Current State of Hepatitis C Care in the VA
The following is a lightly edited transcript of a teleconference discussion of hepatitis C virus treatment in the Veterans Health Administration system.
We are collaborating with HUD-VASH social workers to see if there are more creative ways to connect with these veterans. Some of the ideas include having liver providers visit veteran housing locations, having HUD-VASH social workers convey messages to difficult-to-reach veterans, and problem-solving specific transportation issues that present barriers to care.
Christina Dickson, PharmD. At the VA Maryland Health Care System Baltimore VA Medical Center, we hear from veterans in our education classes about the various myths that are still out there in the community about HCV. Some of these myths are the reason that veterans may avoid seeking treatment or even attending the HCV clinic appointments. Some veterans say they didn’t come in previously because they thought they would need a liver biopsy or because their doctor told them they had to be completely sober in order to be considered for treatment. These can be major deterrents that keep patients away despite our outreach efforts. In addition to miseducation in the community, there also is still a reluctance to talk about HCV and the risk factors. Many patients don’t want to discuss their history or are concerned about their partners finding out, so they instead choose to ignore it altogether. The negative stigma of HCV is still present even in some of our HCPs.
Just as VA San Francisco is working to engage its homeless population, we are looking to work with mental health and substance abuse programs. More and more is being written about the importance of working with such teams and even colocating the HCV clinic with their services. For example, in Baltimore, the methadone clinic is 2 floors above our clinic. Some of the remaining viremic patients will go to the methadone clinic in the morning and then leave despite having an appointment just 2 floors down. Offering HCV services at the same time, in the same area may help to engage veterans to consider their liver health.
Ms. Trimble. VA San Francisco has been fortunate to have the assistance of our opiate replacement clinic staff as well; this is particularly helpful since many veterans visit the opiate replacement clinic daily for medications and know the staff there very well. The staff facilitate communication with the liver clinic, execute warm handoffs to the liver clinic, and provide daily dispensing of hepatitis C medications for a number of veterans who have more difficulty with medication adherence. It has worked very well.
Dr. Ho. I think what you both are pointing out is very important—these patients require teamwork. A multidisciplinary group of HCPs working together in a collaborative, integrated care model has been demonstrated to significantly improve HCV engagement, care, and treatment in these highly comorbid patients.2 Whenever we can work together and build teams and recruit other HCPs in these other clinics, it will really pay off.
Dr. Backus. At VA Palo Alto Health Care System, we also run a program integrated with our 28-day and 90-day residential rehabilitation programs. We realized that those residential treatment programs were a place to reach people who we were having difficulties starting treatment. It was a perfect situation because if you were there for 28 days, we could nearly guarantee that at the very least the patient was going to get 28 days of medications. Particularly now with some of the shorter treatment courses, we only have to get a patient to take another 28 days, which is very doable. Clearly, for the people who are in 90-day programs, the full 8-week or 12-week course of treatment could be completed during the rehabilitation. In addition, we started out at a good place because the programs already screened automatically for HCV on admission to the program, so it was easy to identify people who had HCV.
Ms. Trimble. Specialty Care Access Network-Extension for Community Healthcare Outcomes (SCAN-ECHO) also can help with outreach. Alexander Monto, MD, and Helen Yee, PharmD, conduct weekly SCAN-ECHO video telehealth conferences with outlying HCPs from other clinics. The outlying HCPs submit cases for hepatitis C treatment consideration; then they take the recommendations from their discussion with Dr. Monto and Dr. Yee but lead the treatment with their patients.
Over time, with this ongoing mentoring, the participating providers have gained a lot of expertise in hepatitis C and serve as a local resource for their clinics. One of the clinics is in Eureka, California, which is nearly 300 miles away. In contrast, the other main clinic that participates is the downtown clinic. It serves the most urban and difficult-to-reach patients. The familiarity and rapport that the downtown clinic providers have with their patients allow them to more effectively engage patients for treatment initiation and follow-up.
