Using Project Extension for Community Healthcare Outcomes to Enhance Substance Use Disorder Care in Primary Care: Mixed Methods Study.

BACKGROUND: Substance use and overdose deaths make up a substantial portion of injury-related deaths in the United States, with the state of Ohio leading the nation in rates of diagnosed substance use disorder (SUD). Ohio's growing epidemic has indicated a need to improve SUD care in a primary care setting through the engagement of multidisciplinary providers and the use of a comprehensive approach to care. OBJECTIVE: The purpose of this study was to assess the ability of the Weitzman Extension for Community Healthcare Outcomes (ECHO): Comprehensive Substance Use Disorder Care program to both address and meet 7 series learning objectives and address substances by analyzing (1) the frequency of exposure to the learning objective topics and substance types during case discussions and (2) participants' change in knowledge, self-efficacy, attitudes, and skills related to the treatment of SUDs pre- to postseries. The 7 series learning objective themes included harm reduction, team-based care, behavioral techniques, medication-assisted treatment, trauma-informed care, co-occurring conditions, and social determinants of health. METHODS: We used a mixed methods approach using a conceptual content analysis based on series learning objectives and substances and a 2-tailed paired-samples t test of participants' self-reported learner outcomes. The content analysis gauged the frequency and dose of learning objective themes and illicit and nonillicit substances mentioned in participant case presentations and discussions, and the paired-samples t test compared participants' knowledge, self-efficacy, attitudes, and skills associated with learning objectives and medication management of substances from pre- to postseries. RESULTS: The results of the content analysis indicated that 3 learning objective themes-team-based care, harm reduction, and social determinants of health-resulted in the highest frequencies and dose, appearing in 100% (n=22) of case presentations and discussions. Alcohol had the highest frequency and dose among the illicit and nonillicit substances, appearing in 81% (n=18) of case presentations and discussions. The results of the paired-samples t test indicated statistically significant increases in knowledge domain statements related to polysubstance use (P=.02), understanding the approach other disciplines use in SUD care (P=.02), and medication management strategies for nicotine (P=.03) and opioid use disorder (P=.003). Statistically significant increases were observed for 2 self-efficacy domain statements regarding medication management for nicotine (P=.002) and alcohol use disorder (P=.02). Further, 1 statistically significant increase in the skill domain was observed regarding using the stages of change theory in interventions (P=.03). CONCLUSIONS: These findings indicate that the ECHO program's content aligned with its stated learning objectives; met its learning objectives for the 3 themes where significant improvements were measured; and met its intent to address multiple substances in case presentations and discussions. These results demonstrate that Project ECHO is a potential tool to educate multidisciplinary providers in a comprehensive approach to SUD care.

Participation in Project ECHO to advance rural primary care providers' ability to address patient mental health needs.

The COVID-19 pandemic shed light on the burden of behavioral health conditions prevalent in the United States (U.S.). Consequently, there is a behavioral healthcare provider shortage, particularly in rural areas, to support this need. Recently, primary care providers (PCPs) have shifted to incorporate behavioral health to their practice. However, many PCPs lack knowledge and skills to successfully manage their patients' behavioral health conditions. In response to the need for effective behavioral healthcare across the U.S. Weitzman ECHO launched the Advanced Primary Care (APC ECHO) Adult Psychiatry Module to provide continuing education (CE) for rural PCPs. This study presents the results from the APC ECHO pilot to demonstrate how CE can support PCPs in addressing their patients' mental health needs. Evaluators used a one-group repeated measures study design to assess the APC ECHO Module and understand learner outcomes and individual practice changes. Participant characteristics and individual practice changes were summarized using descriptive statistics, with support from open-ended responses to illustrate findings. Repeated measures analyses of covariance were applied to compare the differences in pre- and post-module learner outcomes. A total of 18 providers participated in the study, with the majority encompassing medical providers (72.2%). There was a significant increase in knowledge (pre-module: 21.11 + 6.99; post-module: 25.08 + 5.66; p < .01), self-efficacy (pre-module: 6.89 + 3.05; post-module: 9.78 + 3.25; p < .01), and skills (pre-module: 7.67 + 4.03; post-module: 10.06 + 3.23; p < .05) gained over the duration of the ECHO module. Additionally, participants indicated they are applying best practices learned through the module to their patients experiencing psychiatric conditions (3.96 + 0.09). This study suggests that tailored CE for PCPs can promote an increase in knowledge, self-efficacy, and skills to apply best practices when treating patients with behavioral health conditions. This, in turn, allows patients to receive more comprehensive care and mitigates access barriers, especially for rural populations.

Instituting Sexual Orientation and Gender Identity Training and Documentation to Increase Inclusivity at a Pediatric Health System.

In this mixed-methods quality improvement project, we implemented and evaluated sexual orientation and gender identity (SOGI) form rollout in the electronic medical record. Families in our gender diversity program completed a baseline survey in 2017 (55/328 responded) and follow-up in 2020 (180/721 responded) to evaluate the frequency of affirmed name and pronoun use in the hospital. Survey feedback informed system-wide inclusivity efforts and training. SOGI was implemented in 2020 after 1,662 providers completed an online training and 11,090 team members completed gender and sexual orientation inclusivity training. We recommend similar trainings for health systems utilizing SOGI.

Macronutrient and Micronutrient Intake in Adolescents With Non-alcoholic Fatty Liver Disease: The Association With Disease Severity.

OBJECTIVES: While dietary changes are recommended to treat pediatric non-alcoholic fatty liver disease (NAFLD), the role of specific nutrients in disease progression is unclear. The objective of this study is to (1) assess the macronutrient and micronutrient intake in adolescents with liver biopsy proven NAFLD [with and without non-alcoholic steatohepatitis (NASH)] and lean controls; (2) determine nutritional predictors of disease severity amongst these groups. METHODS: Adolescents with biopsy-proven NAFLD and lean controls completed the Harvard Food Frequency Questionnaire. RESULTS: Twenty-eight NAFLD and 15 lean controls were studied. NAFLD with (n = 20) and without NASH (n = 8) had similar total calorie, protein, fat, and carbohydrate intake. Subjects with NASH had higher total sugar (122.3 ± 48.3 vs 83.1 ± 38.8 g), glucose (24.3 ± 9.3 vs 15.2 ± 7.5 g), sucrose (42.3 ± 16.9 vs 28.8 ± 11.7 g), and fructose (29.4 ± 12.5 vs 18.1 ± 8.0 g) intake than those with NAFLD but without NASH ( P < 0.05). Both NAFLD groups had similar micronutrient intake. Alanine aminotransferase (ALT) correlated with total caloric intake ( ρ = 0.4; P = 0.04). Total carbohydrate calories correlated with a higher NAS summary score ( ρ = 0.38; P = 0.04) and lobular inflammation ( ρ = 0.50; P = 0.007). Percent calories from added sugar and glucose correlated with worsening NAS summary score ( ρ = 0.44, P = 0.02; ρ = 0.48, P = 0.009) and lobular inflammation ( ρ = 0.51, P = 0.006; ρ = 0.53, P = 0.004). Percent calories from fructose correlated with lobular inflammation ( ρ = 0.56; P = 0.002). Total daily calories, protein, fat, carbohydrate, and micronutrient intake were similar between NAFLD and lean controls. CONCLUSIONS: NASH patients consume similar total calories, protein, and fat as those without NASH, but have significantly higher sugar intake. NAFLD and lean children, however, have similar macro/micronutrient intake. Histologic disease severity correlates with total carbohydrate and added sugar intake, supporting a role for simple sugar intake in NAFLD progression.

Project ECHO COVID-19: Vulnerable Populations and Telehealth Early in the Pandemic.

INTRODUCTION/OBJECTIVES: Project ECHO COVID-19 was launched nationwide on March 4, 2020 to disseminate guidance about COVID-19 in a timely and scalable manner to meet the urgent needs of primary care settings, the first line of defense in a pandemic. METHODS: Data from post-session surveys were analyzed to assess participant satisfaction, knowledge gaps, change in knowledge, and anticipated changes in practice as a result of Project ECHO COVID-19. A content analysis was conducted of the 243 questions and concerns posted by over 2000 participants in the Question and Answer function of Zoom during the first 8 sessions (March 4-April 29, 2020). RESULTS: Of 5243 registrants, 49% attended at least one session. Respondents agreed or strongly agreed that didactic sessions (97%) and case presentations (96%) met their learning needs; 93% reported gaining new knowledge, and 88% would implement that knowledge. Only 32% and 53% of respondents anticipated changing workflows and adapting to telehealth, respectively, despite the need for both as the pandemic continued. The content analysis identified 3 categories: clinical operations (eg, testing, triage, telehealth, billing); patient care (diagnosis and treatment of COVID-19, management of high-risk vulnerable populations); and epidemiology (viral spread, implications for public health). CONCLUSIONS: Care of vulnerable populations and clinical operations should be addressed when planning education and clinical interventions for public health crises. Adapting the Project ECHO model to be more scalable was an effective means of creating a community of practice among health professionals when evidence-based guidance was not available to manage the implications of a pandemic.

A mixed methods evaluation of the feasibility, acceptability, and impact of a pilot project ECHO for community health workers (CHWs).

BACKGROUND: Despite the positive effects of community health workers (CHWs) on addressing social determinants of health, improving patient health outcomes, and decreasing overall healthcare costs, there is a lack of standardization in training and certifying this workforce, resulting in different approaches to integrating this role into medical home models. The purpose of the current study is to evaluate the application of Project ECHO (Extension for Community Healthcare Outcomes) in enhancing CHWs' capacity to address health and social issues of vulnerable populations. METHODS: An explanatory sequential mixed methods design was applied in which all participants (N = 49) completed pre (January 2019) and post (July 2019) quantitative online surveys measuring changes in self-efficacy, behavior change intent, and knowledge. Virtual focus groups were conducted with a subset of participants (n = 20) in July 2019 to assess the feasibility, acceptability, and impact of Project ECHO. RESULTS: There was a statistically significant difference of + 0.453 in the composite self-efficacy mean score pre- to post-series. For every 1 additional Project ECHO CHW session attended, there was a .05 improvement in participants' self-efficacy to perform CHW-related job duties and address social determinants of health (SDOH). Four major themes emerged from the qualitative focus group data: value in learning from other participants' caseloads, CHW-care team integration, availability of training and resources, and shared decision-making with patients. CONCLUSIONS: This evaluation suggests that ECHO is a viable means of increasing access to training resources for CHWs. Future studies on the ECHO model as a means of educating and broadening implementation of CHWs are warranted. Programs such as Project ECHO can support CHWs by providing continuing education opportunities, as well as standardizing training content across large geographic areas.