What is Project ECHO and ECHO’s Role in Addressing the Opioid Epidemic

Transcript

hi everybody sorry to interrupt all the great networking that's going on I'm dr. Miriam Kamara me I am from the echo Institute in Albuquerque New Mexico and I'm going to spend the next little while giving you an overview of the echo model and it's fairly explosive growth over the past decade and then also talk about how we're using echo to address the opioid use disorder in various different ways particularly I'll focus on treatment of opioid use disorders since so many other speakers are focusing on the use of echo for treatment of pain I'm an internal medicine physician and an addiction specialist and my areas of focus within echo are mental health addiction and community health worker programs this picture is worth a thousand words for explaining what echo is let me just start with sort of the origin story of echo so the man in the tie in the upper centre of the picture is dr. Sanjeev Arora and dr. Arora is my boss and he still leads the echo Institute back in 2003 he was working as a practicing hepatologist liver specialist at the University of New Mexico and he was focused on treatment of hepatitis C now New Mexico is a very large rural state and at the time we had the highest rate of hepatitis C in the United States and yet he was the only doctor in the state they had the only clinic in the state that was treating for poor patients who had hepatitis C folks who didn't have private insurance and at that time no primary care providers were treating hepatitis C in New Mexico at the time remember the treatments for hepatitis C were particularly toxic with interferon and other drugs that caused a lot of side effects so primary care providers were really afraid to treat hepatitis C on their own and it just wasn't happening and yet in rural New Mexico dr. Aurora realized that it was going to be very hard to convince a lot of GI specialists to move to rural New Mexico to address the need that was there in the meantime he had a nine-month wait to get into his hepatitis C treatment program at the University of New Mexico and patients were dying while they were on the waiting list furthermore the University of New Mexico is located in the center of New Mexico which is a as I mentioned a very large rural state and when patients needed to come once a week for treatment they were often traveling several hundred miles round-trip and this was prohibitive for the very poor population of the state so he thought about this and came up with an idea that he thought might work to provide mentorship to primary care providers working in these rural and underserved part of the state to help them and support them to take on treating patients who have hepatitis C in their own communities so that access could be expanded and that was really the origin of the echo model what you see here in the large picture on the screen is a group of specialists at the University of New Mexico who are gathered together to teach about treatment of hepatitis C there's Sanjeev who's a gastroenterologist paulinha Deming who's a pharmacist and Shawn yet C who's a psychiatrist and together they had the expertise the interdisciplinary expertise to really provide great deal of help and support to PCPs who wanted to treat Hep C around the edges of this picture you can see individuals and teams from primary care sites around the state of New Mexico some of these folks were hundreds of miles away but we're joining by videoconferencing and the model involves every week in this case for two hours a week these primary care teams join with the specialists and they present cases from their own practice in a de-identified fashion and get mentorship and support there's discussion that's led by the facilitator of the clinic that involves inputs all the other primary care teams who are working with patients with this condition and then specialist input to help guide the treatment of the patients who are presented and help everyone learn and raise the bar in terms of their level of knowledge and confidence in treating hepatitis C or other conditions as echo has later evolved to involve the key here is case based learning so this isn't a webinar or a lecture in which people are sitting passively and absorbing the information it really centers around the fact that these primary care teams are coming to the table with their own cases but the cases that are troubling them and concerning them and they're volunteering to participate because they want to raise their level of knowledge and develop this level of expertise no one you know hepatitis C is not going to be the echo that every primary care provider is going to choose to participate in it's typically people who have a real need in their community and are interested in this area there are now echo programs for a myriad of different conditions more than 50 conditions worldwide and so PCPs gravitate towards echo programs that really serve their own learning needs and help them address the problems in their communities a typical echo session starts with a brief lecture by one of the specialists typically 20 minutes or so of lecture or sort of an update and it's followed by case presentations by multiple primary care teams for some conditions they can work through a lot of conditions a lot of cases quickly and for other conditions it's quite a bit slower it's important to distinguish the echo model from traditional telemedicine so down at the bottom you can see that in traditional telemedicine an individual specialist is providing care for an individual patient who is remote from them this is a very important service and has greatly expanded access to specialty treatment in rural and underserved areas however it differs from the echo model in that it doesn't result in force multiplication in other words when that special seeing that patient they can't be seeing another patient who's in their own in their own area or practice it is a substitution with echo specialists leverage their time in order to train multiple primary care providers who in turn can provide a specialized slice of care to thousands of patients in their own area resulting in a real multiplication of force of the providers who are trained to address that condition this is another way of looking at it that we talked about the hub of specialists who are providing the training and support to a lot of spokes of primary care providers who are typically located over a broad geographic area and those providers in turn are providing that specialized care to the patients in their own primary care setting echo revolves around a few key principles one is using technology in this case video conferencing to leverage scarce healthcare resources and we're talking here about medical specialists who are not available to the vast majority of the population in a state like New Mexico it also involves sharing of best practices so the specialists take responsibility for making sure that the recommendations that they're making are based on the best evidence on recent guidelines on recent literature and often they distribute that literature for the benefit of the learners so that everybody's knowledge increases together rapidly case based learning I mentioned is absolutely key memorizing a set of guidelines is never going to teach you to provide excellent care for complex patients patients don't come in guideline form they come with multiple co-occurring disorders with social barriers with all kinds of problems that mean we all need a nuanced approach to care and the wisdom of experienced specialists particularly when they work in an interdisciplinary fashion can be very powerful for guiding that care and achieving the best outcomes and finally using the web web-based databases to monitor outcomes of care why would rural clinicians choose to participate in such a model first of all most echo programs offer no cost continuing medical education credits nursing credits etc counseling credits and this is definitely a benefit for clinicians working in underserved areas another thing we hear a lot from participants in echo programs is that they really value the professional interaction with colleagues who have a similar interest they feel less isolated and this helps them to stay both in the echo program and in their primary care practice setting as you know there's tremendous turnover among providers in primary care settings and participating in echo helps to shore up their sense of having a virtual community that shares their interests and with whom they can confer when they have a problem it provides a mix of work and learning my friend Leslie Hays who's a family practice stock up in northern New Mexico talks about how you know she spent years in training when the focus was on stuffing her brain full of information then she left training and nobody was that interested in her knowledge they were interested in her producing and caring for patients and she felt like she stopped learning and nearly as meaningful and rich away and participating in echo as a way of continuing that pretty steep learning curve that we had in our training in a relatively painless way in a time efficient way and finally access to specialty consultation so again in a place like New Mexico if you work 200 miles from the University you're not going to have a lot of specialists who refer to and so having a way to make sure that the care and recommendations that you're providing are up-to-date and highly relevant to that patient is key so early on when echo was focused on hepatitis C our goal was to develop a capacity to safely and effectively treat hepatitis C in all areas of New Mexico and to monitor outcomes of that treatment we also from early on we're interested in really developing and fleshing out this model to treat complex diseases in rural locations and even in developing countries and I'll show you kind of how that growth has happened over time so initially when we were focused on hepatitis C one of the benefits of this program is that we partnered across multiple organizations so as you know medicine is often kind of practiced in silos that people who work at the University don't necessarily talk to people working at the federally qualified health centers who in turn don't necessarily talk to people in public health or in prison health etc so we had a goal of bringing together people from these various different practice settings as early as possible the model has worked very well for hepatitis C and many other conditions in the New Mexico program alone more than 6,000 patients have entered Hep C disease management programs and more than 80,000 hours of continuing medical education have been offered in New Mexico when early early on we started surveying participants in Echo about the impact of participation on their practice this was a very early survey where we asked some of these Hep C providers about changes and their ability to manage co-occurring disorders in patients with hepatitis C to serve as a local consultant to other providers in their clinic and their community for treatment of patients with Hep C and ability to educate and motivate Hep C patients and we saw increases in all of these and in fact overall self-rating of competence went up dramatically so we knew that providers liked participating and that it increased their confidence and feeling of self-efficacy but we also need knew that we needed to do more to demonstrate the effects of participation and echo on the patients who were being served so in 2011 we published results of that early Hep C experiment that had started back in 2003 and we compared the care that was delivered by hepatologists working in an academic medical center with the care that was being provided by these primary care teams in rural and underserved areas who were being mentored through the echo program and what we found was that if you look at sustained viral response which is cure of the hepatitis C virus that looking at both of the big categories of genotypes for Hep C that the cure rates were indistinguishable for the primary care folks who are being mentored by echo compared with the hepatologist working in the academic medical center and furthermore a larger proportion of patients of color were treated by the primary care providers working in the rural communities compared with those working in the academic medical center so really having an effect of increasing access to care for traditionally underserved populations with this kind of fueling our our excitement and energy echo has really expanded to multiple other diseases and conditions and when you think about what might be an appropriate target for an echo clinic let's say that you work in a particular disease area and you're trying to think about would this be something that I could or should do in order to sort of expand my reach it's useful to think about common diseases so if you pick a real zebra it's of interest but not to very many people in the world and not to very many primary care providers so if it's a rare condition you're going to have trouble gaining traction with your echo program you want something where the management is relatively complex you need a condition where people want to learn and know that there's a lot to learn and whether ideally are evolving treatments coming coming into the field a high societal impact is helpful something that people care about and something where there are serious outcomes of untreated disease and improved outcomes with disease management I mentioned that we started to add additional conditions we also continued to strengthen our recruitment of participants from various different settings within the healthcare system the University the State Health Department private practice clinicians and community health center teams we've also focused on this force multiplication idea so if you have a primary care provider who's acting somewhat like a specialist you also want to think about how to bring up the capacity of the rest of the team so although echo was initially focused primarily on physicians we quickly realized that primary care is a team sport and that we needed to reach out to a lot of other folks besides the doctors so from the very beginning actually nurse practitioners and physician assistants have played a big role in echo programs but we've also expanded further to have programs focused on nurses community health workers behavioral health therapists and a variety of other groups and helping everybody to kind of work at the top of their capacity at the top of their licensure and game here is a snapshot of a recent schedule of echo clinics that are offered out of the echo Institute in Albuquerque so all week long all day long you can see that there are lots of different topics being covered some of these clinics are restricted to New Mexico but a lot of them are open to folks from all over all over the country and in fact all over the world and you can easily connect to these we use zoom technology for videoconferencing that's easily accessible you can do it from your desktop computer from your laptop from your notebook computer and even from your cell phone in fact in international settings we're seeing that cell phones are the primary way that people are connecting to echo so you'll see a whole screen with little cameos of cell phones folks and each of these occurs on a regular schedule so there'll be a group of participants who joins week after week in order to increase their knowledge of that particular condition and develop expertise this is a drawing of New Mexico with each different brightly colored dot they're showing participation and a different echo program so you can see that all over the state we have providers who are participating in these different programs and in some communities even in some health centers we see real differentiation you know I thought about being a psychiatrist when I went to medical school so I focus on mental health and addictions you might have been interested in cardiology but went into primary care you might join the heart failure echo someone else interested in infectious disease and really struggling take care for some patients who have HIV or hepatitis those might be the programs that they gravitate to so it's a way of developing expertise in a community where expertise is not otherwise available and meeting the needs of a lot of patients who otherwise would not get high-quality care there are now over 70 publications about echo and I'm just going to mention a couple of different lines of evidence about the echo model this study done by Beth Israel I was called about a program called echo age it was a cohort study matching nursing homes that participated in geriatric echo with nursing homes and comparing them with nursing homes that didn't and they found that residents in facilities where the health care team had participated in echo age were 75% less likely to be physically restrained this echo really focused on behavioral techniques for calming patients and approaches that didn't involve physical restraints and they also found that these residents were 17% less less likely to be prescribed antipsychotic medications another geriatric example was from a geriatric mental health echo in Rochester New York and here they had have had many primary care providers participate in their geriatric echo and they've shown a 20% reduction in visits to the emergency department and 24% reduction in overall costs these are data from our organization from an echo that we developed for complex care so these were frequent flyers people who were in and out of the emergency room and hospitalized frequently and who had Medicaid and this shows that over the four years prior to their being engaged in our complex care echo program having their providers engaged in that these patients had a steadily increasing rate of hospitalization and after our program started those hospitalizations went down pretty dramatically similarly for emergency department visits and for overall cost of care I'm not going to spend time on the pain echo data because you're going to hear that later this afternoon we have a number of highly respected and well-known pane echo champions and organizers of pain echo programs who will tell you about the great data that's coming out about the impact of echo that's focused on pain you also heard from David about the UC Davis program earlier this morning I wanted to spend a couple of minutes mentioning as I said we don't just focus on doctors we focus on all kinds of other participants in the healthcare world the healthcare teams and a big focus is community health workers here in the United States we don't have a standard way of paying community health workers and so community health workers lead a kind of challenging professional life because they're kind of going from one grant to another or states that decide to fund them directly in the rest of the world though it's widely recognized that community health workers also known as promotoras or village health workers play a huge role in improving the health of populations they're typically unlicensed they don't have very high levels of formal education they come from the community that they serve and they can serve as a bridge and a translator essential of what patients may want to consider doing to improve their health and often they can communicate with the patients much better than the licensed medical provider can so we focused on developing community health worker training programs and we've trained hundreds of participants in New Mexico and increasingly in other states now we've focused on diabetes and cardiovascular risk reduction we have a collaboration with the CDC for that and a big part of our program focuses in tribal communities opioid use disorder we have a long-standing opioid use disorder echo for community health workers echo care is our complex care project obesity prevention we did in collaboration with our department of public health and Prevention of child abuse and neglect and this is an exciting and growing area and one where there's a lot of interest internationally so we're getting involved in helping people set up international echos focused on community health workers as I mentioned these folks are particularly effective in their work because they often can appreciate the barriers that the patients are experiencing in in their own community as well as being able to spend more time with the patient than the doctor and P or PA can do there's lots of data that community health workers help to improve health overall both in the US and internationally the training for community health workers is slightly different we pretty much always start with a face to face program to teach basic skills and it's typically a three day on-site program and then we use that echo model with case based learning where the community health workers come to the table and present the cases of patients who they're working with in their community the specialists are often experienced community health workers sometimes counselors and nurses and they may focus on things like helping people eat a healthier diet smoking cessation they use a lot of motivational interviewing etc and also helping them figure out how to be part of the disease management team in the American healthcare system one unusual program that we have for community health workers is actually if August in the prison system this is the peer educator program and it actually originated it was inspired by a program here in Texas I don't know if it's still going on the wall talk program that's in the prisons and it's training prisoners to be essentially community health educators in their own prison setting so the prisoners engage in 40 hours of training and then they themselves become trainers to other prisoners and the kinds of things they train on are things like hand-washing avoidance of infection that what is addiction and how to get treatment for addiction how to avoid transmitting and catching hepatitis and HIV and then skills for successfully managing life after discharge like anger management and communication so in terms of the growth of echo over time here's Albuquerque in the middle of the state where echo started at what is now the echo Institute as I mentioned here here are the sites that participated in our initial hepatitis C program here are snapshot of recent participants in all of the New Mexico programs here is what the VA has implemented with echo with out of 11 sites using echo to address a variety of different programs within the VA system echo for pain has also been very widely implemented within the Army and Navy both in the United States and in Europe this note there we go this is a picture of hubs all over the United States and what do I mean by hubs well at the echo Institute a big part of what we do is train other organizations to implement their own echo programs so you can see that many many different organizations around the United States mostly academic medical centers but also departments of Public Health and a few community health centers and private clinics have actually started their eko hubs this is a little bit out of date but you can see that the reach is pretty great for who's been interested in starting their own echo program I also mentioned on this slide super hubs so what's a super hub that is where we're actually training some organizations to train other organizations to start echo programs because we can't keep up with the demand there are so many people who want to start echo programs that we've had to really start to develop that broaden the capacity to train others to do this and there now I think eight trained super hubs around the United States that are starting to offer their own training to organizations that want to implement that go echo is also taking off internationally this is one of the first programs in Africa in Namibia it's an HIV echo program we thought we had challenges in terms of an inadequate physician workforce but you really see what that's about when you look at some other developing countries where the resources are almost laughably you know limited to address these tremendous health problems and so echo is really useful for providing mentorship both to physicians in rural areas and to non physicians who are taking on such a big part of the care here is echo in Vietnam this particular echo is focused on HIV this global map is showing the increasing presence of echo and other countries India has had a very rapid expansion with a couple of super hubs in India and many programs in India most notably TB and mental health and addictions echo actually out of Bangalore their National Institute of Mental Health Services South America has been very active and Africa you're not seeing much happening there from those dots but we're anticipating that by the end of the year twenty five countries in Africa will have launched echo programs often for more than one condition interestingly one of the things they've really taken off with is laboratory medicine they didn't have standardization of the ability to do lab tests and so they have developed echo programs to help standardize testing procedures and interpretation of results in order to improve the comparability of data but obviously also a lot of infectious disease conditions are taking off in a big way in Africa and w-h-o USAID and the CDC are all involved in funding those efforts one sign that echo has kind of grown up is that right before the end of the Obama administration there was a bill that passed unanimously in the House and Senate and was signed into law by President Obama before he left office that's called the echo Act and what it does is it really calls for the federal government to implement studies of echo to look at the impact of echo programs on the quality of care on provider retention the cost of care etc and to examine possible methods for providing sustainable funding at the federal level to help maintain echo programs in in operation now I'm going to talk for just a few minutes about scaling out the echo to address the opioid epidemic so after hepatitis C echo started in 2003 actually the second echo program to start is one that I started in 2005 because of what we were seeing in the hepatitis C echo that so many patients had gotten infected through infection injection drug use many patients were not able to participate effectively in treatment because of ongoing untreated addiction and there was very limited access to treatment for for substance use disorders this is a snapshot from a recent year of the different sites that are participating in our echo program in New Mexico and as you can see again the population is really concentrated in the middle of the state but we also have good penetration to very rural and outline areas joining in this substance use disorder and mental health echo we wanted to look at so from the very beginning of this project we've been very concerned about opioid use disorder so the rest of the country got worried about opioid use disorder in the last decade but actually in New Mexico we've historically had a huge problem with opioid use disorder from heroin way before the analgesic epidemic heroin it's surprising to a lot of people but heroin wasn't just on the coast it wasn't just kind of an imported problem it was actually endemic particularly in northern New Mexico for generations and we've had the highest or one of the very highest overdose rates in the United States for many years so we started early on using our echo network to recruit doctors to participate in the waiver training to be able to prescribe buprenorphine suboxone the very effective office based treatment for opioid use disorder and using our network we were able to recruit a lot of folks from the most rural and underserved areas we looked at this in 2016 and we looked at all of the zip codes in the US that are rural poor and where more than half of the population identifies as non-white and we said well how quickly is the supply of buprenorphine trained providers increasing in those areas so down at the bottom there you can see the gray line which shows how that number has increased across the United States over the last decade and the black line shows you that in New Mexico we've actually had much more rapid growth of providers taking on this training from rural and underserved areas of the state a couple of years ago hersa who funds federally qualified health centers in the United States and is mostly responsible for funding care for the poor across the country got interested in giving grants to health centers to try to increase their uptake of treatment of opioid use disorder and they decided to issue a contract to develop an echo program that would serve federally qualified health centers that were interested in increasing treatment of opioid use disorder so with the funding from hersa we were trying to think about well how can we have an impact because when you think about an echo program I told you that those echo sessions have to be interactive right it can't be a conversation if there are 200 people on the network really functionally it's limited to around 30 and even fewer is better if you want to have a really rich and engage conversation so we thought well we could take that hersa money and we could start an echo program but really what we wanted to do was help to build capacity all over the country and engage providers everywhere so we developed what we call the shared services model if you came to me and said I want to start an echo I would suggest you come and we would train you you'd participate in a three-day training that's free of charge and you could go back and develop your curriculum and your evaluation and recruit your specialists etc but it might take you quite a while to get up and running we wanted to get a fast start out of the starting gate so what we said to multiple other potential partners was if you just bring the specialist to the table we'll do everything else to support you in launching an echo program so three months after receiving funding we were able to stand up five opioid hubs across the country one at University of Washington went out of Billings Clinic in Montana one from our own University of New Mexico one that's a collaborative out of Western New York and finally out of Boston Medical Center and what we did was we brought the specialists together and developed a collaboratively designed curriculum a 12 session curriculum that we all use we provide the IT support to run the zoom sessions the administrative support to communicate and do all the emails the evaluation support to look at what's happening and then also the recruitment from the health centers across the country this has been quite a successful model and one that I think can be used in other settings and for other diseases as well this is a diagram of what's happened in the first year of this program so each of the hubs allows participation from anyone working at a federally qualified health center we had thought that people would sort themselves geographically see if you live on the west coast you joined the University of Washington program on the East Coast the Boston program etc but that hasn't been the case people have joined all of these hubs from all over the country and we've had 355 participants in year one representing a hundred and forty-seven hersa funded health centers we've aimed to make it interdisciplinary because of this conviction that effective health care in the primary care setting particularly for addiction has to be an interdisciplinary effort about half of our participants are medical providers and a third our behavioral health providers with the remainder rounding out with nurses pharmacists community health workers and medical assistants from this national echo we're finding some interesting results when we talk to people who have presented a patient case and we asked them about the impact of presenting the patient ninety-two percent say that the input they received changed their management plans so indicating that they really need this help that they didn't know what to do and they learn something from participating in the echo that really changed what they're doing in addition people learn from hearing others present cases an 81 percent said that they learned something new from a case they heard presented that day which will change the care of their own patients we're also seeing market increases and confidence and increase in positive attitude I'm just going to wrap up here with a couple more thoughts and then we'll have time for discussion but this map shows what's happened over the last couple of years with federal funding for opioid addiction treatment when we started this project when we first talked to her about this national opioid eko there were very few groups in the country that we're doing echoes focused on opioid use disorder since then there's been a tremendous influx of funding so hrq has funded a number of states to do opioid echo programs Fred Thomas from Colorado is one of the the leads on one of those projects which one in Oklahoma one in North Carolina one in Pennsylvania hearse as I mentioned has provided funding to health centers and then to us to do the opioid echoes but the big gorilla has really been the STR funds we were hearing about earlier and one of the things that states could propose to do with their STR funds was the grant the request for proposals itself said you could do opioid focused echo and twenty states wrote in opioid echo as part of their plan so you can see that there's just been this obsolete explosion of groups that are doing or are planning to shortly launch opioid echo programs around the country this is not too surprising since half a billion dollars were distributed across the country to to fund the efforts through the STR but it means that the landscape has really changed in the last couple of years so we had originally thought about continuing our national level opioid echo programs after this hersa funding runs out now we're not planning to and we're focusing instead on on helping states and state level efforts to launch opioid echoes because it is there's so much interest at the state level it's very exciting echo is really all about D monopolizing medical knowledge if you go to our website you can find a tab called join and echo and you can search for different echo programs actually a lot of these opioid echo programs are not listed yet because some of them are just coming online now but many many of these programs are open to people from across the country so it's also possible for folks to join echo programs that are not in their own state and to present patients I brought a flyer for our national opioid echo program which goes on for another year participation is free of charge and we'd love to have anybody from federally qualified health centers join up here on this speaker table I left a bunch of flyers if people want to pick those up the vast majority of echo hubs around the US and around the world do not charge learner or learner organizations for participation and echo obviously the funding has to come from somewhere and organizations are working hard to get grants from foundations from the federal government increasingly states are actually providing funding through a legislative appropriation or through Medicaid programs and so and actually insurers are also getting in on the game that a number of insurers have launched opioid echo programs and other echo programs because they see the value in improving the quality of care and outcomes so feel free to take a look on our website at all the different options for echo programs that are open for folks to join not just opioid echo but all kinds of things at the echo Institute we offer a lot of support for folks who are interested in starting an echo program and again all of this is free of charge we offer a three day what we call immersion training monthly in New Mexico for echo partners so you can come bring your team and spend three days really immersed and what it takes just to develop and launch a successful echo program we also have a lot of tools available for partners in a web-based repository and box including our curriculum that we've developed the 12 session curriculum for our opioid echo that we're offering nationally is available for anyone to use and modify evaluation tools and consultation the last thing I'll mention is that we've started an opioid echo collaborative we just started a couple of months ago but we're bringing together people who are doing opioid echo around the country and catalyzing evaluation and research efforts so that has split off into three different research projects that different groups are joining together to collect data together and work on tools for evaluation so again open to everyone we'd love to have you join my email address is here on the last slide if you want to reach out so the punchline is that states and local organizations can use the echo shared services model to really scale up their workforce to meet the need for prevention screening and treatment of opioid use disorder in their own communities and we have lots of tools available to help you to do that and hopefully this can be one one piece of the puzzle to addressing the opioid epidemic so thank you all very much I [Applause] think we have a few minutes for questions go ahead thank you sure and you may want to chime in on that as well but the state of New Mexico has provided a variety of different kind of support for the echo Institute for some time now there's been a legislative appropriation which has gone down as the fortunes of the state have gone down but hopefully we'll come back up again that provides a line item of funding for the echo Institute to provide services in New Mexico we also have worked with our state Medicaid agency and they have found a way of transferring some funds to echo because so many Medicaid patients are benefiting from providers participating in Echo for a whole variety of different conditions the states also provided focused funding for a variety of different programs some of our community health worker programs like our diabetes program have been funded by the state department of health and the prison peer education program has had some support from the Department of Corrections for the complex care program that we ran we actually had a collaboration with the Medicaid managed care organizations in the state where they worked together and provided salary support for primary care providers who are devoting a part of their time to caring for these very complex patients so there have been a lot of different collaborative efforts did you want to mention anything else in particular or did that get it okay great great how about other questions all right well I know we're running short of time for the next speaker because of scheduling snafus so when and I stopped there thank you all very much [Applause]