Collaborative Health System (CHS) ECHO. Given our existing connection to the PACMAT program, we were able to recruit CHS ECHO participants for this series by emailing the lead contact for each PACMAT program. The PACMAT lead was responsible for providing oversight of physical, mental, and social health services to expand and improve MOUD access within their network, but may or may not have been involved in direct patient care. In all cases, they participated and invited relevant staff to join as well on occasion. These included Addiction Medicine specialists, psychiatrists, project managers, physicians, and senior level executives.

A typical ECHO session targeting clinical providers features a patient case presentation followed by a 10–15 minute brief lecture. In contrast, CHS ECHO sessions featured a health system-based case rather than a patient case. At each session, a different PACMAT awardee was encouraged to present their system, covering hub and spoke characteristics and services, collection and management of provider and patient-level outcomes data, unique strengths, current challenges, and future goals. This allowed for all participants to gain a baseline understanding of the PACMAT, participate in discussion, find common ground, celebrate successes, and respond to challenges presented. Recommendations shared during CHS ECHO sessions were documented and provided to the presenting hub. The CHS ECHO met every other week for eight one-hour sessions.

Quantitative data collection

Using REDCap, a secure web application for survey data collection, parameters at baseline were collected in May 2019 to characterize the scope of the PACMAT network operations including academic affiliation and unified EHR for data extraction, as well as the total number of hub and spoke sites, MOUD waivered providers and number of patients served. At the conclusion of the series in September 2019, a post series survey was shared with all participants.

Key informant interviews

Due to low completion rates of the post series survey, seven months after CHS ECHO sessions concluded between the months of December 2019 and February 2020, a masters trained Project ECHO project manager (PM) reached out to CHS ECHO participants via email (n = 7) and conducted 30 minute telephone interviews with each participant. All seven CHS ECHO participants completed an interview. This PM did not have relationships with the participants/interviewees but provided technical assistance throughout CHS ECHO sessions. A semi-structured guide was written a priori by Project ECHO staff based on their collective decades long experience with ECHO programs and provider training. Two separate staff members authored the first drafts, and a board-certified Addiction Medicine physician revised them (see Supplement 1). The semi-structured guide was adapted from questions included in the post series survey to further explore the impact of CHS ECHO on their PACMAT efforts, share changes they implemented because of participating in CHS ECHO, describe challenges and barriers they faced, and comment on the sustainability of the CHS ECHO format.

Qualitative analysis

Interviews were audio recorded and transcribed by the PM using a naturalized approach by the PM. Three masters trained research support staff members used general inductive and descriptive content analysis to coalesce the data into themes. Interview transcripts were read repeatedly as a whole and then word by word, allowing categories to flow from the data.²² This analysis resulted in a codebook and summary of the discussed themes.

Results

Across the state, 19 of the 67 counties were included in the PACMAT catchment area; each of these 19 counties include at least one PACMAT spoke site (Figure 1) where a total of 9,918 patients were treated with MOUD at 112 clinical treatment spokes. This total number of patients treated was not a current snapshot of active patients, but the cumulative patients treated since inception of the PACMAT grant in 2017. The range of the average number of patients treated per provider within PACMAT spanned 9–99. Half of all PACMAT program recipients were affiliated with a medical school and teaching hospital. Twenty-five percent had multiple hubs in their networks that served over 2000 unique patients in their respective catchment areas. Only one program employed methadone maintenance as part of an opioid treatment program as its hub. Most programs (7 of 8) did not have uniform EHRs for reporting data from community health center spokes (Table 1). All 8 PACMATS were represented during CHS ECHO sessions. To keep discussion on track and engaging, we asked that 1 program administrator or lead physician with an understanding of how their PACMAT operates to participate in ECHO sessions.

Figure 1. PACMAT catchment areas by County.

Chs ECHO impact

During key informant interviews, PACMAT leads were asked about the impact of the CHS ECHO in five areas: (1) confidence with initiating changes to their PACMATs, (2) addressing challenges, (3) knowledge of best practices, new strategies, or resources, (4) motivation to address the opioid crisis through PACMAT work, (5) collaboration with a variety of stakeholders, and (6) ability to contact other PACMAT colleagues outside of regular meetings.

Confidence

PACMAT leads described many benefits to CHS ECHO participation. While each PACMAT had different organizational approaches and faced unique challenges, discussions during CHS ECHO sessions provided an unparalleled opportunity for reflective learning, new idea generation, and resource sharing. In contrast to other meetings that focus on reporting progress, CHS ECHO sessions created an equal environment for fellow grant recipients to engage in constructive and vulnerable dialogue. Reassurance and empowerment from colleagues with diverse roles facing similar challenges across the state helped address professional isolation, while generating increased motivation and confidence (Table 2).

Table 2. CHS ECHO impact on motivation, knowledge, and confidence.

Findings on CHS ECHO Impact	Key Informant Quotations
Discussions occurring during CHS ECHO bolstered motivation and confidence of PACMAT leads.	“Just knowing the fact that everyone [was] working hard to find solutions to the same issues gave me the boost I needed to energize our site-specific solutions.” (Participant 5)
	“Knowing that we all [had] this common goal to develop and make our MAT statewide platform bigger, better, and more productive validated that we [were] all trying to move in the same direction. It [was] very empowering and motivating to know [we were] not the only one trying to make a change.” (Participant 7)
	“Listening to everyone and what they [were] doing within their own practices or within their own systems was [a] high level discussion. [Made] you think and want to change things within your own system and to hear what others [were] doing as well.” (Participant 1)
A critical component of the collaborative peer learning support network of CHS ECHO was a shared trust and vulnerability that facilitated open conversations and systems level information sharing.	“The first time someone expresse[d] a vulnerability and you [could] see that it [was] well-received and other people echo that, it normalize[d] it. I think a lot of times, as leaders we feel like when we’re talking with external partners, we have to tread lightly about our opportunities for improvement and our friction points. When we felt like we could all trust each other and started having an honest conversation, I think that’s where a lot of the power came from. Instead of focusing on all the little things that we’re doing great and then stopping, it’s like oh, and we also have all these challenges. We’re hoping you guys can help us figure this out.” (Participant 4)
	“It’s just a different dynamic that's established in the two different meetings [CHS ECHO vs state quarterly meetings]. [In the] quarterly meeting, most of what we're sharing with each other [is] our successes, and there's very little dialogue about challenges and friction points. I think part of the reason is that there's folks from the state and folks are worried about their image and also worried about the fact that we apply for grants from the folks on the phone or in person. And so, when you take that out of the equation, and it's a lot of folks who are in the similar positions for their health systems, with the same grant, essentially talking about how they're dealing with that same grant, and there's no one who they perceive to be higher than them on the power structure. I think that allows for that kind of constructive and vulnerable dialogue.” (Participant 7)

Addressing challenges

The three most common challenges identified by key informants included: (1) recruitment of and support for MOUD waivered providers, (2) billing and sustainability plans for the post-grant period, and (3) data management. Overall, PACMAT leads confirmed continued difficulty addressing provider recruitment and stigmatization of MOUD. PACMATs shared updates on their continuous efforts to address provider related challenges including hiring additional social workers, case managers, and peer recovery specialists. They also reported use of supplemental telemedicine behavioral support to encourage continued patient engagement with recovery services and to deliver additional referral support to spoke providers facing professional isolation.

While many different strategies for billing and sustainability plans were shared, all PACMATs described ongoing challenges with organizing billable medical and behavioral services for PA Medicaid patients. Additionally, PACMAT leads anticipated challenges with developing financially sustainable business models, funding expansions of their addiction medicine service lines, and coping with the accelerating speed of addiction medicine service line developments. During CHS ECHO sessions, PACMAT leads shared strategies for developing value-based payment model updates and implementing Medicaid billable services.

Finally, each PACMAT lead also described their data collection, reporting, and management practices. One common challenge was the need for immediate development of quality data-metric collection and reporting logistics, as addiction medicine service lines expanded quickly among hubs and spokes that employed nonuniform EHRs. Since PACMAT leads represented different points of care (e.g., linkage versus direct care), some also mentioned the difficulty of maintaining patient contact for the completion of reassessment data if their organization was not the frontline patient contact. All PACMAT leads identified a need for additional support at spokes for streamlined data collection and reporting. In addition to facing many structural and systems-level challenges as described above, PACMAT leads negotiated professional challenges with confidence, knowledge, motivation, and professional isolation.

Best practices and increasing knowledge

PACMAT leads had diverse experiences and credentials as health administrators and clinicians. Through these regular constructive and open discussions with a variety of professionals, PACMAT leads developed a greater ability to articulate their local needs, identify what others have been doing, and envision collaborative efforts to address the opioid crisis. During ECHO sessions, each PACMAT presented their unique strengths. These included access to care management services, proximity to the resources of academic medical centers, and access to teams of multidisciplinary professionals across the spectrum of care. Several PACMAT leads stated that their teams were motivated to implement changes and were highly knowledgeable about MAT best practices. One health system that utilized a uniform EHR across its spokes was able to leverage their funding to develop streamlined data collection methods for MAT quality and outcomes reporting. Additionally, many PACMATs had efficient coordination with spokes that represent a range of services, such as primary care, pregnancy-related care, community recovery centers, criminal justice systems, and EDs. Several PACMATs successfully increased access to harm reduction-based options at their spokes and alleviated patient burden through the development of direct contracts with area payers to secure patient housing, transportation, and food.

Addressing the opioid crisis

CHS ECHO discussions highlighted two important themes for future opioid crisis efforts: (1) the need for strategic and proactive program reevaluation as addiction medicine services lines quickly expand and (2) the sustainability of collaborative peer learning networks as grant funding changes (Table 3). All PACMAT leads shared collective challenges with maintaining an overall design strategy as opioid crisis efforts need to be rolled out rapidly. The speed of program development and expansion often required incremental system fixes, during which new challenges arose. Major topics of collaboration in this area included the need for adequate provision of provider support, system capacity building of expanding MOUD programs, incorporation of MOUD data within EHR systems, and payment models that provided more complete reimbursement of billings and claims for MOUD and behavioral health related services.

Table 3. CHS ECHO themes for future collaborative opioid crisis efforts.

Findings on Themes for Future Collaborative Opioid Crisis Efforts	Key Informant Quotations
CHS ECHO discussions revealed a critical need for strategic and proactive program design and reevaluation as health systems rapidly implement opioid crisis efforts. As addiction medicine service lines continue to quickly expand, the collaborative environment created by CHS ECHO helped PACMAT leads identify important opportunities to improve data management and reporting, provision of provider support, and systems capacity building.	“My major takeaway from PACMAT is that […] the majority of other organizations were doing what we did—which is rolling out this system fix that was based on iterative improvement enhancements—without a big vision strategy of, what are we trying to design yet, particularly with the absence of data. We all really needed to kind of step back and say, what is our narrative and story to date of our accomplishments and to be able to tell that story, not only as individual systems, but also as a state.” (Participant 7)
	“One of the things that was really helpful in giving that presentation was recognizing the difficulties in gathering all the data. As we were building, because we really only started doing this addiction work at the system level about three years ago, […] there were different folks doing different things in different places. And sometimes the data just couldn't match up and there was missing data. It really helped inform us about how important it was to get that [process] shored up before we moved on.” (Participant 2)
	“As we continue to recruit [providers] through the new PACMAT and SAMHSA grant and expand our tentacles here from our hub, there's still a lot of fear from primary care doctors and hospitalists about treating them [people with OUD]. [We need] to draw on our resources here with that goal, in our experience with that goal, and explain to doctors that they're not alone in their fear. We recruited 30 practices for PACMAT and 10 of them said, yeah, we'll do it and then they realize how much work goes into it and they say, now we want to and then the other 10 were too afraid to bring on this population that they didn't think existed. For us, as a recruitment tool, it [CHS ECHO] helps us share that there’s other people all across the state that are facing the exact same issues that we are talking about.” (Participant 1)
	“Another thing that’s been really helpful is that we actually really liked the format. We really enjoyed participating in the ECHO. We realized that that was a really good way to connect people [because] a lot of the work that we do can be very isolating. So, I’m just thinking about some of our primary care doctors who service folks and maybe they’re the only people in their practice doing this work. There’s no one that they can really talk to an outpatient which can be isolating in itself. And so, we are thinking about ways to connect our spokes more frequently, so that they can feel less isolated—we realized that this needed to be a priority.” (Participant 4)
CHS ECHO models a productive collaborative peer learning network that remains sustainable as grant funding shifts. Although not a replacement for in-person interactions, CHS ECHO expands opportunities for regular, structured, and constructive dialogue to more collaborators across the state.	“I think traditionally for [a PACMAT hub] peer learning networks are very significant vehicles for our organizational development, learning and progress. Robert Wood Johnson, HRSA collaboratives, we really learn in that space. In the past we were very dependent on onsite coaching for collaborative learning, but I think ECHO makes you realize it can be more virtual than you imagine.” (Participant 7)
	“It [CHS ECHO] was an added, amplified peer learning support network [beyond] what happens at PACMAT meetings with [Secretary Levine]. We tend to think the state needs to convene these, but we could probably be independently hosting those learning networks if we have the enabling technology to be less dependent on the state. I think that is important because when the grant ends, their funding to provide that neutral platform ends. There is a shift in my thinking—now we are responsible to continue that network and not be so dependent on the state that started it.” (Participant 7)
	“We found this timeframe and occurrence to be convenient to our staff. It allowed for sharing of experiences without the necessity of travel. It offers a different aspect of engagement than in person meetings, but still a useful one. We would still not advocate for elimination of in person meetings, but the [CHS ECHO] can reduce the need for regular travel and the associated time/costs.” (Participant 2)

Sustaining peer learning networks

Key informant interviews included important conversations about sustainable collaborative peer learning networks. While every systems-based presentation described each PACMAT’s sustainability plan for their MOUD services, the format of CHS ECHO also provided a platform for continued peer reflective learning that is sustainable beyond the duration of PACMAT funding. Although most PACMAT leads expressed that CHS ECHO should not be a total replacement for all in-person interactions, they noted that the ECHO format cut down on hours of driving time and allowed more staff at their organizations to attend calls. Additionally, the open information sharing during CHS ECHO generated collaborative connections and opportunities with external partners outside of in-person quarterly meetings with the state or CHS ECHO sessions. With this more convenient and sustainable format, PACMAT leads indicated the valuable utility of CHS ECHO as a structured opportunity for continued constructive dialogue about challenges, which generates new ideas and solutions (Table 4).

Table 4. CHS ECHO impact on collaboration.

Findings on CHS ECHO Impact	Key Informant Quotations
CHS ECHO brought together a variety of professional perspectives on the opioid crisis, allowing PACMAT leads to design innovative site-specific solutions with proactive consideration of collaborative opportunities at different levels of service provision and health administration.	“In their different roles, different responsibilities within their organizations, […] this isn’t just a top down approach or even a bottom up approach. [This is] people from all levels (and not just levels of care, but levels of creating access to care and coordination of care and delivery of care). It’s been motivating, but also given us an opportunity to learn about the different challenges or barriers that we might experience with different levels of service providers or different levels of administration.” (Participant 3)
	“Having access to all those different perspectives has really helped keep the conversation going – helping us to plan and anticipate challenges or barriers we might have before they come so that we can get patient feedback earlier in the process or make sure that all these people are involved in the decision making process or conversations around MAT. Knowing that all these people have some role has helped us to shape the implementation.” (Participant 6)
CHS ECHO jumpstarted more effective collaboration with external partners across the PACMAT network that sustained outside of in-person quarterly meetings with the state or CHS ECHO sessions.	“They know who you are when you're writing them and you know who they are when they're writing you and it's just easier—it facilitates that process.” (Participant 2)
	“The CHS ECHO was helpful in increasing contact with our peers who are doing similar work across the state and to generate new contacts to reach out regarding a variety of issues, including policies, strategies, billing/reimbursements, shared interests, etc.” (Participant 1)
	“We learned a lot about how other systems were managing their data, tracking either internally or using external tech vendors. We were really impressed with [one PACMAT program] […] and how they approached their registry management, data reporting, and software technology. We are working collaboratively with [her] through follow-up to bring it into our opioid dashboard reporting.” (Participant 3)
	“If it wasn’t for CHS ECHO and PACMAT, we wouldn’t even know where the other colleagues are—we all have become very close.” (Participant 3)
	“I've reached out to [another PACMAT lead] a few times […] [it] just really helps [to] strengthen that relationship within you know, when you hear that someone else is doing something neat and you want to get there because we have this relationship that's formed.” (Participant 5)
	“Being able to go to some of these other conferences or statewide convenings, or even national events and knowing other people that are in this space doing the work alongside you, and you have that person that you can sit next to, or you can follow up afterwards and say, what did you think about this? Or, that's something that we talked about in the PACMAT. I think that's been helpful just to have that connection with other people doing the work that you know they’re out there. Before the opportunity to talk to them and collaborate with them and work with them hadn't existed” (Participant 3)

Explanatory Legend.

Project ECHO: Project Extension for Community Healthcare Outcomes.

CHS ECHO: Collaborative Health Systems Extension for Community Healthcare Outcomes.

PACMAT: Pennsylvania Coordinated Medication Assisted Treatment.

EHR: Electronic Health Record.

Discussion

CHS ECHO created a collaborative peer learning network among PACMAT leads with productive bidirectional learning and support. Using Project ECHO principles and technology, PACMAT leads were able to meet every other week to network, discuss respective programs, share strategies, validate common challenges and foster collaborative brainstorming on a more frequent, convenient, and less costly basis. Through systems-level case presentations and open virtual discussions, we were able to identify common opportunities for collaborative opioid crisis response efforts. Prior to the CHS ECHO, PACMAT leads communicated through monthly phone calls and in-person quarterly meetings with state personnel primarily to share updates. Although not a replacement for in-person meetings, CHS ECHO provided an opportunity for more candid dialogues compared to in-person quarterly meetings with the state.

A key pillar of Project ECHO is a level playing field. This environment and regular communication jumpstarted collaborations between external partners, who would otherwise see each other as competing health systems. PACMAT leads also represented different perspectives in health care, which helped PACMAT leads better understand and anticipate diverse challenges in addiction medicine service line expansion. As all PACMATs managed the quick development and expansion of their programs, this proactive health systems evaluation and improvement was especially important. The close-knit and collaborative network that emerged from CHS ECHO participation highlighted the need for democratized knowledge platforms where those involved in opioid crisis efforts could learn from and support each other’s work for a greater collective impact. As demonstrated by the interview data, PACMAT leads reported an increased sense of professional support and motivation, not unlike the improvements in provider sense of isolation seen in individual focused ECHO programs.^23–26

PACMAT leads shared common challenges experienced by addiction medicine service lines nationwide.^27–29 In particular, recruitment and support of MOUD waivered providers remained difficult due to stigmatization of OUD and its pharmacologic treatments; provider burden and burnout; and logistical challenges with medical and behavioral health reimbursements.^{11,12,30–32} Furthermore, most PACMAT hub and spokes did not use uniform EHRs which prevented expedient data sharing, collection, and reporting. Many spokes were community health centers that provided critical safety net treatment in underserved areas, but they had limited ability to report quality and outcomes metrics. However, streamlined MAT data collection was achieved by one health system with a uniform EHR through intensive software development. Robust data collection is crucial for assessing access and quality of patient services, but innovative software development to patch the lack of existing data in EHRs and to develop data sharing capabilities is expensive. Many health systems instead prioritized increasing access to care, community partnership development, or other areas of need. Although each PACMAT has implemented successful strategies the study findings reinforce the message that systems and providers may benefit from additional funding, policy, and logistical support to overcome these barriers.

As indicated above, PACMAT systems were based on VT and RI’s Hub-and-Spoke model of care for addiction. However, several differences between these states presented unique challenges for PA. PA is geographically larger and demographically diverse, leading to variety in program structure and implementation strategy. Requests for new government-positions, like VT’s support staff, may have required inexpedient legislative input during a crisis. Needing urgent opioid crisis strategies with a lower barrier of entry, PA mandated a sustainability provision, requiring that programs coordinate with managed care organizations, PA Medicaid or outside donors to continue services after the grant period ended. Additionally, only one program offered methadone treatment at its hub. Given the extensive requirements for licensure, requiring methadone for hub and spoke networks would likely delay urgently needed patient care. The geographic, funding, and policy considerations of PA are likely to be reflected in other states who create similar statewide hub and spoke systems to address the opioid crisis. Given the urgency of opioid crisis efforts, future hub and spokes will likely continue to be highly heterogeneous as health systems work to cover treatment gaps in diverse areas.

Study strengths and limitations

The PACMAT collaboration to address the opioid crisis is unique. Previously, health systems would infrequently collaborate and largely viewed each other as business rivals, instead of as health care collaborators. With the creation of PACMAT, and the addition of a Project ECHO format, CHS ECHO provided valuable quantitative data on the treatment capacity and number of patients treated, and qualitative feedback regarding how different hospital systems could work together. This work has the potential to enhance reduction of overdose deaths throughout the state by improving access to MOUD. However, due to proprietary data within different health care systems, all data presented was by report and could not be independently verified. In addition, interviews could not be conducted anonymously, and social desirability bias may have impacted feedback on the CHS ECHO sessions. Further studies with independent data verification and anonymous feedback reporting will be needed.

Conclusion

The heterogeneity of the PA Hub and Spoke systems will likely be reflected in other states and future hub and spoke models. As these systems are created, the challenges shared by PACMAT leads demonstrate qualitative evidence that additional and proactive supports may be needed to address waivered provider recruitment and support, outcomes data collection and reporting infrastructure, and financial sustainability. As collaborative opioid crisis efforts develop, a platform for open conversations such as Project ECHO can expedite creative solutions and provide professional support. Project ECHO provided a platform for the continued health systems’ collaboration when funding sources shift.

The relationships between health systems fostered through PACMAT funding and CHS ECHO will facilitate effective coordination for common challenges, such as payment sustainability and data reporting that may require coordinated advocacy at the state level. The work of the PACMAT awardees have revealed several next steps. Specifically, qualitative evidence suggests a need for more uniform data reporting, fewer regulatory and policy restrictions to deliver all forms of MOUD in high-need areas, and training and support for the next generation of MOUD opioid prescribers integrated within diverse treatment settings. The insights that emerged from PACMAT collaboration and CHS ECHO participation have highlighted opportunities in our health system that will lead to better patient care and reduction of overdose mortality in PA.

Author contributions

JK, EF, and SK conceived of the Collaborative Health Systems (CHS) ECHO program. EF, GH, KB, and JK contributed to the operation of the CHS ECHO program. GH, EF, and SK took the lead in writing this manuscript. All authors, KB, SH, JK, PV, AL, JB, MC, LT, MF, JM, GS, and RL, provided critical feedback and contributed to the writing of the manuscript.

Disclosure statement

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

Additional information

Funding

This work is supported by the Substance Abuse and Mental Health Services Administration through grant number TI081432 and in part by the National Center for Advancing Translational Sciences, National Institutes of Health, through Grant TR002014. The UPMC Health Plan was supported by the SAMSHA grant number TI17017. The Pennsylvania Coordinated Medication Assisted Treatment grant awardees and Collaborative Health Systems ECHO were supported by the Pennsylvania Department of Health’s targeted response and state opioid response funding streams. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH or SAMHSA. The funding organization had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.