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Project ECHO Model Helps Nursing Homes Mitigate COVID-19

In This Article

  • Massachusetts General Hospital providers lend expertise to the National Nursing Home COVID-19 Action Network
  • The network offers free training and mentorship to nursing homes to help mitigate the devastating impacts of COVID-19 on this frail vulnerable population
  • The initiative uses Project ECHO, a hub-and-spoke model of knowledge sharing using telementoring via Zoom
  • In the 16-week program, virtual communities of guided mentors and local providers explore evidence-based best practices through focused didactics and case studies
  • Innovations such as Project ECHO have implications for improvement in other areas of eldercare as well

As of early December 2020, 5% of COVID-19 cases in the United States stemmed from nursing homes and long-term care facilities. Yet, this population accounted for 38% of deaths (106,000). In many states, at least half of deaths from the virus are linked to nursing homes.

To help these facilities through the pandemic, Massachusetts General Hospital geriatric and internal medicine physicians are helping to lead in an effort to train nursing home staff in COVID-19 mitigation strategies as part of the National Nursing Home COVID-19 Action Network.

Through the network, Charles Pu, MD, FACP, CMD, attending physician at the Division of Palliative Care & Geriatric Medicine at Mass General and a medical director at Mass General Brigham's Center of Population Health, and Amy Baughman, MD, MPH, physician in the Department of Medicine, use a novel telementoring method called Project ECHO (Extension of Community Health Outcomes).

"COVID-19 exposed a long, smoldering issue in our society: How are we going to care for our aging population?" says Dr. Pu. "Project ECHO coaches and mentors many people at one time in a frequent and systematic way."

How COVID-19 Affects Nursing Homes

Dr. Pu, whose work includes enterprise-level skilled nursing facility (SNF) and home-based medical programs, says the nature of nursing homes, the care they provide and their patient population presented the "perfect storm" for COVID-19 outbreaks:

  • A frail, older population with underlying conditions requiring frequent personal, close-contact care
  • A congregate living arrangement
  • Under-resourced facilities, particularly in terms of personal protective equipment and testing
  • Staff who often work at more than one nursing home facility
  • The asymptomatic, undetected spread of the virus

Project ECHO's Telementoring Model Knowledge and Best Practices

Project ECHO is the brainchild of Sanjeev Arora, MD, a liver disease specialist at the University of New Mexico (UNM). Frustrated by his inability to treat hepatitis C (HCV) patients in his large predominantly rural state, he developed an innovative videoconferencing model in 2003 called Extension for Community Healthcare Outcomes (ECHO) to teach community providers how to treat this complex disease.

UNM specialists and a cohort of local practitioners met online weekly to discuss specific cases and participate in short didactic presentations through a structured format. Results published in the New England Journal of Medicine showed that HCV infected patients could be managed as effectively by these community providers participating in the ECHO model as those treated at Dr Arora's own academic medical center.

Project ECHO uses a hub-and-spoke model to share knowledge. Virtual communities of guided mentors (the hub) and providers (the spokes) explore evidence-based best practices and case studies. An "all learn, all teach" collaborative environment allows mentors and participating providers to learn from each other.

National Nursing Home COVID-19 Action Network

Seeing the need to quickly disseminate information for protecting nursing home residents and staff against COVID-19, the federal Agency for Healthcare Research and Quality (AHRQ) partnered with UNM's ECHO Institute and the Institute for Healthcare Innovation (IHI) to create the National Nursing Home COVID-19 Action Network. Network leaders seek to provide training to 15,000 nursing homes nationwide.

Mentors use curriculum designed by IHI to provide free training and mentorship to nursing homes nationwide. The initiative's goals are to:

  • Keep the virus out of nursing homes where it has not entered
  • Quickly identify residents and staff infected with the virus
  • Prevent the spread of the virus among staff, residents and visitors
  • Provide safe, appropriate care to residents with mild and asymptomatic cases
  • Ensure staff practice safety measures to protect residents and themselves
  • Reduce social isolation for residents, families and staff

Applying Project ECHO Methodology in Nursing Homes

Drs. Pu and Baughman serve as clinical experts in the Network, co-facilitating one of nine COVID-19 Nursing Home Action Network cohorts in Massachusetts. Joining them at the hub as operational expert is nursing home administrator Eric Sheehan of Soldiers' Home in Chelsea. The spokes of their cohort are composed of representatives from more than 30 different nursing homes.

Each week for 16 weeks, mentors and nursing home representatives meet via Zoom. Session topics include :

  • Approaches to cohorting
  • Clinical management of asymptomatic and mild cases of COVID-19
  • COVID-19 testing
  • Creating a safe environment through infection control practices
  • Managing social isolation
  • Personal protective equipment best practices for COVID-19
  • Preventing and limiting virus spread

Leaders update the curriculum weekly to reflect new evidence, innovations in best practices and changes in the pandemic. In addition to access to national and local experts in infection control, safety, quality improvement and nursing home operation, participants receive implementation resources and how-to guides. After 16 weeks, cohort participants can continue to meet in optional Zoom sessions.

"We hope to establish relationships and build connections through community where people realize firstly they are not alone but also able to learn from each other," says Dr. Pu.

Project ECHO for Geriatric Care Beyond COVID-19

The Project ECHO model also has implications for bridging geriatric care workforce gaps and offering alternative modes of care in a rapidly growing field. Just 60 years ago, the average life expectancy in the U.S. was 69.7 years. Today's expectancy is 78.9 years, and in 40 years experts say it will reach 85.6 years. Further, the over-85 age group is projected to increase over 300% until 2050 in contrast to a mere 16.5% increase expected for the under-18 population.

The supply of a skilled geriatric workforce has already fallen behind demand such that The U.S. Department of Health and Human Resources projects a deficit of 26,980 geriatricians nationwide by 2025.

"The blessing of living into advanced older age has historically been a pretty new phenomenon for society which we are just perhaps beginning to wrap our heads around," says Dr. Pu. "The ECHO model serves as a potentially compelling solution, especially in situations where there's a significant knowledge gap for those trained to meet the needs of a society or a population."

As the field of geriatric medicine looks at the whole person, Dr. Pu adds that our health care system must similarly become more holistic, customizable and adaptable to address the heterogeneous complex needs of the frail older adult. One way is to offer more advanced medical care options in the home as exemplified by Mass General's Home Hospital Program. Project ECHO could help in other areas of geriatric care as well.

"There's no silver bullet to managing the challenges in caring for our older adults," he says. "However, Project ECHO could help increase the number of practitioners with the specialized skills necessary to best care for this vulnerable and fastest growing population."

Learn more about Geriatric Medicine at Mass General

Refer a patient to the Division of Palliative Care and Geriatric Medicine


Massachusetts General Hospital's global palliative care team is addressing and overcoming barriers to palliative care access in low- and medium-resource countries.


Maura Kennedy, MD, MPH, of the Department of Emergency Medicine, and colleagues in a multicenter study found 28% of older patients with COVID-19 who presented to emergency departments had delirium on arrival.