Opioids, primarily prescription pain relievers and heroin, are the main driver of overdose deaths. Opioids were involved in 28,647 deaths in 2014 and opioid overdoses have quadrupled since 2000 (CDC, 2015). In New Mexico, rates of OUDs are among the highest in the nation-- 28 of its 33 counties rank above the national average in drug overdose death rates (NM DOH, 2016). The challenge of addressing OUDs in New Mexico is exacerbated by devastating primary care shortages and the rural composition of the population with an estimated 58% of NM?s primary care needs unmet (HRSA, 2016) and majority of NM counties (27/33) designated as micropolitan, rural or frontier (Ingram, 2013). Medication-Assisted Treatment (MAT) is an evidence-based and comprehensive approach to treating OUD using FDA approved medications combined with psychosocial and community based services/supports. Despite its potential, it is vastly underutilized in primary care. For rural areas, one of the main sources of health care is the primary care clinic. Efforts to expand MAT have encountered persistent challenges. The Extensions for Community Healthcare Outcomes ECHO model provides a strong televideo-based strategy for improving practices in primary care. It combines didactic and problem-based learning and has been shown to be effective in improving treatment of Hepatitis C (Arora, 2011). The model has spread widely across a range of health outcomes including behavioral health but little is known about its effectiveness in these new arenas. In fact, a recent review of ECHO studies shows that very little has been published on the model?s efficacy or implementation outcomes (Zhou, 2016). Existing research that documents provider changes in knowledge, attitudes and self-efficacy indicates the model?s strong potential for improving practice in behavioral health (Katzman et al., 2016). Therefore, a study that implements this potentially strong model and includes a focus on implementation outcomes as well as feasibility for behavioral health is long overdue. The present study will implement the ECHO model with a minimum of 80 rural primary care providers across 80 clinics, and include additional clinic staff for comprehensive MAT team training. It will track implementation outcomes and feasibility measures with participating providers. In addition, this study will include added support, as identified/needed, for any provider that does not reach implementation benchmarks within expected timeframes. This combined approach is referred to as ECHO-F and reflects education models such as competency-based learning (US Department of Education, 2016) that provides individualized support, when needed, to help learners achieve desired learning/skills outcomes. Implementation benchmarks achieved via ECHO alone and those that require additional support will be carefully documented to understand the relative contribution of these components and describe possible areas for adaptation of the ECHO model.
Specific Aims : 1.Establish infrastructure for ECHO-F training, support and data collection Assemble advisory board; finalize, training schedule and content; data collection instruments; protocols 2.Implement ECHO-F with rural primary care providers: a. Identify & recruit primary care provider practices; minimum of 80 prescribers across 80 clinics with 160 additional clinic staff over 4 years of the study (target: 240 providers total) b. Train in MAT via ECHO model; monitor implementation benchmarks; provide individual support as needed/requested to accomplish benchmarks 3. Conduct a systematic assessment of implementation and feasibility factors: a. Describe ECHO-F participation (participants; in televideo sessions & individualized supports provided) b. inferential analysis of baseline data and ECHO-F participation related to accomplishment of implementation benchmarks. c. Final reports; adaptation of ECHO-F model; develop/submit multi-site effectiveness study of ECHO-F This study will be supported within an exceptionally research strong, rurally focused, collaborative environment. The Department of Psychiatry and Behavioral Sciences (DPBS) at the University of NM Health Sciences Center is the largest academic health complex in the state. The study PI, Julie Salvador, PhD, with DPBS has led many federally funded rural studies in rural NM, including a study of a model to improve evidence-based practice implementation and successfully recruited over 300 providers in this study. The main study partner is the Department of Family and Community Medicine (DFCM) and study co-investigator Andrew Sussman, PhD, has led many primary care-based research projects statewide and is director of a practice based research network in the state. The ECHO model was developed by Sanjeev Arora, MD at UNM who will provide guidance in the model and who has directly trained the ECHO MAT expert in this study, Snehal Bhatt, MD. William Miller, PhD, developer of Motivational Interviewing has trained study MI lead Jennifer Hettema, PhD, directly. Michael Bogenschutz, MD, will provide research consultation and is nationally known for his opioid use and substance use disorders research.

Public Health Relevance

This study examines an innovative model, ECHO-F, for supporting rural New Mexico provider?s implementation of Medication Assisted Treatment (MAT) for Opioid Use Disorders in rural, high need/low resource settings. ECHO-F combines a well-known televideo-based approach along with personalized supports to ensure providers can identify and overcome challenges in achieving mastery of MAT for OUD. ECHO-F can make major public health advances by expanding access to MAT and understanding critical and as yet unknown aspects of the model regarding its feasibility for improving behavioral health practices and implementing/sustaining MAT in rural primary care.

National Institute of Health (NIH)
Agency for Healthcare Research and Quality (AHRQ)
Research Demonstration and Dissemination Projects (R18)
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Healthcare Effectiveness and Outcomes Research (HEOR)
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Nourjah, Parivash
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University of New Mexico Health Sciences Center
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