Thomas Ambelang sarah Kwasigroch, Pharm.D alaa wasfi , RN, BSN sam forsythe Bernard whitehead

1. Outreach and Clinical Models Designed to Identify and Address Barriers to Hepatitis C TreatmentHoward Brown HealthHepatitis C Team Thomas Ambelang sarah Kwasigroch, Pharm.D alaawasfi, RN, BSN samforsythe Bernard whitehead

2. Conflicts of Interest: • Sarah Kwasigroch works for Walgreen’s Pharmacy

3. Introduction • Hepatitis C is a virus that primarily effects the liver, with few symptoms. • Given enough time, it can lead to cirrhosis, liver cancer or liver failure and the need for a transplant. • For people living with HIV, the progression of Hepatitis C can be faster.

4. Introduction Transmission • Hepatitis C is transmitted through blood only, and is more easily transmitted than HIV. • Contracted through sharing of needles, but also can be transmitted through the sharing of cookers, cottons, straws and pipes • Can be transmitted sexually, especially through anal sex • Prevalent in baby boomers due to surgical equipment prior to universal precautions, and through blood transfusions prior to 1992 before HCV was eradicated from the blood supply.\ • Non professional tattoo and piercing

5. Introduction Nationally, it is estimated 3.5 million people have Chronic Hepatitis C In 2013, there were more HCV related deaths than the 60 other infectious diseases combined, including HIV

6. Hepatitis C in Chicago Over 26,000 people known to be living with HCV in Chicago, and the estimated actual number is between 40-70,000 people Over 800 people died from HCV related causes in 2016 From 2015-2016, confirmed HCV infections increased 16%

7. HCV Treatment Hepatitis C is curable. Improved treatments with improved success, multiple medication options and reduced Medicaid restrictions. Once daily dosing 8-12 weeks. Cure rates greater than 97%.

8. Why? With a cure for HCV, and easier access to medications, why are these numbers so high? Why do so many people still need treatment? Why aren’t more people cured?

9. Populations most at risk and the barriers we’ve identified • PWUD • Baby Boomers • LGBTQ identified clients • Co-infected population • Reentry population • Immigrant population and non-English speakers

10. Barriers Socioeconomic status • Stable Housing; no safe place to sleep or keep meds • Stable income • Consistent access to transportation (transport assistance/rideshares) • Having a way to contact your care team: use of email, and access to a cell phone (client example, experiencing homelessness) How does socioeconomic status play into the experience of other barriers…

11. Barriers Availability of Resources • Lack of health centers in the west and south sides of Chicago • Lack of LGBTQ competent care • Most providers refer out, and there are lengthy wait times for HCV programs (~2 months) • Issue of who is allowed to treat due to state regulations

12. Barriers Information and Education • Many at-risk groups are neglected in health education opportunities (south/west sides, reentry population, etc.) • Many are unaware of what HCV does, why it’s important to treat, and other ways it can be transmitted beyond needles • “I’ve heard of Hep C, but what is it?”

13. Barriers Migration status and native language • Documentation and insurance eligibility • Safety in accessing medical care: fears of new administration, public rule, and implications of these policies • Language Barrier: limited services in our most common 2nd languages, what about the rest? • Cultural Stigma- intersecting your culture of origin with that of the USA

14. Barriers Stigma of Diagnosis and Substance Use • Fear of friends and family finding out status • prohibits both conversations around transmission and entry into healthcare settings • Judgement experienced by patients in health care settings due to their identity or substance use • Beyond judgement: many providers block treatment based on substance use and have instituted their own UDS

15. So how do we address this? What can we do to mitigate these barriers and increase access to available and compassionate care?

16. So how do we address this? • Harm reduction • Outreach • Multidisciplinary care team model

17. Harm Reduction First and foremost, we move everyone towards treatment. Baseline treatment team needs: Can you stay in contact and take these pills at the same time daily.

18. Harm Reduction HCV Program built on flexibility, accommodation and support: • All patients diagnosed with HCV referred to HCV team desktop for outreach. • Unless lost from care, all patients move towards treatment • If lost from care, all patient charts are flagged so when they return the HCV team is again notified.

19. Harm Reduction Emphasis on building relationships: • Time and availability with patients. • Story/Narrative – as much as pt comfortable • Communication – direct contact numbers given to all patients.

20. Harm Reduction Patient Directed • Each care plan and timeline is individualized • Process towards treatment is as short as possible, but as long as necessary • Patient choice emphasized

21. Harm Reduction Not yet ready for treatment • Due to unstable housing, substance use, unemployment, mental health, interpersonal violence, etc. people come in and out of care. • Some patients decline treatment or want to wait • Discussion of reasons • Support and planning offered • Patient assured, when they are ready, we’ll be ready. • Medical reasons

22. Harm Reduction PWID/PWUD • Doesn’t change work towards treatment • Emphasis on safe use, preventing reinfection

23. Harm Reduction Discussion around preventing reinfection Setting up personal rules about not sharing anything with blood contact Use sterile equipment, resources provided Utilize safer sex supplies Ongoing testing for HCV/STI’s every six months

24. Harm Reduction The pros and cons of accommodating instability with flexibility? • Benefits: • We successfully treat patients within a high-risk population • All-inclusive treatment • Decreasing community viral load

25. Harm Reduction Programmatic Stats: Mid - 2019* • 200referrals; 10 self-cleared, 11 were negative on confirmatory • 110people began treatment • 103people were cured • 33people were in treatment mid - 2019 *Medicaid restrictions still effective until 2019

26. Outreach Why has this become such a important element of our care-model?

27. Outreach • Increase education to at-risk groups by providing education in their own communities and organizations • The information travels to them, and then we can set up travel for continued visits • Provide in-person linkage to care for those that don’t come in after diagnosis and education

28. Outreach • Offer people the opportunity to engage where they feel comfortable and accepted • On their terms and in a trusted space • Offer one-on-one assistance so patients can ask the questions they need answered in privacy • Palm cards in Spanish and English with direct numbers to team

29. Outreach How do we go about this? • Contacting entities we’ve identified that cater to at-risk populations, or have already referred patients to us. • Consulting with community/organization leadership to ask what kinds of services and education they’d identified a need for

30. Outreach How do we go about this? • Start events and conversations by asking participants what they want out of it • How do I make this time valuable to you? • Stress the option for short-term engagement • No need to come in for ongoing primary care, if you only want HCV treatment and nothing else- then that is what we’ll do (ongoing communication/ referrals sent to F3s & F4s for ultrasounds).

31. Outreach Including a VARIETY of spaces for outreach • Spanish speaking spaces, and non-English speakers in general • Safe spaces for those who don’t have documentation • Residential programs for aging populations • Reentry populations • Substance use services and sobriety programs (Ex.Haymarket) • Training internal departments and team members • Emphasizing co-infected populations within clinics and in outreach, in all services that cater to PLWHIV

32. Outreach Where we’ve found success: • Completing semi regular education groups within Haymarket • Working in tandem with patient navigators for referrals/transportation • Attending community events featuring at risk groups (ex. Nadaam) • Going to referring agencies to complete linkage to care in person in conjunction with testing events (Gateway) These events and partnerships allow us opportunities to show patients what we are about before they ever walk in the clinic door. It gives a face to the services and reassures patients that they’ll be treated with respect, patience, and acceptance.

33. Care Model: Multidisciplinary Care Team • Team model prevents need for referring out • We can intervene to manage the clinical demands that might prevent treatment (ex. Substance use, comorbidities) • Ensure that the language and messaging clients receive from referral to post-treatment care aligns with the harm reduction priorities of the team

34. Care Model: Multidisciplinary Care Team Providing consistent support: In our first conversation we are providing direct numbers for patients to call with every question and concern • Readily available, with back-up contacts • Complete face to face initiation visit upon starting meds • Pharmacy and Medical support offered at start of treatment • Consistency of care

35. Care Model: Multidisciplinary Care Team Team: Thomas Ambelang- HCV Linkage to Care Coordinator, full time Alaa Wasfi- Registered Nurse, part time, Full time primary care Sarah Kwasigroch- Pharmacist, part time Walgreens partner Sam Forsythe- HCV Case Manager, Outreach Specialist, full time Bernard Whitehead- HCV Case Manager, full time Communication within team; Triage Meetings

36. Care Model: Multidisciplinary Care Team This model allows us the capacity to address barriers: completing insurance enrollment, arranging transportation, calling in orders with patients, check-in’s during treatment, internal administrative tasks.

37. Care Model:Pre-Treatment Case Management: • Establish relationship with patients • Work with providers – necessary labs • Complete Assessments and Care Plans with each patient • Navigate any barriers prior to treatment • Submitting to ADAP and PAP programs • Updating patients throughout process

38. HCV Assessment Tool

39. HCV Care Plan Tool

40. Care Model: Pre-Treatment RN: Entering orders for lab tests Completing Fibroscans, as needed Pharmacy: Consulting on treatment recommendations with CM and Providers Checking on contraindications with current medications Submitting Prior Authorizations to Insurance Companies Navigating co-pay systems as needed

41. Care Model: Treatment Case Management: Assisting Patients with ordering medications Completing initiation visits Following up with patient during treatment – checking on adherence Assisting with refills as necessary

42. Initiation Visit Checklist

43. Initiation Visit Lab Schedule

44. Care Model: Treatment RN: 1. Checking in with patients around adherence 2. Scheduling required lab visits 3. Discussing lab results with patients 4. Ongoing discussions around prevention Pharmacy: Verifying lab results for Medicaid Assisting with any refill issues, as needed. Supplementary prior authorizations as needed.

45. Care Model: Post Treatment RN: Monitor patients with F-scores – F3 and F4 Check in with Providers for Ultrasound referrals ongoing Continued conversation on reinfection risks Case Management: 1. Assist pt in scheduling Ultrasounds as needed.

46. HCV Treatment: Case Analysis 1 Narrative: 57 years old; Transfemale identified Living with HIV and HCV, Fibroscore of F2 Engaged at HBH for primary care Actively snorting heroin, unknown how long Cannot read or write proficiently Primary supports are sister and niece Living with family, no direct phone but could be contacted via sister’s phone Sister had authorization to schedule appointments

47. HCV Treatment: Case Analysis 1 Plan: Pt wanted to immediately start Tx process Would frequently fall asleep during meetings and conversations In recognition of the importance of Tx process, pt asked that sister be involved in care plan Check-in’s with sister after meetings, group calls with pt/CM/sister Appointments scheduled via sister, and sister called for appointment reminders- CM permitted to leave limited details in messages Reinfection conversation: switching out straws Team support to facilitate refills Completed medications 8/15/2019; 8/21 HCV RNA <15

48. HCV Treatment: Case Analysis 2 Narrative: 52 year old cis-male identified Pt reports interest in treatment/demonstrates engagement Pt living with Bipolar diagnosis Pt living with HIV, sometimes adherent to medications Pt has housing instability Pt has cell phone – some interruptions in service Pt (occasionally) PWID

49. HCV Treatment: Case Analysis 2 Plan: Develop relationship while patient gets HIV controlled. Ongoing discussions around adherence and importance of staying in contact. Discussion around phone bills and assistance if needed. Plan for safe keeping of medications. Ongoing discussions around resources, preventing reinfection. Regular contact with Case Manager to maintain relationship. Pt cured – SVR 12 – HCV RNA <15

50. Questions ? Sam Forsythe samf@howardbrown.org Tom Ambelang thomasa@howardbrown.org Sarah Kwasigroch skwasigroch@howardbrown.org Alaa Wasfi alaaw@howardbrown.org Bernard Whitehead bernardw@howardbrown.org