Project ECHO: Enhancing palliative care for primary care occupational therapists and physiotherapists in Ireland

Project ECHO (Extension for Community Healthcare Outcomes) uses videoconfer-encing technology to support and train healthcare professionals (HCPs) remotely. A 4- month fortnightly ECHO programme was developed and implemented to en hance palliative care provision by primary care therapists. Teaching and case- based discussions were facilitated by palliative care specialists. A mixed- methods cohort study was used to evaluate the project. ECHO participants completed pre- and post-programme questionnaires regarding their knowledge and skills across key palliative

yet access to palliative care services is often limited . Increasingly, integrated palliative care services are promoted within primary care to allow for more holistic responses to adults living with life-limiting conditions in the community (den Herder-van der Erden et al., 2017;WHO, 2016).
In Ireland, projections of need for palliative care services are estimated to increase up to 84% between 2016 and 2046 (May et al., 2020). Previous studies indicate that specialist and generalist palliative care capacity and funding in Ireland do not meet current need (May et al., 2014;Weafer & Toft, 2018). Workforce development and service provision in palliative care is required to meet anticipated growth in demand for palliative care services (May et al., 2020).
An interdisciplinary team approach to palliative care is recommended (Jünger et al., 2007;Radbruch & Payne, 2009); however, the composition of healthcare professionals (HCPs) on the team tends to vary, and Høgdal et al., (2020) note the roles of occupational therapists and physiotherapists may be underestimated and may result in patients experiencing unmet needs concerning daily activities, fatigue, pain, concentration and anxiety.
The need for palliative care education that is delivered in an integrated, collaborative and cost-effective way is well documented (WHO, 2018). HCPs have identified education addressing knowledge and application of palliative interventions and practice coaching as key elements which would support integration of a palliative approach within primary care (Nowels et al., 2016). In Ireland, the Health Service Executive Palliative Care Competence Framework sets out the train- Online learning models offer much potential to overcome barriers to accessing education for HCPs, by allowing engagement in learning at a convenient time and location, enabling balance between work commitments and professional development (Sinclair et al., 2015). Project ECHO is a distance health education model, which uses audio-visual technology to connect a team of experts (the 'Hub') with HCPs working in community settings (the 'Spokes').
The ECHO model has been applied to many chronic diseases and patient groups such as hepatitis C, chronic pain, multiple sclerosis, mental health and geriatrics (Alschuler et al., 2019;Arora et al., 2011;Bennett et al., 2018;Carlin et al., 2018;Johnson et al., 2017;Mariciano et al., 2017;Sockalingam et al., 2018). It has also been implemented for palliative care internationally, demonstrating improvements in participants' self-efficacy by enabling HCPs acquire new knowledge, skills and best practice resources in palliative care Burpee et al., 2019;Marr & Neale, 2012;White et al., 2019;Yennurajalingam et al., 2019). ECHO has potential to bridge the gap between the growing need and limited palliative care resources in Ireland by facilitating palliative care specialists to disseminate core principles and best practices to primary care HCPs, thus developing communities of practice.

| Project ECHO: Palliative care for occupational therapists and physiotherapists in primary care
This ECHO programme was developed to improve access to palliative care by offering easily accessible and up-to-date training on palliative care principles and best practices to primary care occupational therapists and physiotherapists throughout Ireland. This study aimed to evaluate the impact of delivering education using the ECHO model on occupational therapists and physiotherapists self-reported confidence in their clinical knowledge and skills in addressing the palliative care needs of patients they work with in primary care settings. The ECHO 'Spokes' were primary care occupational therapists and physiotherapists who attended remotely from their workplaces. The ECHO 'Hub' consisted of senior HCPs with palliative care experience from specialist palliative care settings, including occupational therapists, physiotherapists, a dietitian and a nurse manager.

| Curriculum for ECHO programme
The ECHO team identified 14 topics deemed relevant to occupational therapy and physiotherapy in palliative care based on expert opinion, the Competence Framework and previous training needs analysis. Participants then prioritised the topics they wanted ECHO to address, prior to the commencement of the programme (as presented in Figure 2).

ECHO was delivered utilising the already established 'Palliative
Hub' e-learning platform, designed and hosted by the All Ireland Institute of Hospice and Palliative Care (AIIHPC). Each session included a didactic presentation followed by anonymised case-study

What is known about this topic
• Integrated palliative care services are promoted within primary care to address the needs of adults with lifelimiting conditions living in the community.
• Palliative care education must be delivered to healthcare professionals in the community to support this transition.

What this paper adds
• Project ECHO is an effective and accessible distance learning model which enables primary care healthcare professionals acquire new knowledge and skills within palliative care.
• In addition to dissemination of best practices, healthcare professionals also benefit from establishing a community of practice.
discussions. Specialist clinicians and academics with relevant knowledge provided brief, focused training on a clinical topic, after which Spoke members presented anonymised case studies, using a standardised proforma. Each clinic lasted 90 min and was digitally recorded using Zoom®.

| Design
A mixed-methods evaluation of ECHO in improving primary care occupational therapists and physiotherapists confidence in their knowledge and skills to address the palliative care needs of clients they work with in primary care was undertaken, using a combination of quantitative questionnaires and qualitative focus group discussions.

| Baseline assessment
Prior to programme commencement, participants completed a pre-ECHO online questionnaire using Survey Monkey™. This survey collected demographic characteristics of the sample, their reasons for joining ECHO and self-rated confidence in their knowledge and skills regarding key domains of competence in palliative care practice, using a Likert scale where 1 = Not at all confident; 2 = Not very confident; 3 = Neutral; 4 = Somewhat confident; and 5 = Very confident.

| Post-ECHO assessment
Participants completed another survey following completion of the ECHO programme in which they rated their overall confidence in their knowledge and skills regarding key domains of competence in palliative care practice and also rated statements in relation to their experience of participation in the ECHO programme.

| Focus groups
Two focus groups were held prior the programme commencement to explore participants prior experiences of palliative care. Three focus groups were held upon completion of the final ECHO clinic to explore participants' experience of the overall ECHO programme. A topic guide was used to guide discussion and explored participants experiences of the ECHO format, how the curriculum addressed their learning needs, how they applied learning gained through ECHO, and how it impacted on their contact with specialist services and ideas for future ECHO clinics. An additional focus group was held with Hub members to explore their experiences of participation.

| Recruitment
The ECHO programme was advertised through primary care networks, palliative care and oncology advisory groups, manager advisory groups, the AIIHPC newsletter and the Palliative Rehabilitation Facebook group. A census approach to sampling was undertaken whereby all ECHO participants were invited to complete the evaluation forms and focus group discussion.

| Ethics
The study was given approval by the Research Ethics Committee (approval date 19/3/2019, reference number 20190206). Informed consent was sought from participants.

| Data analysis
Due to small sample size, descriptive statistics were used to describe and summarise participant characteristics and nonparametric Mann-Whitney U tests were used to explore differences in pre-and post-ECHO evaluations. Statistical significance was set a priori at p = .05 and p values reported to provide an indication of the impact of the model on HCP's self-reported confidence in their knowledge and skills.
Focus group discussions were recorded using Zoom®, and audio data were transcribed verbatim. Data were analysed using thematic analysis (Braun et al., 2018). Transcripts were initially coded separately and grouped into categories as appropriate. Categories for both Spoke and Hub focus groups were then combined to form overarching themes. Emergent themes were considered in the context of the existing literature. Constant referral back to transcripts and codes was undertaken to unsure that the analysis remained true to and reflected the developing themes.

| FINDING S
The ECHO programme took place from April to October 2019. Ten fortnightly videoconferences were held. Between 16 and 26 spoke F I G U R E 1 Domains of competence from the HSE palliative care competence framework 1 Principles of PalliaƟve care 2 CommunicaƟon 3 OpƟmising comfort and quality of life 4 Care planning and collaboraƟve pracƟce 5 Loss, grief and bereavement 6 Professional and ethical pracƟce in the context of palliaƟve care participants attended each session. While 13 Hub members were available, typically five Hub members participated in sessions. Over the duration of the programme, 17 spoke participants presented case studies for discussion.

| Participant profile
Twenty-six participants commenced the ECHO programme, and one occupational therapist withdrew mid-programme, citing work pressures. The 'Spoke sites' represented geographical spread across the Republic of Ireland. Sociodemographic and professional profiles of participants are provided in Table 1.
The majority of therapists had more than 10 years of professional

| Pre-ECHO focus group
Participants reported that between 5% and 20% of their caseload in- Participants reported that they did not have much contact with their palliative care colleagues. Participants reported wanting to feel more confident in their skills and in how to communicate with their clients.  Figure 3a,b).

Statistical analysis of scores in knowledge and skills using a Mann-
Whitey U test demonstrated that overall scores were significantly higher post-ECHO across the six competencies for both knowledge and skill (p < .000 and p = .001, respectively). See Table 2 for details.
The post-ECHO survey evaluations also revealed that participants valued the ECHO learning format. Many stated the technology used in ECHO allowed them engage in education that would have been otherwise difficult to access, due to geography and time pressures.
Overall, post-programme evaluation suggests high satisfaction rates whereby 95% (n = 19) of participants felt ECHO met their learning needs and 85% of participants (n = 17) would recommend ECHO to colleagues.

| Focus group interviews
In total, 16 individuals from Spoke sites participated in three focus groups on completion of the programme, to explore their experiences of participation and to determine any perceived benefits to participation in Project ECHO. Nine Hub members participated in a separate focus group. The sessions were topic guided. Transcripts were thematically analysed (Braun et al., 2018), and three key themes were identified and are presented below (Figure 4). From an OT perspective, our input for palliative care was mostly equipment provision… That is something we would like to expand our role… there is so much you can offer… fatigue management, pain management.

(OT, Spoke Focus Group 3)
Hub members recognised not only their own level of expertise but also how that could be shared with their community colleagues via ECHO and the importance of that to enhance patient outcomes.
Hub members reported that they had over-estimated the level of palliative care knowledge their community colleagues had, so it was valuable to become aware of this in order to support them better and to utilise their position in the community to maximise benefits for the client.
There's a huge amount of parallel working, and this of course offers us an opportunity to be able to upskill a whole host of clinicians out there who are working on their own who are really very scared of working with dying patients.

(OT, Hub Focus Group)
Participants reported that patients benefited from this enhanced scope of practice. Overall, participants reported that ECHO had reinforced the need for client-centred approaches. Participants reported that they had changed their practice to ensure they adopted a more thorough assessment of the needs of the palliative care patient.
I am asking more questions and getting more information. I feel more confident to deliver more advice, F I G U R E 3 (a) Self-rated confidence in knowledge for each domain, (b) Self-rated confidence in skills for each domain

Percentage of ParƟcipants who reported confidence in their Skills
Pre-ECHO Post-ECHO n=26 n=21 signpost more services. I feel I can offer more now following that course.

(PT, Spoke Focus Group 2)
Participants reported increased confidence, particularly in relation to facilitating difficult conversations, having adopted a more comprehensive assessment that specifically considered palliative care needs, which led to better patient outcomes: It did lead to me setting goals that might have been missed otherwise… before it might have been something I might have avoided because of feeling uncomfortable.

(OT, Spoke Focus Group 2)
Participants described the benefit of enhancing their knowledge of interventions and practical techniques, such as use of fans in breathlessness management. Participants reported better awareness of current best practice and evidence which subsequently influenced the treatment approaches they were taking.

(PT, Spoke Focus Group 3)
The structure of how services are currently set-up hampers multidisciplinary liaison and collaboration which was perceived to be a barrier to effective or efficient service provision. Participants described the need for better understanding of how services are structured and crossservice strategic planning to ensure clarity on roles and scope of practice: All the different members of the team not under the same roof…so that is barrier because we are all working off different pages.

| Theme 2: Community of practice
Participation in ECHO allowed establishment of a network of HCPs working in palliative care which was valued by participants. Participants reported it was useful to hear about practice across the country, and they were reassured that HCPs in different counties were experiencing similar challenges and were adopting similar approaches in their efforts to provide quality services and also that this allowed sharing of ideas: Everyone wanted to provide the best possible service to this client group… there were great ideas generated through the format.
(OT, Spoke Focus Group 1) Optimising comfort and quality of life .000 .000 Care planning and collaborative practice .000 .000 Loss, grief and bereavement .000 .000 Professional and ethical practice in the context of palliative care .000 .000 Note: The significance level is 0.05.

F I G U R E 4 Themes from focus group analysis
Expanded scope of pracƟce Community of PracƟce

UƟlity of ECHO Format
Participants reported intentions to further exploit the relationships they had fostered through participation in ECHO and to further enhance patient pathways and address areas for improvement: We are going to do a meet and greet with them… as a result of Project ECHO… to have a better understanding of each other's services. While it has always been good, it is only going to get better because of Project ECHO.

| Theme 3: Utility of ECHO format
Overall, participants reported a positive experience of the ECHO format. Having the programme run over a number of months was preferable to "a one or two day intensive course and it's so much information at the time that you cannot really process" for the majority of participants. Participants reported that the more protracted format allowed deeper engagement with the course content and allowed time for reflection on practice.
You had the presentations and the online informa-tion… I dipped back in and out of it and read about it, thought about clients I had worked with…it prompted reflection in practice and also to get the really up to date information was hugely beneficial.

(OT, Spoke Focus Group 2)
In resource constrained environments, participants valued the ease of accessibility the online format offered, its interactive nature and the benefit of not having to travel to attend: It was very cost effective with regard to time, patient time that we would have lost out on.
(OT, Spoke Focus Group 1) While most participants were satisfied with the overall format, there were some suggestions for future developments of the programme including "advancing the level or grading up" the content now that a basic level had been achieved, specialising in one of the areas to develop deeper understanding and skills. In post-ECHO surveys, some participants suggested practical experience and opportunities to visits hospice settings to observe practice as a means to improve the programme in future. Others suggested condensing topics into blocks which may be easier for clinicians to engage with from a timemanagement perspective. However, other participants were contented with the existing fortnightly structure and felt if sessions occurred on a monthly basis "you might lose momentum".
The use of case studies was a contentious issue, as while some participants described benefit from engaging in the process of presenting their case studies, others found this an ineffective learning method and were reluctant to engage in this aspect of the course.
Participants expressed preference for more reflexive discussions with more practical application where people would share practice examples about what worked such as "the ideal interventions could be XYZ and the ordinary ones that worked could be ABC".
Participants suggested integrating the case study aspect into the session topic from the outset rather than a presentation at the end: The case studies, while I thought they were interesting, I don't know did I gain a lot from them either. I would probably like a little bit more discussion… prior to the session we could reflect on that topic and see have we questions around it in relation to specific clients.

(OT, Spoke Focus Group 2)
Hub members considered an initial meeting of all participants may have been useful to build group cohesion and trust and to encourage active participation in this aspect of the programme: We didn't bring all of the participants together as a group for the first session… other versions of project ECHO do that… it would have created a group bond.

(OT, Hub Focus Group)
Hub members suggested a more consistent Hub membership may also support better engagement, where participants would be more comfortable sharing their practice: a small expert panel where you have really three support experts and your external speaker that that creates more security for the participants.

| D ISCUSS I ON
to develop and sustain communities of learning, following the initial course.
This programme suggests significant potential for improving access to palliative care in rural areas or communities without local hospice services. HCPs in rural areas face numerous barriers to obtaining education including geographic isolation, distance from tertiary services, lack of financial support for travel and difficulty taking time away from clinical work due to staffing shortages, which impacts on their professional development (Curran et al., 2006;Doorenbos et al., 2011;Sinclair et al., 2015;Tilleczek et al., 2005). A key feature of ECHO, compared to other online education, is the interaction between hub specialists and spoke participants which fosters and sustains development of communities of practice. Communities of practice are formed by people who engage in a collective process of learning about a shared concern, such as improving their practice (Wenger-Trayner & Wenger-Trayner, 2015).
Technology-enhanced communication and online networking enables communities of practice that are temporally and geographically dispersed to work towards a common purpose (Sims, 2018).
ECHO goes beyond a virtual classroom by developing knowledge networks that promote real-time multidirectional peer learning and sharing, where knowledge delivery is combined with mentoring and live discussion of complex cases, facilitating timely access to specialist knowledge and expertise (Struminger et al., 2017). Participation in ECHO reduces feelings of isolation as it provides a virtual community to interact with around patient care and feeling supported and encouraged by ECHO experts (Dearing et al., 2019;Zhou et al., 2016). The success of ECHO model depends on the quality of relationship between the Project ECHO team and participating clinicians (Johnson et al., 2017). Some participants suggested that an initial meeting would have developed rapport and may have allowed subsequent online sessions to be more productive. Other ECHO programmes (e.g., Bouchonville et al., 2018) have facilitated an initial training session to focus on technology use, team-building and clinical skills. Some participants suggested visiting specialist palliative care services, which may be impractical or resource prohibitive.
Nonetheless, having established relationships with local specialists, further learning opportunities with these sites which may have otherwise not been possible may be explored.
Regarding content delivery, participants strongly valued the didactic part of the sessions, suggesting it may be an efficient and effective way to acquire knowledge and resources in time-pressured practice. Some participants reported the case studies did not contribute to their learning. Hub members observed reluctance to participate in case discussion and interpreted this as participants not wanting to expose gaps in knowledge and professional competence.
Participants made suggestions to make case studies more effective and reflective, such as revising the case study preparation pro forma or adjusting the session format to incorporate case study questions.
Case discussions are a core component of ECHO and case-based training is predictive of meaningful behaviour change by clinicians (Johnson et al., 2017); therefore, the case discussion component of ECHO requires further consideration for future programmes.

| Limitations
There were limitations in both the delivery and evaluation of ECHO which must be considered in interpreting our findings and developing future programmes. While ECHO seeks to be a 'force multiplier' by transferring specialist skills to primary care HCPs, Furlan Sinclair et al., (2015) caution that e-learning is not an educational panacea, and evaluation must go beyond knowledge acquisition and user satisfaction. Future research may consider how learning is contextualised into clinical practice and whether it leads to sustained clinical behavioural change and influences patient outcomes. Such changes take time to embed into practice and were beyond the scope of this study.

| CON CLUS ION
Given projected demographic changes, more people with lifelimiting conditions will live in the community, requiring a palliative approach to their care. As ECHO addresses disparities in access to care and slow dissemination of best practices within existing resources, it offers much potential to expand capacity in resource constrained contexts. Overall, results from this study support the use of Project ECHO for HCP palliative care education in primary care. The utility of this format was confirmed as an effective and accessible model. Findings demonstrate positive impact on confidence in self-rated knowledge and skills and on establishing a network of practice between specialist services and primary care, across disciplines and geographical areas. Future developments to nurture local relationships formed to ensure sustainable practice change were highlighted to ensure ECHO directly impacts service delivery and improves the capacity of quality palliative care provision.

DATA AVA I L A B I L I T Y S TAT E M E N T
The data that support the findings of this study are available from the corresponding author upon reasonable request.