project echo evaluation report...

Project ECHO Evaluation Report 2016/17

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Contents

Contents

Abbreviations

Introduction

Project ECHO 2015-16


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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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)

http://echonorthernireland.co.uk/2016/05/echo-ni-evaluation-report/

http://echonorthernireland.co.uk/2016/05/echo-ni-evaluation-report/

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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


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



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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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.

mailto:[email protected]

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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.

http://www.hscbusiness.hscni.net/services/2612.htm

http://www.hscbusiness.hscni.net/services/2612.htm

http://www.hscbusiness.hscni.net/pdf/DEVELOPING_EYECARE_PARTNERSHIPS_2012(1).pdf

http://www.hscbusiness.hscni.net/pdf/DEVELOPING_EYECARE_PARTNERSHIPS_2012(1).pdf

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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


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


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


Future Plans


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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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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


Key Challenges


Future Plans


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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.

49 | P a g e

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.

http://www.google.co.uk/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwjPnbCQ9MTTAhWHI8AKHYMZBgkQjRwIBw&url=http://wvik.org/post/new-i-74-bridge-schedule&psig=AFQjCNGKa1jWi6Bxhn6BR5cDaxnBCYHFkw&ust=1493391722241521

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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. “

project echo evaluation report...

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