Our Story
The Rheumatology Access Expansion (RAE) Initiative was established in 2021 to support people living with rheumatoid arthritis in communities with limited access to local rheumatologists.
A Shortage of Rheumatology Providers
Rheumatoid arthritis (RA) is the most common form of autoimmune arthritis, affecting more than 1.3 million Americans. When inadequately treated, RA is associated with substantial pain, deformity, and disability. However these poor outcomes can largely be avoided through early diagnosis and appropriate management. It is well-established that the burden of RA in the United States falls disproportionately on communities of color and rural populations. Navajo Nation, the largest American Indian reservation, is an example of a community that is especially hard-hit, faced with high RA prevalence and disease severity, and limited access to local rheumatology specialists.
Given the shortage of local rheumatology providers in many rural and suburban communities across the US (and worldwide), a large portion of of RA care falls to primary care providers (PCPs). Supporting PCP-lead management of RA is key to reducing suffering and improving the lives of those living with RA.
Our project uses an established educational model, Project ECHO (Extension for Community Healthcare Outcomes), to remotely mentor PCPs in the diagnosis and evidence-based treatment of RA, with the primary goal of improving RA disease-associated outcomes and reducing health disparities. Weekly interactive Zoom conferences are led by an interdisciplinary team of RA experts, and include high-yield didactics on core topics in RA diagnosis and treatment, as well as interactive case-based discussion.
1.3 million Americans
affected by RA
A Spotlight on Navajo Nation
When the RAE Initiative was first established in 2021, our core mission was to support people living with RA on Navajo Nation. Navajo Nation is the largest American Indian reservation, home to over 170,000 on-reservation tribal members. It is estimated that the Navajo community has approximately 5 times the prevalence of RA compared to the overall US population. Given the vast size and rurality of Navajo Nation, combined with the scarcity of local rheumatology providers, people living with RA and other rheumatologic conditions on Navajo often face significant barriers to accessing specialty care.
The first RA ECHO Curriculum was created in close partnership with community health leaders and providers on Navajo, specifically to support PCPs and patients on Navajo Nation. In partnership with local community health organizations, the RAE Initiative continues to promoting community awareness about RA and celebrating the strength and resilience of those living with RA on Navajo Nation. Community-centered projects have included:
- – Digital Storytelling Workshop, led by Healthy Native Communities Partnership, in which individuals shared their personal stories of how RA has impacted their lives.
- – Rez Cafes (community round-table discussions) focused on arthritis
- – A Joint Health training symposium for Community Health Representatives
- – Development of RA patient education materials specifically for the Navajo community
- Be
Expanding the Reach of the RAE Initiative
Since 2023, we have partnered with Indian Country ECHO to offer access to the Rheumatoid Arthritis ECHO Curriculum to all primary care providers serving Indian Country, nation-wide. To date, more than 100 PCPs have completed the RA ECHO curriculum, from 16 different states. In the future, we hope to expand the reach of Rheumatology ECHO programs further, to reach all PCPs who wish to enhance their knowledge of common rheumatologic diseases, with the hope of expanding access to excellent rheumatology care and reducing health disparities.
A
Nearly 5X
the national prevalence of RA on Navajo Nation
Rheumatoid arthritis (RA) is the most common form of autoimmune arthritis, affecting more than 1.3 million Americans. When inadequately treated, RA is associated with substantial pain, deformity, and disability. However these poor outcomes can largely be avoided through early diagnosis and appropriate management. It is well-established that the burden of RA in the United States falls disproportionately on communities of color and rural populations. Navajo Nation, the largest American Indian reservation, is especially hard-hit, faced with high RA prevalence and disease severity, and very limited access to rheumatology specialists.
Given the shortage of local rheumatology providers, the majority of RA care falls to primary care providers (PCPs). Supporting PCP-lead management of RA is key to reducing suffering and improving the lives of those with RA on Navajo Nation.
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Our project uses an established educational model, Project ECHO (Extension for Community Healthcare Outcomes), to remotely mentor Navajo Nation PCPs in the diagnosis and evidence-based treatment of RA, with the primary goal of improving RA disease-associated outcomes and reducing health disparities. Weekly interactive Zoom conferences are led by an interdisciplinary team of RA experts in and around Navajo Nation, and from the University of California San Francisco.
In partnership with local community health organizations, the RAE Initiative is promoting community awareness about RA and celebrating the strength and resilience of those living with RA on Navajo Nation. Projects for 2022 include a Digital Storytelling Workshop, led by Healthy Native Communities Partnership, in which individuals will share their personal stories of how RA has impacted their lives.
Rheumatoid arthritis (RA) is the most common form of autoimmune arthritis, affecting more than 1.3 million Americans. When inadequately treated, RA is associated with substantial pain, deformity, and disability. However these poor outcomes can largely be avoided through early diagnosis and appropriate management. It is well-established that the burden of RA in the United States falls disproportionately on communities of color and rural populations. Navajo Nation, the largest American Indian reservation, is especially hard-hit, faced with high RA prevalence and disease severity, and very limited access to rheumatology specialists.
Given the shortage of local rheumatology providers, the majority of RA care falls to primary care providers (PCPs). Supporting PCP-lead management of RA is key to reducing suffering and improving the lives of those with RA on Navajo Nation.
1.3 million Americans
affected by
Rheumatoid arthritis (RA)
Nearly 5X
the national prevalence of RA in the Navajo Nation
Our project uses an established educational model, Project ECHO (Extension for Community Healthcare Outcomes), to remotely mentor Navajo Nation PCPs in the diagnosis and evidence-based treatment of RA, with the primary goal of improving RA disease-associated outcomes and reducing health disparities. Weekly interactive Zoom conferences are led by an interdisciplinary team of RA experts in and around Navajo Nation, and from the University of California San Francisco.
In partnership with local community health organizations, the RAE Initiative is promoting community awareness about RA and celebrating the strength and resilience of those living with RA on Navajo Nation. Projects for 2022 include a Digital Storytelling Workshop, led by Healthy Native Communities Partnership, in which individuals will share their personal stories of how RA has impacted their lives.
Our Collaborators
Gwendolyn Grant
Jeannie Hong
Jennifer Mandal (PI)
Jinoos Yazdany
Marita Jones
Mimi Margaretten
Nat Cabrera
Tabitha Carroway
Tina Tso
Starla Hairston Blanks
Dr. Gwendolyn Grant
MD
CHPG Rheumatology Southwest
Dr. Gwendolyn Grant is a practicing rheumatologist in southwest Colorado who provides part-time rheumatology consultations to patients on the Navajo Nation, and has extensive experience with the Project ECHO model, having previously led the development of a Rheumatology ECHO in collaboration with the University of New Mexico.
Dr. Jennifer Mandal (PI)
MD
UCSF
Dr. Jennifer Mandal (PI) is an Assistant Professor of Medicine at UCSF, the UCSF School of Medicine Lead for Interprofessional Education, and the Director of Evaluation for the UCSF Rheumatology Fellowship Program. Her clinical work focuses on the care of vulnerable patients with severe RA at the Rheumatoid Arthritis Clinic at Zuckerberg San Francisco General Hospital.
She has more than a decade of experience in medical education, including curriculum development, evaluation and assessment, interprofessional education research, and simulation, and has received national recognition as a leader in interprofessional health education and research. Her education research has been published in peer reviewed journals and presented nationally and internationally. Her primary interest is in utilizing novel education techniques to promote interprofessional collaboration and improve access to rheumatology care.
Dr. Mimi Margaretten
MD
UCSF
Dr. Mimi Margaretten is a Professor of Medicine at UCSF and the Rheumatology Clinic Chief at Zuckerberg San Francisco General Hospital. Her clinical work centers on taking care of patients with severe rheumatoid arthritis and musculoskeletal diseases to focus on delivering outstanding care to vulnerable patients. In her leadership role as clinic chief, she is responsible for all aspects of rheumatology clinical activities at ZSFG.
She is an accomplished clinical educator who has developed and maintained innovative curricula for multiple learners, including the UCSF School of Medicine Bridges Curriculum for medical students, the Longitudinal Clerkship Experience for general internal medicine residents, and Clinical Problem-Solving Cases for rheumatology fellows.
Her expertise in answering “real-world” rheumatology questions is reflected by her publications in JAMA, The New England Journal of Medicine, and Arthritis Care and Research. Her work as an educational leader has been recognized with numerous University of California San Francisco teaching awards.
Dr. Jinoos Yazdany
MD, MPH
UCSF
Dr. Jinoos Yazdany is a Professor of Medicine at UCSF and the Chief of the Division of Rheumatology at ZSFG. Her scholarship focuses on improving health care quality, safety and outcomes for individuals with chronic rheumatic diseases. She co-directs the UCSF Rheumatology Quality and Informatics Lab, an interdisciplinary group that uses health services research, informatics, and implementation science to inform national health care improvement initiatives. She has worked with colleagues to develop the American College of Rheumatology’s RISE registry that aggregates and analyzes data from rheumatology practices around the country to inform quality improvement and research projects. She has developed a number of quality measures that have been endorsed by the National Quality Forum and are being used in federal programs. She has served as PI of grants from the NIH/NIAMS, AHRQ, and CDC and is the recipient of a NIAMS K24 mentoring award. Dr. Yazdany also serves as co-director of a research core – one focused on human subjects recruitment and clinical informatics support – for the NIH/NIAMS-funded P30 UCSF PREMIER Center. Nationally, Dr. Yazdany has held numerous leadership positions, including serving as co-chair of the ACR’s Quality Measures Subcommittee, chair of the ACR’s Registries and Health IT Committee, chair of Research and Publications for the RISE registry, and member of the NQF’s Health Professional Council. She has earned several honors and awards for her work, including the Mary Betty Stevens Young Investigator Prize from the Lupus Foundation of America, the Ephraim Engleman Award for Arthritis Research, and the Hulda Irene Duggan Arthritis Investigator Award from the Arthritis Foundation.
Marita Jones
MPH
(Dine’/Navajo)
Healthy Native Communities Partnership, Inc.
Marita Jones is Bitterwater Clan, born for Manygoats clan, maternal grandfathers are Folded Arms clan, and paternal grandfathers are Towering House clan. She is from the western part of the Navajo Nation and works in Shiprock, NM near the 4-corners area. She lives on a small ranch with her husband, horses, sheep, a donkey, dogs and cats.
As the Executive Director of Healthy Native Communities Partnership, Inc. (HNCP), she brings over 30 years of experience in working with communities of diverse cultures throughout Indian country. Her interest has been in connecting with local community to realize their own vision of wellness. Her vision is for healthy and strong Indigenous communities.
Tina Tso
(Dine’/Navajo)
Healthy Native Communities Partnership, Inc.
Tina Tso is of the Towering House clan, born for the Deer Spring people, maternal grandfathers are of the Water Edge people and paternal grandfathers are of the Rock gap people. She is from the Western part of the Navajo Nation and works in Shiprock, NM with the Healthy Native Communities Partnership, Inc. She is married and has two wonderful daughters and just became a grandmother!
Tina assisted with the development of curriculum, implementation and evaluation of Healthy Native Communities Partnership programs such as the Creating Community Circles for Change gatherings, and the Healthy Native Communities Fellowship. She researches, negotiates and makes logistic arrangements for in-person gatherings and meetings throughout the country. She provides mentoring, technical assistance and support to HNCP partners locally and throughout the country. She provides onsite and online training on effective group facilitation methods and community wellness planning. She works in recruiting and training communities across the Navajo Nation in planning and implementing Community Wellness strategies. She also conducts presentations on community wellness to Dine’ College Public Health classes. She is fluent in Navajo and English language.
Tabitha Carroway
MPH, CPH
UCSF
Tabitha Carroway is from a small town in rural Oklahoma. She attended The University of Oklahoma for her bachelor’s degree in Biology, Psychology and Chemistry. She then went on to obtain a master’s degree in Public Health. She is extremely passionate about sustainably elevating the social determinants of health in vulnerable populations and increasing access to quality healthcare in rural areas. She has worked on several public health projects, including the expansion of reproductive healthcare services in rural primary care settings, IHS cancer screening process improvement, and health promotion for Oklahoma’s uninsured. She is thrilled to be working in collaboration with this amazing team to promote health equity and improve health outcomes on the Reservation.
Nat Cabrera
American College of Rheumatology
Nat Cabrera joined the COIN team in 2021, bringing extensive experience in program and association management. Nat started at the ACR in grants administration with the Rheumatology Research Foundation and most recently worked in the Strategic Relations department. She also spent time with the American Academy of Allergy, Asthma, and Immunology where she worked in Research and Training, acting as the liaison and managing relationships with training programs, the National Residency Match Program, and the ACGME. She received her Bachelor’s degree in International Relations from Emory University.
Starla Hairston Blanks
MBA, MPH, CPHP
American College of Rheumatology
Starla Blanks serves as the Director of Collaborative Initiatives for the American College of Rheumatology. Starla brings experience from working in academic, association and community settings on chronic disease management, help-seeking behavior, community health workers, public health practice and health policy to her current position. She is a nationally recognized trainer with certifications in public health practice, adult learning, community organizing, smoking cessation and chronic disease who holds a Bachelor of Science degree in Political Science, a Master’s degree in Business Administration with a specialization in non-profit leadership and a graduate degree in public health.
Dr. Jeannie Hong
PharmD, MPH, BCPS, LCDR
Phoenix Indian Medical Center
Dr. Jeannie Hong is a Rheumatology Specialty Pharmacist at the Phoenix Indian Medical Center located in Phoenix, AZ. She received a B.S. in Chemistry from Virginia Commonwealth University, and her Doctor of Pharmacy and Master of Public Health degrees from the University of North Carolina at Chapel Hill. She proudly serves the Native Americans and Alaska Natives as a U.S. Public Health Service officer and has been board certified in pharmacotherapy.
The American College of Rheumatology (ACR) is a professional membership organization committed to improving the care of patients with rheumatic disease and advancing the rheumatology subspecialty. It is the premier national professional organization for advancing rheumatology in the United States with a membership of over 9,000 rheumatology health professionals. The ACR has over fifty years of experience in advancing the science and awareness of rheumatoid arthritis and over ten years of an intentional focus on eliminating health disparities, including through the establishment of its Collaborative Initiatives (COIN) Department which concerns itself with advancing health equity and improving quality of life for people with rheumatic disease.
Since Project ECHO was established in 2003, more than 860 ECHO Programs have been created across 40 countries, and more than 100,000 health care workers have been trained. The mission of Project ECHO is to demonopolize knowledge and amplify the capacity to provide best practice care for underserved people all over the world. This low-cost, high-impact intervention is accomplished by linking expert interdisciplinary specialist teams with primary care clinicians through teleECHO clinics, in which the experts co-manage patient cases and share their expertise via mentoring, guidance, feedback and didactic education. This enables primary care clinicians to develop the skills and knowledge to treat patients with common, complex diseases in their own communities, in this way reducing travel costs, wait times and avoidable complications.
The Bristol Myers Squibb Foundation supports community-based programs that promote cancer awareness, screening, care and support among high-risk populations. The mission of the Bristol-Myers Squibb Foundation is to help reduce health disparities by strengthening community-based health care worker capacity, integrating medical care and community-based supportive services, and mobilizing communities in the fight against disease.
Through creating opportunities to collaborate and share knowledge, Indian Country ECHO is growing a welcoming professional community that enhances providers’ ability to offer American Indian and Alaska Native patients high-quality, specialized care.
One of the ways we foster collaboration is through offering teleECHO programs – friendly, interactive online learning environments where clinicians and staff serving American Indian and Alaska Native patients can connect with peers, engage in didactic presentations, collaborate on case consultations, and receive mentorship from clinical experts from across Indian Country.
In addition to offering providers a variety of teleECHO programs, Indian Country ECHO provides no cost trainings, as well as technical assistance and capacity building services. We also facilitate The Indian Country ECHO Collective – a community of predominantly Indigenous organizations that provide ECHO services across the globe.
The Indian Country ECHO network is here to help and support in planning and implementing your own ECHO program step-by-step. Learn more about replicating the ECHO model.
Indian Country ECHO is a project of the Northwest Portland Area Indian Health Board.
The University of California San Francisco (UCSF) is a world leader in patient care, biomedical research, healthcare professional education, and health policy. UCSF’s Division of Rheumatology has identified expanding access to rheumatology care for underserved populations as one of its guiding missions. The UCSF rheumatology team brings world-class expertise not only in RA management and research, but also in implementation science, health services research and informatics, and curriculum development and evaluation.