UF Health MedMatters

Coaching Calls: Project ECHO Diabetes Provides Education and Support to Patients and Providers Across the State

Project Echo Diabetes provides the expertise of a multidisciplinary team, including endocrinologists, to help primary care providers treat underserved patients with Type 1 and Type 2 diabetes who might not be able to visit a specialist the recommended four times a year.

Ashby Walker, PhD, understands that a person with diabetes is best served by seeing an endocrinologist four times a year. Experience, however, demonstrates many patients won’t — or can’t — do that.

Roque shows Nichole Stephens how to track her blood glucose levels using an app during a meeting at UF Health Family Medicine – Old Town

Walker, director of health equity initiatives at the University of Florida Diabetes Institute, said the reasons are many: a chronic shortage of endocrinologists, sometimes leading to long wait times for appointments; a reluctance to visit a specialist for fear of being judged or being stigmatized for poor diabetes management; and people feeling more comfortable seeking diabetes care with their primary care physician.

“We also know that distance is a real obstacle for people in rural catchment areas of the state of Florida,” said Walker. “And it becomes difficult for people in working-poor communities to take off work four times a year and lose their daily wage.”

Project Echo Diabetes is designed to bridge that diabetes divide. The program, based at the University of Florida and Stanford University aims to improve access to care for children and adults with Type 1 diabetes and those with Type 2 diabetes who require multiple daily doses of insulin.

The program was launched at UF in 2017, and following a successful pilot program, it was expanded in 2019 with a $7.6 million, three-year grant from The Leona M. & Harry B. Helmsley Charitable Trust. The UF Diabetes Institute receives about $3.3 million from the grant, enabling Project ECHO Diabetes to expand its service area to include 20 health care centers across Florida and reach an estimated 50,000 people with diabetes.

The effort uses the Extension for Community Health Care Outcomes model created by the University of New Mexico — hence the name, Project ECHO — that has been adapted for a range of diseases, from hepatitis C to chronic pain.

Project ECHO Diabetes employs a two-pronged approach, said Walker, the project’s co-primary investigator.

An important element of the program involves patients meeting with diabetes support coaches who offer peer mentorship. Coaches also live with diabetes, which provides a level of credibility that allows them to strongly connect with patients who might be facing a difficult time with their diabetes management.

In addition to direct interventions by the coaches, the program empowers primary care providers to deliver diabetes care in the family medicine setting. For many diabetes patients, their only interaction with a health care provider may occur at a primary care clinic, so providers must build a confident knowledge base to best serve this population.

This is accomplished, in part, through ECHO clinics held by videoconference. Walker works with Michael Haller, MD, a professor and chief of pediatric endocrinology at the UF College of Medicine, and other UF experts to host a regular series of educational sessions, or clinics, on diabetes-related topics and to run through a patient case study to discuss best practices. Physicians from participating health centers from across the state call in, give input and ask questions.

Walker said these clinics educate providers on health disparities some people with diabetes face, including access to technologies like continuous glucose monitors or insulin pumps, products that studies have shown to be used less by some groups based on race and socioeconomic status.

“By holding these clinics, we’ve been able to educate providers on topics they have very low confidence in, like diabetes technologies,” Walker said. “We’ve seen a clear dissemination of better information to people who can be advocates for their patients to get these technologies, providers who know how to get these devices for their patients and know what their advantages are for improving patient outcomes.”

Haller serves as a co-primary investigator for Project ECHO Diabetes in collaboration with Walker. He said the 2019 grant they received enables them to assess if the program is making participants healthier by tracking patient hospitalizations, emergency room visits and hemoglobin A1C. He hopes this research proves the effectiveness of ECHO programs for patients and providers.

“We want to see this become a public health initiative, where everybody utilizes ECHO programs to care for people with diabetes and other diseases,” said Haller, who holds the Silverstein Family Eminent Chair in pediatric endocrinology. “We want to show that not only do doctors feel better about providing diabetes care, but that we also are tangibly improving the quality of life and health outcomes for people living with diabetes.”

Primary care providers also can contact the Project Echo Diabetes team whenever needed to tap its expertise, said UF Health endocrinologist William T. Donahoo, MD, an associate professor in the UF College of Medicine’s division of endocrinology, diabetes and metabolism. His work is focused on obesity and diabetes.

“The critical part is that we as endocrinologists or other specialized health care providers like dietitians, psychologists and others, are able to provide the primary care providers with the additional tools sometimes necessary to help patients successfully manage their diabetes,” Donahoo said.

He also noted it is useful for him as an endocrinologist to hear primary care physicians discuss their interactions with patients at the team’s regular videoconferences.

“One of the huge benefits of this is that we get to learn from each other,” Donahoo said. “It’s really rewarding to interact with the doctors on the front lines and seeing how this extra support can make a difference in their practice. This is one of the highlights of my week.”

Adapting to a Crisis

When the COVID-19 pandemic swept across the nation in spring 2020, Project ECHO Diabetes pivoted to focus on what its patients needed most: education and access to technology. Coaches began conducting sessions with patients over the phone and video chat that focused on the risk of more severe COVID-19 complications for those living with diabetes. For patients without access to these technologies, Haller said, Project ECHO acted swiftly to provide this population with the tools they needed to receive medical attention via telehealth appointments.

“Many of the patients we are serving with Project ECHO don’t have consistent access to the internet or videoconferencing capabilities due to the lack of a computer or smartphone,” Haller said. “We are working to address those issues with additional funding from the Helmsley Trust.”

While Haller, Walker and fellow UF faculty focused their ECHO clinic videoconferences on educating providers about diabetes and COVID-19, coaches in Miami ramped up efforts to serve as many patients as possible by holding teleconference meetings for the local community.

“We want to show that not only do doctors feel better about providing diabetes care, but that we also are tangibly improving the quality of life and health outcomes for people living with diabetes.” - Michael Haller, MD

“Our coaches in the Miami area are serving populations most impacted by disparate outcomes in COVID-19 — African American and Hispanic communities,” Walker said. “They are holding virtual town hall meetings in English and Spanish for people living with diabetes and reaching out by phone.”

Right now, Project Echo Diabetes researchers are collecting data to measure whether the implementation of the program is effective. Does it, for example, improves outcomes, reduce health care costs and empower primary care providers and their patients?

Walker said the hope is that this model could eventually be replicated nationally beyond just California and Florida. She encouraged endocrinologists outside of Florida to contact her or Haller at the UF Diabetes Institute, at 352.294.8985, or officials at the University of New Mexico, at 505.750.3246 if they would like more information about Project ECHO or to inquire about starting a Project ECHO model in their own state.

Walker said it is important to note that primary care providers involved in Project Echo Diabetes still urge patients to see an endocrinologist. Reality, however, shows this isn’t always going to happen.

“The knowledge that an endocrinologist has is critical to improving the lives of people who live with diabetes, and sharing that knowledge with primary care physicians might not be what we normally envision when we think about educating patients,” Walker said. “But sharing that knowledge with a primary care provider can be a critical way of scaling impact in what is a provider-to-provider empowerment model.”

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University of Florida Health Shands Hospital has been recognized among the nation’s best hospitals in seven adult medical specialties. Overall, UF Health Shands Hospital was recognized as one of the best hospitals in Florida. In addition to being ranked among the nation’s top 50 hospitals in seven specialties, UF Health Shands Hospital also was listed as “high performing” in seven specialties, including abdominal aortic aneurysm repair, colon cancer surgery, COPD, heart failure, lung cancer surgery, neurology & neurosurgery and orthopaedics.