Project ECHO: A Telementoring Network Model for Continuing Professional Development.

Background:Project ECHO (Extension for Community Healthcare Outcomes) is a telehealth initiative that aims to reduce disparities in delivery of health care by leveraging technology and local expertise to provide guidance on specialized subjects to health care providers across the world. In 2018, a new ECHO hub convened in Indianapolis with a focus on health care for individuals in the lesbian, gay, bisexual, trans, and queer (LGBTQ+) populations. This ECHO iteration was one of the first of its kind and would soon be followed by a new human immunodeficiency virus (HIV) ECHO as well.Case Presentation:In a novel approach, information professionals participated in the early planning stages of the formation of these ECHO teams, which enabled the provision of real-time medical evidence and resources at the point-of-need once the teams were launched. This case study demonstrates proof of concept for including health sciences librarians and/or information professionals in the ECHO as hub team members. In this case study, the authors describe and quantify the value added to the HIV and LGBTQ+ ECHO sessions by the medical librarians, as well as provide a template for how other telehealth initiatives can collaborate with their local health information professionals.Conclusions:Librarian involvement in Project ECHO over the past three years has been enthusiastically received. The librarians have contributed hundreds of resources to ECHO participants, helped build and curate resource repositories, and expanded the embedded librarian program to an additional two ECHO iterations. ECHO hub team members report high rates of satisfaction with the performance of embedded librarians and appreciate the provision of point-of-need evidence to ECHO participants.

Direct-acting antiviral (DAA) medications are highly effective in treating hepatitis C virus (HCV) infection. However, use of DAAs in rural and underserved areas is low owing to limited access to specialist physicians with experience in care of HCV infection. Project ECHO (Extension for Community Healthcare Outcomes) is a distance education model that trains primary care physicians to improve access to care for underserved populations with complex diseases such as HCV infection. Evidence on whether Project ECHO is associated with increased DAA use is limited. To examine the association between Project ECHO and use of DAA treatment in patients with HCV infection. This cohort study used data from Medicare beneficiaries who newly sought care for HCV infection between January 1, 2014, and December 31, 2017. Data were analyzed between September and December 2020. Project ECHO. Use of DAA treatment. Discrete-time hazard models with state and year fixed effects were used to examine the association between Project ECHO and DAA use in rural areas and areas with low specialist density. A total of 267 908 patients (mean [SD] age, 60.7 [11.5] years; 57.9% male; 66.6% White patients) were included in the analysis. For every 100 clinicians attending a Project ECHO training, the odds of DAA treatment initiation among patients with HCV infection increased by 9% (adjusted odds ratio [OR], 1.09; 95% CI, 1.07-1.11; P < .001) in nonrural areas with specialist density equaling 0. The association between DAA use and Project ECHO was stronger in areas with lower vs higher specialist density. For every additional 100 Project ECHO participants, the odds of DAA use decreased by 1% as specialist density in the area increased (adjusted OR, 0.99; 95% CI, 0.98-1.00; P = .03). There was no association between Project ECHO and the odds of receiving DAAs among patients in rural vs urban areas (adjusted OR, 1.01; 95% CI, 0.99-1.02; P = .49). In this cohort study, implementation of Project ECHO was associated with increased DAA use in areas with few specialist physicians, suggesting that Project ECHO may enhance access to DAA treatment through expanding the capacity of primary care physicians to treat HCV infection, especially in underserved areas.

530 Background: Annually, more than 95,000 children, adolescents, and young adults receive a cancer diagnosis before the age of 40 in the United States. While 85% survive at least five years, this growing population faces a range of long-term complications from both the disease and its treatment. Survivorship care remains inconsistent, and many health care professionals lack training to address the complex needs of this population. To advance quality cancer care and close this gap, the American Cancer Society (ACS) developed an ECHO program to educate multidisciplinary teams about the distinct needs of pediatric, adolescent, and young adult (PAYA) cancer survivors and to support implementation of best practices. A core innovation of this ECHO was the integration of lived experience experts (LEEs) to elevate patient perspectives, enhance provider learning, and drive improved patient-centered care. Methods: Project ECHO (Extension for Community Healthcare Outcomes) is a learning framework where participants engage in a virtual community with peers and experts through didactic and case-based presentations. This fosters an “all teach, all learn” approach to disseminate and implement best practices. Project ECHO is widely recognized as a scalable approach to improve high quality, cost-effective care. Over 12 months, we held monthly one-hour interactive sessions on-line that focused on topics such as models of survivorship care, late effects, psychosocial needs, financial toxicity, fertility impacts, genetic counseling, and exercise and nutrition. A total of 220 unique participants across 36 U.S. states, one federal district, and five countries participated in the program. The heart of the ECHO Model is case-based learning. Traditionally, cases focus on system- or patient-level challenges. The ACS PAYA Survivorship ECHO was one of the first oncology ECHOs to feature LEEs as the case presentation in each session. Our 11 LEEs ranged from 3 to 36 in age at diagnosis, and the time from diagnosis was over 40 years from diagnosis. This approach brought patient and survivor voices directly into the clinical learning environment and emphasized the importance of integrating lived experiences. Results: The inclusion of LEEs deepened the emotional and educational impact of the sessions, encouraged clinicians to reflect on gaps in care, and fostered stronger connections to the survivor experience. On average 82% of participants reported learning something new from the LEE cases. One participant shared, “I loved hearing about experiences of others. It helps to understand how to address their needs and better understand their experiences.” Conclusions: By embedding patient and survivor voices into a scalable education model, this ECHO demonstrates a replicable strategy for advancing quality, patient-centered survivorship care.

Project ECHO (Extension for Community Healthcare Outcomes) uses videoconferencing technology to support and train healthcare professionals (HCPs) remotely. A 4-month fortnightly ECHO programme was developed and implemented to enhance 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 care domains. Focus groups were held before programme commencement to explore participants' attitudes and experiences of palliative care and after programme conclusion to explore their experiences of ECHO. Twenty-six primary care HCPs commenced the ECHO programme. Mean scores in self-rated confidence in knowledge and skill improved significantly(p<.002) following the programme. Twenty-one primary care HCPs completed the post-ECHO surveys and scores of self-rated confidence in knowledge and skills were significantly higher than pre-ECHO scores. Ninety-five percent of participants (n=19) reported ECHO met their learning needs and was an effective format to enhance clinical knowledge. Eighty-five percent of participants (n=17) would recommend ECHO to their colleagues. Project ECHO improved palliative care knowledge and skills of primary care HCPs in Ireland, with potential to address the growing need for integrated palliative care services.

Although Africa has the highest burden of cervical cancer in the world, educational resources to achieve the 90-70-90 targets set by the World Health Organization in its strategy to eliminate cervical cancer are lacking in the region. To adapt, implement, and evaluate the Project Extension for Community Health Care Outcomes (ECHO), an innovative learning tool, to build capacity of clinicians to better incorporate new evidence-based guidelines into cervical cancer control policies and clinical practices. This cross-sectional study assessed knowledge and practices of clinicians and support staff regarding cervical cancer prevention and control and compared them among respondents who had attended Project ECHO sessions (prior ECHO attendees) with those who had not but were planning on attending in the near future (newcomers) as part of the Cameroon Cervical Cancer Prevention Project ECHO. Satisfaction of prior ECHO attendees was also evaluated. Data were analyzed from January to March 2022. Main outcomes were practices and knowledge regarding cervical cancer education and prevention and preinvasive management procedures compared among prior ECHO attendees and newcomers. Of the 75 participants (mean [SD] age, 36.4 [10.0] years; 65.7% [95% CI, 54.3%-77.1%] women) enrolled in this study, 41 (54.7%; 95% CI, 43.1%-66.2%) were prior ECHO attendees, and most were clinicians (55 respondents [78.6%; 95% CI, 68.7%-88.4%]). Overall, 50% (95% CI, 37.8%-62.2%) of respondents reported performing cervical cancer screening with visual inspection of the cervix after application of acetic acid (VIA) and/or visual inspection of the cervix after application of Lugol's iodine (VILI), 46.3% (95% CI, 34.0%-58.5%) of respondents reported performing human papillomavirus (HPV) testing, and 30.3% (95% CI, 18.9%-41.7%) of respondents reported performing cervical cytological examination in their practices, Approximately one-fourth of respondents reported performing cryotherapy (25.4% [95% CI, 14.7%-36.1%]), thermal ablation (27.3% [95% CI, 16.2%-38.3%]) or loop electrosurgical excisional procedure (LEEP, 25.0% [95% CI, 14.4%-35.6%]) for treatment of preinvasive disease. The clinical use of many of these screening and treatment tools was significantly higher among prior ECHO attendees compared with newcomers (VIA/VILI: 63.2% [95% CI, 47.4%-78.9%] vs 33.3% [95% CI, 16.0%-50.6%]; P = .03; cryotherapy: 40.5% [95% CI, 24.3%-56.8%] vs 6.7% [95% CI, 0.0%-15.8%]; P = .002; thermal ablation: 43.2% [95% CI, 26.9%-59.6%] vs 6.9% [95% CI, 0.0%-16.4%]; P = .002). Knowledge about cervical cancer education, prevention, and management procedures was satisfactory in 36.1% (95% CI, 23.7%-48.5%) of respondents; this proportion was significantly higher among prior ECHO attendees (53.8% [95% CI, 37.7%-69.9%]) compared with newcomers (4.5% [95% CI, 0.0%-13.5%]; P < .001). Approximately two-thirds of participants (68.8% [95% CI, 51.8%-85.8%]) reported that they had applied knowledge learned in our ECHO sessions to patient care in their practice or adopted best-practice care through their participation in this ECHO program. These findings suggest that the Project ECHO e-learning and telementoring program was associated with improved skills for clinicians and support staff and enhanced quality of care for patients. In the COVID-19 era and beyond, reinforced efforts to strengthen cervical cancer knowledge and best practices through distance learning and collaboration are needed.

Buprenorphine is an approved medication for opioid use disorder (MOUD); however, prescribing buprenorphine is limited by a requirement to obtain a waiver to prescribe it (hereinafter, "DATA [Drug Abuse Treatment Act]-waiver") and a lack of knowledge of the best practices among clinicians. To examine how Project ECHO (Extension for Community Healthcare Outcomes) telementoring is associated with changes in DATA-waiver attainment and buprenorphine prescribing among primary care clinicians in Minnesota. In this retrospective matched-cohort study of 918 clinicians, ECHO-trained clinicians were enrolled on the date they first attended ECHO (January 3, 2018, to June 11, 2020); comparison clinicians were assigned an enrollment date from the distribution of the first ECHO sessions. The baseline period was 12 months preceding enrollment, with follow-up for 18 months or until June 30, 2020. The ECHO-trained clinicians were a population-based sample of primary care clinicians who treated Medicaid patients in Minnesota 12 months prior to the initiation of ECHO training. This analysis used propensity score matching to select comparison clinicians who were similar across demographic and clinical practice characteristics at baseline in a 2:1 ratio. Follow-up was available for 167 ECHO-trained clinicians (54.6%) and 330 comparison clinicians (53.9%) at 18 months. ECHO-trained clinicians attended at least 1 weekly, hour-long ECHO session. Comparison clinicians never participated in any ECHO sessions. DATA-waiver attainment, any buprenorphine prescribing, and the percentage of patients with opioid use disorder (OUD) who were prescribed buprenorphine. The final sample included 918 clinicians (ECHO-trained [306]; comparison [612]), of whom 620 (67.5%) practiced outside the metropolitan Twin Cities (Minneapolis-St Paul) region. The mean (SD) age of the ECHO-trained clinicians was 46.0 (12.1) years and that of the comparison clinicians was 45.7 (12.3) years. Relative to the changes among the matched comparison clinicians, the ECHO-trained clinicians were more likely to obtain a DATA-waiver (difference-in-differences, 22.7 percentage points; 95% CI, 15.5-29.9 percentage points; P < .001) and prescribe any buprenorphine (16.5 percentage points; 95% CI, 10.4-22.5 percentage points; P < .001) after 6 quarters of follow-up. ECHO-trained clinicians prescribed buprenorphine to a greater share of patients with OUD (a difference of 7.6 percentage points per month; 95% CI, 4.6-10.6 percentage points per month; P < .001), relative to that prescribed by the comparison clinicians. According to the findings of this matched-cohort study, ECHO telementoring may be associated with greater prescribing of buprenorphine by primary care clinicians. These findings suggest that Project ECHO training could be a useful tool for expanding access to MOUD.

<h3>Objectives</h3> The Extension for Community Healthcare Outcomes (ECHO) is a proven model to improve specialty care for underserved communities. The IGCS uses the Project ECHO platform to connect multi-disciplinary teams across disparate regions, through virtual tumor board case discussions and didactic presentations. In the Project ECHO sessions, international pathologists provide pathology review, which is often based on limited imaging embedded in Power Point slide presentations. We present an initial review of our experience integrating pathologists into the IGCS virtual tumor boards. <h3>Methods</h3> We solicited feedback from pathologists and clinicians participating in the IGCS ECHO sessions in individual and small group settings. <h3>Results</h3> Clinicians appreciate the inclusion of pathology images and teaching in ECHO sessions with good clinical and educational value. However, challenges were noted with engagement and scheduling with in-country pathologists. Challenges noted by the consulting pathologists included: being asked to offer an opinion with limited information or images, poor quality images, lack of the final pathology report, coping with apparent diagnostic errors, lacking an established relationship with the local pathologist, and the local pathologist not always being present to discuss or explain findings. Opportunities identified include: establishing telepathology connections to facilitate case review, leveraging the IGCS Global Curriculum international mentor/local mentor/trainee model to create parallel and synergistic international and local pathologist collaborative relationships beyond ECHO sessions, further program strengthening through international exchange trips for international and local pathologists. <h3>Conclusions</h3> Inclusion of pathology experts in Project ECHO sessions is key to successful tumor boards. Addressing the above-noted challenges will strengthen the entire collaboration.

Project Extension for Community Healthcare Outcomes (ECHO) uses tele-education to bridge knowledge gaps between specialists at academic health centers and primary care providers from remote areas. It has been implemented to address multiple medical conditions. The authors examined evidence of the impact of all Project ECHO programs on participant and patient outcomes. The authors searched PubMed, MEDLINE, EMBASE, PsycINFO, and ProQuest from January 2000 to August 2015 and the reference lists of identified reviews. Included studies were limited to those published in English, peer-reviewed articles or indexed abstracts, and those that primarily focused on Project ECHO. Editorials, commentaries, gray literature, and non-peer-reviewed articles were excluded. The authors used Moore's evaluation framework to organize study outcomes for quality assessment. The authors identified 39 studies describing Project ECHO's involvement in addressing 17 medical conditions. Evaluations of Project ECHO programs generally were limited to outcomes from Levels 1 (number of participants) to 4 (providers' competence) of Moore's framework (n = 22 studies, with some containing data from multiple levels). Studies also suggested that Project ECHO changed provider behavior (n = 1), changed patient outcomes (n = 6), and can be cost-effective (n = 2). Project ECHO is an effective and potentially cost-saving model that increases participant knowledge and patient access to health care in remote locations, but further research examining its efficacy is needed. Identifying and addressing potential barriers to Project ECHO's implementation will support the dissemination of this model as an education and practice improvement initiative.

Project ECHO (Extension for Community Healthcare Outcomes) is an evidence-based telementoring approach to connect often siloed school nurses with a network of expert clinical and academic faculty, as well as school nurse colleagues throughout the country by engaging in case-based learning. Managing Students with Seizures ECHO: The Importance of School Nurses (MSwS ECHO) provided two cohorts of school nurses with an interactive, bidirectional educational program focused on various aspects of seizures and epilepsy relevant to school nurse practice. MSwS ECHO enhanced school nurses’ confidence in caring and advocating for students with seizures and epilepsy, expanded school nurses’ access to resources and professional networks, and provided the opportunity to collaborate with experts and colleagues to problem solve challenging real-life cases. The ECHO Model is a unique and effective teaching modality that can be applied to a variety of school health topics and chronic conditions. School nurses are encouraged to participate in forthcoming ECHO-based learning opportunities.

Background Barriers and facilitators to implementation of comprehensive person-centred assessment and support within palliative care have been identified (Ewing & Grande, 2018). To address the challenges, an online toolkit was developed to provide organisations with structured implementation guidance for the Carer Support Needs Assessment Tool (CSNAT) intervention. However, feedback from practitioners undertaking previous face-to-face CSNAT intervention training and from online toolkit participants highlighted the benefits from follow-up support calls with the opportunity to ask questions and problem solve with their peers, the opportunity to build networks with other organisations completing the training, and having a point of contact to ask questions (Diffin, Ewing, Rowland, Grande, 2018). Currently there is no method for providing this additional support. Project ECHO™ (Extension for Community Healthcare Outcomes) is a tele-mentoring programme which uses video-conferencing to deliver best practice guidance and education from specialists, and case-based learning with opportunities for questions and discussion with peers, and therefore could overcome this gap. Aim To identify if Project ECHO™ could be used to establish a community of practice and support implementation of the CSNAT intervention. Methods and results We will draw on the CSNAT implementation evidence base to illustrate the importance of supporting practitioners to gain knowledge about how to use the CSNAT in practice, and enhance their confidence in carrying out assessments. In addition, we will reflect on the implementation support needed at an organisational level, to include practical guidance and opportunities for peer support. In turn, we will highlight how Project ECHO™ could be used to help overcome identified gaps in support through reflection on the core benefits of this methodology to include a curriculum identified by the network participants themselves, case-based learning, and the ability to join remotely. Conclusion This paper identifies how Project ECHO™ could be utilised to establish a community of practice to support implementation and embedding of comprehensive person-centred assessment and support for family carers into everyday practice.

Overdoses and alcohol consumption rose during the pandemic. However, uptake of practices which reduce mortality (eg, medications for opioid use disorder, harm reduction practices) remains insufficient. Provider training and telementoring is needed to ensure sufficient capacity for treating substance use disorders (SUDs) with evidence-based practices. The Project ECHO (Extension for Community Healthcare Outcomes) model involves the use of web technologies to deliver didactic and case-based learning through a panel of experts to build such competency in a community of learners. Project ECHO was leveraged to implement a statewide telementoring center of addictions-focused ECHO programs, including programming in prescribing, harm reduction, recovery support services, collaborations with first responders, and systems-level challenges. Participants represented health and behavioral health disciplines practicing across the state of Texas in metropolitan and rural areas. Learners were administered: (1) an online registration form that inquired about basic demographics, (2) a post-session survey at the conclusion of each session capturing satisfaction and likelihood to implement, and (3) annual surveys measuring changes in knowledge and self-efficacy. Attendance and other learner data were stored and extracted from the partner relationship management database: iECHO. Training programs were attended by 968 learners, with an average of 48 learners per session. Geographic reach included 47 Texas cities. Post-training survey results indicated high rates of learner satisfaction, with an average rating of 4.68 on a 5-point Likert-like scale. Annual surveys indicated improvements in provider knowledge and self-confidence across all programs. Early results indicate robust uptake, wide geographic reach, high learner satisfaction, and provider knowledge and confidence gains. This preliminary evidence supports the use of the ECHO model as a potential tool for scaling comprehensive SUD telementoring centers to meet workforce development needs over large geographic areas.

IntroductionAdverse Childhood Experiences (ACEs) are traumatic events that occur before 18 years. ACEs, associated with increased health-risk behaviors and chronic health disorders, disproportionately impact people from marginalized communities. Evidence shows that toxic stress from ACEs and adverse social determinants of health can be prevented and treated with trauma-informed care (TIC). The purpose of this educational program was to train a maternal and child health workforce to bring evidence-based trauma-informed care to all impacted people.MethodsParticipants were professionals recruited from Federally Qualified Health Centers, community behavioral health organizations, educational institutions, and agencies serving low-income children and families. 100 unique participants representing 3 counties and 54 agencies joined sessions. Twelve virtual educational sessions were convened over 6 months using the Project ECHO® model via Zoom technology. Sessions consisted of didactic lectures and case-based discussions.ResultsAfter completion of the series, participants reported high satisfaction and increased knowledge and confidence in using TIC best practice skills. After participation, a significant number of participants voluntarily completed an additional online training about the specific TIC best practices that had been taught in the ECHO. Participants rated the opportunity for interprofessional collaboration and peer support for vicarious trauma as program strengths.DiscussionThis project demonstrated feasibility and effectiveness in delivery of a curriculum on trauma-informed care to cross-sector, multi-agency maternal and child health workforce professionals using the Project ECHO® model. Robust interprofessional collaboration and participants’ request for more sessions demonstrate the potential for this model to effect change at a local systems level.

Primary care clinicians have an important role in the management of dementia and have expressed interest in continuing education. The authors describe a model they used for providing dementia education in primary care, Project ECHO (Extension for Community Healthcare Outcomes), and an overview of its major features. A partnership including academic institutions and a national healthcare association is then outlined, including the unique features of the ECHO model developed through this partnership. A mixed-methods methodology was used for programmatic evaluation. This use of mixed methods adds vital new knowledge and learner perspectives that are key to planning subsequent ECHO courses related to dementia and primary care. The discussion includes an exploration of the significance of these findings for understanding the motivations of primary care providers for participation in the educational program, as well as the limitations of the current study. A final section explores the next steps in the continued development of the model and its implications for geriatrics education in dementia care, especially the supportive role that ECHO courses can play in meeting the challenges of dementia care.

<h3>Context</h3> Rheumatoid Arthritis (RA) is a common, chronic, and complex disease that affects 1% of the population in Ontario, with a higher prevalence in First Nations populations at 3%. Timely and aggressive treatment of RA with disease-modifying antirheumatic drugs (DMARDs) can lead to effective management of symptoms. Left untreated, however, RA can lead to deformed joints, debilitating pain, and significantly reduced quality of life. ECHO Rheumatology (‘ECHO’) was a program developed to address the burden of RA and other rheumatic diseases in Ontario. ECHO began running weekly sessions in January 2017. <h3>Objective</h3> This study describes the patient characteristics and quality improvement (QI) initiatives in ECHO. <h3>Study Design</h3> A mixed methods study with a QI lens <h3>Setting</h3> ECHO (Extension for Community Healthcare Outcomes) is a collaborative model of medical education and care management, designed to increase capacity and access for care. In each weekly session, a healthcare provider (HCP) presents a patient case using a standardized patient case presentation form. Recommendations are then made from the interprofessional group and community. <h3>Population Studied</h3> Patient cases were summarized using the data extracted from HCPs’ weekly case presentation forms. QI opportunities were also identified from provider- and patient-level data. <h3>Outcome Measures</h3> 1)Descriptive characteristics of patients presented and HCP participants 2)Differential diagnoses and recommendations following ECHO patient presentation <h3>Results</h3> From January 2017 to December 2019, ECHO provided 112 sessions with a total of 117 patient cases presented. 180 HCPs attended at least one session and 64 (36%) presented at least one case. At baseline, 63 (54%) of patients were female and mean age was 58 (range = 20-80). 24 (21%) patients had no diagnosis at baseline and 24 (21%) were on DMARDs. 27 (23%) were referred to a rheumatologist after presentation. <h3>Conclusions</h3> ECHO Ontario Rheumatology has gained uptake across Ontario. Patients presented at ECHO were complex, with multimorbidity, and reflected a mixture of classically inflammatory and mechanical pathologies mechanical pathologies, with relative prevalence reflecting the typical burden of rheumatologic and musculoskeletal diseases. Next steps in ECHO’s evaluation will address its impact on practice change through systematic follow up with participating health care providers, and on “real world” integration with preexisting models of care.

In 2016, the Government of India launched a national program for screening and prevention of oral, breast, and cervical cancer. In support, the National Institute for Cancer Prevention Research (NICPR) adopted the Project ECHO (Extension for Community Healthcare Outcomes) model for training health care providers in cancer screening. We assess change in knowledge and skills among physicians attending hybrid (i.e., online and in person) NICPR-ECHO trainings and impact on implementation of cancer screening services. Prior to the start of the online phase and upon completion of 14 weeks, trainees answered a 23-item online questionnaire, including visual vignettes. We conducted descriptive and bivariate analysis of pre-post assessments from trainees participating in the online phase and wherever available report on the weekly quizzes and the hands-on workshop assessments. A total of 641 medical officers participated in the trainings from May 2019 to February 2020. Across nine cohorts of trainees, only 116 primary care physicians completed both the pre- and post-assessments. Almost two-thirds completed medical training (69.7%) and 85% were working in government healthcare facilities. Trainees reported statistically significant improvements before and after the online phase, when queried specifically on knowledge and skills using visual vignettes about oral (p < 0.001), breast (p = 0.35), and cervical cancer screening (p < 0.001). Study findings support the effectiveness of Project ECHO in reaching primary care physicians across the country and improving their knowledge and skills related to screening for breast, oral, and cervical cancer, with additional support needed for implementation of clinical cancer screening services.