EXECUTIVE SUMMARY
The Project Extension for Community Healthcare Outcomes (ECHO) connects multidisciplinary skilled nursing facility teams with a multidisciplinary hospital team via videoconferencing.
- The program effectively reduces patient readmissions and SNF length of stay.
- With better communication through the program, healthcare professionals can avoid miscommunication over medications, appointments, and goals of care.
- The videoconferences include a short, bullet point-style narrative that relies on key issues summarized in one or two sentences.
A new care transition program successfully improved outcomes for patients discharged to skilled nursing facilities (SNFs).
Project Extension for Community Healthcare Outcomes (ECHO) connected multidisciplinary SNF teams with a multidisciplinary team at the discharging hospital via videoconferencing. The program proved effective in reducing patient readmissions and shortening SNF length of stay.1
“Care transitions from hospital to post-acute care is particularly dangerous for older people,” says Lewis Lipsitz, MD, professor of medicine at Harvard Medical School and chief academic officer and director with the Marcus Institute for Aging Research.
Poor communication during transitions can cause miscommunication over medications, appointments, goals of care, and additional problems. “Quite a few errors are made. As a result, adverse outcomes occur when patients are transitioned from one place to another,” Lipsitz adds.
Project ECHO started in 2003 as a way to improve care of rural people with hepatitis C who could not access modern medical care for the disease, Lipsitz notes. At the University of New Mexico, Sanjeev Arora, MD, MACP, FACG, set up a video camera in the rural setting and used it to communicate with physicians at an academic health system, where hepatitis C treatment was well established.2
“We adopted that model for the care of older people with dementia, who were living in nursing homes where their physicians and nurses were relatively isolated from up-to-date geriatric information,” Lipsitz says. “We taught the caregivers how to manage dementia and behavioral problems from an academic perspective, and learned from them how our recommendations needed to be adapted to the realities of the nursing home care environment.”
Building on this positive experience, researchers at Beth Israel Deaconess Medical Center developed ECHO-Care Transitions to improve communication and reduce errors when patients were transferred from the acute care hospital to post-acute care SNFs.
“This provided a mechanism for better communication between the hospital team of clinicians, pharmacist, and case manager, and the multidisciplinary team at each SNF,” Lipsitz says. “The weekly videoconferences include brief discussions of each patient who was transferred to the participating SNF that week, including information about patients’ medications, allergies, goals of care, and care plans.”
ECHO-Care Transitions reduced hospitalization costs. “We showed in our first study that we were able to reduce patients’ length of stay in the SNF and reduce hospitalizations, amounting to a savings of about $2,600 per case discussed, compared to the healthcare costs of patients who were not discussed in ECHO sessions,” Lipsitz says.3
ECHO-Care Transitions’ hospital team includes hospitalists, pharmacists, social workers, case managers, and residents. Hospitalists, case managers, and pharmacists are the chief members.
To keep the teleconferences from dragging on too long, they are formatted as bulleted, structured discussions, he adds.
Problems Arise from Lack of Communication
When there is inadequate communication between hospitals and SNFs, problems can occur, including omitted medications or pills, such as blood thinners, that are left on a list even though they can cause drug interactions.
“That may not have been recognized and reported to the nursing home,” Lipsitz says. “Also, patients might be on the wrong dose because of renal failure, and no one recognized the issue.”
In other cases, a patient might have decided to not undergo a certain procedure or be readmitted to the hospital and asked for a do-not-hospitalize order, and the nursing home did not recognize or know that.
“Or, a patient may need a follow-up because of stitches after an operation, and no one communicated a follow-up with the surgeon,” he adds.
As a result, the patient could have stitches for a long time. “These are the problems that could be missed,” Lipsitz says.
The bullet point-style narrative in these videoconferences rely on summarizing key issues in one or two sentences, such as: “The patient had CHF [congestive heart failure]; found fluid in lungs; given a diuretic and another medication; weakened in hospital, and now needs rehab.”
“That’s an intro statement,” Lipsitz adds. “Then, we review the medications, and the pharmacist may say the patient is on XYZ and the dose should be reduced because of renal failure.”
The hospital team will recommend a particular dose and note the team reviewed the patient’s advance directives and plans of care and will say whether the patient chose to be Do Not Resuscitate and/or not to be hospitalized.
“We talk about appointments, follow-up with the surgeon in two weeks, and how the patient is doing in the nursing facility,” Lipsitz says. “The nurse may talk about how the patient can now walk 100 feet without assistance, and then we ask if there are any questions.”
During the 2020 spring surge of COVID-19, the videoconferences were suspended for two months because the nurses were overwhelmed with COVID-19 patients.
“Nobody had time to do it, and many of our nurses got sick and couldn’t [work], so there was a labor shortage,” Lipsitz says. “Everyone wanted to resume the sessions, but we had to suspend them.”
With evidence that ECHO works, the next challenge is paying for it. “We think it does save money, so the best place it can be paid for is within shared savings plans,” he says.
Any insurance plan that uses savings from healthcare efficiencies to pay for supportive care, such as case management, could fund an ECHO program.
“If there is that type of organization, it would be a no-brainer for them to support this type of activity,” Lipsitz says. “For the hospital to support it, they are banking on savings from fewer admissions and [shorter] length of stay, but it’s hard to prove to hospitals that it should be supported.”
ECHO costs about $100,000 a year, and it includes the cost of participation among all the doctors and nurses. “This is a model that makes perfect sense: Talk to each other,” he says. “People can say, ‘Why not use the telephone?’ But the video helps create a relationship.”
Through video interactions, team members build trust and relationships. “After a period of time, they get to know each other and care about each other,” Lipsitz says. “It’s a bonding experience that results in better care, and that’s the advantage of doing it as video communication.”
REFERENCES
- Junge-Maughan L, Moore A, Lipsitz L. Key strategies for improving transitions of care collaboration: Lessons from the ECHO-Care Transitions program. J Interprof Care 2021;35:633-636.
- Arora S, Thornton K, Jenkusky SM, et al. Project ECHO: Linking university specialists with rural and prison-based clinicians to improve care for people with chronic hepatitis C in New Mexico. Public Health Rep 2007;122 Suppl 2:74-77.
- Moore AB, Krupp JE, Dufour AB, et al. Improving transitions to postacute care for elderly patients using a novel video-conferencing program: ECHO-Care Transitions. Am J Med 2017;130:1199-1204.
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