LRMC tele-mentoring program extends care beyond borders

A tele-mentoring session discussing “Use of Naloxone as a Harm Reduction Tool” which is comprised of physicians, advanced practice clinicians and health care teams from across Europe and the Middle East, is shown during one of Landstuhl Regional Medical Center-hosted sessions, Jan. 7. Weekly hour to hour and a half sessions allow health care professionals to share best practices and provide input on anonymous medical cases across most of the Eastern hemisphere, reducing noncombat medevacs of Service Members serving overseas to LRMC, saving millions of dollars in logistics, increasing unit readiness by taking care of Soldiers where they are at and limiting time away from duty.

Deploying innovative technology to provide medical education is nothing new for the U.S. Military. Office of The Surgeon General — Army Pain Management Task Force has partnered with Project ECHO, an educational program developed at the University of New Mexico, to expand access to pain specialty care. The military has been deploying this hub and spoke model for over eight years.

Originally adopted by the U.S. Army, Landstuhl Regional Medical Center provides this program to others including the Air Force and Navy.

“I’m proud to be part of a team that helps our military community address health care initiative through the ECHO model… to de-monopolize education that will ultimately impact the treatment of patients,” said Lester Gresham, Health System Specialist that manages the ECHO Program at LRMC.

The LRMC ECHO tele-mentoring model uses a knowledge network of 20 military facilities to share best practices and science-based interventions through videoconferencing and virtual learning sessions. Weekly sessions comprised of physicians, advanced practice clinicians and health care teams from Regional Health Command Europe’s (HUB) footprint to the outlining communities (SPOKE).

By supporting providers with limited access to educational programs in chronic pain management, the program aims to build supportive relationships to overcome barriers.

One of LRMC’s pain specialist, Dr. Octav Constantinescu, has been moderating the program since its adoption and believes, “ECHO allows us the space to think deeply, in a multidisciplinary team, about how to best address tough chronic pain problems. It combines continuing medical education with rigorous case discussion and vital experience sharing among providers at various MTFs, enabling us to coordinate care, disseminate best practices and improve quality of care and Soldier readiness.”

LRMC’s Interdisciplinary Pain Management Center is one of seven IPMC’s that serve as a regional hub and also as the tertiary level of pain care on the Army’s Stepped Care Model of Pain. Effective pain management is critical for service member readiness and acute and chronic pain are the primary reasons that service members present for medical care and become medically non-available.

The stepped care model of pain starts with education and counseling by the patient’s primary care provider which is why quality pain education is important to get best practices shared with the entire medical community.

“Traditional methods of pain control such as opioids and other medications for chronic pain have not been shown to improve long term function and Soldier readiness,” stated U.S. Army Lt. Col. Brian McLean, chief of the LRMC IPMC and ECHO director. “Quality pain management focusing on self-care, functional rehabilitation and the stepped care model will help return service members to duty and avoid complications of poly-pharmacy.”

Another major task for ECHO is to educate the community on opioids while minimizing the impact to the military force, with the goal of decreasing possibility of addiction in a patient population which is prone to such prescriptions due to the nature of their duties. While chronic use of opioids (defined as those receiving at least 90 days of opioids in a 180-day period) peaked in 2007 in the U.S. Army, from 2012 to 2016, the rate of chronic opioid use decreased by 45 percent thanks to efforts like tele-mentoring and other applications in the Army’s pain management program.

“When the opioid epidemic was emerging, we focused many topics to educate our community on; opioids, buprenorphine training, behavioral management, and holistic treatment options,” said Gresham.

As the only forward-stationed United States medical center, LRMC serves as the evacuation and treatment center for all injured U.S. service members and civilians, as well as members of 56 coalition forces serving in Afghanistan, Iraq, as well as Africa Command, Central Command and European Command. LRMC’s use of the platform has helped reduce noncombat medevacs of service members serving overseas to LRMC, saving millions of dollars in logistics, increasing unit readiness by taking care of Soldiers where they are at and limiting time away from duty.

At LRMC, the IPMC has increased the coordination of interdisciplinary patient-centered treatment to improve outcomes, as evidenced during a recent patient encounter where the patient was referred to LRMC’s Neurosurgery Clinic for a noncombat injury but eventually deferred to the IPMC where pain management was able to return the Soldier to duty rather than re-deploy back to CONUS.

“Having patients referred to the Pain Clinic first is absolutely the right thing to do,” said U.S. Army Lt. Col. Michael Dirks, chief of Neurosurgery at LRMC.

Because certain specialty care like neurosurgery at LRMC is limited to emergent care, patients are at times sent back to where they’re stationed if their situation is non-emergent. These circumstances can be curtailed via tele-mentoring and exploiting more providers across the area of operations to availability and operations at LRMC. Additionally, the platform may afford providers to manage patient treatments at the point of injury.

“This new strategy for (noncombat) medevacs is going to enable us to do a better job of generating medical readiness for our supported combatant commanders,” said Dirks.

“For the patients, not only are we keeping them in the fight, but it’s also like having 12 doctors working on you instead of just one, a force multiplier model that ECHO brings to the table,” said Gresham. “The whole purpose is to discuss amongst everyone. The people that are (part of tele-mentoring sessions), the physicians that are specialists, help facilitate the discussion, and help the extension of care for better health outcomes.”