ECHO for Diabetes and Multiple Chronic Conditions Study

Persons with diabetes mellitus and multiple (2+) chronic conditions (DMMC) are at increased risk of functional decline, lower quality of life, and mortality. In a state ranked among the largest, poorest, and most rural, a high proportion of the diverse residents of New Mexico (NM) belong to groups at risk for developing DMMC. Lack of access to quality healthcare is a key risk factor. Healthcare teams at Federally Qualified Health Centers (FQHCs) in medically underserved areas must have knowledge of, and be able to implement, evidence-based management guidelines to address disease complexity such as DMMC, but the healthcare teams face barriers including lack of confidence in managing complex DM and comorbid conditions and keeping up with evolving best practice guidelines. Our primary research question is whether the Project ECHO model (ECHO), a telehealth intervention for healthcare teams, can achieve significant and durable reductions in HbA1c levels relative to usual care in patients with DMMC seeking care at NM's FQHCs clinics.

Project ECHO is a "telementoring" program for remotely training healthcare teams to enable the healthcare teams to provide specialized medical care at local clinics under the ongoing mentorship of an interdisciplinary team of specialists based at academic medical centers. The ECHO model uses a combination of didactic and case-based learning to help healthcare teams, specialists, and other participants co-develop treatment plans for their patients with complex conditions. Through iterative guided practice, healthcare teams gain expertise in administering specialized medical care in primary care settings. Unlike traditional direct service or specialty consultation telehealth models, the ECHO model works on the principle of workforce multiplication, expanding access to best practice specialty healthcare by increasing healthcare team capacity to care for DMMC patients closer to their homes.

The ECHO for Diabetes and Multiple Chronic Conditions (E4DMMC) study is a cluster-randomized pragmatic trial, and will investigate the effectiveness of Project ECHO's telementoring intervention, compared to usual care practices, for optimizing the management of DMMC within vulnerable populations seeking treatment in NM FQHC clinics. E4DMMC aims to achieve, relative to the usual care arm: (1) a clinically significant ( ≥0.5%) reduction in HbA1c on average, and ≥15% reduction in rate of patients with HbA1c \> 8.5% at 18-months into-intervention; (2) significant and clinically meaningful improvements on secondary clinical outcomes for other chronic conditions (blood pressure, cholesterol level, depressive symptoms, and referrals to smoking cessation); (3) similar improvements in clinical outcomes across telehealth modalities (e.g., audio-only vs. videoconference); (4) increased adoption of clinical best practices; and (5) increased patient activation and satisfaction with care. Thus, we will evaluate outcomes at both healthcare team level and at the level of patient empaneled to the healthcare team.

Our primary patient population consists of an estimated 7000 patients with DMMC actively receiving routine care from the 20 Presbyterian Medical Services (PMS) FQHC clinics with the highest patient volume and identified through PMS EHR. This population is diverse and underserved: 45% are Hispanic/Latino, and 14% are American Indian and Alaska Native; and 48% are insured through Medicaid. Across the 20 clinics, 25-48% of these patients with DM reported an HbA1c \> 8.5%. Eleven clinics are in rural or mixed rural/urban counties, serving 55% of all patients with DMMC in this population. The median number of healthcare team members across these clinics is five, including clinicians, registered nurses, physician associates, and medical assistants.

The investigators will partner with PMS, the largest system of FQHC clinics in New Mexico to randomize 20 PMS FQHC clinics, 10 each to the ECHO intervention arm and Usual Care comparator arm. For the intervention, an ECHO program consisting of weekly videoconference sessions will mentor healthcare teams on complex care strategies for patients with DMMC, emphasizing evidence-based best practices related to common chronic conditions (e.g., diabetes, chronic kidney disease (CKD), hypertension, hyperlipidemia, and depression). The comparator will consist of clinical sites where healthcare teams are practicing usual care for DMMC patients, continuing standard practices for ensuring best practice care. Primary outcome data will be tracked for 21 months post-intervention in the ECHO intervention arm.

• Use of any tele-med modalities for patient visits [Time frame: Every encounter per EHR during 12 months baseline prior to intervention, during the study period (18 months intervention and up to 18 months follow-up for the intervention arm)]
• Hypertension [Time frame: Per encounter; per EHR during 12 months of baseline prior to intervention, during the 18 months of intervention period and up to 18 months of follow-up]
• Cholesterol [Time frame: Annual during 12 months of baseline prior to intervention, during the 18 months intervention and up to 18 months of follow-up; per EHR]
• Kidney function [Time frame: Annual during 12 months of baseline prior to intervention, during the 18 months intervention and up to 18 months of follow-up; per EHR]
• Depressive symptoms - Large version [Time frame: Per encounter; per EHR during 12 months of baseline prior to intervention, during the 18 months of intervention period and up to 18 months of follow-up]
• Depressive symptoms - Small version [Time frame: Per encounter; per EHR during 12 months of baseline prior to intervention, during the 18 months of intervention period and up to 18 months of follow-up]
• Obesity [Time frame: Per encounter; per EHR during 12 months of baseline prior to intervention, during the 18 months of intervention period and up to 18 months of follow-up]
• Receipt of appropriate exams [Time frame: Annual during 12 months of baseline prior to intervention, during the 18 months intervention and up to 18 months of follow-up; per EHR]
• Rates of prescribing DM meds in accordance with guidelines [Time frame: Per encounter during 12 months baseline prior to intervention, 18 months intervention, and up to 18 months follow-up]
• Rates of prescribing hypertension meds in accordance with guidelines [Time frame: Per encounter during 12 months baseline prior to intervention, 18 months intervention, and up to 18 months follow-up]
• Rates of prescribing CKD meds in accordance with guidelines [Time frame: Per encounter during 12 months baseline prior to intervention, 18 months intervention, and up to 18 months follow-up]
• Rates of prescribing hyperlipidemia meds in accordance with guidelines [Time frame: Per encounter during 12 months baseline prior to intervention, 18 months intervention, and up to 18 months follow-up]