A Hepatitis C Treatment Program Based in a Safety-Net Hospital Patient-Centered Medical Home

Lasser KE, Heinz A, Battisti L, Akoumianakis A, Truong V, Tsui J, Ruiz G, Samet JH
Source: Ann Fam Med
Publication Year: 2017
Patient Need Addressed: Behavioral health, Care Coordination/Management, Financial insecurity, Homelessness/housing, Patient satisfaction/engagement, Substance Use, Transportation
Population Focus: Low income
Demographic Group: Urban
Intervention Type: Staff design and care management
Type of Literature: White
link: https://www.ncbi.nlm.nih.gov/pubmed/28483892
Abstract

Hepatitis C virus (HCV) infection is a major public health problem. Urban safety-net hospitals are a prime location for HCV treatment delivery. Showing that physicians in primary care settings can deliver HCV infection care is important to expand treatment; models doing so in the era of newer oral HCV medications are needed. This article describes an innovative and successful HCV primary care treatment program in a patient-centered medical home based at an urban, safety-net hospital. The program is public health oriented in that a central team member is a public health social worker who performs population management and addresses underlying social determinants of health to facilitate engagement in HCV treatment. Other team members include general internists trained to treat HCV infections, a pharmacist, and a pharmacy technician. The program is funded with revenue generated by the 340b drug discount program, which allows providers to generate revenue when patients fill prescriptions at pharmacies in safety-net settings, as insurance reimbursements for medications exceed the cost at which safety-net providers purchase medications. During the course of 1 year, the program received 302 referrals. Of these approximately 23% have received treatment.

Insights Results

Overview of article

  • In the United States, hepatitis C virus (HCV) infection is a major public health problem, causing 15,000 deaths annually. Urban safety-net hospitals, serving large populations of patients with substance use disorders, are prime locations for treating HCV-infected patients
  • Prior studies have demonstrated that general internists can successfully deliver HCV care for urban underserved patients in primary care settings
  • This study implemented a primary care, multidisciplinary treatment model supported by revenue from the 340b drug discount program. Currently 40% of US hospitals participate in the program, which allows safety-net hospitals and health centers to generate revenue when patients fill prescriptions at their pharmacies, as insurance reimbursements for medications exceed the cost at which safety-net providers purchase medications. Such revenue can be used to support multidisciplinary staffing models to deliver treatment

Results

  • The program is based in the Adult Primary Care Practice at Boston Medical Center, an accredited patient-centered medical home (PCMH). The program includes 9 general internists who completed the American Association for the Study of Liver Diseases online training modules and are thus trained to treat patients infected with HCV
  • Primary care physicians and nurse practitioners who do not treat HCV-infected patients refer them to the program based on laboratory notifications of positive tests, electronic health record (EHR) reports of HCV-infected patients who are not engaged in care, and peer referrals. The multidisciplinary team includes a public health social worker (case manager), the primary care physicians trained to treat HCV-infected patients, a pharmacy technician, and a pharmacist
  • Before the visit, the case manager reviews charts and calls patients if the chart shows viremia, no engagement in care of HCV infection, and no comorbidities requiring specialty treatment. The case manager also provides appointment reminder calls, troubleshoots insurance and transportation issues, and maintains a log to manage the patients from referral to discharge
  • During the patient’s first visit with the physician, the physician pages the case manager to meet the patient. The case manager assesses income, housing, legal issues, substance use, mental health, and transmission risk factors. He or she also provides education about HCV and the treatment program. The case manager then schedules follow-up to address psychosocial needs and refers, as needed, for psychiatry and counseling services, substance use treatment, transitional assistance, housing resources, transportation, social security, and job training
  • This primary care treatment program for patients infected with HCV shows promise for curing selected patients. This program is unique in 2 ways; it is situated in a PCMH based in a safety-net hospital and uses a multidisciplinary approach with primary care staff working at the top of their license (that is, each team member practices to the full extent of their education and training instead of performing tasks that could be completed by another team member)

Key takeaways/implications

  • The authors believe this model has transferability beyond large urban academic medical centers. Community health centers, for example, may have 340b pharmacies and are accustomed to delivering multidisciplinary care
  • Key to the program’s success is the central role of a public health social worker, who performs many patient navigation functions
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