A Novel Approach for Building Clinical Capacity of Pediatric Providers in Rural and Underserved Communities Predominantly Serving Native American Populations in the Southwest.

Background: ECHO Autism and ECHO Autism STAT are novel approaches for building provider capacity to treat patients with Autism Spectrum Disorder (ASD) in rural and underserved communities. Developed by clinicians and researchers at the University of Missouri Thompson Center, these approaches connect rural primary care providers (PCPs) to an interdisciplinary team of ASD experts at a university setting. Their impact has led to increases in PCP self-efficacy in managing patients with ASD and in early identification of symptoms using validated screening tools (Mazurek, et al., 2017; 2018). Through funding from the Autism Treatment Network (ATN)/Autism Research Intervention for Physical Health Network (AIR-P), both ECHO approaches have been implemented in New Mexico and Northern Arizona since January 2017.

Objectives: The objective of this project was to review the feasibility of and challenges associated with implementing the ECHO Autism and ECHO Autism STAT approaches with providers in rural and underserved areas of New Mexico and Northern Arizona.

Methods: The ECHO programs were designed for PCPs and included biweekly, 90-minute virtual clinics using zoom technology. Clinics focused on case presentations and included a standard, brief didactic curriculum about autism screening and identification, medical and behavioral management, and evidence-based intervention. ECHO Autism included training on the M-CHAT-R/F, while ECHO Autism STAT added a two-day training on the Screening Tool for Autism in Toddlers (STAT) and ECHO Autism STAT diagnostic model.

Results: Implementation of ECHO Autism and ECHO Autism STAT revealed challenges in three areas: recruitment, provider engagement, and operational efficiency. Recruitment was more time-intensive than anticipated. We contacted clinic managers, disseminated printed and electronic brochures, and presented at a local conference. The most effective method was in-person presentations at staff meetings by professionals of similar training background. Involvement of clinic administration was critical for provider engagement due to the potential impact on patient scheduling. The day, time, duration, and frequency of the clinic were chosen to minimize impact on scheduling and optimize provider availability. Clinician engagement was maximized when they presented their own cases and shared knowledge with participants experiencing similar challenges. Follow-up documentation of recommendations and resources provided targeted and concrete action items. Resource constraints limited implementation of some recommendations, such as access to community interventions. . Operationally, the efforts of the ECHO clinic coordinator proved invaluable for supporting operations and responsive communication between all parties. Centralizing information in an online platform offered consistent communication between everyone, as well as easy access to information discussed during the clinics. Due to the rural nature of several practices, we experienced difficulties with internet connectivity to utilize the online platform and video technology.

Conclusions: Implementation of ECHO Autism and ECHO Autism STAT proved feasible, but highlighted important considerations that will benefit others who are considering this model for their communities. These extra efforts, though substantial, can positively impact patient care within rural and underserved communities, and may be applicable to other communities who face similar challenges as those in New Mexico and Northern Arizona.