Universities, academic medical centers, health systems, nonprofits, military, and professional associations hosted ECHO hubs and programs we studied.

ECHO hubs are frequently associated with a university and, more specifically, with academic medical centers or schools of public health. More than half of the ECHO hubs we studied were affiliated with a university or college. Universities and medical colleges are likely adopters as they are populated by subject matter experts, often have experience with medical continuing education, and ECHO, as an educational intervention, fits with their mission.

Yet, ECHO hubs are not always located within a university or medical college. Some ECHO hubs are hosted by a health care system or affiliated with providers who are not based in a college or university. These organizations also have access to subject matter experts and participants may be providers within the system – such as with Ochsner Health Systems and the U.S. Army. ECHO hubs are also hosted by professional associations, nonprofits, and regional/state networks. Professional associations, such as the American Academy of Pediatrics, and other types of nonprofits, such as Huther Doyle, have broad access to subject matter experts and can recruit from their networks of members.

The organizational home of an ECHO hub, at least initially, typically aligns with where the champion or sponsor who launches the ECHO works. What’s important about organizational location is finding a fit between ECHO and the mission or aim of an organizational unit.

The organizational home of an ECHO hub, at least initially, typically aligns with where the champion or sponsor who launches the ECHO works. What’s important about organizational location is finding a fit between ECHO and the mission or aim of an organizational unit.

Each adopting organization has its own unique structure, even when they are in the same institutional sector. Variance in ECHO hub location is easily observed when looking at hubs affiliated with universities or medical colleges. For example, the following ECHO hubs are all within schools or colleges of medicine at universities. Each is affiliated with a unit where ECHO fits the mission of that unit.

At Southern Illinois University, the ECHO hub was located within the School of Medicine’s Office of External Relations which focused on community relations, regional programs, clinical outreach, and advocacy.

Project ECHO Nevada was housed within the Office of Statewide Initiatives at the University of Nevada, Reno School of Medicine, which aimed to improve access to quality health care for rural Nevadans.

ECHO-Chicago was located within the University of Chicago’s Biological Sciences Division in the Department of Pediatrics but was also part of UChicago Medicine’s Urban Health Initiative which aimed to improve access to high quality care in urban, under-resourced communities.

Show-Me ECHO was part of the Missouri Telehealth Network in the School of Medicine at the University of Missouri.

After looking across 34 ECHO hubs, we identified three types of hub structures: Independent hubs, nested hubs, and loosely structured hubs. These structures differ in the degree of separateness or autonomy and the extent to which ECHO is the only or the primary focus of work. Each of these structures can work well. In addition, a hub that starts off as loosely structured can become a nested or independent hub over time.

Independent stand-alone hubs typically have their own budgets and staff dedicated to ECHO and focus only, or primarily, on ECHO related work. For example, Show-Me ECHO at the University of Missouri had a staff of 27 people and 38 programs. ECHO hubs that stand-alone include those located within the University of Colorado, Rutgers University, the University of Chicago, Indiana University Purdue University at Indianapolis (IUPUI), Penn State University, and the Oregon Health and Sciences University.

Some ECHO hubs are nested within a larger department or division and are a programmatic area of work. These hubs typically do not have a budget dedicated to ECHO and ECHO is often one of several programs that they provide. For example, the ECHO hub at West Virginia University was part of the Clinical and Translational Science Institute (WVCTSI). The budget for ECHO was part of the larger WVCTSI budget and ECHO was one programmatic area within WVCTSI. Three staff worked full-time on ECHO programming and they drew on the talents and expertise of colleagues in the WVCTSI who did not work solely on ECHO.

In some instances, an organization may have one or more ECHO programs that operate independently and without a centralized hub. We identify these as loosely structured hubs. We observed that in this model you typically have one or two people who focus on ECHO programs who also have other roles and responsibilities. ECHO work at NEOMED was located in the Department of Health Affairs. They did not have full-time staff devoted to ECHO or a specific ECHO budget, though several people were working on ECHO projects. Staff working on ECHO sometimes coordinated their work but programs operated independently. Similarly, ECHO programs at Ochsner Health were coordinated by a staff person in the Multi-Organ Transplant Institute who had ECHO as part of her responsibilities.

There was little question about the value of attending immersion (launch) training at the ECHO Institute.

Nearly all of the respondents in our study who participated in immersion training, did so in-person at the University of New Mexico. The University of New Mexico experience was highly regarded by interviewees (one leader at the University of Colorado attended immersion training four times). It was common for teams to attend training together as it provided time to focus on ECHO and develop relationships that strengthen the team. For example, at Southern Illinois University, teams attended immersion training together so they could develop ideas and concepts in a quiet place away from distractions. ECHO teams from other institutions also reported returning from immersion training with an implementation plan.

The value of attending immersion went beyond the time away from the office and the practical guidance offered. Attendees returned with a deeper understanding of why ECHO was important and how their work fits within the larger ECHO movement. They also met staff from other ECHOs and developed working relationships that lead to ongoing discussions about how best to implement and sustain ECHO.

With COVID, immersion training moved on-line. Few of our respondents had participated in the online immersion training. Still, some of what we learned about the value of in-person immersion can apply to an online experience. For example, teams can attend online immersion at the same time from the same location. In addition, online participants can reach out to each other and develop virtual relationships that can lead to discussions about implementing ECHO.

Nearly all ECHO hubs provided some in-house guidance or training for staff and subject matter experts. The training complements and sometimes supplants immersion (launch) training at the ECHO Institute. Internal training programs vary in the extent of training and who participates. We found many instances of hubs and programs using or adapting training materials available from the Project ECHO Resource Library (PERL).

Project ECHO at Penn State had a well-developed in-house training program for hub members and expert presenters. The training included a staged 10-minute video of a case discussion that participants watched before they came to the training. During the training, participants practiced a mock ECHO case discussion and debrief. Facilitators had a best practice facilitation guide that was shared among the entire hub team.

The Weitzman Institute initially sent staff to immersion training but transitioned to offering an in-house training program. Training was provided to all education team members even if they were only tangentially involved in ECHO programs. Faculty attended an ECHO orientation where they learned about expectations and how ECHO was different from a webinar. Faculty were asked to review an exemplary recorded session and participate in a “dry run.”

ECHO superhubs offer training to staff at other hubs, as well as provide training within their organization. For example, the ECHO Ontario Superhub, at the Centre for Addiction and Mental Health and University of Toronto, provided rigorous training on the ECHO Model including details of all four components of the ECHO Model, a simulation, and facilitation training.

No two ECHO hubs we studied were staffed the same – titles, responsibilities, and time devoted to ECHO differed, though there was a distinction between those with administrative responsibilities across several ECHO programs – often a project manager or a director – and those providing support to programs – such as coordinators. Staffing levels varied from one person doing all ECHO work as part of their responsibilities, to larger hubs with multiple staff with specialized ECHO roles.

At some ECHO hubs, no one person was assigned full-time to work on ECHO. Rather, ECHO was just part of a job description. For example, ECHO was part of a larger set of responsibilities assigned to existing staff who were coordinating or managing other programs, interventions, or initiatives at the Association of Community Cancer Centers, Texas Tech University, Northern New England ECHO Network, and Huther Doyle.

At other ECHO hubs, one person was assigned to work on ECHO – and only ECHO. This was the case at the University of Virginia, Southern Illinois University, and Minnesota Rural Health. Individuals at these three ECHO hubs facilitated meetings, recruited participants and subject matter experts, and assisted with feedback and evaluation.

An ECHO hub may also have several people working fulltime on ECHO programs. At Rutgers University, for example, the director initially hired two staff – one with a background in education and the other with advanced work in public health and evaluation. Over time, this staff grew to three program administrators, a full-time assistant director of evaluation and quality improvement, a full-time finance and operations staff member, and several clinical coordinators. ECHO-Chicago at the University of Chicago also had a large, dedicated ECHO staff that grew as ECHO programming expanded. When the Chicago ECHO work was starting out, each person was a jack-of-all-trades. As more staff were added, role and responsibilities became more specialized. The Missouri Telehealth Network Show-Me ECHO Team included 27 people, with eight partnerships with other organizations. For one of those eight partnerships, Show-Me ECHO was funding .10 FTE of 23 University of Missouri Extension Specialists to build community understanding of ECHO as a means of increasing participation by providers across the state.

Partnering with or leveraging resources elsewhere in the organization can help reduce the cost of operating an ECHO and collaborating can build support for and knowledge about ECHO. In addition, ECHO can provide benefits to partners.

The SiNERGe ECHO drew on experts affiliated with the Johns Hopkins University Medical School to present didactics and as panel members to discuss case presentations. Similarly, ECHO hub staff affiliated with the Universities of Nevada-Reno, Colorado, Chicago, Rutgers, Kansas and Missouri and others mentioned reaching out to experts within their institution to support ECHO programs.

At some institutions, such as Southern Illinois University, partnerships extended to offices of marketing, communication, community relations, government relations, and telehealth programs. The Penn State ECHO team worked with development office staff in the College of Medicine to publicize ECHO work and identify potential supporters of the operation.

At the University of Kansas Medical Center, the ECHO hub linked to disease-specific units such as oncology and population-specific units such as pediatrics, along with outreach, continuing education, and telehealth. These links across units benefited ECHO; in turn, the ECHO work raised the profile of each unit in addressing health disparities, reaching rural populations, and using new communication technologies.

Changing administrative homes is not common but it does occur. Organizational shifts may sound surprising and even concerning. We found, however, that fidelity can be maintained and sustainability increased as ECHO hubs move within and across organizations if the staff remain constant.

ECHO hubs typically align with the interests of the subject matter experts who initiated ECHO. But as the number of programs increase and the topics begin to incorporate new subject areas, it sometimes makes sense for the home location of the hub to move. For example, in response to a merger with the campus eConsult program, ECHO Colorado transitioned from the School of Public Health to the School of Medicine. Utah ECHO started with a Hepatitis C ECHO program housed in the transplant service line. As the focus of the ECHO programming broadened and funding lines shifted, the ECHO portfolio of programs was moved to the Office of Network Development and Telehealth and placed within the Education Team.

At the Northeast Ohio Medical University, the Department of Family and Community Medicine contracted with the ECHO Institute to offer a community health worker ECHO program. When the initiating staff left the university, the Department of Psychiatry took the lead on ECHO and expanded programming. Discussions about becoming a superhub led to a decision to relocate ECHO to the Department of Health Affairs to increase institutional support and broaden collaboration across the university.

Shifts can be more dramatic than this. The Rural Addiction ECHO in Minnesota and the Northern New England ECHO Network each changed organizations twice during our study such that we observed their respective ECHO work across three organizations.

Where a hub is located can and often does influence ECHO work. A hub’s reporting structure may bring more or less leadership support, autonomy, credibility, and financial resources. Reporting structures do matter – and we found successful implementation in many different reporting structures. For example:

The Weitzman Institute was the research, education, and policy arm of the Community Health Center, Inc. (CHC), the largest federally qualified healthcare center in Connecticut. ECHO was situated within the educational work stream and was one of several models or programs that the Institute supported. Being nested in the education workstream allowed the Institute to consider if ECHO was the best model for an educational program compared to other models they could draw on.

The ECHO hub at Southern Illinois University was located within the School of Medicine’s Office of External Relations which focused on community relations, regional programs, clinical outreach, and advocacy – and this influenced how the staff talked about and acted on ECHO opportunities.

The Indiana University Purdue University at Indianapolis ECHO Center, located within the Richard M. Fairbanks School of Public Health, had autonomy and flexibility, but was not initially affiliated with an academic department, making it more challenging to tie the work to the academic core. The Center was actively exploring integration with an academic department which could lead to more cost sharing and support from leadership.

ECHO Colorado moved to the School of Public Health to the School of Medicine which opened up opportunities to work with more medical faculty.