Extension for Community Healthcare Outcomes (ECHO) Telementoring in the Military: Where We Are Now, Opportunities and Challenges.

INTRODUCTION: In collaboration with the ECHO (Extension for Community Healthcare Outcomes) Institute since 2012, the Army, Navy, and Air Force have developed medical teleECHO programs to address various health and safety issues affecting military personnel. This article describes and compares the current state of military teleECHOs as well as the growth and change over time. MATERIALS AND METHODS: This study evaluated continuing education units (CEUs) offered, average session attendance, and number of spoke sites for current military teleECHO programs across the service branches. RESULTS: Between 2012 and 2019, the military teleECHO initiative grew from one program to seven different teleECHO programs, covering topics from pain to diabetes to amputee care. Military ECHOs now provide training to 10 countries and 27 states in the United States. Between October 2018 and September 2019, the military ECHO programs provided a total of 51,769 continuing medical education (CME) hours to a total of 3,575 attendees from 223 spoke sites. CONCLUSIONS: The military has successfully used the ECHO model to improve the health and safety of active-duty military, retirees, and dependents.

How Hands-On Pain Skills Intensive Trainings Complement ECHO Pain and Opioid Management Programs: A Program Evaluation with the Indian Health Service.

OBJECTIVE: To evaluate the impact of Pain Skills Intensive trainings (PSIs) as a complement to the Indian Health Service (IHS) and the Chronic Pain and Opioid Management TeleECHO Program (ECHO Pain) collaboration. DESIGN: On-site PSIs conducted over two to three days were added to complement ECHO Pain at various IHS areas to enhance pain skills proficiency among primary care teams and to expand the reach of ECHO collaboration to ECHO nonparticipants. SETTING: This evaluation focuses on two PSI trainings offered to IHS clinicians in Albuquerque, New Mexico, and Spokane, Washington, in 2017. METHODS: The mixed-methods design comprises CME surveys and focus groups at the end of training and 12 to 18 months later. Quality of training and perceived competence were evaluated. RESULTS: Thirty-eight participants attended the two PSI workshops. All provided CME survey results, and 28 consented to use of their postsession focus group results. Nine clinicians participated in the virtual follow-up focus groups. IHS clinicians rated the PSIs highly, noting their hands-on and interdisciplinary nature. They reported above-average confidence in their skills. Follow-up focus groups indicated they were pursuing expanded options for their patients, consulting other clinicians, serving as pain consultants to their peers, and changing prescribing practices clinic-wide. However, rurality significantly limits access to ancillary and complementary services for many. Clinicians reported the need for additional training in integrating behavioral health into their practice. CONCLUSIONS: Hands-on pain skills and information on medication-assisted treatment (MAT) are critical to the successful treatment of chronic pain and opioid use disorder. The PSIs provide clinicians with critical competencies in assessment and screening, pain management, and communication skills, complementing required IHS training and telementoring from ECHO Pain.

Army and Navy ECHO Pain Telementoring Improves Clinician Opioid Prescribing for Military Patients: an Observational Cohort Study.

BACKGROUND: Opioid overdose deaths occur in civilian and military populations and are the leading cause of accidental death in the USA. OBJECTIVE: To determine whether ECHO Pain telementoring regarding best practices in pain management and safe opioid prescribing yielded significant declines in opioid prescribing. DESIGN: A 4-year observational cohort study at military medical treatment facilities worldwide. PARTICIPANTS: Patients included 54.6% females and 46.4% males whose primary care clinicians (PCCs) opted to participate in ECHO Pain; the comparison group included 39.9% females and 60.1% males whose PCCs opted not to participate in ECHO Pain. INTERVENTION: PCCs attended 2-h weekly Chronic Pain and Opioid Management TeleECHO Clinic (ECHO Pain), which included pain and addiction didactics, case-based learning, and evidence-based recommendations. ECHO Pain sessions were offered 46 weeks per year. Attendance ranged from 1 to 3 sessions (47.7%), 4-19 (32.1%, or > 20 (20.2%). MAIN MEASURES: This study assessed whether clinician participation in Army and Navy Chronic Pain and Opioid Management TeleECHO Clinic (ECHO Pain) resulted in decreased prescription rates of opioid analgesics and co-prescribing of opioids and benzodiazepines. Measures included opioid prescriptions, morphine milligram equivalents (MME), and days of opioid and benzodiazepine co-prescribing per patient per year. KEY RESULTS: PCCs participating in ECHO Pain had greater percent declines than the comparison group in (a) annual opioid prescriptions per patient (- 23% vs. - 9%, P < 0.001), (b) average MME prescribed per patient/year (-28% vs. -7%, p < .02), (c) days of co-prescribed opioid and benzodiazepine per opioid user per year (-53% vs. -1%, p < .001), and (d) the number of opioid users (-20.2% vs. -8%, p < .001). Propensity scoring transformation-adjusted results were consistent with the opioid prescribing and MME results. CONCLUSIONS: Patients treated by PCCs who opted to participate in ECHO Pain had greater declines in opioid-related prescriptions than patients whose PCCs opted not to participate.

A 2-Year Holistic Health and Stress Intervention: Results of an RCT in Clergy.

INTRODUCTION: This study sought to determine the effect of a 2-year, multicomponent health intervention (Spirited Life) targeting metabolic syndrome and stress simultaneously. DESIGN: An RCT using a three-cohort multiple baseline design was conducted in 2010-2014. SETTING/PARTICIPANTS: Participants were United Methodist clergy in North Carolina, U.S., in 2010, invited based on occupational status. Of invited 1,745 clergy, 1,114 consented, provided baseline data, and were randomly assigned to immediate intervention (n=395), 1-year waitlist (n=283), or 2-year waitlist (n=436) cohorts for a 48-month trial duration. INTERVENTION: The 2-year intervention consisted of personal goal setting and encouragement to engage in monthly health coaching, an online weight loss intervention, a small grant, and three workshops delivering stress management and theological content supporting healthy behaviors. Participants were not blinded to intervention. MAIN OUTCOME MEASURES: Trial outcomes were metabolic syndrome (primary) and self-reported stress and depressive symptoms (secondary). Intervention effects were estimated in 2016 in an intention-to-treat framework using generalized estimating equations with adjustment for baseline level of the outcome and follow-up time points. Log-link Poisson generalized estimating equations with robust SEs was used to estimate prevalence ratios (PRs) for binary outcomes; mean differences were used for continuous/score outcomes. RESULTS: Baseline prevalence of metabolic syndrome was 50.9% and depression was 11.4%. The 12-month intervention effect showed a benefit for metabolic syndrome (PR=0.86, 95% CI=0.79, 0.94, p<0.001). This benefit was sustained at 24 months of intervention (PR=0.88; 95% CI=0.78, 1.00, p=0.04). There was no significant effect on depression or stress scores. CONCLUSIONS: The Spirited Life intervention improved metabolic syndrome prevalence in a population of U.S. Christian clergy and sustained improvements during 24 months of intervention. These findings offer support for long-duration behavior change interventions and population-level interventions that allow participants to set their own health goals. TRIAL REGISTRATION: This study is registered at www.clinicaltrials.gov NCT01564719.

Use of a randomized multiple baseline design: rationale and design of the spirited life holistic health intervention study.

Clergy suffer from high rates of obesity, chronic disease, and depression, and simultaneously underestimate the toll these take on their daily functioning. Health interventions are needed for clergy and may be tailored to their occupational context and theological beliefs. Few studies have sought to improve clergy health. No prior studies have utilized a randomized design. Spirited Life is a randomized, multiple baseline study that offered enrollment to nearly all United Methodist Church clergy in North Carolina in fall 2010. A total of 1114 clergy (response rate = 64%) enrolled. Using a multiple baseline design, we randomized participants to three cohorts. Each cohort began the health intervention in one of three consecutive years. The third cohort served as a randomized waitlist control cohort, allowing comparisons between the first and third cohorts. The two-year Spirited Life intervention consists of: 1) a theological underpinning for health stewardship based on incarnation, grace, and response and delivered during workshops; 2) the stress management program Williams LifeSkills; 3) Naturally Slim, an online weight loss program; 4) phone contact with a Wellness Advocate; and 5) $500 small grants for health goals. Metabolic syndrome is the primary endpoint. Stress and depressive severity are secondary endpoints. We measured each construct before, twice during, and at the end of the two-year intervention. Study outcomes, to be published after follow-up data are gathered, will provide evidence of the effectiveness of the combined intervention components of Spirited Life. If successful, the intervention may be considered for use with other clergy and faith populations.

Tailoring health programming to clergy: findings from a study of United Methodist clergy in North Carolina.

Research indicating high rates of chronic disease among some clergy groups highlights the need for health programming for clergy. Like any group united by similar beliefs and norms, clergy may find culturally tailored health programming more accessible and effective. There is an absence of research on what aspects clergy find important for clergy health programs. We conducted 11 focus groups with United Methodist Church pastors and district superintendents. Participants answered open-ended questions about clergy health program desires and ranked program priorities from a list of 13 possible programs. Pastors prioritized health club memberships, retreats, personal trainers, mental health counseling, and spiritual direction. District superintendents prioritized for pastors: physical exams, peer support groups, health coaching, retreats, health club memberships, and mental health counseling. District superintendents prioritized for themselves: physical exams, personal trainers, health coaching, retreats, and nutritionists. Additionally, through qualitative analysis, nine themes emerged concerning health and health programs: (a) clergy defined health holistically, and they expressed a desire for (b) schedule flexibility, (c) accessibility in rural areas, (d) low cost programs, (e) institutional support, (f) education on physical health, and (g) the opportunity to work on their health in connection with others. They also expressed concern about (h) mental health stigma and spoke about (i) the tension between prioritizing healthy behaviors and fulfilling vocational responsibilities. The design of future clergy health programming should consider these themes and the priorities clergy identified for health programming.

The life of leaders: an intensive health program for clergy.

Clergy suffer from chronic disease rates that are higher than those of non-clergy. Health interventions for clergy are needed, and some exist, although none to date have been described in the literature. Life of Leaders is a clergy health intervention designed with particular attention to the lifestyle and beliefs of United Methodist clergy, directed by Methodist LeBonheur Healthcare Center of Excellence in Faith and Health. It consists of a two-day retreat of a comprehensive executive physical and leadership development process. Its guiding principles include a focus on personal assets, multi-disciplinary, integrated care, and an emphasis on the contexts of ministry for the poor and community leadership. Consistent with calls to intervene on clergy health across multiple ecological levels, Life of Leaders intervenes at the individual and interpersonal levels, with potential for congregational and religious denominational change. Persons wishing to improve the health of clergy may wish to implement Life of Leaders or borrow from its guiding principles.

Light still shines in the darkness: decent care for all.

Health care is in crisis at the global, national, and local levels, with hundreds of millions living without basic care, or with insufficient care. Current health care models seem to have ignored, muted, or excluded the voices of the people they were intended to serve, resulting in health systems and care delivery models that do not respond to the needs of the people. This article describes a values-based approach to health and health care services in which the voices of the people are heard and listened to, and in which individuals and communities are informed participants in their own care. We draw parallels between contemporary concerns for decency in care giving to Florence Nightingale's path-breaking work, first with the British military medical system and then Great Britain as a whole.