Project ECHO Evaluation Report 2016/17
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Contents
Contents
Abbreviations
Introduction
Project ECHO 2015-16
Project ECHO 2016-17
Evaluation Summary
Opthalmic Services – Macular & Glaucoma
Opthalmic Services – Acute Eye
Regional Quality Improvement & Patient/Client Safety
Pain In palliative Care/Cancer Pain in Northern Ireland
Prison Healthcare SEHSCT
ICP North Respiratory Implementation Group
NI paediatric network
Nursing Home In Reach and Palliative Care
Marie Curie provision of education to Health Car Assistants
Health Visitor Support (Autism)
Dementia
Practice Based Pharmacists via GP Federations
Carers
Diabetes
Outpatient reform – Dermatology
Palliative & end of life care needs – SEHSCT
Outpatient reform – Gynaecology
Regional Child and Adolescent mental Health Services
Outpatient Reform – Cardiology
Conclusion
Appendix 1 – Hub survey monkey summary
Appendix 2 – Quotes from 2016-17 participants
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Abbreviations
AMD Age-related Macular Degeneration
DHSSPS Department of Health, Social Services and Public Safety
ECHO Extension for Community Healthcare Outcomes
GP General Practitioner
GPST GP Speciality Trainee
GPwSI GP with a special interest
HCP Healthcare Professional
HSC Health and Social Care
HSCB Health & Social Care Board
ICP Integrated Care Partnership
NH Nursing Home
NI Northern Ireland
NIH Northern Ireland Hospice
NIMDTA Northern Ireland Medical and Dental Training Agency
TYC Transforming Your Care
USA United States of America
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Introduction
Project ECHO® (Extension for Community Healthcare Outcomes) http://echo.unm.edu is a
pioneering telementoring programme which was developed in the School of Medicine at the
University of New Mexico. ECHO uses point to point video-conferencing technology
involving a central multidisciplinary specialist ‘hub’ linking remotely with ‘spokes’
(Professionals in the community with a shared interest)
Accessible education for healthcare professionals (HCPs) is essential in providing high
quality care in a rapidly evolving health care environment. This is particularly challenging
within a community context as practitioners may work in rural/isolated settings, with varied
access to educational opportunities and peer review of practice. With the constraints of
limited resources and the isolated setting in which many HCPs work, new innovative
approaches to education and mentorship that facilitate individual and collective learning
and changes in practice are required.
People need access to specialty care for their complex health conditions.
There aren't enough specialists to treat everyone who needs care, especially in rural and
underserved communities.
ECHO trains primary care clinicians to provide specialty care services. This means more
people can get the care they need
Patients get the right care, in the right place, at the right time. This improves outcomes and
reduces costs.
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ECHO uses a collaborative model of medical education and clinical support, and aims to
empower HCPs to provide better care to more people, close to where they live. Participants
in the primary care setting (at the spokes) receive evidence-based or best practice guidance
from specialists at the hub, case-based learning from peer-presentations and have
opportunity for live questions and answers. The ECHO model does not provide direct patient
care, but through training using real life cases provides front-line HCPs with the knowledge
and support to manage similar patients with complex conditions. It does this by engaging
HCPs in a sustained learning system and partnering them with specialist mentors to form a
community of practice. It is therefore different from telemedicine (Image 1), which aims to
treat patients directly. Instead it aims to ‘multiply’ knowledge through educating others to
treat more patients than could ever be directly cared for by one individual HCP. Through
ECHO there is opportunity to quickly translate new knowledge into practice, and thus
improve outcomes for patients in more remote settings.
Image 1
ECHO uses cloud based ‘Zoom’ software which is compliant with encryption standards and
which allows staff to connect with ECHO sessions using standard computers, laptops,
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tablets and hand held devices. Zoom allows for up to 100 spokes to join a single ECHO
session and does not require expensive dedicated telemedicine equipment though is
dependent on a reliable broadband connection.
Project ECHO fits well with the strategic objectives of Delivering Together and The Bengoa
Review, Systems, not Structures in terms of provision of services more locally, more
integration of care across primary and secondary care, building capacity in primary and
community care and aligns well with the establishment of ICPs, GP Federations and
opportunities for wider HSC Reform.
The Project ECHO methodology has been extensively researched and has been proven to effectively
up skill GPs to deliver hepatitis C care to an equivalent standard to that in a specialist centre in the
USA. Adoption and use of the methodology is growing on a worldwide basis. ECHO is now used
across the United States of America (USA) for 45 different disease and health conditions
including hepatitis C, diabetes, asthma, pain management and rheumatology, and has been
shown to improve patient outcomes. The impact on such outcomes, and the reduction in
waiting lists at central specialist clinics have been key in promoting its widespread uptake in
health systems which are struggling to meet the needs of patients living far from central
services. The Senate in the USA has passed a bill supporting the widespread use of ECHO
across the country.
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Project ECHO 2015-16
The Health and Social Care Board received funding of £403k from the Executive Change
Fund in 2015-16 and worked in partnership with Northern Ireland Hospice to pilot the use
of the Project ECHO® model across the HSC using a “hub” and “spoke” model in the
following 5 areas;
GP Trainees – Dermatology
Palliative Care – Nursing Homes
Optometry/Ophthalmology
Diabetes and Palliative Care
Carers.
Evaluation
The ECHO NI pilot was evaluated in line with UNM guidance by a research team within NI
Hospice not directly involved with Project ECHO. The main findings were as follows;
Two networks showed statistically significant improvements in knowledge and self-
efficacy, in keeping with the results from the initial NI ECHO pilot in community
hospice nurses
The response rates for the Diabetes and Nursing Home networks were low and
statistical analysis couldn’t be performed
Feedback from the four networks which engaged Health Care Professionals (HCPs)
showed an overall very positive view on the ECHO networks and their impact on
patient care by both the participants in the spokes and the hubs, and this was
confirmed by the focus groups
All felt it had improved the care they provided for patients, perhaps the best marker
of the networks
Carers network had some positive outcomes and many challenges with suggestions
for the way forward
Link to 2015/16 evaluation report: http://echonorthernireland.co.uk/2016/05/echo-ni-
evaluation-report/ (link will be updated when new website is live – expected January 2018)
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Project ECHO 2016-17
In 2016-17, the Project received £484k from the Transformational Fund and established 19
Project ECHO Networks in the following areas;
Optometry/Ophthalmology (Acute Eye)
Optometry/Ophthalmology (Macular and glaucoma)
Regional quality improvement & patient/Client safety
ICP North Respiratory Implementation Group (COPD)
NI Paediatric Network
Practice Based Pharmacists via GP Federations
Nursing Home IN Reach and Palliative Care
Prison Healthcare
Marie Curie education to Health Care Assistants
Dementia
Outpatient Reform - Dermatology
Pain in Palliative Care/ Cancer Pain Northern Ireland and Liverpool
Outpatient Reform - Cardiology
Diabetes
Regional Child & Adolescent Mental Health Services
Outpatient Reform - Gynaecology
Carers Support
South Eastern Trust Palliative Care
Health Visitor Support (Autism)
As requested by the Project Board, the ECHO NI Working Group developed a proposal for
the service model for Project ECHO NI going forward. In order to overcome some of the
challenges faced with running this project year in year, and to ensure both capacity to
develop new networks but also to help ensure the sustainability of the networks established
to date the working group recommended a three year plan.
The proposal was based around a model as described below;
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3 year cycle for Project ECHO NI
Year 1 Networks
New to ECHO
Clinical leadership available in establishing an ECHO Network
Network may commence on a smaller scale
Hub funding available via Project ECHO NI (if required – TBC)
Admin & IT Support available via Project ECHO NI
Basic Evaluation – Does Project ECHO model work for this clinical area?
Year 2 Networks
Progress on from Level 1
Develop the knowledge network/community of practice, involving more disciplines &
members
Clinical leadership available in developing the ECHO Network
Hub funding available via Project ECHO NI (if required – TBC)
Admin & IT Support available via Project ECHO NI
Evaluation – More robust evaluation which should be able to start to demonstrate
positive outcomes for the clinical area & patients/service users
Year 3 Networks
Progress on from level 2
Well established network and starting to really consider how to embed ECHO in their
service delivery model. i.e. building into service model, job plans, getting ready to be
self-sustainable
Clinical leadership & support in how to align to service model
Change management leadership & support available
Consideration of funding arrangements
Consideration of commissioning arrangements
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Hub funding available via Project ECHO NI (if required – TBC)
Admin & IT Support available via Project ECHO NI
Evaluation - Robust evaluation demonstrating quantitative and qualitative outcomes
for the clinical area & patients/service users. Plans will be required on how Project
ECHO will fit into new service model (Level 4)
Year 4 Networks (Project ECHO is embedded in new service model)
Knowledge network no longer managed via Project ECHO NI
Network required to maintain fidelity to the ECHO model
No hub funding available
Knowledge network will continue to use Project ECHO NI Headquarters for ECHO
sessions in terms of Project ECHO Admin & IT personnel and equipment. Hubs may
be virtual but will be centrally managed via Project ECHO NI HQ to ensure fidelity to
the UNM Model.
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Evaluation
The Evaluation of the 2017-18 Project ECHO has been compiled from the following
elements;
Knowledge Network individual evaluation reports
Each individual knowledge network was asked at the outset to complete an evaluation of
their Project to ascertain if the ECHO Methodology worked for their particular clinical area
and to help inform decisions around the future of Project ECHO in Northern Ireland. Many
of the networks completed a pre and post ECHO questionnaire and/or run a focus group.
Each network was also asked to propose how they plan to align Project ECHO to their
service delivery model further down the line.
Meetings with Network Leads
Martin Hayes (ECHO Lead HSCB) & Áine McMullan (ECHO Project Manager) met with the
majority of Knowledge Network Leads. The following headings were discussed;
1. What do you feel helped you establish your ECHO Knowledge Network and get buy
in from your spokes?
2. What do you feel worked well for your network?
3. What do you feel were the main challenges for your network?
4. What did you expect from Project ECHO and did it deliver?
5. What are your plans for moving forward with Project ECHO?
6. Was hub funding used and do you think it is required for future ECHO?
7. Do you have any suggestions for improving Project ECHO?
Survey Monkey Questionnaire
A short survey monkey was sent to all hub and spoke participants. Unfortunately the
response rate was very low from the spoke side and was therefore not representative to use
in this evaluation report. The hub survey feedback was very positive and can be seen in
appendix 1. The chart on Page 54, under the heading “Did you learn from participants at the
spokes?” demonstrates that nearly 74% of hub respondents per felt they had learnt from
spoke participants. This demonstrates that the learning from Project ECHO is not one way.
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Overall Successes
The below highlights some of the benefits reported in feedback from the 2016-17
knowledge networks.
Ability to share high level HSC Priorities & planning
Change in referrals patterns by participating Optometrists (Acute eye ECHO)
Minor Surgery biopsies now being done in participating practices as opposed to
referral to Secondary Care (Dermatology ECHO)
Integration and relationship building between Primary care & Secondary Care
Democratisation of knowledge
Practice changed as a result of knowledge and discussion shared during ECHO
session
Opportunity to upskill staff, especially in rural areas
Knowledge acquisition – flexible, time efficient and supportive manner
Evidence of growing networks of like-minded colleagues and increased
communication and understanding between primary and secondary care.
Learning for hub members in how primary care works & current challenges
A positive shared learning experience – increasing confidence and clinical decision
making
Ability to discuss issues with colleagues and hear other viewpoints – not working in
isolation
Flexibility of location
Ability to update learning with experts in an informal setting at a convenient time,
and able to ask questions directly on specific areas in a “safe space”
Ability to cascade learning to other members of practice team
Opportunity to bring a lot of GP colleagues together in a time efficient way to learn
together and improve patient care.
Discussion between GPs and consultant- improving primary/secondary care
relationships
Creating networks/communities of practice to further knowledge and then using
new skills to expand/transform service
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Welcomed the opportunity to share good practice, to discuss problematic cases and
to gain input from peers and secondary care specialists with expertise in the chosen
topic
Overall Challenges
Sort term funding
Administrative staff issues (absenteeism & performance)
Inconsistency of attendees in some networks
Difficulty in scheduling sessions to minimise time out of practice v availability of
clinical presenters
As facilitator - ensuring optimum participation of all spokes
Limited timeframe for translation of discussion and learning points into change of
practice (late starters)
Lunchtimes busy - maybe offer evenings
Issue with single handed GP’s getting time out of practice
Poor attendance at times due to staff pressures and shortages
Issue with Trust technology in outlying premises - had to buy ipads
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Suggestions/Recommendations from 2016/17 networks
Majority of networks, keen to progress to the next level
Align ECHO topics to ongoing focus of new clinical strategies
ECHO - To support movement from silo leadership to system leadership and
integration
ECHO is key enabler to deliver system change/transformation of services
Wider systems conversations required. Need to align all priorities in clinical area
How can ECHO can be integrated into job plans? Needs to be normal procedure
within practice with protected time
ECHO to support peer review & peer support
Network Lead – needs protected time to develop network
Use ECHO - To look at variation and high referrals
Most networks – One session per month
Some networks would like to consider remote hub
Some networks would like option of evening ECHO’s
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Knowledge Networks
There were 19 knowledge networks supported by Project ECHO NI in 2016-17. The
summaries below provide;
An overview of the clinical area
Key successes
Key challenges
Future Plans
Individual evaluation reports will be available to access from the ECHO NI Website when it is
operational (expected mid January). In the meantime, if you would like a copy of individual
reports, please contact Áine McMullan ([email protected]).
Training day
At the outset, each network had a training day where by all hub and spoke participants
involved in the network came together to learn about the Project ECHO Model, agree dates,
times, curriculum topics and case presenters. The training session is extremely important as
it allows the community of practice to come together and agree their agenda collectively
which contributes greatly with buy in and ownership. This is demonstrated in the feedback
from both hub and spoke participants.
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Ophthalmic Services
Ophthalmology is a high demand specialty, typically accounting for approximately 10 % of all
outpatient appointments, regionally and nationally, each year and accounts for 7.1% of all
consultant led appointments. In the Northern Ireland context, this demand is in excess of
100,000 acute care appointments annually.
Many ophthalmic conditions are age-related, and many are long-term conditions (LTC’s)
where ‘cure’ may not be possible, and management to maintain useful vision the goal.
Glaucoma and macular degeneration are such conditions. In addition to the long term or
‘chronic’ ophthalmic conditions, patients who have a sudden onset or ‘acute’ eye condition
contribute to the demand for unscheduled or emergency eyecare. Audit and pilot service
evaluation has demonstrated that many of these patients could be safely and effectively
managed by primary care optometrists. Optometrists working in the community have the
knowledge, skills and equipment to assess, triage, manage and treat many of these patients.
Developing Eyecare Partnerships: Improving the Commissioning and Provision of Eyecare
Services in Northern Ireland (DEP) is a five year plan to reform and integrate eyecare
services with twelve identified objectives. Ophthalmic Services in the Health and Social Care
Board have worked collaboratively and in partnership with key stakeholders and service
users to plan and implement changes in the eyecare pathways for patients with both ‘long
term’ and ‘acute’ eye conditions.
The Optometry / Ophthalmology ECHO Knowledge Networks had the aim of democratising
and de-monopolising medical knowledge, allowing primary care optometrists a safe space
to improve their knowledge base, and in turn helping them to better manage patients who
Present with suspect glaucoma or macular eye disease
Present with an acute eye condition
By tele-mentoring and case-sharing, ECHO will enhance the knowledge and skill in primary
care, helping to improve case-handling and referrals patterns. As the Optometry /
Ophthalmology Knowledge Networks embed into the clinical practice of both Optometry
and Ophthalmology the ECHO community of practice will be developed and strengthened.
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This will provide the foundations on which DEP can progress further service developments
in the eyecare pathways. Supported by the educational governance and communications
portals which ECHO affords, the vision of ‘shared’ care for patients with stable long term eye
conditions in the primary care setting can be realised which will help to manage demand
and facilitate the treatment of patients closer to home. In this way, optometry primary care
can be fully utilised, ensuring that each element of the ophthalmic workforce works to the
top of their licence, helping to manage demand and delivering patient-centred, local and
accessible care.
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Macular and glaucoma ECHO
Topics
Retinal Vein Occlusion
Multimodal Imaging / Differential Diagnosis
Diabetic Macular Oedema
New and emerging treatments/surgery
Vitreo-retinal interface
Investigations and Interpretation
Enhanced case finding in primary care & fields progression in monitoring
Current treatment options & systemic medications
Key Successes
Excellent attendance - 85% (average).
Positive comments from spoke Optometrists in regard to clinical knowledge gained
and learning.
Positive feedback from spoke Optometrists in regard to personal and professional
benefit of ECHO®.
Self-Efficacy – in 8 out of 9 self-efficacy questions posed to the spoke Optometrists
(pre and post-ECHO®) the average score for self-efficacy improved.
Clinical Knowledge – 67% of the spoke Optometrists achieved the same or improved
score in the clinical knowledge evaluation post-ECHO®. Mean sore for the clinical
knowledge assessment improved from 12.72 pre-ECHO® to 13.11 post-ECHO®.
Clinical Leadership - supportive of ECHO Methodology
Ability to share high level HSC Priorities & planning
Dedication of Hub team ensuring stability & building a solid community of practice
Collegiate nature of the network
Improved confidence in Primary Care to manage clinical issues
Democratisation of knowledge
Support for service transformation
Integration and relationship building between Primary Care & Secondary Care
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Key Challenges
Spokes getting time out of practice to attend - run early morning ECHO sessions to
facilitate
Ensuring optimum participation of all spokes
Future Plans
The Optometry/Ophthalmology Glaucoma & Macular ECHO® Knowledge Network has been
identified as a Level 3 ECHO® Network for the years 2017/18 and 2018/19. The Network is
well established and there is a vision and plan for how the Network and ECHO® can be
utilised in supporting ophthalmic service development and transformation in the glaucoma
and macular care pathways. Project ECHO® has afforded the opportunity to improve
learning and governance and for the building of relationships between primary and
secondary care.
The HSCB will engage and work with the Optometrists and Ophthalmologists in the Network
to develop a service specification for provision of ophthalmic ‘step-down’ care in primary
care optometry practices. ECHO® will be embedded into the service specification to provide
governance and support for the clinicians involved in co-management schemes delivering
enhanced care in the optometric primary care setting.
This ECHO knowledge network will;
Consider how ECHO can be integrated into job plans
Deliver system change/transformation of services
underpin delivering together agenda
Resource Management – Primary Care & Secondary Care - care where needed
Move from silo leadership to system leadership
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Acute Eye
Topics
Flashers & Floaters
Red Eye
Disc Disease
Sudden Sight Loss
Cornea/Contact Lens
Dry Eye
Headaches
OCT
Referrals
Current treatment options & systemic medications
Key Successes
Clinical Leadership - supportive of ECHO Methodology
Ability to share high level HSC Priorities & planning
Change in referrals by participating community optometrists
Key Challenges
Choreography - Scheduling sessions to minimise optometrist time out of practice v
availability of clinical presenters
Different clinical presenter at each session which limited the relationship and
confidence building of community of practice with hub
Future Plans
It would be anticipated that ECHO will be used in the future to support the delivery of
services by primary care optometrists involved in the acute eyecare pathway. While it
proved extremely beneficial for the participating clinicians this ECHO programme is unlikely
to continue until NI PEARS is rolled out regionally. It would be particularly useful to support
independent prescriber optometrists involved in the primary care level of the acute eyecare
pathway regionally.
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Regional Quality Improvement & Patient/Client Safety
Quality Improvement (QI) is an important enabler for the Health & Social Care (HSC) system
as it seeks to improve safety, reduce error and change the way services are delivered.
The HSC Safety Forum is a regional unit, sitting within the Public Health Agency (PHA) with a
remit to support HSC organisations in their drive for QI and safety of patients/clients – this
includes building QI capability and capacity.
The key aim of the QI ECHO is to provide staff in HSC Trusts with training in QI methodology
while at the same time supporting the development and success of current trust-based QI
projects. This includes teaching on a framework for QI such as the Model for Improvement,
using measures for improvement, PDSA cycles and understanding your system.
Topics
Where Do I Start?
Supporting Change.
Develop And Test A Change.
Moving From Testing.
Key Successes
From the feedback received, participants valued the core teaching time from the
hub. This was crucial to enable participants to learn and apply these techniques in
real time within their chosen projects.
Most participants also valued the time to discuss each other’s projects
There was also great enthusiasm for the closing event, this allowed participants to
share their stories, learn from each other and celebrate success. The addition of an
expert speaker also added to the content of the day.
The use of QI ECHO provided opportunities for HSC staff to avail of training in Quality
Improvement methodology whilst minimising disruption to clinical services as travel
was minimal.
It was evident from the feedback received and on review of the projects presented
at the showcase event that staff not only were aware of the methodologies and
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approaches but were able to apply them in the frontline setting to demonstrate
improvements in care.
Participants were able to demonstrate that through the ECHO medium they were
able to undertake a QI project. All projects certainly learnt the application of the
approaches during the lifespan of the QI ECHO. Some were only at the end of the
learning and testing phase and were about to move forward with implementation.
Others had moved at a quicker pace and were ready to spread. This would be in
keeping with our experience of running traditional face to face teaching in QI
programmes.
This approach afforded the opportunity to over 50 members of staff to take part in
this programme, sharing and discussing local QI projects through case presentations.
Moving forward it may be beneficial to theme future cohorts to allow more in-depth
discussion on subject matter.
For the didactic Hub teaching components the HSC safety Forum were able to call
upon clinical QI champions and regional staff to deliver the teaching component.
This minimises potential costs and reflects the current context of care delivery in NI
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Key Challenges
Challenges with frontline pressures taking priority.
Some challenges with the technology as some teams had not tested out the
connectivity in advance of the sessions. These were ironed out as the ECHO
progressed.
The diverse range of projects sometimes made it challenging to be able to comment
fully on subject matter.
Some negative feedback from Trust colleagues who felt this was not inclusive of QI
work already happening in Trusts
Future Plans
The HSC Safety Forum wish to be included in future ECHO programmes to continue to
promote the use of QI methodology and to support and engage with teams who are
undertaking this work. Using the QI approach is in line with the strategic direction set out in
Quality 2020, The Right Time the Right Place (Donaldson, 2014), Systems not Structures
(Bengoa, 2016) and Health and Wellbeing 2026 (DOH,2016) which all reference and
promote the use of a quality improvement tools and techniques to redesign and improve
services.
Reflecting on the experience gained through the pilot QI ECHO the lead has suggested the
network amend the programme to theme groups of similar services i.e acute, community
etc. together to boost discussion on the chosen QI projects and therefore enhance the
experience of participants. They also plan to build improved links with the established local
Trust QI programmes e.g. SQE, SQB etc. who could provide more local person to person
coaching where necessary.
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Pain in Palliative Care/ Cancer Pain Northern Ireland
Palliative Care Teams in Northern Ireland manage cancer pain and other pain in palliative
settings by a variety of means including medication, physical and psychological therapies. In
terms of interventional pain procedures, some are not performed in Northern Ireland e.g.
Cordotomies, and for others which are not readily available to patients with palliative care
needs.
Most palliative care teams in NI have a good working relationship with local acute and
chronic pain teams but there are no dedicated services for this purpose and chronic pain
teams have a limited knowledge and practical experience in managing cancer pain.
The potential of a more active palliative care pain intervention service is that patients will be
able to access more effective symptom control with a reduction in medication side effects.
This ECHO network is provided in conjunction with an established chronic pain / palliative
care interventional partnership based in the Walton Hospital Liverpool and Woodlands
Hospice
Topics
Cordotomy
Epidurals, implantables and IT lines
Chest wall pain
Spinal pain/instability
Head & neck
Pelvic pain
Upper GI Pain
Nursing Support
Challenges of Service
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Key Successes
Information to be provided
Key Challenges
Information to be provided
Future Plans
Information to be provided
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Prison Healthcare SEHSCT
Northern Ireland has three prisons Magilligan, Maghaberry and Hydebank Wood College. In
2008 The South Eastern Health and Social Care Trust (SEHSCT) started providing the
healthcare in all prison sites. There are 130 staff working throughout all healthcare
disciplines.
Project ECHO for Prison Health created an opportunity to help build a community of
practitioners providing best patient care, through sharing of best practice, Hub specialist
advice and reflective learning. By enabling a multidisciplinary group of healthcare and prison
staff to meet at each spoke, it will engender an integrated approach to patient care across
specialities and health and justice. It will also enable a combined approach and a
standardisation of best care across the three N.I. prison estates. The sessions will aim to
build expertise in front line staff, and meet the need for specialty care in the prison
population.
Multidisciplinary teams from other UK prisons acting as spokes in the ECHO project was
considered to be an innovative way to share best practice. It enabled a collective approach
to problem solving in prison healthcare and broadened the knowledge of the Northern
Ireland prison teams. This will be a platform for future collaborative research and education
and if evaluated as beneficial to patients and staff be replicated in other prison settings.
There were 67 Participants involving frontline staff, management and clinical specialists in
SEHSCT and the Northern Ireland Prison Service. Spokes included the three Northern Ireland
prisons, a team from the Criminal Justice Inspectorate Northern Ireland, HMP Whatton, a
collaboration from the Cardiff Prisons and representation from Health and Justice England.
The ECHO network set out to provide teaching on the following four themes:
1. Palliative Care
2. Blood Borne Viruses
3. Chronic Respiratory Diseases
4. Sexual Health and Harm Reduction.
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Topics
Palliative - Patient care/Pain relief pathways
Palliative - Support for patient and family/ Difficult conversations/BBVs
Transmission - myths and facts, and prevention/HIV in prisons
Medical Ethics in Custodial Health
Self Harm - Risk assessment and understanding self harm
Self Harm - SPAR Process and best practice
Self Harm - Supporting staff involved in care of self-harm
NPS - Drugs, Risk, Management
Key Successes
The interdisciplinary nature of the network, enabled a greater understanding of the
complexity of providing healthcare in prisons.
There has been reported improved collaboration by frontline health and prison staff
in patient care.
Linking with the English and Welsh Spokes brought a great challenge and sharing of
best practice between the prisons.
linking the secondary services and regional specialists to the prison healthcare team,
breaking down barriers to care
Project ECHO has been instrumental in promoting a positive culture and service
delivery in prison health.
This was the first joint education project between staff working in the prison
environment including Northern Ireland Prison discipline staff alongside South
Eastern Trust Healthcare Staff.
Improvement in interdisciplinary working, paralleled with improved understanding
of the delivery of systems.
Enriched understanding of the respective roles and responsibilities of both
organisations and opportunities to enhance joint working to improve patient
outcomes.
Enhanced team relationships, challenging silo working.
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Learning and collaborating with world renowned External Spokes.
Partnership with SEHSCT Specialist Services resulting in improved referral pathways.
Key Challenges
Rotation of staff by both health care and prison meant that there was inconsistency
of attendees
Minimal buy-in by the mental health team
Limited timeframe for translation of discussion and learning points into change of
practice
Future Plans
Both the SEHSCT and NIPS would be very keen to continue the prison pilot and link the
discussions to outcomes and improvement to patient care and align ECHO topics to ongoing
focus of prison health strategy. They would also be keen to link with other UK and Irish
prisons.
The Prison Project ECHO aims to focus on the issue of Self Harm in Custody, which is a key
patient safety issue and National priority. This will involve a committed multidisciplinary
team at each Spoke to explore and develop best practice in services.
A Revised Strategy for the Management of Self Harm has been developed by SEHSCT and
NIPS. The ECHO sessions will facilitate implementation of the strategy and complement the
core objectives of the strategy focusing on recovery, treatment and rehabilitation. The
sessions will involve input from regional specialists, people in custody and UK prisons as
external spokes.
The Joint Strategy focuses on the continuous development of the workforce and the ECHO
sessions will be instrumental in this. The service will seek to develop specific indicators and
measures to evidence improved outcomes.
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ICP North Respiratory Implementation Group
The aim of the Northern ICP respiratory group is to develop an integrated model of care for
patients with chronic obstructive pulmonary disease, incorporating early diagnosis,
enhanced community-based management and improved end of life care.
UK figures estimate that 50-70% COPD is undiagnosed with 30% cases only diagnosed at the
time of a hospital admission. Many already have severe disease at the time of diagnosis.
Conversely 25% of those with a diagnosis are wrongly diagnosed.
The rate of decline of lung function is faster in the early stages of the disease but is more
amenable to treatment so early diagnosis and evidence based treatment is essential.
To further these aims an education package suitable for all primary care practitioners, GPs,
practice nurses, community pharmacists, community respiratory team practitioners, has
been developed.
ECHO sessions are one of three components of this education package. By telementoring
and case discussion, ECHO will enhance the knowledge and skill in primary care, helping to
improve patient management and referrals patterns.
Topics
Diagnosis and early COPD
Managing Exacerbations
When to and who to refer?
Pharmacological Management of COPD
Inhaler and devices
Key information for patients
Physiotherapy and Pulmonary Rehabilitation
LTOT and NIV
Palliation
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Key Successes
To be submitted
Key Challenges
To be submitted
Future Plans
To be submitted
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NI Paediatric Network
Specialist Paediatrics are tertiary level specialities that are provided from Royal Belfast
Hospital for Sick Children (RBHSC) at the Belfast Trust for the population of Northern
Ireland. They include Paediatric Cardiology, Paediatric Neurology, Paediatric
Neurodisability, Paediatric Neurosurgery, Paediatric Endocrinology, Paediatric
Gastroenterology and others.
These services look after the sickest, most complex children in Northern Ireland. However,
given the small paediatric population in Northern Ireland and the distribution of children,
there is a need to make sure children can receive services as close to home as possible.
The other four Trusts in Northern Ireland all have paediatric services, including inpatient
units. The strategy for specialist paediatrics in Northern Ireland is to develop strong, high
quality, sustainable specialist services in Belfast which, as well as managing patients in
Belfast will support the management of children closer to home in partnership with local
paediatricians.
The aim of this network is to support DGHs providing paediatric care to develop the capacity
to safely and effectively treat complex diseases closer to family’s homes in Northern Ireland.
Topics
Low Cell Counts
Management of Abnormal Puberty
Surgical Feeding Devices
Management to Tone
Interpreting Sleep Studies
Syncope
Funny Shaped Heads
Hypoglycaemia
Challenging Nephrotic Syndrome
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Key Successes
The Project Echo for Specialist Paediatrics was very well received and attended by
both the tertiary service consultant staff providing educational sessions and the
district general hospital consultants providing cases to discuss.
Knowledge of referral pathways and criteria including when to refer has improved
amongst district general hospital consultants and equally learning about suggested
improvements for the tertiary level consultants has improved the patent/referral
pathway.
Another aspect that has improved through Project Echo is the relationships and
communication between clinical teams in both paediatric tertiary and secondary
care.
Key Challenges
One aspect of the year 1 Project Echo which didn’t deliver as planned was the
administration support. We would hope this could be better in year 2.
Paediatrics staff in the Belfast Trust were not aware the ECHO Network was
happening and would have liked to be involved. Better publicity can be addressed
next phase.
Future Plans
Year one of Project Echo included sessions for 10 different tertiary level services each
delivering one session. In year 2 the network would like to expand the number of sessions
delivered by a single speciality by 3 or 4. This would means that three specific specialities
such as cardiology, rheumatology and gastroenterology can deliver 3 or 4 sessions each to
provide more depth in learning.
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Nursing Home IN Reach and Palliative Care
The key aim of the Nursing Homes In-Reach initiative is to build skills and knowledge
of nursing home registrant staff to maintain their residents in their care home safely for as
long as possible and thereby improve the resident experience. Objectives are to reduce
unnecessary ED attendances and to reduce length of hospital stay. A further objective
is that nursing home staff will feel empowered to access relevant Trust services
appropriately and to become an effective connected learning community.The Nursing Home
ECHO supports nursing home staff throughout Northern Ireland to improve their knowledge
and skill in the care and management of patients with a wide range of healthcare
needs. Issues such as renal failure, palliative and end of life care, drug management, and
heart failure are discussed with a team of multi-disciplinary professionals.
Topics
QI
Medicine
Behaviour
GP
Falls
Nutrition
Delirium
Relatives
Consent
Young Resident
Key Successes
Practice changed as a result of tips and solutions shared during ECHO
Attributes Framework was opened up for this ECHO
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Key Challenges
Problems with NH engagement
E-mail contact wasn’t necessarily the right person
Focus Group - only 2 out of 30 attended
Late changes to schedule
Admin issue
Few completed survey monkey
Conflict at outset - in terms of agenda and curriculum
Future Plans - To be submitted
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Marie Curie provision of education to Health Care Assistants
The Marie Curie ECHO network was initially designed to upskill independent domiciliary care
staff to enable them to competently adopt palliative and end of life care. By using video
conferencing facility the network planned to address some of the issues faced by the
independent sector with regards to staff attrition rates and inability to release staff to
attend training.
The aim was to increase participants’ knowledge, skills and change attitudes with regards to
the 5 key domains in palliative care:
1. Overarching Values and Knowledge
2. Communication Skills
3. Assessment and Care Planning
4. Symptom management, maintaining comfort and wellbeing
5. Advance care planning.
The programme was originally intended for Domiciliary Care providers but following much
engagement it was realised that the uptake would not be sufficient to continue with this
cohort. The reasons given for the poor uptake were mainly issues around lack of backfill.
It was then decided to roll the ECHO programme out to Health Care assistant staff currently
working within Marie Curie. This was successful as staff within Marie Curie had recently
been issued with tablets and could link into the Echo sessions from their own homes.
Topics
Non Malignant Disease – MND Case Study
Practicalities of End-of-Life Care and Recognising Dying
Difficult Symptoms in Palliative Care - restlessness/insomnia/breathlessness/pain
Common Medications used in Palliative Care
Social Issues (Isolation/Complex Family) and Self Care
Communication - difficult conversations and planning for end of life care, ACP etc.
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Key Successes
The Echo programme met with staff expectations despite there being initial concerns
regarding the use of IT.
Key findings were that staff enjoyed the sessions and learnt to participate well as the
sessions progressed. The staff had for the first time used both Echo and Zoom and
appeared to manage this well, gaining greater confidence as the sessions
progressed.
All staff evaluated the programme positively and agreed that should an opportunity
arise again that they would be interested in taking part.
The evaluation confirmed that all key learning outcomes had been achieved.
Key Challenges
Releasing staff to participate in ECHO
Future Plans
To roll the ECHO Project out to registered nurse staff group who could also benefit from this
programme. The roll out to registered nurses would happen in much the same way as it did
with the Health Care Assistant project. This would be a progression from level 1 developing
the knowledge network/community of practice, involving more disciplines and new
members.
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Autism/Health Visitor
Increased awareness and recently launched NICE Guidelines on ADHD and Autism have
resulted in increased numbers of younger children being referred to assessment and
intervention services across BHSCT related to children’s Developmental, Emotional,
Behavioural and Social Communication needs.
This has overwhelmed the capacity of these services to deliver this care in a timely way.
After some audit of referrals and pilot of Project Echo in 2016/17 we have found that the
health visiting team have benefited from educational presentations from the specialist team
involved in this work (Paediatricians, Psychologists, Occupational Therapists, Speech and
Language Therapists and CAMHS Practitioners) and from formal, structured discussion of
challenging cases on the Health Visitors Caseload.
This encourages learning across the health visiting and specialist team and provides the
opportunity for early intervention and timely consultation in a tiered way. This facilitates
improved access to appropriate levels of care according to needs.
At the training day, it was felt that this knowledge network was not in a position to proceed
as initially intended and it was felt that the appropriate people who could commit and sign
up to a regional Project ECHO for Autism were not necessarily those attending the training
day. As the overall Project was nearing completion, BHSCT decided that they would give
ECHO a go for Belfast Trust HCP’s with the view to involving more Trusts in future years if
the Project was to continue.
Topics
The Path to here
Speech, Language & Communication Development in the Preschool Child
Sensory Processing
Attachment Theory
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Key Successes
The Project Echo for BHSCT Health Visitors was very well received and attended
by both the Specialist staff (Paediatricians, Psychologists, Occupational
Therapists, Speech and Language Therapists and CAMHS Practitioners) providing
educational sessions and the BHSCT Health Visitors providing cases to discuss.
Knowledge of referral pathways and criteria including what can be achieved with
local intervention and when to refer has improved amongst Health Visitors and
equally learning about suggested improvements for the Specialist teams has
improved the patent/referral pathway.
Another aspect that has improved through Project Echo is the relationships and
communication between the respective clinical teams.
Key Challenges
One aspect of the year 1 Project Echo which didn’t deliver as planned was the
administration support.
Future Plans
Year one of Project Echo included a very limited number of sessions as the original Project
Echo suggested couldn’t be agreed with the main stakeholders. Following some pilot
sessions in year 1 it was found to be a very helpful model for delivering and sharing this
knowledge. In year 2 this network would like to expand the number of sessions delivered to
10 per year (once monthly except July and August).
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Dementia
The new Stepped Care Framework to govern the delivery of Dementia Services has recently
been published. The new model aims to integrate the roles of Primary Care and Secondary
Care (Memory Clinics) in both the diagnosis and follow on care for people with Dementia.
Currently the majority of dementia diagnoses are made by Consultant Psycho-Geriatricians
with follow on care being provided by a combination of Consultants and Specialist Nursing.
The new model aims to enhance the role of General Practitioners and Nursing in the
Assessment, Diagnosis and following on care for older people with Mild Cognitive
Impairment/Early Stage Non-Complicated Dementia.
To achieve this objective the ECHO model will assist in capacity building, knowledge
transfer, and through the provision of outreach expertise from Consultant Psycho-
Geriatrician/Geriatrician they will provide the necessary clinical governance both in
formulation of diagnoses and in management of pharmacological interventions.
Topics
Diagnosis/ Awareness
Dementia Subtypes & Early Onset
Medication
Capacity/Driving/Risk
Community/Carers/Support
Behavioural Issues
Homebased Rehabilitation/Quality
Communicating with PWD
End of Life
Key Successes
Qualitative comments received from participants indicates that the initial project
supported integrated practice between primary care, secondary care and third
sector providers as well as being an excellent platform for knowledge exchange.
There was some evidence that GPs greatly valued the opportunities to seek advice
40 | P a g e
on patient management with secondary care consultant old age psychiatrists and
that the provision of on-going clinics utilising the ECHO technology would enhance
their confidence in carrying out further assessments with a view to diagnosis for the
non- complex patient group.
The initial project supported multi-directional professional development and
learning as was the intention with learning across the hub, across the spoke teams
and between hub and spoke teams. The position afforded by primary care
particularly community pharmacists to flag up the initial concerns about patients
was recognised as invaluable to early intervention and good patient management.
The initial project saw high levels of engagement between participants with the
educational presentations and case presentations proving very beneficial to
increased dialogue and learning. The project also provided the opportunity to learn
of new initiatives in various areas in regard to dementia as well as useful practical
tips to employ with patients, families and carers.
The project allowed participants to appreciate the issues and constraints faced by
colleagues in a different work environment or sector.
Participants became comfortable very easily with the zoom technology and saw the
great benefits it can bring, mainly the ability to link up without the need to travel
and the time and cost savings therein.
Key Challenges
Some hub members suggested they would prefer to join remotely as opposed to
travelling to Belfast
The number of hub participants was on most occasions was higher than the number
of spoke participants
It was felt by some participants that this forum wasn’t always appropriate for the
patient representative who participated
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Future Plans
The eHealth and Data Analytics programme seeks to support through ECHO capacity
building in primary care to enable earlier diagnosis and provision of appropriate support to
those with dementia. The specific target within the programme is that by June 2019, 42
health and social care staff will be trained per year, for two years with 10 GP practices and
will deploy the Project ECHO approach, reducing waiting times for memory clinics and
speeding up diagnosis within primary care.
In addition ECHO has significant potential to enhance dementia care within nursing and
residential care settings as it provides an easily accessible multidisciplinary platform for staff
and service users to increase their knowledge and skills whilst providing an integrated
service.
Some of the Trusts have indicated they would like to run their own local ECHO Networks as
they feel advice would be more meaningful if localised to the services and service provision
from the Trust in the area of the spoke members. The plan for a future Dementia ECHO is
therefore still under consideration.
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Practice Based Pharmacists via GP Federations
DHSSPS has agreed that Practice Based Pharmacists will be placed within each GP practice in
NI via a sub-contract arrangement with GP Federations.
Practice Based Pharmacists (PBPs) will work as a team across all practices within each GP
Federation. The PBPs will deliver direct patient care within parameters defined by their job
descriptions and the individual practice within which they work.
They will work with the wider practice team to improve the safety and quality of prescribing
by focusing on the following areas:
management of prescribing systems within the GP practice
outcome focused face to face medication review
medicines reconciliation as patients transition from care settings
NI Formulary implementation, in particular to improve antimicrobial prescribing
reduce prescribing expenditure
reduce variation in prescribing practice
Through case discussions, team members will develop a greater awareness of the
knowledge, skills and experience that exists within the team. It is hoped that the medical
and nursing participants in the hub and spokes will also learn from the pharmaceutical
expertise of the PBPs and this in turn will lead to safer and more rational prescribing by
other healthcare professionals.
Topics
Diet and Nutrition
Medicines and Medication Management
Carers Support – Benefits and Finance
Planning for the Future
Self-care – Health & Well-Being
Equipment & Manual Handling
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Signposting and Support
Life after Caring
Key Successes
The pre and post ECHO session self-efficacy assessment demonstrated that there has
been significant improvement in confidence levels in carrying out the key tasks
expected of a PBP as well as their understanding of the processes and procedures
that they will be managing. This is a substantial outcome given that the majority of
the PBPs coming into post had had no previous experience of working in this area of
pharmacy and it was necessary for them to gain this confidence and insight
reasonably quickly to demonstrate the value they can bring to the multidisciplinary
practice team.
The ECHO model allowed the PBPs collectively to hear their colleagues describe the
work they are carrying out, the constraints they are managing and overcoming and
the successes that have been possible. This has proven to have had huge benefits in
allowing the PBP to learn from relate to the experiences of other pharmacists
carrying out the same function.
Key Challenges
No challenges identified
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Future Plans
There has been significant learning from the sessions that have been run to date and we
would welcome the opportunity to build upon this experience and feedback from
participants – there is now a better understanding of the huge benefits of the ECHO model
and how the curriculum could be shaped to address the learning needs of the group
Our PBP Knowledge Network participated in ECHO sessions at a time when the PBP project
was at a very early stage of implementation and development. We now have a much better
view of the project and the learning needs and so we would have a different approach to
curriculum setting. Some topics are better suited to an ECHO session eg therapeutics,
specific drug groups where the learning for other topics such as processes may be better
dealt with in another way. In addition, we have found that there is greater benefit when the
topic is more specific eg ‘Use of analgesics in the treatment of nerve pain’ rather than ‘Pain’.
We are now better placed to develop a clear progression of learning for some topics as
needs of the PBP group develop due to their emerging role in GP practices.
All participants have benefitted from presenting cases and hearing the discussions that
follow. There is some developmental work required in improving presentation skills and also
how to choose a case that is appropriate for the session – some cases were beyond the
scope of the session and had limited applicability.
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Carers
This ECHO network aims to provide support to carers of people with palliative and end of
life care needs and who are availing of specialist care services. Over the course of the
programme, participants were offered advice on a range of subjects such as nutrition and
diet, medication, self-care, and managing stress.
Topics
Diet and Nutrition
Medicines and Medication Management
Carers Support – Benefits and Finance
Planning for the Future
Self-care – Health & Well-Being
Equipment & Manual Handling
Signposting and Support
Life after Caring
Key Successes
Provided a positive shared learning experience
Provided a positive support network among carers
Enabled carers to cascade learning to others (families and other carers)
Being able to link from home was deemed very beneficial
Moodle site was very useful, and it was helpful to have presentations and
resources to refer to if they missed a session or need to refresh an aspect.
Good and robust infrastructure
Positive shared learning experience
ECHO proved a positive support network
Hub and spoke members both reported they were able to cascade the new
knowledge to others
Moodle site provided added valued if a sessions was missed or to access information
at a later time when needed.
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As carers were able to link from home it enabled them to participant in this
programme
Potential to expand and add new specialised subjects relating to specific conditions
eg Parkinson’s
Consensus from hub and spokes to have another Carer Support ECHO
Key Challenges
Availability of spoke participants due to their caring commitments
Future Plans
This network would like to expand and add new specialised subjects relating to specific
conditions e.g Autism /Parkinson’s etc. The Network would also like to Involve more carers
(new) by potentially linking individuals and existing support groups together via ECHO.
During Carer Support ECHO the ability for the carers to link via zoom from their own home,
feel comfortable to leave the session if they needed to provide care and the option to
review the session, presentations and information are some of the key factors which makes
the ECHO model a feasible model to support carers across the region.
The network will consider moving to more case presentations from carers as their
confidence has grown in learning in the ‘ECHO safe space’.
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Diabetes
The Diabetes ECHO network trains and supports primary care providers to improve their
knowledge of and skill in the care and management of patients with diabetes. Issues such as
diagnosis, appropriate use of Type 2 agents, use of insulin, and management of diabetes at
end of life are discussed on a weekly basis in a community of practice with a team of
experts.
Topics
Therapeutics
Starting insulin
Sick days
Diabetes & Driving
ED
How to run a clinic
Key Successes
Information to be provided
Key Challenges
Information to be provided
Future Plans
Information to be provided
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Outpatient Reform – Dermatology
This network is aimed at GPs to build Dermatology capacity and skills within their own
practices. The service model has already developed an accredited training package to
support GPs, increase capability and ensure good clinical governance across the service.
Project ECHO will promote an active learning environment ensuring the transfer of
knowledge across three LCG areas to establish a GP community of expertise and promote
greater networks between Primary and Secondary Care.
The service model is predicated on peer review between participating GPs but in particular
within practices to ensure the safe management of patients with dermatological conditions
in a sustainable way.
Topics
Actinic Keratoses
Genital Dermatology
Urticaria
Systemic Illness
Alopecia
Eczema
Paediatric Conditions
Psoriasis
Facial Rashes, e.g. Acne
Key Successes
Relationship building across PC & SC
Recordings - invaluable educational resource
Has created demands from others wanting to be involved
Safe space is so important
**MS biopsies are now being done in practice as opposed to referral to Primary Care
Educational benefit to the GP’s involved.
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Opportunity to enhance relationships between primary and secondary care.
Case based discussions very useful programme with clinicians sharing experiences in
both primary and secondary care
Opportunities to ask clinical questions and prevent unnecessary referrals
Multidisciplinary involvement with pharmacist.
It was very useful to know you were meeting regularly with a team of interested
doctors and this actually saved a number of referrals and created more appropriate
referrals as we were able to discuss cases which we had seen in practice with
consultants in dermatology. This is very difficult to do normally due to difficulty in
communication across the primary secondary care interface and work load
pressures.
People got to know each other and this aided an understanding of the pressures and
constraints affecting our daily work on both sides of the interface
Key Challenges
Lunchtimes busy - maybe offer evenings
issue with single handers
Got the really interested GP's in this cohort
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Future Plans
The Dermatology Network would like to continue on their ECHO journey with both existing
spokes and also a new cohort of interested GP’s, on a monthly basis. It has been suggested
that the hub could maybe be a remote Hub, supported centrally by the ECHO Team. It is felt
that Project ECHO needs to be normal procedure within practice with protected time.
It is important that we enable these GP’s who may feel challenged by dermatology cases to
participate in more basic training whilst allowing others more experienced to continue their
personal development at a more advanced level. Part of this would include training in
dermoscopy, this would lend itself beautifully to this technology and feed into the photo
triage pathway. Practices could identify GPs (champions) who would be responsible in that
practice for dermatology who could attend ECHO and then cascade the educational
information to the remaining practice team. The Network may consider looking at variation
and referral with GP Federations.
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Palliative and end of life care needs - SE Trust
Community nursing teams working within primary care in The South Eastern Health and
Social Care Trust provide care and support for patients and families who have complex
palliative and end of life care needs The Community Palliative Care ECHO project was
introduced as a pilot project to develop a knowledge network for those community teams
working in rural areas. This knowledge network aimed to improve the participants’ skills
and knowledge by encouraging a culture of shared learning. It also sought to support staff
regarding decision-making, both from a clinical aspect (improve confidence in professional
discussions and symptom management) and from a social care stance (issues regarding the
provision of care).
The SET community palliative care echo project consisted of a hub and 6 spokes. The 6
spokes were district nursing teams from the rural areas of the SET.
Topics
Communication and Supportive Services
Complex Pain Management
Advanced Care Planning
Ethical at the end of life
Dementia and palliative care
End Stage Heart Failure and palliative care
Key Successes
The planning afternoon was very beneficial as the district nurses were able to discuss
and plan the format and topics for the six sessions. This created enthusiasm and
gave the nurses ownership of the programme.
Opportunity to upskill staff, especially in rural areas
For staff to hear they done the best they could at a patients end of life
Networking and sharing of best practice across the Trust
Safe learning space
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**Changed practice - eg use of pain chart following advice of Palliative Consultant
Echo provided an excellent way of networking and strengthening relationships
between community nursing teams across the Trust
Participants gained new knowledge and planned to put their learning into practice
Knowledge regarding chronic life limiting conditions improved
After initial anxiety surrounding the ECHO technology and this new learning
environment the participants became more confident about discussing case studies.
Key Challenges
Poor attendance at times due to staff shortages
Issue with Trust technology in outlying preises - had to buy ipads
Future Plans
Involve more DN Teams (52 in total) & more GP's
Consider virtual hub
Better manage DN Workload so they can be released (wider Trust Support)
Link to QI Agenda
The next stage of SET Project ECHO will be:-
Hold monthly sessions
Continue to encourage exchange of knowledge and learning through presentations
and case discussions
Continue to strengthen relationships between district nursing and Health and Social
Care
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Outpatient Reform – Gynaecology
Integrated Care Partnerships (ICPs) are currently developing service reform proposals for a
number of elective care specialties, one of which is Gynaecology. The service reform
proposals will focus on two main areas; the management of demand from primary care for
the use of secondary care services, and delivering new models of care within and across
providers.
The Gynaecology network aims to support doctors and increase knowledge on a range of
topics such as Menopause, Urinary Incontinence and Pelvic Pain.
Topics
Menorrhagia
HRT / Menopause
IUCD / LARC
Pelvic Pain/Dysmen/ Psychosexual
Urinary Incontinence/ Prolapse
Discharge/IMB/PCB
Red Flags
PCOS/Amennorrhoea/Fertility
Vulval Skin
Key Successes
Evidence of specific learning noted in all sessions with cascading of knowledge to
colleagues in practice.
This knowledge acquisition took place in a flexible time efficient and supportive
manner.
Evidence of growing networks of like-minded colleagues and increased
communication and understanding between primary and secondary care.
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Welcomed the opportunity to share good practice, to discuss problematic cases and
to gain input from peers and secondary care specialists with expertise in the chosen
topic
Spokes welcoming the discussion, networking and peer support.
were encouraged by others good practice and the ability to benchmark their
knowledge and practice against peers and specialists alike
In summary, there was evidence of specific learning noted in all sessions with
cascading of knowledge to colleagues in practice. It encompassed peer review and
specialist input. While it occurred there was evidence of growing networks of like-
minded colleagues and increased communication and understanding between
primary and secondary care.
Learning through ECHO has enhanced the skills and knowledge of those GPs who
joined as spokes and many of this cohort have expressed an interest in providing the
additional service capacity that is required within primary care gynaecology.
An important part of any network is cascade of knowledge and as evidence by
feedback the gynaecology ECHO spokes have noted such cascade at their own
practice level.
Key Challenges
There were only a minor number of negative comments largely pertaining to one
particular presentation which was felt to be too simplistic and not covering one
aspect of the agreed topic,
A few technical difficulties that some of the spokes had connecting at practice level
e.g. lack of Wi-Fi.
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Future Plans
The spokes also noted new areas for future ECHO sessions as well as suggesting some
further topics for gynaecology. These new ideas included neurology, paediatrics / childhood
behavioural problems and dermatology.
Elective care reform in gynaecology will involve the creation of increased capacity in primary
care to deal with common gynaecological conditions in primary care. It will improve the
patient journey and result in a reduction in referrals into secondary care for these common
conditions. It will enhance knowledge through a process of peer support and education at
practice level.
In order to grow this capacity, there will be a need for general practitioners with enhanced
skills in primary care gynaecology. It is envisaged that such practitioners shall manage
women with common gynaecological conditions (3 areas specifically).
The use of a phase two ECHO to further support the GPs with enhanced gynaecology skills,
who will be providing the enhanced capacity within primary care that would prove a more
effective use of this resource.
It is recognised that those service providers will required ongoing support and training in
order to deliver a safe effective and high quality service to our patients.
Within phase two it is hoped to build on the network from phase one. Participants had
hoped to cover further clinical areas relating to primary care gynaecology.
The phase two ECHO will also further support the GPs with enhanced gynaecology skills,
who will be providing the enhanced capacity within primary care.
These GPs have already experienced the benefits of peer support, networks and have
started to build improved primary / secondary care relations and communication. Such
relationships could enhance support for these GPs as they embark upon the new service
provision, providing support / mentoring and further learning in what has already been
established as a very positive learning environment.
Plan to build knowledge network to include participants from all three areas involved in
gynae elective care reform.
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Regional Child & Adolescent Mental Health Services
CAMHS services across the region have been engaged in the implementation of the DHSSPS
guidance, the Stepped Care Model, as the service model for CAMHS. An independent
external evaluation of Acute CAMHS highlighted the need to strengthen care, discharge,
transition, planning and delivery in acute care through the adoption of more standardised
approaches.
The CAMHS ECHO network aims to improve consistency in practice across all CAMHS service
provision, Primary Care, wider children services and other key service interfaces such as
secure care, forensic care and Youth Justice.
ECHO will enable the effective assessment and appropriate intervention in respect of young
people presenting with complex and high risk behaviour, particular at a local practitioner
level.
Topics
Self Harm and Suicide Ideation
Challenges of Home Treatment
Managing transitions into adult services
Drugs, Alcohol and Co-morbidities
Promoting Family and Staff Resilience in the face of Risk
Managing Mental Health needs in the Justice System
Risk Management in the looked after population
Managing clients with eating disorders
Managing Gender Identity issues
Key Successes
The CAMHS ECHO Project delivered a total of 7 sessions in line with the original
programme (2 sessions proved unable to be scheduled)
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A total of 21 CAMHS clinicians from all Trusts signed up originally to participate in
the sessions which were scheduled to run weekly through late January – March
2017.
Responses overall in terms of participation were inconsistent as clinicians were
unable to make a consistent weekly commitment. This meant that discussion was
more limited and the networking opportunities reduced.
A very limited response was also provided to the evaluation of the project although
the returns forwarded were very positive and in particular in relation to outcomes
relating to improved partnership working and improvement to knowledge of
responses and interventions to children and young people presenting with complex
mental health and social needs.
Feedback and responses to individual sessions also highlighted helping to improve
practice.
Key Challenges
Poor attendance at times
Future Plans
The plan is to build on the project as conducted to date, identifying a pool of 3 Facilitator’s
and target and secure commitment from CAMHS staff, especially working in acute CAMHS
and staff from other key interface provision.
It would be planned to deliver the outstanding sessions from the original programme and to
identify a new programme around the delivery of monthly sessions which should secure a
more realistic commitment in line with CAMHS’ staff capacity.
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Outpatient Reform – Cardiology
Cardiovascular disease remains a major cause of death in Northern Ireland. With the
improvement in survival after myocardial infarction and an ageing population the incidence
of heart failure and atrial fibrillation are rising by around 3% per year. The presenting
symptoms of these conditions are breathlessness and palpitations and early identification of
patients with these conditions is vital to improve prognosis and avoid hospitalisation.
An audit of referrals from GP’s to cardiology demonstrated that 41% of referrals consist of
palpitations, suspected heart failure and atrial fibrillation.
The network is aimed at GP’s and aims to:
Increase effectiveness of primary assessment, including symptoms to look out for and
investigations to carry out
Improve the interface between primary and secondary care, defining referral criteria
Facilitate the management of stable long term heart conditions in community clinics or
enhanced primary care
Topics
Atrial Fibrillation
Palpitations
Heart Failure
Chest Pain
Inherited Cardiac Disease
Syncope / Faints and Funny Turns
Hypertension
Assessing Risk
Anticoagulation
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Key Successes
GP feedback very positive
Learning for hub members in how primary care works
Hospital Pharmacy found very beneficial
Learning experience for Hub secondary care members in how primary care works.
GPs reported very positive feedback with heightened knowledge and confidence to
care for patients in the community where possible.
Project Echo setup/structure of programme was very well developed but should be
executed regionally (was only SE and Belfast involved).
Need for dedicated admin team.
Open membership to pharmacists and other healthcare professionals.
Some tension between participants because of the different pathways in Belfast and
SE.
Please see appendix 2 for full cardiology project echo evaluation report.
Key Challenges
Admin & organisational side
ore recordings and resources for longerNeed archive to st
Some tensions as different patheays and services in different Trust areas
Day and time not ideal for Trust Clinicians but suited GP's
Future Plans
To develop a Level 2 Network to further develop primary care pathways for patients
presenting with cardiac sounding symptoms in addition to those with stable chronic cardiac
conditions. This may involve a number of GP’s already a part of the initial cardiology ECHO
network and invitation to new members. Recently a number of GP practices in BHSCT and
SET have requested funding to buy ambulatory ECG monitors. In conjunction with this
development of a primary care palpitation pathway is required. Continuation of Project
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ECHO could invite those practices who have acquired ECG monitors to join or the cardiology
ECHO network and jointly develop pathways of care for palpitations and other cardiac
conditions such as heart failure and atrial fibrillation. The aim would be to develop and
embed these pathways into clinical practice with measurement of impact on patient
experience, clinical outcomes and impact on referrals to secondary care. The Level 2
Network could also include basic ECG interpretation required for a palpitation pathway and
for diagnosis and treatment of atrial fibrillation etc. and provide a forum for mutual support
during implementation.
In addition to heart failure and AF, further areas or consideration are hypertension, angina,
sudden cardiac death – sports cardiology, preventative strategies, risk and shared decision
making.
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Conclusion
In the pilot phase of Project ECHO (2015-16), the main objectives of the evaluation were to
ascertain if Project ECHO worked in Northern Ireland and to measure an increase in
knowledge and self-confidence of HCP’s involved in the Project. You can see from the
information summarised above for each knowledge network that using Project ECHO
…is increasing knowledge
…is breaking down barriers
…is increasing HCP knowledge and self confidence
…is changing practice
This is evident from every ECHO session that takes place but is often difficult to measure
and report on. Although the feedback is very positive, most of the outcomes are qualitative
at this point in time. It is anticipated that we use a logic model with Knowledge Networks in
2017-18 and beyond. Each individual ECHO will discuss and describe their own evaluation
logic model and current units of measurement to include;
a. Objectives: ‘outcome and impact to measure and report on’ b. Inputs and activities: ‘counting and recording the things we do and with
whom’ c. Outputs: ‘the things produced from our ECHO’ d. Outcomes: ‘The immediate difference our ECHO has made’ e. Impact: ‘The longer-term difference our ECHO made/will make or the real
world change our ECHO is trying to impact’ f. Units of measurement: ‘what to measure and document to determine
whether progress is being made or achieved’
Network Leads will require guidance and support to evaluate their ECHO in this way.
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Key Learning
Buy in
Importance of initial training day with facilitator who understands the clinical areas
and challenges faced
Importance of hub and spoke participation at training day to set the cirriculum and
choose topics of importance to spokes (see blurb from SE palliative)
Importance of facilitation training and on-going support to facilitator
Promotion of ECHO as a safe space for learning and sharing and transforming how
we provide services and care for patients
Protected time and funding needed to support the time of a dedicated Network Lead
Operational/delivery
Dedicated & consistent Admin & IT Support is key
Paperwork needs to be out in more timely fashion
Consensus – 1 session per month
Moodle site is very useful to refer to presentations, discussions and resources if
session missed or to refresh. Consider time period information held
Consider evening sessions to facilitate time out of practice
Some networks would like to consider virtual hub managed centrally from ECHO NI
HQ
Funding
Ensure continuation of ECHO through recurrent and dedicated funding streams
GP backfill is currently essential but expensive
Need protected time for lead
Most networks don’t require hub funding element to participate (£8,000 p/a in
16/17)
Slush fund for extras suggested as opposed to hub funding
Some networks open to contributing to future involvement in Project ECHO
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Use of ECHO Methodology
‘Safe’ space so important
ECHO is enabler for transformation
ECHO is excellent facility to support the education and governance of new services
Adopting a robust approach to evaluation is challenging for each network to take
forward and there is a need to consider more effective evaluation methodologies
In taking forward this 3 year plan, it will be important to ensure that lessons learned to
date as outlined above are addressed and that a focus continues on maintaining fidelity
to the ECHO model, working closely with UNM, considering new evaluation
methodologies and ensuring there is capacity to continue to develop the potential of the
ECHO service model in NI.
ECHO can help build a bridge across health care settings, and
truly provide health care without barriers barriers.
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Appendix 1 – Hub Survey Monkey
Has ECHO offered you an effective platform with which to pass on relevant
knowledge and skills to others?
Do you feel you have learnt personally through participating in ECHO?
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Did you learn from other Hub members?
Did you learn from participants at the spokes?
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Do you think that participating in ECHO has improved the care you provide
for patients?
Do you think the format of ECHO helps translate knowledge from teaching
into practice?
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Do you think your participation in ECHO has changed your practice at all?
Would you recommend ECHO to other Healthcare professionals in your area?
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Appendix 2 - Quotes from ECHO NI Participants
“MDT working between professionals within Trust, Primary care, and staff in nursing homes
to target residents who present with behaviours difficult to manage. Sharing practice and
sharing initiatives which overall promote a positive experience for all patients is key”
“I think ECHO is a wonderful, innovative way of learning and sharing of knowledge,
particularly for optometry where historically communication between primary care and
secondary care has been fairly limited. Personally as an optometrist it was so helpful and
inspiring to be able to share and discuss clinical issues directly with specialist clinicians that
can have an immediate, direct impact on patient care.”
“The ECHO process is an excellent platform for teaching and learning. It is very much a two
way process. Highly recommended. “
“I see ECHO as contributing to the necessary governance, learning and communication
aspects of transformation and reform of existing pathways, enabling more patients to be
assessed closer to home, and maximising system resource.”
“The use of a phase two ECHO to further support the GPs with enhanced gynaecology skills,
who will be providing the enhanced capacity within primary care, that would prove a more
effective use of this resource. It is recognised that those service providers will require
ongoing support and training in order to deliver a safe effective and high quality service to
our patients.”
“In my view ECHO provides a perfect forum for isolated practitioners to avail of peer
expertise, mentorship and support which potentially could encourage standardised
enhanced care for respiratory patient's in the community.”
“I really was impressed by the quality of the ECHO sessions and the ability to discuss cases
with Primary and Secondary Care staff. It provided a unique learning environment and was
relaxed and used friendly and times very suitable for primary care.”
“The concept of protected time for learning with appropriate financial and time resource
needs to be embedded into every GP's work plan. “
“It was so helpful and inspiring to be able to share and discuss clinical issues directly with
specialist clinicians that can have an immediate, direct impact on patient care.”
“The ECHO process is an excellent platform for teaching and learning. It is very much a two
way process. highly recommended.”
“Is an excellent facility to support the governance of new services”
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“I see ECHO as contributing to the necessary governance, learning and communication
aspects of transformation and reform of existing pathways, enabling more patients to be
assessed closer to home, and maximising system resource. “