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The ECHO® Heard Around Western North Carolina

UNC Health Sciences at MAHEC’s innovative virtual training removes barriers to quality healthcare in rural communities.

Last month, a troubled student sat down with a school nurse to talk about what was making it hard for her to stay calm and stay in class. So hard, in fact, that she often ran out of the classroom without warning and hid until the sound of her crying gave her away.

The nurse supported this student, a trauma survivor, in a variety of ways. She encouraged her to come by her office, helped her set goals and offered motivational rewards, strategized options with her parent, and made referrals to counseling and social services. Unfortunately, the child was continuing to struggle, and not much progress had been made.

A student with the same problem walked into a nurse's office in an elementary school on the other side of town. And a school nurse several counties away was dealing with an identical scenario.

These nurses were not only seeing the same behavioral health challenge, they were seeing the same student. She was being evaluated by a team of medical experts from UNC Health Sciences at MAHEC and more than 20 nurses from across Western North Carolina who were all considering how to best meet her needs.

A new way to learn

Thanks to Project ECHO®, an innovative virtual training model offered by UNC Health Sciences at MAHEC, no one had to leave their office to help this student or the thousands of other children in their care.

The accessibility of this online training is what first attracted Kelly Martin-Hicks, RN, a school nurse from Haywood County.

"I was grateful that I didn't have to travel to Asheville and could do it at a time that worked in my schedule," Martin-Hicks shares.

"We don't have a lot of access to mental health services in our county," she explains. "But we're seeing a lot of behavioral health issues including depression and suicide. We're having to triage to address these issues in the schools without a lot of training in them."

MAHEC's Project ECHO® for School Nurses, which is being offered for the third time in the fall of 2019, consists of ten live videoconference sessions on school health topics that include behavioral health, diabetes, seizure disorders, asthma, and skin conditions. After each expert-led presentation, participants have an opportunity to get guidance on actual patient cases like the student struggling with the aftermath of trauma.

Moving knowledge, not patients

Project ECHO® (Extension for Community Healthcare Outcomes) was developed at the University of New Mexico to reduce barriers to specialty care in rural areas like WNC. The hub-and-spokes training model brings together healthcare specialists at a learning hub to share information in real-time with primary care providers who are geographically dispersed.

This approach brings healthcare training to the places where it is needed most.

"I love this teaching and learning model," shares Susan Alexander, MD, a MAHEC family physician and medical director for the virtual trainings.

"As a rural physician, I never liked the isolation I felt in webinars," she explains. "Project ECHO® does something different. It brings together colleagues who are dedicated to serving our WNC communities. Because this model emphasizes sharing knowledge, the learning flows in all directions."

In each Project ECHO® session, MAHEC's medical experts share specialized knowledge with providers across WNC, but the experts also learn from providers' first-hand experiences. Participants help each other and build a supportive community as they discover best practices.

Martin-Hicks didn't realize this training would encourage her to become a teacher too.

"I was surprised to discover how valuable it is to talk with providers and share what we have to face as school nurses on a day-to-day basis," she explains. "I don't think many providers realize just how much school nurses do. It was really validating to have a behavioral health specialist acknowledge we are facing some intense challenges."

But knowledge isn't the only thing participants share.

Every ECHO session includes real case studies submitted by participants or experts in advance. Cases are presented for feedback and recommendations for next steps. Participants share educational and community-based resources that enhance their learning and patient care.

"When we explore case studies together, we learn from each other's experiences," Martin-Hicks explains. "We learn by working through actual issues that come up in our schools."

In rural healthcare, access is everything

UNC Health Sciences at MAHEC was one of the first academic health centers in North Carolina to use Project ECHO® trainings to support rural communities where geographic and socioeconomic barriers can make access to specialty care difficult if not impossible.

In just two years, the WNC-based organization has led 19 different ECHO trainings on 9 unique topics including rural medicine, chronic pain management, medication-assisted treatment for opioid use disorder, behavioral health, high-risk prenatal care, breastfeeding support for high-risk mothers, school health, and geriatric care. This fall, a new ECHO series will focus on understanding and mitigating the health impacts of adverse childhood events.

Over this past year, more than 1,126 healthcare providers from 43 NC counties have participated in Project ECHO® trainings led by UNC Health Sciences at MAHEC. Eight more ECHO training series are scheduled this fall.

The first ECHO launched in late 2017 for MAHEC's rural fellows and focused on health conditions that can be hard to treat in rural areas including Type II diabetes, epilepsy, COPD, Hepatitis C, substance use disorders, and other complex health conditions. These ECHOs now support three cohorts of fellows spread across 11 rural WNC counties.

"This technology helps us bridge the distance between our rural fellows and build a supportive cohort," shares Benjamin Gilmer, MD, MAHEC family physician and rural fellowship advisor. "These virtual clinics allow us to bring healthcare specialists to the doors of each fellow remotely so they can provide more specialized care for their patients in need."

Project ECHO® rural fellow, Kelly Garcia, MD, appreciates the case-based learning these series offer. "As I transitioned out of residency, opportunities for formal learning were fewer, especially for those of us in rural areas."

Learning how to stop an epidemic

Nowhere is specialized learning more important than in the effort to stop the opioid epidemic which has hit WNC harder than most places in the state and the nation.

MAHEC's chronic pain ECHOs aim to reverse this trend by changing prescribing patterns to reduce the number of people who become dependent on opioids, which puts them at greater risk of accidental overdose and death.

These ECHOs focus on safer ways for providers to help their patients manage chronic pain and are led by Blake Fagan, MD, chief education officer for UNC Health Sciences at MAHEC and CDC Foundation NC clinical consultant for the opioid crisis, and a team of pain experts.

When MAHEC's Project ECHO® program coordinator, Lourdes Lorenz-Miller, MSN, initially met with providers across the region to identify their healthcare training needs, chronic pain management topped the list.

"Chronic pain affects more than 100 million Americans-more than heart disease, cancer, and diabetes combined-and it's a challenging condition to treat," Lorenz-Miller shares. "Especially in rural counties where access to pain clinics and other supports is limited."

MAHEC also leads an ECHO on medication-assisted treatment for opioid use disorder and participates as a perinatal substance use treatment expert on a statewide ECHO led by the University of North Carolina at Chapel Hill.

Expanding the impact by making an ECHO

UNC Health Sciences at MAHEC has an ambitious vision for this telementoring training model: to make healthcare expertise and best practice care available to improve lives throughout WNC.

"Project ECHO® allows us to share what we have learned with providers and their patients across the region," Lorenz-Miller shares. "This is what makes this model so exciting. It has the potential to address pain and other health challenges in a big way by reaching more people."

For more information, contact Lourdes at 828-257-4758 or

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