Collaboration in a Time of Crisis: Adapting a Telementoring ECHO for Addiction Leaders during COVID-19

Research letter

Substance use disorder (SUD) systems are often siloed, with little integration or communication across specialty addictions treatment, healthcare, harm reduction, policy, and advocacy organizations. 1 COVID-19 emerged in the midst of a relentless overdose crisis, 2 and created pressing leadership need given a global health emergency, a rapidly changing environment, widespread anxiety, and lack of governmental guidance.

Project ECHO (Extension for Community Healthcare Outcomes) is a distance tele-mentoring medical education model that connects specialists with generalist providers across geographically diverse communities. 3 ECHO is highly interactive, and uses case-based learning and brief expert presentations. In April 2020, we quickly repurposed existing ECHO infrastructure 4 to convene leaders in substance use treatment, advocacy and policy making across the US state of Oregon to participate in an SUD COVID Response ECHO. We aimed to:

Share emerging resources and best practices to deliver SUD care during the COVID-19 pandemic (e.g. low-barrier telemedicine; virtual peer support)

Unlike traditional ECHO programs, which are generally structured around core faculty experts who support and guide participant-learners, we intentionally amplified the ECHO philosophy of “all teach, all learn.” The rapidly changing environment that emerged in the wake of COVID-19 meant that all parties were adapting as quickly as possible, and in their own ways. Thus, instead of designating specific faculty experts we determined that all – and no – participants were experts as we confronted this unsettling new landscape. This letter describes our experiences and lessons learned, highlighting implications for future collaborative efforts across regional and state SUD organizations.

ECHO timeline and recruitment was as follows: On March 23, Oregon's Governor issued a statewide stay-at-home order. 5 On March 24th, we emailed 28 state-wide SUD agency leaders and asked those leaders to invite others whom they believed would be both interested and have population-level needs, insights and contributions. On April 1 we launched the ECHO with 48 participants across 32 organizations. Leaders heralded from SUD and behavioral health treatment agencies (12); primary care (11) and hospital (1) addiction teams; peer agencies (2); harm reduction organizations (2); advocacy and social service organizations (2); Medicaid payers (1); and state agencies (1). Participant disciplines included physicians and advance-practice providers (21), social workers and counselors (8), public health (3), peer support specialists (2), medical students (4), and others (10). On average, 34 participants attended each session.

The ECHO included twelve weekly hour-long virtual meetings, each including a 5–7 minute didactic by one of the participants followed by a “practice situation,” presented by a different participant. We developed an initial set of didactics based on our own knowledge of community challenges and innovations and expanded that list based on participant feedback and expertise. For example, one didactic outlined how a local treatment center adapted alcohol-withdrawal management protocols to an ambulatory settings after reducing its inpatient bed-capacity to enable physical distancing. The Table 1 describes each of the didactics and summarizes policy/practice implications.

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Table 1

Summary of SUD COVID response ECHO didactics and practice situations.

Didactics
Week	Description	Reflections, responses, and key implications
1	Oregon SUD Resource Collaborative: Medical student described a project started in the first weeks of COVID-19 to (1) collect and disseminate real-time changes in local SUD services, and (2) identify and address immediate resource needs. 6	Identified concerns for possible buprenorphine shortages and identified need for naloxone distribution, syringe, pipe, injection (e.g., alcohol wipes), and hygiene (e.g., soap) supplies. Student group to follow-up.
2	Methadone Access during COVID-19: Opioid Treatment Program (OTP) Medical Director discussed COVID regulatory changes and considerations re patients’ take-out frequency.	Clarified OTP efforts to reduce COVID transmission, including increased take-outs for some, expanded operating hours, physical distancing cues.
3	Buprenorphine prescribing: Medical Director of a low-barrier buprenorphine clinic reviewed ASAM best practices for buprenorphine prescribing during COVID-19. 7 and changing regulations. Shared virtual visit best practices.	Discussed ways to expand access including role for low dose buprenorphine (“microdosing”) inductions and offering virtual visits at bottle drop sites.
4	Ambulatory Alcohol Withdrawal Management: Medical Director of detoxification center reviewed ASAM guidelines and their protocols for ambulatory alcohol withdrawal. 8	Discussed barriers for alcohol withdrawal when patients take methadone. Shared alcohol-specific harm reduction strategies, including safer drinking tips.
5	Telemedicine implementation and support: Primary care clinic director shared best practices implementing telemedicine during COVID-19 pandemic.	Discussed approaches to telemedicine for people living outdoors, with mental health conditions, with phone and internet barriers, and with apprehension answering blocked numbers.
6	Peer support in COVID-19: Peer Support agency director presented an overview of peer support service adaptations during the COVID-19 pandemic.	Discussed ways ECHO participants could help overcome barriers to peer integration into general healthcare settings.
7	Street outreach: Harm reduction volunteer described a community-led, independent bottle redemption service that emerged in response to state shutting down bottle collection sites in COVID-19. 9	Participants appreciated innovative approach to addressing economic vulnerability. Discussed ways to obtain personal protective equipment for street outreach volunteers; equitable bottle bill and other advocacy opportunities.
8	Rural and Frontier Health in COVID-19: Frontier County Public Health Director discussed COVID response considerations in rural areas, where there are high rates of SUD, childhood poverty, teenage parents, domestic violence, farming and food processing, and few work-from-home options.	Group acknowledged preexisting broad resource gaps in rural Oregon and acknowledged risks of increased use and shuttered services imposed by the pandemic. Identified advocacy and partnership opportunities across ECHO participants.
9	Harm reduction during COVID-19: Syringe service leader described COVID-related changes to harm reduction services, identified challenges that people who use drugs may face, and identified opportunities to increase access to harm reduction services.	Discussed best practices including needs-based syringe distribution. Discussed concerns around riskier substance use due to changes in methamphetamine supply, increased social isolation and stress.
10	Billing and Coding: Medicaid administrator shared overview of COVID-related billing changes, focusing on telehealth and reviewed options for peer billing.	Discussed strategies and resources to support organizations to bill telehealth encounters. Identified few mechanisms to support billing for peer support as a widespread barrier.
11	Digital Recovery Support during COVID-19. Executive Director of national digital recovery support service organization described available services and tools, implementation opportunities, and potential benefits and barriers.	Discussed ways to address limited internet access which is significant barrier for many.
12	SUD Advocacy in COVID-19. Executive Director of an statewide Addiction Advocacy Organization described their organization's response to COVID-19 and described key principles of effective advocacy with local and state policy-makers.	Discussed opportunities to identify anti-racist actions needed across organizations; opportunities to educate state and local policy-makers of challenges introduced by COVID-19.

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Practice situations
Week	Practice Situation Topic
1	Participant introductions and brief ECHO orientation.
2	Methadone access for medically fragile patients during COVID-19: primary care and hospital-based providers raised concerns over medically fragile patients deemed unstable for takeout dosing. Questions: How medical providers can partner with OTPs to inform and understand decisions that take into account SUD stability and medical risk?
3	Buprenorphine extended-release (XR) injection: Understanding which patients may benefit most from buprenorphine XR is evolving. Medication may have novel applications in COVID-19. Questions: Who is using XR buprenorphine, for which patients, and with what results? Do clinics have effective workflows for purchasing and administering the medication? How do we maintain awareness of cost?
4	Community-based recovery supports: Long-term recovery support systems are under-funded and separated from most addiction treatment at baseline. This is worse in COVID-19, where community recovery supports are even more important. Questions: How might healthcare systems better connect with community-based recovery supports?
5	Community outreach and pathways buprenorphine and other medical care: COVID-19 may increase some people's motivation to initiate buprenorphine treatment, and tele-buprenorphine can increase access. Lack of one-stop-shopping (for insurance, healthcare services) for folks without telephones, transportation, or limited English is limiting. Questions: what are streamlined ways to get folks in Medicaid and primary care? How can we support telephone access to do this? How do we do this work in a sustainable way that relies on systems and not luck or volunteers?
6	Naloxone access for OTP clients: OTP clients have limited naloxone access during COVID-19 – many are avoiding pharmacies and transportation is challenging. OTPs providers are concerned given that they are observing high-risk medication-related events (often in context of more take-home doses), and patients are increasingly isolated. Question: how to support naloxone distribution to OTP clients?
7	Integrating Mental Health and Addictions care: Access gaps for mental health services and addictions care in people experiencing homelessness are exacerbated in COVID and have surfaced repeatedly in ECHO; particularly around medication adherence, limited telehealth capacity, patient engagement. Questions: How are agencies approaching care for people with unmet mental health needs and limited engagement, housing/ shelter needs, and limited phone access?
8	SUD COVID Response ECHO Future Directions: Summarized findings of mid-program evaluation and sought participant feedback on future directions. Question: How, if at all, should the SUD COVID Response ECHO collaborative continue in the future?
9	CARES Act and 42 CFR: CARES Act aligns aspects of 42CFR and HIPAA. Discussed changes and implications among organizations represented in ECHO. Question: how do we optimize provider communication expectations, and continue to protect patient privacy?
10	Urine drug testing: One organization that provides SUD treatment, primary care, and housing has inconsistent policies about urine drug testing (UDT); some programs are abstinence only and people can lose housing or services if they disclose use or have an aberrant UDTs. Other services are more permission. UDT results are shared across the agency. Question: how to balance these competing demand?
11	Medication in residential SUD treatment: Most residential SUD treatment programs in our state contract outpatient providers to manage medications for SUD; care is commonly fragmented and communication challenging. One outpatient provider expresses concern about prescribing buprenorphine with limited knowledge of client's care and progress in this setting. Question: How to increase communication around client care and progress to ensure outpatient prescribers can provide appropriate medical treatment?
12	Engaging medically complex patients in resource scares areas: Systems are ill-equipped to support people with severe SUD and complex medical/ end-of-life needs, especially in rural areas. Question: How to maintain treatment engagement with medically complex patients with low motivation to quit using, in rural areas with limited community SUD resources and support?

Practice situations included leaders’ challenges addressing addiction from a systems or population level, and could include administrative, resource, process, or other systems-level challenge. We used an SBAR (Situation, Background, Assessment, Request) format and followed presentation with collaborative problem solving among diverse participants. For example, in the first session a physician shared concerns about buprenorphine supply shortages due to longer prescriptions written to minimize in-person clinic and pharmacy time. In response, a participant from the Oregon Health Authority elevated the concern to the state pharmacy board, and a group of medical students systematically contacted pharmacies to assess medication stocks. Over the ensuing weeks, the group shared updates about medication access and efforts underway to prevent shortages. The Table 1 describes the practice situations participants brought to the ECHO, and some practical solutions that emerged.

We conducted a program evaluation in response to early positive feedback about a future-role for the group. We distributed a mid-program open-ended survey exploring participant experiences with COVID-19, with the ECHO, and the group's future. Twenty-one participants completed the survey. We also added an extra session for feedback and future planning, which 26 participants attended. Many participants described an important comradery and support that helped leaders “keep [their] energy going during these strange times.” Many also felt that this collaboration – which included diverse agencies, disciplines, and regions, and focused on concrete and pressing challenges – was long-overdue in a state already struggling to meet needs of people with SUD. Participants noted that the pandemic provided a reason to move past silos and ECHO provided a structure that emphasized collaborative problem solving around discrete issues. Finally, many felt that the presence of strong peer and harm reduction leaders helped center practice and policy decisions on needs of the most vulnerable patients.

We submitted a Request for Determination and the Oregon Health & Science University institutional review board determined this study was not human subjects research.

Participants’ conviction of the value of ECHO beyond the acute COVID-19 crisis pushed us to launch a year-long SUD Leadership ECHO in August 2020. This ECHO builds on strengths of the SUD COVID Response ECHO and expanded recruitment to further engage rural, culturally-specific, and abstinence-based SUD programs; housing, law enforcement, and corrections; government officials; and payers.

Lessons learned include that an SUD COVID Response ECHO provided time and space for shared problem solving and leadership support, resulting in immediate solutions to emergent pandemic-related challenges, and sowing seeds for long-term advances in systems for people with SUDs in our state. The ease of recruitment, robust participation, and positive participant experience highlighted that this kind of collaboration – which helped bridge gaps among the diverse agencies, disciplines, and regions addressing SUDs in the state – was long overdue. ECHO provided a forum to gather around a unifying, common challenge – addressing SUD population health and organizational needs in the pandemic, and is informing how we continue to collaborate and lead amidst an unrelenting substance use epidemic. We hope that our experience is valuable to others working to build more integrated and responsive regional SUD systems.