Childhood obesity has been a difficult problem for health providers to tackle, for a myriad of reasons.
Obese children living in remote or underserved areas often lack access to the care they need to get healthy because local communities simply lack the resources required to set them up for success.
But, thanks to an Extension for Community Healthcare Outcomes (ECHO) grant, Karla Lester, M.D., hopes to change that.
Dr. Lester, Medical Director of the Children’s Center for The Child & Community at Children’s Hospital & Medical Center in Omaha, explains what the ECHO grant means for patients, providers, and others trying to address the challenge of childhood obesity.
0:21 — Dr. Lester explains what the ECHO grant is all about
1:01 — How the ECHO grant is being used to combat childhood obesity
3:35 — What providers can gain by participating in this program
CHN News: We are speaking today with Karla Lester, Medical Director of the Children’s Center for The Child & Community at Children’s Hospital & Medical Center in Omaha, Nebraska. Karla, can you tell us about the ECHO grant that you just received from the University of New Mexico, and what its purpose is?
Karla Lester, M.D.: Project ECHO stands for Extension for Community Healthcare Outcomes. The American Academy of Pediatrics’ Division of Innovation awarded two grants nationwide to launch ECHO hubs in underserved areas—so those areas of the country that didn’t have ECHO.
ECHO is a telementoring project, so it’s different from telemedicine. It’s a connection between specialists and community providers to address the gap in specialty care and also the underserved areas.
CHN News: What will the project involve for Children’s Hospital? What specifically will you be doing?
Dr. Lester: The child health topic we chose was addressing childhood obesity. We know that at least one third of children nationwide and in our communities are obese and overweight. And when you look at the children who are disproportionately affected by the obesity epidemic, those are children who are minority children, children in poverty, and children who live in certain geographic regions.
We knew that primary care pediatricians and family physicians aren’t always trained in diagnosing and assessing obesity and the comorbidities—the diseases associated with obesity, such as type 2 diabetes, high blood pressure, high cholesterol, fatty liver disease, etc. And we know it affects every body system.
So, we have many children who are not being worked up or assessed because we haven’t had the appropriate training. There’s also a lack of reimbursement for physicians and lack of community programs. So, if a community physician wants to work on a patient and do a laboratory workup, then they oftentimes don’t have the community resources to address those.
Also, it’s hard to get in to specialists. There may be long wait times. So, with ECHO, we’ll be able to educate them and increase the standard of care by sharing best practices around the assessment and management of obesity and comorbidities in children.
CHN News: Tell me what an ECHO clinic is typically going to involve. What happens?
Dr. Lester: There’s an ECHO hub team that will be at Children’s. We’ll have a group of us who are working as clinic facilitators, someone who handles all of the IT issues, someone who’s a scribe, and also a specialist and a case facilitator. We’ll have the specialist come in—we’ll have done some work on the front end recruiting the community spokes.
So, working with our statewide partners and community partners within the healthcare system to recruit community spokes, so that they are ready to participate in all of the sessions.
The community spokes are the physicians, pediatricians, family physicians, PAs, and nurse practitioners in communities across Nebraska. And then there are teams within their clinics who they think are the best to participate.
CHN News: And these are the providers who will be participating in the clinics to learn more and receive more education and training on childhood obesity and its comorbidities?
Dr. Lester: Yes, exactly. They will be learning from the specialists. It starts with a 15- to 20-minute didactic session where the specialist might come in and talk about hypertension in obese children and the assessment and management.
And then, prior to the ECHO clinic session, the local providers will have uploaded case presentation forms. So, they will have all of the identified patient cases with information on the child’s history, their family history, and any imaging studies that the specialists will have reviewed.
Then we’ll go through the cases and the specialists and all of the participants will weigh in on the management. Typically, in an ECHO clinic session, you might go through three different cases of local providers.
CHN News: How often will these clinics occur and for how many months?
Dr. Lester: We’re thinking we’ll go for twice a month, so every couple of weeks.
CHN News: And when do they begin?
Dr. Lester: September is our goal launch date, so we’re front-end planning for about four months and then about eight months of implementation with the clinics happening every couple of weeks.
CHN News: You mentioned also that bidirectional communication is part of this project. Can you tell me a little bit about what that means?
Dr. Lester: One of the main goals or visions with ECHO is that you create learning networks or knowledge networks, so that you’re sharing knowledge—not only just the specialists sharing knowledge with the community providers.
Bidirectional learning is where we’re learning about the barriers and what’s happening on the community level — so that if we have a recommendation that a specialist gets, we learn what happens and how it’s applied in the real world. So, we’re learning both ways.
CHN News: Can you give us an example of the types of obstacles that community providers run into when they do try to treat childhood obesity in their communities?
Dr. Lester: I think the number-one issue is time. I think another issue is parental apathy. To be honest, when we surveyed providers, they said it was really hard to get the parents and the whole family engaged in a level of change and to motivate them to make the changes that they need to make. That’s a real challenge for all of us.
We know that we have public health issues — like not having enough community support programs or intervention programs to refer the children to. We need to work up these comorbidities, but almost all of them fall into needing to eat-better, move-more buckets, so that becomes a challenge for the providers.
Another challenge is a lack of reimbursement on the front end for prevention services: BMI counts — physicians are not reimbursed for that.
And then also if the child is obese but doesn’t have the comorbidities or any laboratory abnormalities, oftentimes, offices are not reimbursed by the insurance companies until the children have developed a slew of comorbidities. And that can sometimes be tough to turn those kids around.
CHN News: We’ve talked, too, about how childhood obesity is driving up healthcare costs in local communities and states across the US. Can you put some numbers on that — are you aware of any that you can share?
Dr. Lester: We know that when we have 6% of US children who are severely obese now — and that number is increasing — and we have even young children diagnosed with fatty liver disease, type 2 diabetes — and that is going to be very costly to our healthcare system.
CHN News: Because they take these issues into adulthood, right?
Dr. Lester: Absolutely.
CHN News: What are you doing to prepare for the ECHO clinics that are coming up in September?
Dr. Lester: We just participated — along with the other team that was chosen from across the country — in a two-day training at the American Academy of Pediatrics national headquarters. So, we had an ECHO training for two days, and then we launched into our planning period.
We’re looking at plans for recruitment of community spokes. We also need to work internally at Children’s because we need buy-ins from the specialists. We need to determine who is on the hub team and get the IT support and marketing support. So, we’re going to be working on issues such as that.
And then the issue we’re really going to be moving on quickly is developing a curriculum. We have some nice support from the American Academy of Pediatrics’ section on obesity and the American Academy of Pediatrics’ Institute for Healthy Weight.
So, we can start launching the development of what potentially could be a standardized curriculum for this ECHO.
CHN News: If community providers are interested in participating in these clinics, how can they go about getting on board or registering for that?
Dr. Lester: If they are a part of Children’s Health Network, that would be a mechanism to become involved through their contacts there.
And we will be reaching out through the network and also through our statewide partners with the AAP state chapter, the Academy of Family Physicians, the Nebraska Medical Association, the Academy of Physician Assistants—so we’re really going to do a big reach to recruit spokes. They’ll be receiving information.
CHN News: And will providers receive continuing medical education credits for this course?
Dr. Lester: Yes, they will. We’re working with Children’s CME office to make sure that they receive CME credit for participation.
CHN News: Ultimately, what do you hope community providers take away from these clinics?
Dr. Lester: I really hope they feel a connection with the Children’s team — the specialists.
I hope they feel like they’re not alone. This is such an overwhelming issue and sometimes you feel a little bit hopeless and helpless, to be honest, as a provider — especially in a rural community or underserved community.
So, I would hope that they feel like they have a partner. Together, we’re going to be learning from each other and working on this really tough issue.
CHN News: Dr. Lester, thank you so much for being with us today.
Dr. Lester: Thank you.