Well, we are going to go ahead and get started. There are absolutely plenty of seats a little closer, but I know that some of you want to sit in the back and doze, and that's fine with me. But if anybody wants to move up, feel free to do so. We really hope to be able to have some good Q&A after, so we'll leave plenty of time for that. Yes, whoever said that. I was outside, wasn't I? So, I'm Alan Anderson. I'm the director at Banner Alzheimer's Institute in Tucson, and I will allow my two esteemed colleagues from Phoenix to introduce themselves at the beginning of their talks. Also, worked through the University of Arizona there, where we have a residency, and we have a geriatric psychiatry fellowship, which unfortunately did not fill either of the two spots for 23 this summer, start. And these lucky folks have two for their slots, so we're competing against each other, but we don't really compete against each other. We actually have a nice setup where all the faculty from both sites do some of the teaching for the fellows, regardless of where they reside. And last year, we had two and you had one. So, I have some slides on that issue anyway, so welcome. Just a curious question. Anybody here a current resident or student? Okay, how about geriatric psychiatrists? How many are in the audience? A fair number. So, and general psychiatrists, most of the rest of us. Child and adolescent who didn't read the slide? No. So, you know, collaborative care, it really has been moving in a direction of greater implementation, but it's not necessarily an easy thing to implement. How many people here are engaged in some sort of collaborative care, behavioral health collaborative care model? A few. So, you might wanna share with us some thoughts about that. As I was preparing for this talk, before we get to my slides, I thought I would take a chance to look at the 2023 Alzheimer's Association Facts and Figures 2023, just because it usually will give you the most latest kind of up-to-date numbers. And so in that, it estimated that the current load of Alzheimer's patients in this country is about 6.7 million expected to get up to about 14 million or so by 2050, 2060. And we're really clearly not ready to deal with that number of Alzheimer's patients hitting our medical system. Here's one question I do lay audience, so I'll just do it for fun here. I actually did it at the AMA House of Delegates a few years ago when I was testifying on an important resolution. But I want you to look to your right, just to look at the person on your right. Yeah, if you don't have someone on your right, sorry. And then look to your left and look at that imaginary person. What I say when I give late talks is two out of three of you are gonna be impacted by Alzheimer's disease. And the reason I say that is either you're gonna be in that one third, and this is if you live long enough. Look, I hope everyone in this audience lives a rich, long life. But as you know, age is the greatest risk factor for Alzheimer's disease. And by the 80s, you have about a one in three chance of falling to that disease. And then you have to think, well, okay, that's one third. I said two thirds. Well, the other third is gonna be married or a child or related in some way in taking care. And there's no other condition, no other condition in medicine where two thirds of people who live into their 80s are gonna be affected by that disease. That's just astounding, right? And there is one condition, though, that's greater than that. Anybody know what that is? Death. Death affects 100% of us, right? So we have to think that we need more funds, more research, more things devoted to Alzheimer's and dementia care. And the other kind of statistics that are scary is we don't have enough specialists. And most of the time, individuals are not being diagnosed even by general psychiatrists. They're being diagnosed and sometimes incorrectly diagnosed by their family physicians or some other clinician. And those of us that do dementia care know that sometimes that works out okay and a lot of times it doesn't. You know, a lot of times what people get is what they term the diagnosis in adios. I don't know who came up with that term, but Pierre Terrio of our group told it to me first. And it's like, yeah, you got dementia. It's probably Alzheimer's disease. Here's some denepas over the stigmine. We'll see you in a year. Good luck, you know? And that's not what we do at Banner Alzheimer's and it's not what some of you do that work in other comprehensive models of care for dementia care. But part of the problem with comprehensive dementia care programs is you're not gonna find them in the Ozarks. You're not gonna find them on the Upper Peninsula of Michigan. You're not gonna find it in rural America. Very atypical. You're gonna find it in urban areas. You're gonna find it often associated with academic centers. We need to figure out some better way that we can manage our entire U.S. population of dementia, not just those who are fortunate enough to live near academic centers and have that advantage. By the way, we have increased in our rate of death from Alzheimer's disease, although COVID overtook it. But COVID now is coming down. COVID became the fifth leading cause of death and Alzheimer's then dropped to the sixth. But Alzheimer's will get back into number five spot soon if they haven't already. But the increase in deaths due to Alzheimer's disease from 2000 to 2019 is 145% compared to the curve being flat for breast cancer and prostate and a negative, a drop in deaths from heart disease and stroke. So we're really improving the care of people with other diseases, but we're lagging behind in dementia care. As you know, dementia care is an enormous cost to our society. Not only for the medical care, but also for the cost on families and lost wages and what people have to do to take care of their loved ones. As you know, one of the downsides about reimbursements for care is that there's no insurance that covers long-term care in terms of a national insurance like Medicare or Medicaid, just for dementia care. People, some people do have long-term care insurances, but I find that those policies are dwindling in how comprehensive they are and how much they really pay out. And with PCPs making most of these diagnoses, I saw a statistic that even if every person that said, my specialty is dementia care and Alzheimer's, treated, worked diligently to fill all their hours and see patients, we would only be seeing about 10% of the people with this disease. So that's sort of somewhat of my introduction. Okay, so I don't have anything to disclose. So again, what's our model like? Well, we have a very comprehensive model. We incorporate physicians from these three specialties predominantly. And then we also use advanced practice providers. Currently in Tucson, we have an NP, but we just hired our second NP. If you haven't heard, we hired that person. And they have NPs and no PAs right now, right? At your site? We had a great PA that worked with us, but she turned 70, retired last year. And then we also have two social workers at our site. Now, they do provide some psychotherapeutic treatments. You know, they're often seeing mild patients who are struggling with anxiety, depression. They may also work with spouses. They may do family work. It's really something that's very helpful and beneficial for our patients and family. And then we also have an entire research team. But you'll be hearing from our other speakers about some of the things we've been doing that reach out more into the community and how that's been helpful. But just one other mention about this comprehensive care model. And I worked for one back in Maryland. Anybody from Maryland? Larry? So I worked at Copper Ridge Institute, which was associated with Hopkins. And we ran very comprehensive assisted living programs that really supported our outpatient memory program, which we lost money at. And at 10,000 a month, our assisted living was able to sort of shuttle some money to us. And my story about that is, as things were progressing, Copper Ridge was a leader years before I ever got there. I didn't detract from their leadership, but they really had a great referral source. And as time went on, their buildings were aging. And unfortunately, families were voting on bricks and mortars and not programs. They saw the place down the street that was brand spanking new, nice outdoor arrangements that were more modernized than what we had. Suddenly our revenues from assisted living started shrinking and they started cutting programs. And I was fortunate enough to be able to move to Tucson and be part of the group that the three of us are in, in Banner Al Simons Institute. And our family and community service, as I mentioned about psychotherapy and counseling, but a lot of community programs, support groups, educational programs. We have a big speaker's bureau. We have a great newsletter. And if anybody's interested in any of that, we can give you some information. But we've also recently done a great podcast. And there's a number of, in fact, the most recent podcast was on dementia care partners, which you'll be hearing about. So 25 years ago, I was the director of behavioral health services for a large system. We had three hospitals. We had inpatient units, everything from child up to geriatric, IOP, outpatient and all. And administrators said, hey, we got this cool meeting we want you to go to in Chicago. And it was this sort of look to the future. And what they were presenting was a collaborative care model. That was 25 years ago. We're still nowhere near implementing a behavioral health collaborative care model today. It was fun to go to Chicago for a weekend. Anybody read Lori Rainey's book? It's still available. It's a good read. She's a pioneer in this area. So that's her book on integrated care. And just so you know, there are kind of different kind of terms. Integrated care, that's more of what we think of as a system-oriented approach to collaborative care, where you combine things like admin, EHR, billing and finance. Collaborative care is more related to the relationship. And that's people, physicians and other practitioners working together towards the better goal of the patient and family. So why collaborative care for dementia? And actually I forgot I had the 2022. So it's gone up by 200,000. So we're now at 6.7. And we talked about the death rate and the costs and the fact that the majority of people are seeing by their PCPs. And I'm not here to knock PCPs. I don't know how they do it all. I had my annual visit. I don't have any medical problems, but once a year I visit my PCP. And man, was he going to town on the keyboard. I mean, I've never seen anybody type faster than him when we were talking. And I said, Dr. X, I said, I've never seen anybody type that fast. His comment was, he laughed. He goes, Alan, I'm a primary care physician. This is what I do all day, which is rather sad when you think about it, right? But he, I mean, he still is a personable person and he's a QWERTY typist. So he can type that fast and still have that face-to-face with you. We talked about some of this. And again, you get out into rural America and most of these things just do not exist. Now we've had a COVID experience where suddenly some of this stuff could exist because people could do virtual visits. Not sure where that's going. I mean, there's some thoughts that there's going to be some changes maybe by 2024. You talk to people that do, how many people do a fair amount of psychotherapy virtually these days? Not too many, but when you talk to social works and people that do psychotherapy for a living, some of them are entirely now virtual. And why do we not utilize a model? Well, it's sort of the needle in a haystack for one of the most important components of collaborative care models. And here it is, good luck staffing. We've been recruiting for a geriatric psychiatrist down in Tucson for just about as long as I've been there. And it's a struggle to find good people in geriatric psychiatry and behavioral neurology. I know many of you are not neurologists, but the field of behavioral neurology who often specialize in dementia care. But I think the harder thing to find if you're going to do a collaborative care model of a typical model is a care manager that knows dementia. So if I'm doing a behavioral health care model and I'm talking about all ages or adults, if you want to just limit it to adults, it should be a fairly good pool that I can choose from, from social work, advanced practice nurses, nurse practitioners who really know behavioral health. But to find one of them that know dementia care, which is quite different, is not easy. And then here's the problem with revenues. I remember when a talk was given a few years ago at AAGP by one of our past presidents and leading people in the clinical field, he basically said, the only way collaborative care models work is if you work in an academic setting where you have a large body of people working through that academic to make that collaborative care model work. Does anybody know what the biggest problem with the collaborative care CPT code is for psychiatry? No takers? It's the money. The money doesn't go to us. The money goes to the PCP. The primary care provider then determines in the collaborative care, if you're using the code, there's the code, maybe you didn't know that there's a mental health collaborative care code, but that money goes to the primary care provider. They then get to decide how to use those monies and they're not wanting to pay you all sitting down here what you're worth, I can tell you that. So it's harder to set up in a non-academic setting for that reason. Geriatric medicine. You look at the numbers of people in 2022, there were 411 spots of fellowships in geriatric medicine. This would be either family medicine, docs finishing a residency or internists. And about half went into that specialty. We need to, if we were gonna treat elderly, even beyond dementia care, we need to probably at least quadruple that number. But it's not happening. What about psychiatry fellowships? And if you look at geriatric in the red, if you look at the bars on the right, we went from 58 in 2014 and in the past, we were actually up to about 70 or so spots that were open. And then you look over to the right, we're down now to 52 being filled. So we're really not doing a great job with fellowships for geriatric psychiatry. About the only one that seems to be growing much is child and adolescent. And then the other one that tends to be one that people go into financially that's doing okay is forensics. And so the five-year change for geriatric psychiatry fellowships is a negative 21.4% over five years. Now this was data going up to 2021. I tried to get newer data, but I couldn't find it. But still, given our experiences and your experiences in Phoenix, we struggle to fill these fellowships. Way back when I was in Maryland working with this company, I said to myself, you know, we're gonna do a pilot program. We're gonna get some funds and we're gonna do it just with a, there was a primary care group I knew well, four docs, four nurse practitioners, and we'll do this pilot project. And we got funded at X amount of dollars and things were moving along swimmingly. It had a lecture component once a month where the doctors would attend. It had the typical features of a collaborative care model. And as we moved later down the road, I talked to the medical director, a friend and colleague who said, Alan, what are we getting from this financially? And as well, you know, you're gonna be getting great talks. You're gonna be understanding how to treat your dementia patients and how to do it the right way. Yeah, but what about financially? Oh, we're gonna pay for the care manager and that won't come out of your cost? No, what are the docs gonna get? And I said, what do you mean? For my docs and my nurse practitioners or the practice nurse practitioners, nor his personally, of course, to attend your monthly lectures for an hour, we're gonna need the dollars that they would have recouped in revenues from seeing patients for that full hour. And suddenly eight times that number monthly broke the bank and we ditched it. So this is a little typical diagram of a typical collaborative care model where you have the psychiatric consultant that is gonna be working somewhat with the patient and medical provider, but really be in touch on the bottom line with the behavioral health care manager, going over cases and deciding which cases they may need to see or which cases they may need to discuss with the primary care doc. And so most of the things that are going on in a true collaborative care model are between the psychiatrist and the care manager working in these primary care offices. And the use of the registry is important for data mining and keeping up with the data of these programs. There are other models. There's a model of co-located care where you sometimes see that. We have some places in Tucson that do that where they have behavioral health and primary care right in the same facility. You probably have some of those in Phoenix as well. And then other, the coordinated care and then the integrated care. So you could just look over that slide briefly. By the way, did people know that you can get these slides on the app? I didn't realize that until I looked at that. So a lot of these slides are available on the app. And this is from a colleague who is up at Harvard, although moving to Tufts, Brent Forrester. And I quoted this from one of his recent papers. Successful implementation will require internal champion leaders from primary care, geriatric psychiatry, behavioral neurology, social work to collaborate and convince their leadership and colleagues of the health care savings and quality of care improvements that can be realized by timely and coordinated implementation of these evidence-based collaborative care models. And this is just another impactful statement. Focused dementia care training enriches care conversations in important topic areas for persons living with dementia and their family caregivers. So we need to move here. We need to move here yesterday. I don't know that CMS is ready to look at how much they would be willing to spend on a dementia collaborative care effort, but we need to convince them that this has to happen. We are in a state of Arizona where we have the largest increase in new cases. We lead the nation 33% compared to many other states who are in the single digits or teens of new dementia cases. We're going to move on now to our other speakers, and you're going to hear about these three programs that we're currently running. One of the topics for questions and answers might be, you know, the big question in my mind about some of these programs is sustainability. You know, it's great when you can get large grants and run some things, but you have to figure out how do we do it when that grant money is over. So we'll take questions at the end. I'll have Ganesh come up and he'll introduce himself. Great. Thank you, Alan, for setting this talk up. So me and Dr. Joshi are going to talk about specific models of care that we have operationalized at Banner Alzheimer's Institute. I am Dr. Ganesh Gopalakrishnan. I am a geriatric psychiatrist, and I am the associate clinical director for the clinic at Banner Alzheimer's Institute. I am also the program director for the Geriatric Psychiatry Fellowship at the University of Arizona, Phoenix. So I'm going to talk about a couple programs here. One, first disclosure, I work as a consultant for, like, Roche Navify. I don't think there's any implications to this presentation, but if you feel otherwise, please let me know. The objectives for this part of the talk, just to understand what Project ECHO is and what are we doing at Project ECHO for Dementia at Banner Alzheimer's Institute and what are the outcomes and challenges that we've had running this program so far. So how many of you here are familiar with Project ECHO? Okay, so a lot to learn for this group then. This is a very interesting model of education. So this was launched in 2003. Dr. Sanjeev Arora was kind of the pioneer of this program. He's a hepatologist and a social innovator in University of New Mexico. So he started noticing that patients were coming in really late in the course of hepatitis, having hepatic cancer, and he was wondering, like, how can he change this trajectory so that people can get the help with their primary care physicians or the frontline workers that they see routinely and how to equip them with that knowledge. So he literally started driving across the state and meeting all these people and starting training them as to how to take care of patients with hepatitis. And then they moved this model to a virtual platform. So they use a platform like Zoom, and they started interacting with primary care physicians who take care of patients with hepatitis, training them periodically based on case discussions and seeing what their outcomes were. Eventually they published this paper in EJM, comparing their outcomes at University of New Mexico in their specialized center with the folks who participated in this project, and they were very comparable. So that really showed how effective this program was. And since then, this has kind of really blown up. There's so many project echoes that's been used for all types of chronic disease management, and even with COVID, there were so many project echoes that were operational. And it is not all out of University of New Mexico. Anybody can incorporate it. It's kind of the idea that you train people to take care of these medical conditions, and it can be a lot of different things. But interestingly, it's been even taken into fields like education, social welfare programs. Across all continents, their goal is to touch 2 billion lives or something like that. So I think they're just going to be on the way to get that done. So the key aspect of Project ECHO is how can we get high-quality services with how much of geographical and economic disparities we have? How can we reduce it and get that high-quality service in remote locations? And from people they know and trust, like primary care physicians that they go see frequently. So they use adult learning techniques and interactive video technology connecting community health workers with specialists at centers of excellence in real-time collaborative sessions. So this is a hub-and-spoke model, with the hub being the specialized center and the spokes being the community health providers. And it's all geared towards developing and disseminating best practices, case-based learning. So you will see that the format is very much typical of any Project ECHO session. It's meant to have a didactic session where we focus on one small topic and then to have case discussions about the cases that people are seeing in their field of work and what specialists have input on those cases and how they can treat them better. So this provides skills and confidence for the providers who are taking care of these patients. And specialists also learn new approaches for disseminating their knowledge across diverse cultural and geographical contexts. So this is a very important slide. It's not telemedicine. The people or the providers at the specialist centers are not providing direct patient care to the patients. They're, in fact, training those providers to take care of those patients. So we don't deal typically with any HIPAA material. So it's different from traditional telemedicine. Now, Alan has gone over this quite in detail, so I'm not going to stress too much about this slide. We already know how much of a significant problem Alzheimer's disease is. But like Alan alluded to, even if we fill all the fellowships, which is stretch and aspiration, we will not be at a point where we can meet all the needs of the dementia patients with specialists. So I think we need to figure out how to train other physicians and workforce taking care of these patients. So now Banner Alzheimer's Institute, where all three of us work, has a three-part mission. End Alzheimer's without losing another generation. And the second is set a new standard for patient and family care and forge new models of collaboration in biomedical research. And we believe that Project ECHO really relates to the second and third missions for us. So setting a new national standard for patient care, we partnered with Project ECHO to work towards it and train professionals with specialty knowledge and tools, helping them manage memory disorder patients in their clinics. In 2020, we became a hub for Project ECHO. The way you go about it is you have to enter a collaboration agreement with them and agree to adhere to their practices and what their model of education is. So we launched it in 2020. So this became Project ECHO with our BAI became the Dementia ECHO for us. So this was right in the middle of the pandemic, and good luck finding anybody who wanted to collaborate with us talking about dementia care. Because everybody was remote, they were really grappling with the pandemic, and we couldn't really find cohorts to start working with us. We got a little bit innovative and started working with the VA locally for training the psychiatrists, neurologists, PCPs there, and eventually we have grown. And I'll talk about what we've done so far. It benefits to the participants with our program. You know, they get low-cost CMEs. If they're part of the Banner system itself, it's free, but apparently there's some antitrust laws which we don't understand very well, the lawyers told us that we cannot give out CMEs easily. So it's $35 for 12 CMEs, which is as cheap as it gets. Then we also have certificates of attendance for other specialties. We, you know, promote professional interactions with colleagues with similar interests, mixing work and learning to promote their knowledge. So we have 12 sessions. A lot of the project echo sessions are perpetual, like they just keep on going. They're not time-limited, but we made a strategic decision of having 12 sessions to improve engagement and retention through the process. And it's always hosted on Zoom over six months, so it's every two weeks. We engage with the participants. So, like I said, 15-minute didactic session. I'll show you the curriculum in a little bit, focusing on one specific area of the knowledge. We put together the didatics to kind of cover everything you need to know about dementia care, and this is followed by about 40 minutes of case discussion. We encourage participants to bring their own cases, and as you'll see, that's one of the big challenges we have with this program. And here's kind of an example of a case presentation form that we put together to just allow them to think as to what are the things that they would need to present that case. Here's kind of the curriculum. Again, like I said, we wanted to focus on everything that's needed for someone to take care of patients with dementia, and this is that 15-minute didactic sessions. And it's always aligned with the case that we are going to discuss on that day. So if nobody brings up the case, we have some cases that we can get from our practice and just demonstrate what to do in those situations. As you can see, we have a good amount of education about introduction to Alzheimer's, how to convey diagnosis, pharmacological treatment, and we focus heavily on non-pharmacological treatment, medical-legal issues, and end-of-life treatment, too. And we also are really keen on getting the data and seeing how effective these programs are. So we do baseline surveys to assess confidence, knowledge, and attitude among participants, and then we again repeat it at the end of the course. They also get a survey after every session, which is brief, but we are really specific about getting the post and pre-session. Again, I mentioned this already, so it's really no cost for people with Banner, but cheap for others, too. We start in October 2020, like I said, and we have completed six cohorts. One is in progress. We are about to complete it, and we have three more scheduled for this year. We have also engaged trainees who are about to graduate, because those are the people who are going to go out and practice dementia care. So we have tried to get geriatric medicine fellows, psychiatrists, psychiatry residents, family medicine residents to come in and attend on an abbreviated course. So that's one of those three scheduled for 2023. So far, as of December 2022, we have had 77 sessions, so I think now we are about 85, with over 250 so far that we have trained. I'll show you the different specialists that have participated in these sessions in a bit. We have engaged with a lot of different health systems. Cigna Health Care locally, the VA is one of our main partners that we have worked with over the years, and Banner, we have engaged with the hospice group, the palliative care group, home health, pharmacy. We've tried to get as much interdisciplinary focus into that program as possible. Last year, we got awarded $250,000 from the Maricopa County, which is the biggest county. I'm sure you've heard about Maricopa County over the last couple of years for other reasons. In September, we got this grant, and we are planning to train another 250 individuals by 2023. So this is kind of one of the challenges with ECHO programs, as Alan alluded to, sustainability. How do you sustain these programs? We were able to get this off the ground due to philanthropic support from a big donor, but keeping this running is going to be a challenge going forward. It's kind of the breakdown of all the specialists or professional backgrounds that we've had participating. We participate as a group from Banner Alzheimer's Institute, as a multidisciplinary group, and we also invite people to come from all types of medical competencies. We have physicians, nurse practitioners, physician assistants, medical assistants, psychologists, social workers, and this other sometimes includes physical therapists, occupational therapists, music therapists, and it's amazing the cases that they bring in and the perspective they bring into these cases. It's been really very interesting. And you can see that on the key, some of these outcomes on a scale of 0 to 10, how likely are you going to recommend this program to the colleagues? In a 40, we were at 9.4, 4.7 for people who felt this was valuable in their job and how it improved their satisfaction in their job. So we are really proud of what this program has done so far. So barriers and implementation, the biggest thing is to ask for time. When we started the program, we knew exactly who we wanted to target. It was obvious it was going to be Banner system, which is the health system in Phoenix, primary care physicians in Banner. Obvious, no question. But then we started this in the middle of the pandemic. We asked the leadership and they're like, oh, no, don't even bother PCPs. They're too swamped now. We cannot do it. And then just a couple of months ago, we're like, okay, now the pandemic is all done. It's behind us. Can we have this conversation? And they're like, no, we have been asked to do too many things. I cannot ask this to be a mandatory thing. So they were willing to have this as like an option for them to participate, but getting the time out of the clinic and dedicating it to this session is kind of the challenge. Finding collaborators, again, similarly in the community, finding time. The other low-hanging fruit, in our opinion, is long-term care facilities. There are so many people with dementia in these facilities and so much of hospitalization. We really think that this training can reduce costs. But again, how do you find time with those people? When do you get, is this between shift changes or is it after their break? Is it on a weekend? How are you going to reimburse those times? So it's all these things are very challenging. The second biggest challenge we have is once we get these people into these programs, is to have them bring them cases. So oftentimes that's probably the biggest strategical discussions we have in our team meetings as to how to improve case discussions. We've kind of tried a lot of different things, and we think we got something, but it keeps changing. Sustainability is going to be a continuing challenge with this. And also training a team and making sure that we have backups available, because I've been running this program for a couple of years now, and I need to have backups. If I'm not able to do it, somebody else can lead the discussions. The other thing that we have learned in this process is what is the right time for the group to engage. There's a typo here. The leader may not know. So we engage with the leader. The other thing we have learned is if we identify a leader, a champion in this group of these medical providers or this team, and if they say, you know, this is a good program, come on, I want you to attend it, just one email just gets us a lot of registrations to the program. But that leader may not know what is the best time that would work for that group. So we will have to kind of think about, okay, is this a noon hour or is it after hour? Because one example I'll tell you, this health system lead said that five to six on a Tuesday would be the best time. We said, okay, we'll make it work. It was a stretch for us, but we will make it work. But we didn't have much participation. But noon hour has tended to be a much better bet for us. So we are really thinking about, like, how can we integrate and be sustainable being part of value-based health systems? And we've been working with population health management groups in Banner. And I think this is going to be a very important piece. And now we have some engagement with a couple of groups who are interested in keeping this as a part of their training programs, even as a bid for their proposals. And I'll talk to you about, like, a program called DCP, and we see a lot of mutual fit. And here comes DCP. So DCP, or Dementia Care Partners, started off as kind of like, how can we make primary care physicians just focus on what they're doing with taking care of patients with dementia? You know, they have multiple medical comorbidities. Let them take care of that. How can we assist them in managing the non-pharmacological, social aspects of dementia care? So that's kind of like the idea of Dementia Care Partners. And we have a few, a couple other programs in the country which are similar to this, but we essentially want to provide that non-medical education support to the PCPs. These services are provided either in the patient's home or after the pandemic. It's mostly virtual, either through a video visit or a phone call. And what we have really wanted to do is to create this workforce with CNA-level dementia-capable health coaches. So we provide them intensive training over eight weeks. And this is overseen by a multidisciplinary group, including myself as the medical director, a registered nurse, social worker, overseeing the work of the CNA-level health coaches. And I've been really amazed to what level the health coaches can work at. They're just getting all kinds of nuances about like how to do a cognitive evaluation, functional evaluation, presenting these cases and providing education for these patients too. It's a free service. Again, this is funded by philanthropic support by a couple grants. So it's right now, it's a free service. We started off piloting with a few groups and then we expanded it. And now you will see that we are going into a different phase of the program where it's open for the whole state of Arizona essentially. So the eligibility, the way we defined it was it should be a person more than 65 years of age residing within the 30 mile radius, had a caregiver who resided in the house. So we did not want to take anyone who was in a facility because we didn't think it would be useful for them. And who did not have like an unstable psychiatric condition and is not currently in hospice. We also kind of restricted the eligibility to people with Banner Health Network so that we wanted to see how the outcomes were. We were under the impression that we would get the data from them easily if we restricted to the Banner Health Network. So overall, our goals were to reduce total healthcare costs. We believe that we can reduce ER visits, hospital admissions, improve the quality through appropriate medication usage. And that includes taking people off of inappropriate medications and putting people on appropriate medications like cholesterol inhibitors and antidepressants. And increase provider and caregiver satisfaction and reduce caregiver burden. These were our main goals. And one of the main caveats or mission of this program is to reduce the burden on primary care and improve their efficiency. And we really want to focus on how to communicate with the PCP very effectively on Cerner. Keep it very plain and see how we can assist them in making good decisions. Also, we provided them with initial updates saying that, okay, this person is enrolled with us. This is what we think we should do. And then again, quarterly, just to tell them what's going on with that program. We want to minimize barriers and prevent crisis. And again, one of the main things is to develop this new workforce. So in the first phase of this program, we identified 1,763 patients. Eventually found 445 as eligible and enrolled 203. And we finally engaged about 102 to complete this program. We published the results of this data in Journal of Geriatric Sciences. The key things that we learned was it requires a very effective and abundant diet referrals. Like we need to get that information as to who's eligible and so that we can engage with them. There is a lot of gaps in data collection. One of the other things that we really learned is the information in your medical records are almost always wrong. Either medications, diagnosis. We think that this person has dementia but they've been diagnosed with mild cognitive impairment or something else. So it's, but they're already on cholinesterase inhibitors and memantin. And they're also on noxivutinin. And it's a lot of errors. So there's also some difficulty maintaining engagement over a period of time and some duplication in documentation too. So now the DCP 2.0. This is the version that we created after our first program pilot was completed. And we want to restrict this to only six months. And the idea was to improve diet engagement retention and develop a hybrid in-person virtual visit model. And also we excluded MCI cases. In the first model we had people with MCI. But oftentimes they were not engaged because they did not have much of functional deficits. They're like, what are we doing here? So we wanted to take them out and focus only on patients with dementia. And we also streamlined our instruments that we used because some instruments that we incorporated initially were like, why are we doing this? And we are not even looking at this data for whatever we are doing. So we just changed those things. And we reduced redundancy and increased efficiency for the whole program. So the key things are we can, we want to have an interdisciplinary approach. And this is some of the other things beyond DCP that we offer from family community services. We also have a support line for patients to just call in at any time and get some input as to how to deal with behaviors. Before we had a lot of problems with transportation because if we had like two diets then they were separated by 20 miles. People had to go one place to the other. We had to factor in the transportation time. Now we've switched to mostly virtual visits. So that has cut down that requirement quite a bit. And we have been really good in even doing the virtual visits too. And again, it's philanthropic funded. This is another place where we, this is, sustainability is an issue. And we have partnered up now with the long-term care services group. And they have expressed interest in making this part of their bid. So we are trying to see how we can get into a cost-sharing agreement for the risk when they put in their bids for the product. So with that, I'll leave this slide here as a transition slide for Dr. Joshi to step in. These are the project echo sessions that are going on. The one starting February 2023 is in the, we are in the middle of it. So we should be winding that down. But we have a couple more starting soon. So if people are really interested in participating in it, just please email us and we will get you on it. Thank you. All right. Thank you, Dr. Anderson and Dr. Gopalakrishnan for such a great introduction. Thank you all for being here on Saturday morning. My name is Pallavi Joshi. I'm a geriatric psychiatrist at Banner Alzheimer's Institute and I'm also the associate program director of our geriatric psychiatry fellowship. So I'm gonna be talking about our geriatric psychiatry clinic, no disclosures. So earlier we found out that a lot of you are geriatric psychiatrists and the ones who aren't clearly have some interest in geriatric psychiatry. Otherwise you wouldn't be here. And we know anecdotally and empirically that there is a significant number of people, of older adults in the US struggling with various mental health conditions. This shows a graph from the Commonwealth Fund International Survey that 32% of US Hispanic adults and 21% of US adults who identified as white have been diagnosed with a mental health condition. That number far outweighs the number in other countries. The access to care is key to diagnosis. So we are just looking at the proportion or the number of people who have received a diagnosis. We are not even capturing the vast number of people who haven't seen a mental health care provider or even a primary care physician to have a mental health diagnosis. The suicide rates in adults over 70 are 36.26 per 100,000 individuals. So we do have a geriatric mental health crisis. We have a geriatric suicide crisis. And despite this, there are significant treatment gaps. Mental health services are underutilized. Only about 3% of older adults have access to specialty mental health care providers. And older adults with psychiatric conditions have poorer health outcomes and increased health care costs compared to younger adults. Geriatric psychiatry is already pharmacologically and socially complex. But when you add dementia to the mix, it complicates the picture even further for a number of reasons. The first is that the goal, the treatment goal of psychiatric conditions like anxiety, depression, psychosis is treatment to remission. But there is no treatment to remission in dementia. And so how do you really measure the health care outcome or the treatment outcome in a condition that you know will not remit? And how do you compare the current improvement from what could have been? The second thing is that we know that while the prevalence of behavioral and psychiatric symptoms or neuropsychiatric symptoms in dementia is high, it's ever evolving and varied and heterogeneous. And so it's a moving target. So once you stabilize one neuropsychiatric symptom of dementia, that may not be a permanent state. Another symptom may emerge or that symptom may worsen in severity. So keeping track of the ambiguous and ever emerging neuropsychiatric symptoms in dementia, it does complicate the picture further because you can never really be assured that once you've stabilized one condition that they are perfectly okay to be discharged back to primary care and will never experience another neuropsychiatric symptom again. And the risk is much higher than in a general adult population or a population without comorbid dementia. So Dr. Anderson talked a lot about collaborative care. There was a study that compared integrated mental health services versus enhanced referral to specialty mental health services in 10 randomized sites and looked at close to 25,000 primary care patients who were age 65 and above. And they found that the retention to treatment was significantly higher in the integrated care model compared to the enhanced referral model. So as realtors say, location, location, location. If you look at this graph, it shows how location and co-location of services affects treatment engagement and affects treatment engagement. Starting from the right, if you look at the yellow bar, there were people who received enhanced referral care to facilities within 10 miles off each other, totaling five clinics. The treatment engagement was a little over 40%. When the location was changed to the same medical campus, the treatment engagement slightly increased. And then when it changed to the same building, it is now a little bit above 50%. However, when they change it to the same practice area, so not the same building, but the same practice area, so perhaps the same floor or the same wing, the treatment engagement is now close to 70%. So location does matter when it comes to treatment engagement. So I'm gonna talk a little bit about the Geriatric Psychiatry Clinic at Banner Alzheimer's Institute. Our mission is trifold. The first is education. There is a shortage of geriatric psychiatrists. There is a dearth of fellowship spots. So our mission is to train residents who, even if they don't pursue geriatric psychiatry as a specialty or fellowship, are competent in diagnosing and addressing some geriatric psychiatric presentations. And it's also to train our PGY3 residents in their ACGME-required clerkship as well as our geriatric psychiatry fellows. Second mission is clinical care through the Geriatric Psychiatry Clinic. And the third is to pilot these new models of collaboration. So we have a fairly small provider group of about six providers. The majority are neurologists. And we have two broad models. The first is internal referral. So they would make a referral, they would be seen in our clinic, very straightforward. The second is curbside consultations. There's often a prevailing myth, I think, among geriatric psychiatrists that other people don't want to do geriatric psychiatry. We found that not to be really true with our neurologists. They've really taken to this. And so usually, I mean, classic presentation would be a patient of theirs with dementia who has a neuropsychiatric symptom. Let's say it's depression. They start an SSRI. The SSRI isn't working that well in the curbside consult. What do you recommend for augmentation? Over the past year, they've stopped even asking me that question. They just tell me, oh, by the way, I decided to read an article and I just decided to augment with Abilify. So they've really taken this ownership on the next level and are really excited to be doing this. So I think our colleagues in other specialties are excited to learn geriatric psychiatry and use it in their own patients. All right. So we have several ambitious goals. Some are a little bit grandiose. So the long-term goals for our clinic are number one, to reduce the total healthcare costs and reduce the number of emergency department visits and psychiatric hospitalizations. We know that managing neuropsychiatric symptoms in dementia decreases the overall rate of ED visits and psychiatric hospitalizations. It also reduces the overall healthcare costs and healthcare utilization. And finally, it helps enhance interdisciplinary care. Another goal is to improve treatment efficacy by decreasing time to evaluation. So in this manner, the curbside consultation comes in handier because the patient doesn't have to wait for an intake spot to open up for them to be seen. The neurologist or geriatrician who's already seeing them and knows them is able to either start a medication or augment or through curbside consultation, perhaps even determine that that is not a need. And that decreases the time to evaluation and treatment. And thus moves to a faster remission of symptoms. And finally, one of our goals is to decrease polypharmacy. Another educational goal is to increase geriatric psychiatry competency among trainees. So we know that the number of geriatric psychiatrists is limited. And even if there were a lot of geriatric psychiatrists, there are people in rural areas who will not be able to have access to a geriatric psychiatrist. It's just not possible. So we need to extend that competency to non-geriatric psychiatrists so they can at least, they can competently manage this population. And also to increase recruitment to geriatric psychiatry. So a lot of the, I mean, our current fellow who were graduating in about a month became interested in geriatric psychiatry when she started doing the clinic with Dr. Gopalakrishnan. So being involved in that clinic, seeing the impact that this management can have on patient outcomes, and also realizing that there is some value to geriatric psychiatry training attracts residents to geriatric psychiatry fellowship. And finally, it increases patient and provider wellness. Management of the neuropsychiatric symptoms decreases caregiver burden, improves patient satisfaction and patient wellness, and also decreases provider burnout because the patient is now, patient has decreased complexity and morbidity. Okay. There are still several barriers to our geriatric psychiatry clinic, especially to recruitment and turnover. Currently, our referrals are predominantly internal. We have started to get some outside referrals, but we're still a new clinic. We've only been active for less than two years. So increasing awareness in the community, increasing awareness outside of our healthcare system to community PCPs has been challenging. And then there's also screening for appropriate referrals. So we may get a referral from a community, but they may be somebody who is not geriatric, not psychiatric. It may be a case management referral. It just may not be an appropriate geriatric psychiatry referral. We're limited by our resources as well. There's a limited number of trainees and a limited number of attendings. And that limits how many patients can be competently seen and managed. And the staff time is also limited in terms of the administrative management of this clinic. While the collaborative approach reduces the time to evaluation, it can sometimes increase time to remission of symptoms. So non-specialty providers may be more reluctant to increase doses of medications. They may not feel comfortable augmenting. And so it does increase time to remission of symptoms. And there may be provider discomfort, which is why our subspecialty system exists for referral. And finally, cognitive impairment, as we all know, poses barriers just to the individual visit itself. We may need a longer duration of visit for somebody who is cognitively impaired. The reimbursement rates are an issue. And sometimes people who are cognitively impaired but still living independently may need multiple reminders or multiple ways of being reminded about their appointment, which utilizes more staff and provider time. They may no-show, which also takes away from a potential clinic spot that could have been used. And then even though the data shows that co-location improves outcomes, sometimes in multidisciplinary teams, that can be a little bit confusing. So, you know, we see our dementia patients in the Banner Alzheimer's Institute, and then they're referred to the Geriatric Psychiatry Clinic, which is also in the same floor. And now there's a little bit of confusion. Well, I thought my appointment was in six months. Why are you telling me to come back in four weeks? I thought I was seeing this doctor. Who is this doctor? When are we, you know, are we going to talk about my dementia? Like, actually, no. The resident is not going to talk about your dementia. They're going to talk about your depression. So it's confusing for the patients and the staff. So, all right. So, actually, that's the end of the presentation, which leaves us with plenty of time for questions. Thank you, PJ, and also thank you, Ganesh. So I'm glad that we have plenty of time for discussion. Knowing that lunch is right around the corner, none of us are going to be upset if people want to leave early, but I'm hoping to get some input from you. I have one quick question. How many folks here, when you do a psychiatric evaluation on a patient, send that evaluation to the primary care doctor? Not many hands went up. A couple. So those of you who do that, you're actually doing a form of collaborative care. How many people have been using time codes since 2021, using time? Not many. How many people do it by MDM, if you know what I'm talking about? Yeah. Okay. So MDM, medical decision-making, is really what psychiatrists, neurologists, geriatricians, internists, that's how we really prove our worth, right? Is how do we take what's up here, apply it to this patient in front of us, and make some difference in their life? And I have always instructed folks to write notes in that regard. And since I worked for many years in a rural area, I wanted to make sure that these primary care doctors knew what was up here. And what was very rewarding, having worked there for almost 30 years, is you weren't getting as many people referred to you because they kind of knew how to do this. They kind of said to themselves, well, what would Anderson do in this case? And so if you've been some, and that's why I hate notes that just say, assessment and plan, dementia start ariseft, all right? Or, you know, depression start acetalepram. I really like to put out in my notes what is the reason why I went into this field, is to explain to these doctors that are going to get this note, what's in my head that makes me think that this treatment is what they need. So if you've been doing that, and hopefully you will, that's kind of a version of collaborative care, reaching out to the primaries and letting them know how you're managing that. You've heard some different models we're doing, both of which are, well, not necessarily the resident clinic, but the other two, the dementia care partners and Project ECHO, are sponsored through grants. And again, we really need to find a way to have some of this paid for. So I'm hoping that people may have some thoughts about that. And one of the things I'll mention, you know, you have our names from the talk or on your device or in the program. All our emails are very easy, by the way. It's our firstname.lastname at bannerhealth.com. So you can contact any of us, firstname.lastname bannerhealth.com. We'd like to hear from people that come to this talk. We really want to figure out how do we get this covered better? How do we get it out to the hinterlands? And I'm excited that some of this is going to be going to rural areas of Arizona. But we have plenty of rural areas that are just underserved. And by the way, that's like one of the, just as an aside, one of the biggest crying foul of the Alzheimer's Association, right? They're not approving these latest advancements in Alzheimer's disease, these monoclonal antibodies for payment. They're saying, well, we need more data. You've got to be in a study. Well, that doesn't help people that live in rural America because they're not going to be living near any place that's likely going to be doing a study of leucanomob, denanomob, aducanomob. And so we're really disenfranchising our rural populations by having things like that. Now, that being said, you know, there's pros and cons of these new medicines and some concerns about side effects that certainly complicate that picture. But how about some people standing up to the mic and giving some thoughts or questions for any of our discussants here? Everybody's saying, you know, lunch is right around the corner, you know? Any other thoughts that you want to share in case somebody wants to come up? So I have one concern. Yeah, thanks. So one concern with many of the health systems that's sharing records to primary care physicians is that on Epic, they have actually turned down that so that none of the other people can see a psychiatry because of the confidentiality. But that's why unless it is asked specifically or a release of information has been signed by the patient, we don't usually share it. The second problem is, you talked about writing a good formulation of why you came up with a diagnosis. The problem why in a department that people don't do that is they're like, you know what, I can spend my whole day writing that note, but how many less patients will I be seeing because of that? So those are the two main problems that you get with sharing notes, doing more of an in-depth assessment. Using the resident clinic, because I run that, is a good model to doing that because we have one hour per patient for every patient. So there you can do that, which is much more of a teaching role where they present the information to the patient and their families while the chair, that is me, is sitting there listening to the conversation. So I facilitate the discussion, but I do not discuss anything else because that's their role as a provider for doing that, which is more cost effective because most of the collaborative care is not paid through reimbursement from private insurance or other things. It's actually paid by grants, like you pointed, or philanthropy. Now that's the problem with that, it's not sustainable. When it runs out, it's great care, everybody loves it, but who's gonna pay for it is the question. So I think the easier model of sharing this would be for using trainees to actually be the primary psychiatrist while attending supervised, so they can supervise more number of trainees, do the great work, because as you pointed out, clearly we are going down the number of geriatric psychiatrists in the country. So using them as teachers, facilitators, rather than primary psychiatrists. Because I think it's sustainable that way, so they get the reimbursement rather than individual one-to-one patient issues. So it's a problem and it's probably a solution. Thank you, Dr. Tempe. What Dr. Tempe just did was a commercial on how our health system is broken. If you don't already know that, you might remember a guy named Bill Clinton when he was president, had a great healthcare plan, but of course it wasn't gonna fly because it meant that we would have some sort of national EHR. And so the whole point of EHRs helping doctors, how many people feel it's made our lives easier? But EHR does collect data, that's an important point of EHRs, to be able to get data, to use big data, help our public with use of that big data, but at the same time it's not helped us. In terms of the confidentiality, I'll take a little different viewpoint. If I get someone referred to me for an evaluation by a PCP, I don't worry about confidentiality because the expectation is they're coming in voluntarily, they're agreeing to come in, of course I'm gonna send that doctor a note. I don't worry about whether there's a signed consent, I just send the note. Now of course I can't send it in, we use Cerner, I can't send it in Cerner to an outside doctor who's not on our system. And so it also means that my medical assistant has to then take that note and put it in a fax and fax it to the doctor, but they're still getting it. But I understand that, and it just seems crazy that now, I don't know how long it's been since Clinton's been president, but it's a number of years, we still don't have a system. I think that our European colleagues and other places laugh at us because we're 38th in the world in quality, but we far exceed the costs. And a lot of it is this fractionated care that people get where there's lack of communication. We gotta fix that, folks. And thanks for your comments, and I understand that. I just am still caught up in my way of doing it too, and it takes time. We fortunately are able to do that too because we give ourselves an hour and a half for a new patient. So we have the time to really put our thoughts into that medical decision-making piece, which is the important piece of why we're in the business. Thanks. Yes, thank you. It's an exciting time for medicine, providing care to the communities because taking the science, technology, you know, medicine to a different place, and it's changing how we do things. And the big challenge I find in working institutions is creating a vision for them. They need a vision. We know we want to make a change. We know we need to change, but we're so used to doing it this way. They just see the old way of doing things. And the goal is to create that vision for someone to see it. And I find it's better to do, instead of going to a large institution, but again, going to maybe one small section of the institution. We're gonna go to Four North, and that's the only place we're gonna do it. You follow me? Something like that. And finding people that have a strong interest in making change, and they can see the vision. Because we do need to make a big change. Thank you for the work you guys are doing. Yeah, well, thank you for your comments. How about some comments from the two of you on that issue? Yeah, I think one of the key things, one of the main challenges is change is hard, right? Like anybody, you propose change, it just means that life is gonna alter, and they have to make adaptations. Change is hard anywhere. I think also we are in a place where we have to show effectiveness for people to incorporate change. And that becomes a challenge when you're coming up with this idea which has never been tested. So I feel very fortunate to be in a place where it's kind of an incubator. I've come up with ideas, and okay, let's go ahead and do it. We've done some of these projects. But, yeah, I see the point. It's challenging. It may not work out everywhere. PJ, any comments? I think, you know, speaking of change, I think it's even more challenging when you're trying to train a new generation of psychiatrists because I think we have to be mindful of their workload and capacity, and the ACGME is increasingly making that a priority, you know, as they should, but they're increasingly making resident wellness and resident time commitment a priority. So we have to be mindful not just about the amount of work but the kind of work that we're asking them to do and adding, you know, stressor or change. When it's not really clear how that'll support their ACGME milestone development, it's extra challenging. Other thoughts from the audience? Were you having lunch? You know, at some of these conferences, the exhibit halls would open and there'd be lunch for us, right? I don't think that's the case here. Yes, come on up. This is a great presentation. I want to comment on the ECHO program a little bit. There's a lot of experience with ECHO and educating primary care and other disease states. You touched on the hepatitis index experience. If anyone ever gets a chance to kind of poke around on the ECHO website and your website to understand how many people this program impacts from a primary care perspective and from a patient care perspective. I mean, their mission is to reach 1 billion people worldwide. You are one element of that, but it touches on pain, depression, diabetes. You named the disease state. ECHO is a way to really touch a lot of lives and it's fantastic to see that you're doing this work here because the dementia is exploding. It will explode when the new therapies come. Primary care will have this task and they're not ready. They're not ready. You're helping it ready, but ECHO is a big way of expanding that reach. And that's one point, the breadth of experience. The second point is there's often, and you touched on this, there's this emphasis that it's a vision of telemedicine. It's not. And I know you highlighted that, but it's also there's this vision that the hub is coaching the spoke. And that's not true. It is really bi-directional. The spoke gives a lot of information to the hub. So if you're in rural Arizona and you know where to get a walking care where you can get a discount for people who have functional impairment, you can feed that to the hub in ways that the hub would never know. This has really had an impact on the diabetes world. For example, you know who the diabetes educators are that are involved in a given community or where the best restaurants are to eat a healthy diet, etc. It is really bi-directional. So that was two points. Breath, bi-directional. I agree. I'll start with the first point you made. I think it's a great tool to reach a lot of people. I think it's an amazing invention in my view. They do a phenomenal job collecting the data as to who is coming to these sessions, how much lives they can impact. That's how they're tracking. So all of our sessions get fed into their database as to how many people attended our sessions, how many people are completing our evaluation. We're also collaborating with Alzheimer's Association. They have their own Project ECHO. So we have collaborated with them in our local chapter. They have a national Project ECHO that they do. There are similar programs out of Washington. Portland has one. So there's multiple of these programs and they tend to coordinate some. But all of them feed that data to them. So I think they will reach that goal very soon. And I agree with you. It's very bi-directional. I think the best anecdote is a musical therapist presented a case. And you don't think about like, I mean, you read about music therapy having good evidence in calming down patients with dementia. But you don't see that play out in these cases. And she was just training as to how she would start. Like if someone is very agitated with a very fast-paced beat on a song, and then slowly bring it down, and people calm down with it. And I had no clue about that. You know, you always learn things in these sessions. So it is bi-directional. Well, you know, one of the things, and I've participated in some of these Project ECHOs as a discussant. They're really a fun thing to do and to be part of. And one of the things that sometimes the speakers take a little bit more than 15 minutes, you know. But I remember when I was in college, the saying was after the first 20 minutes, no one pays attention to anything you're saying anyway. So you really want to condense it down. I'm not saying anything about this crowd, though. I know everybody was quite in tune the whole time you were here. But how many people think that primary care is in crisis? Yeah. I mean, I don't know how anybody would go into that specialty at this point in time. You know, I gave you the anecdote of my PCP, who just was typing with a fury. And when I commented, he said, well, that's what I do, I'm a primary care physician. I actually had even one time someone way back when it was a resident in internal medicine. Well, I'm a resident in internal medicine. I look at lab tests, not patients. So OK, that's kind of sad. But I've been in Banner for now almost four years. I'm on my fourth primary care doctor, even though Banner has a good set of primary care doctors. They just come and go. And I think we ought to do something better to make primary care better. And I think these kind of things with them feeling connected to us in some collaborative care way may help. So I think we have to do a lot to make our whole medical field better than what it is. And hopefully some of you will take from this and think about collaborative plans that you can work on. Right. Right. Again, we've got a fragmented health care system, and I hope we can change it in my lifetime. Well, listen, I want to thank everybody for showing, unless anybody wants to run up to a mic. I know your stomachs are grumbling, I think, mine is, and have a good lunch. Thanks for coming. Again, think about sending us some input. Certainly reach out to us if you have questions about Project ECHO or Dementia Care Partners or the resident clinic. And we need to keep building on this, so thanks for coming.

Alzheimer's

dementia care

geriatric psychiatry

Banner Alzheimer's Institute

Project ECHO

hub-and-spoke model

collaborative learning

primary care

rural healthcare

mental health access

healthcare models

specialist collaboration