The COVID-19 and Children with Medical Complexity (CMC) Extension for Community Healthcare Outcomes (ECHO) was developed as a “just in time” learning format to respond to the vast number of challenges faced by health care clinicians, public health professionals, and families/caregivers of CMC during the coronavirus disease 2019 (COVID-19) pandemic. A unique aspect of the ECHO was the meaningful integration of family leaders who participated as faculty, learners, case study presenters, and guest lecturers. Another distinguishing feature of this ECHO was its inclusion within a Collaborative Improvement and Innovation Network. A mixed methods analysis found that the COVID-19 and CMC ECHO was associated with significant gains in knowledge and confidence in caring for CMC and their families during the COVID-19 pandemic. This article provides an overview of the results of the COVID-19 and CMC ECHO and provides recommendations related to utilizing the ECHO model as a rapid response mechanism for systems improvement, clinical practice improvement, and education during a public health emergency.
Children with medical complexity (CMC) are a diverse, yet high-risk subset of children and youth with similar themes of multisystem compromise, required home-care support, and escalated risk for hospitalization and mortality from infectious disease or disruption of care routines. Many of these children have rare conditions for which interventions may be only evidence-informed or anecdotal; general pediatric care standards cannot necessarily be applied to their care. Complex medication regimens, technology dependence, and mobility and neurosensory challenges required vast adaptations in the isolation, masking and nursing, and supply chain disruptions brought about by the coronavirus disease 2019 (COVID-19) pandemic. The American Academy of Pediatrics (AAP) COVID-19 and Children with Medical Complexity Extension for Community Healthcare Outcomes (ECHO) was developed to help address the many emerging challenges impacting CMC, their families, and clinicians.
Program Description
Project ECHO is an innovative hub and spoke program designed to create an interdisciplinary community of learners by bringing together public health and health care professionals (learners) and subject matter experts in topical areas (faculty) through a tele-mentoring program.1,2 Using brief lectures and case‐based presentations, the ECHO model increases the capacity of participants to identify, treat, and manage the care of patients within medical homes.3,4 Participants learn from experts and peers; experts also learn from the participants and each other. This bidirectional virtual knowledge network allows participants to improve knowledge, confidence, and treatment practices related to the targeted condition, building capacity for providers to deliver best-in-practice care to their patients. As an ECHO superhub, the AAP offers training for new ECHO hubs, technical assistance to the pediatric ECHO community, and fosters interdisciplinary collaboration and sharing of best practices in pediatric care.
The AAP COVID-19 and CMC ECHO was built on the learnings of the Collaborative Improvement and Innovation Network to Advance Care for Children with Medical Complexity project (CMC CoIIN). Its goal was to increase the knowledge, skills, and confidence of an interdisciplinary group of learners, including health care professionals, public health professionals, family leaders, and others, regarding caring for CMC and their families during the COVID-19 pandemic. The program ran from May 2020 to June 2021, hosting >300 unique participants in 28 individual virtual sessions with ∼24 participants per session. The atypically long time frame of this ECHO indicates a responsiveness to “real time,” evolving need. The ECHO included interdisciplinary faculty with expertise in emergency preparedness and response, family leaders with lived experience, mental/behavioral health, infectious disease, hospital medicine, primary care, public health, social work, and palliative care.
Each ECHO cohort met twice per month for a 1-hour ECHO session consisting of the following components:
Welcome, guidelines/expectations and introductions (10 minutes; AAP moderator)
Topic-related presentation (15 minutes; subject matter expert faculty)
Question and answer segment (5 minutes; all)
Case-based scenario presentation (10 minutes; self-selected participants)
Facilitated group case discussion (15 minutes; all)
Closing remarks (5 minutes; AAP moderator).
Unlike many ECHO programs that have a set curriculum determined by faculty before launching the ECHO, the COVID-19 and CMC ECHO used a responsive model that based the curriculum on the real-time needs of participants (identified through postsession surveys and questions/comments from participants during the ECHO), guidance from faculty, and evolving scientific knowledge. Topics and speakers were often determined 1 to 2 weeks in advance of each ECHO session. ECHO sessions were held on a broad array of clinical and systems-focused topics.
Table 1: COVID-19 and CMC ECHO Sessions and Topics
Due to a strong interest in the topic area, the COVID-19 & CMC ECHO included 2 cohorts of participants. One cohort included interdisciplinary state CMC CoIIN teams. Participants in this cohort included pediatricians, registered nurses, family leaders, Title V representatives, care coordinators, public health professionals, and others. The second cohort included pediatricians and other health care professionals across the United States.
COVID-19 and Children with Medical Complexity ECHO Sessions and Topics
Date . | Topic . |
---|---|
May 2020 | COVID-19 and CMC: An Overview |
June 2020 | Home Care Supports for CMC in COVID-19 Pandemic Part 1 |
Home Care Supports for CMC in COVID-19 Pandemic Part 2 | |
July 2020 | School Reentry for CMC Part 1 |
July 2020 | Telehealth for CMC in the time of COVID-19: A Crash Course in a New Model of Care |
August 2020 | Supporting Education of CMC in the COVID-19 Era |
August 2020 | Telemedicine/Telehealth Billing and Coding for CMC |
September 2020 | Supporting the Mental Health Needs of CMC and their Families in the Time of COVID-19 |
September 2020 | Burnout and Secondary Traumatic Stress Among Clinicians |
October 2020 | COVID-19 and Influenza in CMC |
October 2020 | COVID-19 and Testing in CMC |
November 2020 | Addressing Social Determinants of Health for CMC in Clinical Practice |
November 2020 | Virtual Care Coordination in an Era of Pandemic |
December 2020 | Family Presence Policies for Pediatric Inpatient Settings |
December 2020 | Disaster Planning for CMC: Preparing for the Unexpected |
January 2021 | Challenges for Families of CMC During the Pandemic |
January 2021 | COVID-19 Vaccine and Considerations for CMC |
February 2021 | Risks and Protections for Patients with Disabilities During the Pandemic |
February 2021 | Mental Health and Well-Being of Families and Siblings of CMC During the Pandemic |
March 2021 | COVID-19 Variants and Considerations for the Care of CMC |
March 2021 | Burnout and Secondary Traumatic Stress Among Clinicians Part 2 |
April 2021 | Disaster Preparedness for CMC: Lessons Learned from the Texas Winter Storm of 2021 |
April 2021 | Medicaid Policy Flexibilities to Support CMC and Their Families During the Pandemic |
May 2021 | Face Mask Considerations for CMC in a School Setting |
May 2021 | Best Practices for Providing Telehealth Care to CMC |
June 2021 | Screenings and Preventative Care Considerations for CMC During COVID-19 |
June 2021 | COVID-19 Vaccination for CMC |
June 2021 | AAP COVID-19 and CMC ECHO Wrap-Up Session |
Date . | Topic . |
---|---|
May 2020 | COVID-19 and CMC: An Overview |
June 2020 | Home Care Supports for CMC in COVID-19 Pandemic Part 1 |
Home Care Supports for CMC in COVID-19 Pandemic Part 2 | |
July 2020 | School Reentry for CMC Part 1 |
July 2020 | Telehealth for CMC in the time of COVID-19: A Crash Course in a New Model of Care |
August 2020 | Supporting Education of CMC in the COVID-19 Era |
August 2020 | Telemedicine/Telehealth Billing and Coding for CMC |
September 2020 | Supporting the Mental Health Needs of CMC and their Families in the Time of COVID-19 |
September 2020 | Burnout and Secondary Traumatic Stress Among Clinicians |
October 2020 | COVID-19 and Influenza in CMC |
October 2020 | COVID-19 and Testing in CMC |
November 2020 | Addressing Social Determinants of Health for CMC in Clinical Practice |
November 2020 | Virtual Care Coordination in an Era of Pandemic |
December 2020 | Family Presence Policies for Pediatric Inpatient Settings |
December 2020 | Disaster Planning for CMC: Preparing for the Unexpected |
January 2021 | Challenges for Families of CMC During the Pandemic |
January 2021 | COVID-19 Vaccine and Considerations for CMC |
February 2021 | Risks and Protections for Patients with Disabilities During the Pandemic |
February 2021 | Mental Health and Well-Being of Families and Siblings of CMC During the Pandemic |
March 2021 | COVID-19 Variants and Considerations for the Care of CMC |
March 2021 | Burnout and Secondary Traumatic Stress Among Clinicians Part 2 |
April 2021 | Disaster Preparedness for CMC: Lessons Learned from the Texas Winter Storm of 2021 |
April 2021 | Medicaid Policy Flexibilities to Support CMC and Their Families During the Pandemic |
May 2021 | Face Mask Considerations for CMC in a School Setting |
May 2021 | Best Practices for Providing Telehealth Care to CMC |
June 2021 | Screenings and Preventative Care Considerations for CMC During COVID-19 |
June 2021 | COVID-19 Vaccination for CMC |
June 2021 | AAP COVID-19 and CMC ECHO Wrap-Up Session |
Each session was presented twice; once to the CMC CoIIN cohort of learners and once to the cohort which was not affiliated with the CMC CoIIN.
The COVID-19 and CMC ECHO built on the core values of the CMC CoIIN project, which included family leaders as equal partners in all aspects of the project. As a result, a unique aspect of the COVID-19 and CMC ECHO compared with other ECHO programs was the meaningful integration of family leaders with lived experience into all aspects of the ECHO, including as faculty, highly engaged participants, case discussion presenters, and guest lecturers.
The AAP COVID-19 and CMC ECHO used a mixed-methods evaluation to assess the program. The evaluation included an integrated feedback structure that used postsession and retrospective postprogram surveys, as well as a postprogram focus group to assess the ECHO programs’ effectiveness at meeting its educational objectives. We collected quantitative and qualitative data through a retrospective postprogram survey from June 2021 to July 2021. A total of 15 individuals completed the postprogram retrospective survey.
Table 2: Demographics of Retrospective Postprogram Survey Participants
Also, after the COVID-19 and CMC ECHO concluded, we conducted semistructured focus groups at 2 different times with 15 total participants. The CMC CoIIN cohort focus group included 9 participants (professionals represented were social worker [1], pediatric providers [5], community health workers [2], and nurses [1]); all participants took part in 6 or more ECHO sessions in real time. The second focus group was the CMC non-CoIIN cohort focus group, 6 participants (professionals represented were public health workers [1], pediatric providers [4], and nurse practitioners [1]); all participants took part in 5 or more ECHO sessions in real time. All gave informed consent and there was no remuneration for the participants’ time.
Demographics of Retrospective Postprogram Survey Participants (n = 15)
. | Frequency (%) . |
---|---|
Practice setting | |
Rural (<9999 residents) | 0 (0%) |
Suburban (between 10 000–49 999 residents) | 1 (6.6%) |
Urban, not inner-city (50 000 or more residents) | 2 (13.4%) |
Urban, inner-city (50 000 or more residents) | 12 (80.0%) |
Credentials | |
Physician (MD, DO) | 11 (73.3%) |
Nurse practitioner | 3 (20.0%) |
Public health | 1 (6.7%) |
ECHO sessions attended | |
1–9 | 4 (26.7%) |
10–19 | 4 (26.7%) |
20–27 | 5 (33.3%) |
Don’t recall | 2 (13.3%) |
Number of years in practice/profession | |
≤5 | 1 (6.7%) |
6–10 | 2 (13.3%) |
11–14 | 2 (13.3%) |
≥15 | 10 (66.7%) |
Practice description | |
Multispecialty group practice | 1 (6.7%) |
Academic medical center | 6 (40.0%) |
Public health/health department | 2 (13.3%) |
Hospital-affiliated practice | 3 (20.0%) |
Other | 3 (20.0%) |
CMC CoIIN state team member | |
Yes | 3 (20.0%) |
No | 12 (80.0%) |
. | Frequency (%) . |
---|---|
Practice setting | |
Rural (<9999 residents) | 0 (0%) |
Suburban (between 10 000–49 999 residents) | 1 (6.6%) |
Urban, not inner-city (50 000 or more residents) | 2 (13.4%) |
Urban, inner-city (50 000 or more residents) | 12 (80.0%) |
Credentials | |
Physician (MD, DO) | 11 (73.3%) |
Nurse practitioner | 3 (20.0%) |
Public health | 1 (6.7%) |
ECHO sessions attended | |
1–9 | 4 (26.7%) |
10–19 | 4 (26.7%) |
20–27 | 5 (33.3%) |
Don’t recall | 2 (13.3%) |
Number of years in practice/profession | |
≤5 | 1 (6.7%) |
6–10 | 2 (13.3%) |
11–14 | 2 (13.3%) |
≥15 | 10 (66.7%) |
Practice description | |
Multispecialty group practice | 1 (6.7%) |
Academic medical center | 6 (40.0%) |
Public health/health department | 2 (13.3%) |
Hospital-affiliated practice | 3 (20.0%) |
Other | 3 (20.0%) |
CMC CoIIN state team member | |
Yes | 3 (20.0%) |
No | 12 (80.0%) |
DO, Doctor of Osteopathic Medicine; MD, Doctor of Medicine.
Focus group data were transcribed from a video recording, deidentified for confidentiality, and reviewed by AAP ECHO program evaluation staff. We used a team-based approach for iterative–inductive analysis of qualitative data involving thematic analysis of focus groups. The program evaluator on the research team read through each transcript 3 times, coding key statements. The iterative coding process involved the clustering of keywords followed by thematic analysis, whereby a search for themes that emerged in the data set occurred. The evaluator then brought preliminary thematic analysis to the rest of the team, where we discussed the significance and collaborated to reach a consensus on themes.
Table 3 : Themes Identified Through Qualitative Analysis
This study has been reviewed and determined as exempt by the institutional review board at the American Academy of Pediatrics.
Themes Identified Through Qualitative Analysis
Theme . | Subtheme . | Sample Quotes . |
---|---|---|
Knowledge Gained | Relevant and Timely Information, Value of ECHO Format, Faculty Experts, Rich Discussion | “I appreciated having different providers presenting in the ECHOs so we could hear different perspectives with different expertise. Similarly, having different people presenting the case studies provided that variety that would have been lacking if the same people presented every time. I also really appreciated an ECHO with providers, as well as people with lived experience having equal input, a rare situation to have equity practiced in real time.” “ECHO helped me be able to understand and educate the community on why it was important to wear a particular type of mask, not just a cloth mask. It helped me to understand from the community (view) of the things that everybody else on the CoIIN and the ECHOs were seeing across the country.” “I gained a lot from this, at least in terms of what I can take to my complex care team as it pertains to issues related to COVID-19 and a variety of other, just important, anecdotes that I think are picked up from these sessions that maybe can’t be found in established literature or other things along those lines. So, I found this very valuable.” “It increased my awareness in dealing with families and patients with complex medical health issues. You really had a group of experts in medically complex pediatric care, sharing about what we were seeing on the ground in terms of inequity of service delivery and needs for this group of patients.” |
Diffusion of Knowledge | Packaged Format, Dissemination to Peers and Patients, Support | “I have been able to share stories of other patients around the country with my own patients and families. This gives them a sense that they are not alone and that the issues they face are faced by many others around them.” “Another connection that we made with the ECHO about CMC was returning to in-person education options. I shared this with a group that has an NIH grant specifically about how we can have CMC return to schools safely. So, the content spread outside of the CMC CoIIN.” |
Change in Workflows | Review Policy, Planning for the future | “One of the ways in which that image is helpful, I think, is like COVID-19 just cut all the spokes off of the wheel for a lot of families and left them with just their little nuclear family hub to take care of a child…I think the discussions in this group around care team and care access certainly fostered that to take hold in our group, and we’re still working to improve it.” |
Theme . | Subtheme . | Sample Quotes . |
---|---|---|
Knowledge Gained | Relevant and Timely Information, Value of ECHO Format, Faculty Experts, Rich Discussion | “I appreciated having different providers presenting in the ECHOs so we could hear different perspectives with different expertise. Similarly, having different people presenting the case studies provided that variety that would have been lacking if the same people presented every time. I also really appreciated an ECHO with providers, as well as people with lived experience having equal input, a rare situation to have equity practiced in real time.” “ECHO helped me be able to understand and educate the community on why it was important to wear a particular type of mask, not just a cloth mask. It helped me to understand from the community (view) of the things that everybody else on the CoIIN and the ECHOs were seeing across the country.” “I gained a lot from this, at least in terms of what I can take to my complex care team as it pertains to issues related to COVID-19 and a variety of other, just important, anecdotes that I think are picked up from these sessions that maybe can’t be found in established literature or other things along those lines. So, I found this very valuable.” “It increased my awareness in dealing with families and patients with complex medical health issues. You really had a group of experts in medically complex pediatric care, sharing about what we were seeing on the ground in terms of inequity of service delivery and needs for this group of patients.” |
Diffusion of Knowledge | Packaged Format, Dissemination to Peers and Patients, Support | “I have been able to share stories of other patients around the country with my own patients and families. This gives them a sense that they are not alone and that the issues they face are faced by many others around them.” “Another connection that we made with the ECHO about CMC was returning to in-person education options. I shared this with a group that has an NIH grant specifically about how we can have CMC return to schools safely. So, the content spread outside of the CMC CoIIN.” |
Change in Workflows | Review Policy, Planning for the future | “One of the ways in which that image is helpful, I think, is like COVID-19 just cut all the spokes off of the wheel for a lot of families and left them with just their little nuclear family hub to take care of a child…I think the discussions in this group around care team and care access certainly fostered that to take hold in our group, and we’re still working to improve it.” |
NIH, National Institutes of Health.
Results
Each ECHO session brought together health care clinicians, child health experts, family leaders, and public health professionals from urban, rural, and suburban areas of the United States. The initial AAP COVID-19 and CMC ECHO hosted 311 unique attendees, from 114 organizations, with ∼24 participants per session. Participants in the retrospective survey and focus groups offered a unique perspective on the ECHO. The postprogram survey asked participants to reflect on knowledge and confidence regarding providing well-child visits and other primary care services for patients during a pandemic, both before and after the COVID-19 and CMC ECHO.
Participants self-reported statistically significant improvements across nearly all knowledge and confidence items.
Table 4 : Quantitative Analysis of Confidence and Knowledge from Retrospective Postprogram Survey
The greatest confidence gain was in integrating telehealth into longitudinal care for patients, with self-reported post-ECHO mean scores 2.21 points higher than pre-ECHO scores (z = 3.097, P = .002, n = 14). We saw a confidence gain in managing patients potentially exposed to COVID-19 who are present in the office setting, with ECHO participants self-reporting a post-ECHO mean score 1.67 points higher than pre-ECHO scores (z = 2.848, P = .004, n = 15). Additionally, we saw a confidence gain in supporting families during a public health emergency and/or natural disaster mean score of 1.47 points higher (z = 2.958, P = .003, n = 15) over the pre-ECHO score.
Quantitative Analysis of Confidence and Knowledge from Retrospective Postprogram Survey
Confidence Statementsa . | Median Pre-ECHO (Mean; SD) . | Median Post-ECHO (Mean; SD) . | n . | Zb . | P . |
---|---|---|---|---|---|
Managing patients potentially exposed to COVID-19 who are present in the office setting | 2 (2.333; 1.234) | 5 (4.125; 1.228) | 15 | 2.848c | .004 |
Understanding best practices about personal protective equipment in the care of CMC | 3 (3.467; 1.642) | 5 (4.6; 1.121) | 15 | 2.232c | .026 |
Finding resources to keep you informed on COVID-19 and its variants | 3 (3.20; 1.656) | 5 (4.40; 1.298) | 15 | 2.220c | .026 |
Supporting patients during a public health emergency and/or natural disaster | 2 (2.80; 1.474) | 5 (4.267; 1.099) | 15 | 2.825c | .005 |
Supporting families during a public health emergency and/or natural disaster | 2 (2.60; 1.404) | 5 (4.267; 1.099) | 15 | 2.825c | .005 |
Supporting colleagues during a public health emergency and/or natural disaster | 2 (2.533; 1.457) | 5 (3.8667; 1.356) | 15 | 2.958c | .003 |
Finding resources to support family education on COVID-19 | 3 (2.733; 1.387) | 5 (4.40; 1.056) | 14 | 2.694c | .007 |
Integrating telehealth into longitudinal care for patients | 1.5 (2.00; 1.302) | 5 (4.214; 1.533) | 14 | 3.097c | .002 |
Integrating virtual care coordination for patients | 2 (2.429; 1.667) | 5 (4.00; 1.579) | 14 | 2.701c | .007 |
Providing well-child visits and other primary care for patients during a pandemic | 3 (3.182; 1.952) | 5 (4.182; 2.282) | 11 | 2.041c | .041 |
Conducting developmental screenings and providing dental and mental health care and immunizations | 5 (4.091; 2.171) | 5 (4.363; 2.210) | 11 | 0.816 | .414 |
Providing strategies for implementing social determinants of health screening into the care of CMC and their families | 2.5 (3.3071; 1.726) | 5 (4.000; 1.579) | 14 | 2.392c | .017 |
Differentiating between influenza and COVID 19 in the clinical setting | 2 (2.071; 1.437) | 3 (3.356; 1.552) | 14 | 2.716c | .007 |
Knowledge statementsa | Median pre-ECHO (mean; SD) | Median post-ECHO (mean; SD) | n | Zb | P |
Understanding transmission rates and treatment options for patients related to COVID-19 | 2 (2.60; 1.242) | 4 (3.867; 1.060) | 15 | 2.840c | .005 |
Identifying strategies to obtain access to home care supports for families | 2.5 (2.571; 1.298) | 4 (3.643; 1.352) | 14 | 2.719c | .001 |
Conducting telehealth visits for CMC | 2.5 (2.214; 1.279) | 4 (3.857; 1.404) | 14 | 3.241c | .001 |
Coordinating virtual care coordination for CMC | 2 (2.214; 1.162) | 4 (3.714; 1.457) | 14 | 2.994c | .003 |
Understanding how to code efficiently and effectively for telehealth visits | 1.5 (2.071; 1.335) | 2.5 (3.286; 1.624) | 14 | 3.213c | .001 |
Applying guidelines to support shared decision-making with families of CMC returning to in-person learning | 2 (2.60; 0.986) | 4 (3.733; 0.798) | 14 | 3.354c | .001 |
Identifying/discussing practical strategies to support the mental health needs of CMC and their families in times of stress | 2 (2.533; 0.833) | 4 (3.60; 0.986) | 14 | 3.176c | .001 |
Identifying strategies to support the mental health needs of clinicians/staff | 3 (2.733; 0.9612) | 4 (3.667; 1.047) | 15 | 3.071c | .002 |
Understanding best practice guidelines in protecting and treating against influenza | 4 (3.857; 1.404) | 4 (4.286; 1.309) | 14 | 1.857 | .063 |
Understand the various authorities available to states in a PHE and examples of the modifications/waivers available under them and their significance to CMC and families | 1 (1.846; 1.242) | 2 (2.769; 1.549) | 13 | 2.414c | .016 |
Conducting developmental screenings and providing dental and mental health care and immunizations | 4 (3.727; 1.869) | 4 (4.273; 2.066) | 11 | 1.890 | .059 |
Confidence Statementsa . | Median Pre-ECHO (Mean; SD) . | Median Post-ECHO (Mean; SD) . | n . | Zb . | P . |
---|---|---|---|---|---|
Managing patients potentially exposed to COVID-19 who are present in the office setting | 2 (2.333; 1.234) | 5 (4.125; 1.228) | 15 | 2.848c | .004 |
Understanding best practices about personal protective equipment in the care of CMC | 3 (3.467; 1.642) | 5 (4.6; 1.121) | 15 | 2.232c | .026 |
Finding resources to keep you informed on COVID-19 and its variants | 3 (3.20; 1.656) | 5 (4.40; 1.298) | 15 | 2.220c | .026 |
Supporting patients during a public health emergency and/or natural disaster | 2 (2.80; 1.474) | 5 (4.267; 1.099) | 15 | 2.825c | .005 |
Supporting families during a public health emergency and/or natural disaster | 2 (2.60; 1.404) | 5 (4.267; 1.099) | 15 | 2.825c | .005 |
Supporting colleagues during a public health emergency and/or natural disaster | 2 (2.533; 1.457) | 5 (3.8667; 1.356) | 15 | 2.958c | .003 |
Finding resources to support family education on COVID-19 | 3 (2.733; 1.387) | 5 (4.40; 1.056) | 14 | 2.694c | .007 |
Integrating telehealth into longitudinal care for patients | 1.5 (2.00; 1.302) | 5 (4.214; 1.533) | 14 | 3.097c | .002 |
Integrating virtual care coordination for patients | 2 (2.429; 1.667) | 5 (4.00; 1.579) | 14 | 2.701c | .007 |
Providing well-child visits and other primary care for patients during a pandemic | 3 (3.182; 1.952) | 5 (4.182; 2.282) | 11 | 2.041c | .041 |
Conducting developmental screenings and providing dental and mental health care and immunizations | 5 (4.091; 2.171) | 5 (4.363; 2.210) | 11 | 0.816 | .414 |
Providing strategies for implementing social determinants of health screening into the care of CMC and their families | 2.5 (3.3071; 1.726) | 5 (4.000; 1.579) | 14 | 2.392c | .017 |
Differentiating between influenza and COVID 19 in the clinical setting | 2 (2.071; 1.437) | 3 (3.356; 1.552) | 14 | 2.716c | .007 |
Knowledge statementsa | Median pre-ECHO (mean; SD) | Median post-ECHO (mean; SD) | n | Zb | P |
Understanding transmission rates and treatment options for patients related to COVID-19 | 2 (2.60; 1.242) | 4 (3.867; 1.060) | 15 | 2.840c | .005 |
Identifying strategies to obtain access to home care supports for families | 2.5 (2.571; 1.298) | 4 (3.643; 1.352) | 14 | 2.719c | .001 |
Conducting telehealth visits for CMC | 2.5 (2.214; 1.279) | 4 (3.857; 1.404) | 14 | 3.241c | .001 |
Coordinating virtual care coordination for CMC | 2 (2.214; 1.162) | 4 (3.714; 1.457) | 14 | 2.994c | .003 |
Understanding how to code efficiently and effectively for telehealth visits | 1.5 (2.071; 1.335) | 2.5 (3.286; 1.624) | 14 | 3.213c | .001 |
Applying guidelines to support shared decision-making with families of CMC returning to in-person learning | 2 (2.60; 0.986) | 4 (3.733; 0.798) | 14 | 3.354c | .001 |
Identifying/discussing practical strategies to support the mental health needs of CMC and their families in times of stress | 2 (2.533; 0.833) | 4 (3.60; 0.986) | 14 | 3.176c | .001 |
Identifying strategies to support the mental health needs of clinicians/staff | 3 (2.733; 0.9612) | 4 (3.667; 1.047) | 15 | 3.071c | .002 |
Understanding best practice guidelines in protecting and treating against influenza | 4 (3.857; 1.404) | 4 (4.286; 1.309) | 14 | 1.857 | .063 |
Understand the various authorities available to states in a PHE and examples of the modifications/waivers available under them and their significance to CMC and families | 1 (1.846; 1.242) | 2 (2.769; 1.549) | 13 | 2.414c | .016 |
Conducting developmental screenings and providing dental and mental health care and immunizations | 4 (3.727; 1.869) | 4 (4.273; 2.066) | 11 | 1.890 | .059 |
PHE, public health emergency.
a 5-point Likert scale was used with the anchors to score: Very confident, 5; confident, 4; somewhat confident, 3; slightly confident, 2; not confident, 1.
b Wilcoxon signed ranks test.
c Statistically significant difference.
The greatest knowledge gain was in conducting telehealth visits for CMC with ECHO participants’ self-reported post-ECHO mean score 1.64 points higher than pre-ECHO scores (z = 3.241, P = .001, n = 14). Another important knowledge gain was in managing virtual care coordination for CMC with ECHO participants’ self-reported post-ECHO mean score of 1.5 points higher than pre-ECHO scores (z = 2.994, P = .003, n = 14). Also, understanding how to code efficiently and effectively for telehealth visits saw a significant increase of 1.21 points higher from the pre-ECHO score to post-ECHO (z = 3.213, P = .001, n = 14). Additionally, increases were noted in pre–post ECHO scores on the application of guidelines to support shared decision-making with families of CMC who were returning to in-person learning with self-reported post-ECHO mean score 1.13 points higher than pre-ECHO scores (z = 3.354, P = .001, n = 14).
Three major themes emerged from the review of the qualitative data. The first theme related to knowledge gained. Participants identified that the effectiveness of the ECHO in offering timely, up-to-date information and resources was extremely important. The second theme was the dissemination of the information or knowledge found in the ECHO. The ECHO provided participants with the most recent guidance related to COVID-19 and increased their ability to disseminate this information to other health professionals, which created a pipeline into the first theme. The final theme was that the ECHO was pivotal in initiating workflow changes within institutions to better respond to a public health emergency to support patients and family/caregivers.
Participants reported that they had gained new knowledge and skills through participation in the ECHO. This was from a combination of didactic lectures with an overview of the current guidelines that formed the starting point in the case discussions and led to the exchange of knowledge and skills among the ECHO faculty and participants in the spokes. The learning was not just limited to the ECHO sessions because participants took the didactic lecture slides and lessons learned from the discussion back to their networks, as indicated by a focus group participant: “…data on the complex pediatric population were really not viable in terms of best practices around COVID-19, to have a group of experts around the country, basically meeting to share our opinions and get pieces of advice, I think was valuable. I brought it back to our group here…”. Participants applied acquired knowledge and skills to their own patient population and reported disseminating information to policymakers and staff, as well as colleagues.
A distinct outcome of participation in the ECHO was the theme of changing workflows to improve systems or change policy. Participants felt that the combination of access to a panel of experts and being able to participate interactively made the ECHO a unique learning experience both personally and professionally, which fostered new workflows on how to address issues raised in the session. Participation in the ECHO led to emergency planning by identifying that “…we need to talk with patients to advocate for a disaster plan to modify or create a route for them to stay engaged and supported,” and “we were doing this…anyway with a longitudinal plan of care within our electronic medical record, but basically incorporating the notion of asking preemptively at wellness visits and care coordination visits about the care maps,” thus enabling providers to better support patients and their families during emergencies. Focus group participants agreed that the ECHO sessions aided in the development of or reaffirmed their actions or guidance around offering care or guidance to the wider public. This reassured participants, which increased their self-confidence and motivation to discuss testing, screening, or care during the pandemic with patients, caregivers, staff, and administrators.
Participants in the retrospective survey and focus groups offered a unique perspective on the value of the ECHO. Participants brought lessons learned from the ECHO back to their networks to support patient and staff education on self-protection against COVID-19. The ECHO supported knowledge and confidence gains in participants, enabling them to better support CMC and their families during a public health emergency.
Discussion
In this mixed-methods analysis, we found that the COVID-19 and CMC ECHO was associated with significant gains in knowledge and confidence in meeting the needs of a vulnerable population during a public health emergency. A growing body of evidence documents the educational efficacy of the ECHO model for rapid learning and the spread of reliable and accurate information.1,–3
This COVID-19 and CMC ECHO series applied several unique adaptations to the ECHO model. By expanding the learning audience beyond health professionals, including families with lived experience as faculty, advisors, participants, and presenters, expertise was heightened. At a baseline, these families are chronically marginalized and dependent on support from a variety of sectors because of the severity of their child’s health status, with these stressors amplified by the pandemic. The families were critical contributors to the multidisciplinary and interdisciplinary community which formed and grew throughout the yearlong ECHO. They joined nurses, therapists, infectious disease and mental health experts, pediatricians, public health, and Title V leaders, each contributing knowledge to be shared in the “All Teach, All Learn” model.
As well, focusing on a high-risk diverse population rather than a single condition permitted the inclusion of a broad array of clinical topics (Table 1). Additionally, with ECHO modules delivered concurrently while the pandemic and scientific understanding evolved, this yearlong series provided expert, current information on emergency management in a “just-in-time learning” format.4 Guidance by the AAP’s experience and publication on the construction of the virtual ECHO platform and participant cohorts provided essential infrastructure; having repositories of subject matter experts via both the AAP and the National Advisory Committee of the CMC COIIN project enhanced the speed of implementation and flexibility of the development of clinically relevant content and cases.
Participant data reported statistically significant knowledge gain and dissemination of new knowledge across participants, with individuals from both cohorts reporting high levels of satisfaction with the ECHO educational model (Table 3). They also reported support for improving processes and workflows during the pandemic, with particular benefits in implementing virtual care and care coordination processes via telehealth. In addition to knowledge gained, participants reported the greatest confidence gain in integrating telehealth into longitudinal care for patients. New implementation of telehealth increased acutely and dramatically during the pandemic, demanding process development, privacy protections, and patient education on this emerging modality.5 Such improvements in virtual care can have longer-term implications for the longitudinal care of CMC, addressing access, transportation, and inclusion barriers. Participants also reported a confidence gain in supporting families during a public health emergency and/or natural disaster, which highlights the value of the ECHO model in sharing strategies to meet the needs of families during a challenging time. At every level, knowledge gain and spread was valuable during the fear and uncertainty of the pandemic.
This work has limitations by its focus on the high-needs CMC population, which is small, yet increasing in number. Although narrative feedback from participants reports value from increased knowledge and information dissemination, the small number of respondents in the postsurvey is a limitation.
Implications of this ECHO series include the documented feasibility and applicability of the ECHO model for use in emergencies and the ongoing need for efficient knowledge exchange beyond the COVID-19 pandemic. Partnership with families added expertise to this ECHO series and highlighted the critical collaboration of health care systems with their community resources and patient/family colleagues. Offering virtual education and problem-solving aligns with the rapid expansion of clinical telehealth services and can be incorporated into a learning network such as this COIIN. An ECHO series could be used in advance preparation for health system crises/disasters, sharing information about a population and its diverse needs rather than singular clinical topics. Certainly, as was Dr Arora’s intent, this ECHO model “moved knowledge, not patients” as isolation became a mandate rather than a function of geography.1 Finally, this ECHO was implemented with grant funding; more information is needed on fiscally viable models of ECHO support.
On the basis of the learnings from the COVID-19 and CMC ECHO program and evaluation results, we have developed the following recommendations that have implications for systems, clinical practice, and education.
To meaningfully address systems issues, care provision for CMC should integrate collaboration across the full spectrum of the health care, social, and community-based service sectors. The ECHO, with its interdisciplinary and collaborative approach, provides a model for bringing together diverse perspectives to share strategies for addressing systems issues.6
ECHO superhubs should continue to center families/caregivers and people with lived experience at all levels of participation and leadership within the ECHOs, and adapt processes as needed toward this end. Families/caregivers should be included as compensated faculty, as well as participants, case presenters, and guest lecturers. For the CMC population in particular, family/caregiver experience was essential to understanding the impact COVID-19 had on the availability of home- and community-based services and supports widely used by families/caregivers.
The interdisciplinary ECHO model should be used as a tool for organizing practice and health systems change. In particular, the ECHO model can be used as an effective modality to improve processes and workflows within health care systems.
The ECHO revealed several systems challenges and barriers for CMC and their families during times of disaster, such as problems accessing home care supports and medical supplies. Further research should be done to identify ways in which to adequately manage and respond to future disasters to meet the needs of CMC and their families.
The ECHO model should be more widely used in the future for disaster preparedness and response, not only by the pediatric clinical care community, but also by first responder organizations such as the Emergency Medical Services for Children program in each state, Red Cross chapters, and the Federal Emergency Management Agency. In particular, the ECHO structure allows for rapid dissemination of information and knowledge sharing during times when new information arises frequently. It also allows for flexibility in discussion topics to meet the needs of participants and allow space for the discussion of emerging issues. For instance, sessions related to telehealth and vaccines provided vital information and practical strategies to ensure continuity of care for CMC and their families during the pandemic.
Mental health needs of child, family, and provider should be addressed in future ECHOs and other health care professional learning models focused on public health emergencies for CMC.
Conclusions
As our health care and delivery systems adapt in response to the COVID-19 pandemic, experience gleaned from the use of the ECHO model as an interdisciplinary, population-level disaster management education tool should be more widely applied.
Acknowledgments
We thank all of the COVID-19 and CMC ECHO faculty for their individual expertise and valued contributions, with a special thank you to Meg Fisher, MD, FAAP, for her expert guidance and unwavering support throughout the ECHO.
Ms Boothby contributed to the draft and revisions of the manuscript; Dr Lail participated as faculty for the Extension for Community Healthcare Outcomes for Children With Medical Complexity series and contributed to the draft of the manuscript; Dr Agrawal participated as faculty during the COVID-19 and Children with Medical Complexity Extension for Community Healthcare Outcomes, and contributed to the draft and revisions of the manuscript; Mr Corcoran designed the data collection instruments, coordinated data collection, conducted the initial analyses of the data, and critically reviewed and revised the manuscript; Ms Comeau contributed to the draft and revisions of the manuscript; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.
FUNDING: Supported by the Health Resources and Services Administration of the US Department of Health and Human Services under grant number UJ6MC32737: Health Care Delivery System Innovations for Children with Medical Complexity ($11 630 000 in total). This information or content and conclusions are those of the authors and should not be construed as the official position or policy of, nor should any endorsement be inferred, by the Health Resources and Services Administration, the US Department of Health and Human Services, or the US government.
CONFLICT OF INTEREST DISCLOSURES: The authors have indicated they have no conflicts of interest relevant to this article to disclose.
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