Enhancing Hepatitis C Testing and Treatment for Young Injection Drug Users

This toolkit provides resources and best practices to strengthen provider capacity to identify hepatitis C infection, and to successfully engage individuals with hepatitis C infection in curative treatment.

This toolkit focuses on reaching individuals who use injection drugs, especially those individuals under the age of 30 years. However, the toolkit includes information and resources with applicability to other populations. The toolkit was designed for primary care providers, but includes tools and information which others may find useful.

This toolkit is the culmination of an evaluation of primary care models of hepatitis C screening and treatment for people who use injection drugs and who are younger than age 30 years. It was developed through collaboration with the New England AIDS Education and Training Center (NEAETC), and in consultation with five primary care practices that participated in the evaluation: Barre Family Health Center, Community Health Center of Franklin County, MGH/Chelsea Health Care Center, South End Community Health Center, and Stanley Street Treatment and Resources. The toolkit incorporates Best Practices identified by the clinics, as well as tools and resources contributed by these five clinics.  We are grateful for their participation and contributions.

Table of Contents

Engagement / Special Considerations for Young Injection Drug Users

Best Practices

  • Accept and treat without judgement - see addiction as an illness and young injection drug users as people.
  • Provide all care at one site to facilitate easy and more efficient access.
  • Incorporate outreach to “meet the client/patient where they are.”
  • Include all team members in cultural competency/sensitivity training including non-clinical staff e.g., front desk staff.

Resources

  • Myths about Treating Substance Users with Hepatitis C Virus (Source: National Coordinating Resource Center, AIDS Education and Training Center Program) - This infographic identifies common misconceptions associated with treating HCV in substance users with HIV. People with substance use disorder have been cured of HCV and have low rates of re-infection. However, provider myths regarding patient readiness and the cost-effectiveness of care present challenges and can delay initiation of HCV treatment and care.  The resource is available as a downloadable, printable and shareable flyer, and as a training slide set. 
  • Myth-Busting HCV Treatment: Demystifying HCV Treatment in At-Risk Populations (Source: New England AIDS Education and Training Center) – This part of the “Myth-Busting HCV Treatment” series explores how advances in HCV treatment have affected the clinical management of people who inject drugs, especially younger individuals, and persons with SUD. It also examines various monitoring strategies that can be used during HCV treatment and follow-up for hard-to-reach populations.  
  • Myth-Busting HCV Treatment: Integrated Models of HCV Care Delivery (Source: New England AIDS Education and Training Center) – This part of the “Myth-Busting HCV Treatment” series describes the process of care and patient outcomes in a practice serving young injection drug users with integrated HCV treatment services and opioid use disorder services.

Testing/Screening

Best Practices

  • Maintain formal, written HCV testing/screening protocols.  These should include written documentation of workflows, and a job aid for providers to reference when needed.  All materials should be accessible/shared via document repository or email.
  • Incorporate screening into electronic medical record (EMR) through pop-ups/reminders, task boxes, or similar strategies. Add hot button in SBIRT section of EMR to capture data in relation to drug injection practices. If possible, prepopulate subsequent appointments notes for additional review/interviews.
  • Offer multiple opportunities for screening e.g. via tablet while patients wait for exam; administered during intake by medical assistant (MA); administered by clinician during examination.
  • Many EMRs have tools to support pre-visit planning, population health management, or clinical quality improvement activities.  Explore with your clinic administrator and/or IT department whether these tools can be activated or purchased.  Some community health centers use the Azara DRVS system, which can populate HCV antibody screening into pre-visit planning forms that can be reviewed during pre-clinic MA/Provider huddles. DRVS functionality includes an HCV patient registry.
  • Identify specific staff and expected roles/responsibilities relative to various steps in patient flow. For example, MAs conduct assessment of patient and recommend screening; nurse practitioners (NPs) deliver test results and initiate treatment; community health workers (CHWs) conduct follow-up with patients to support medication adherence.
  • Implement testing/screening dashboards/benchmarks for staff and monitor as part of routine quality management activities.
  • Prioritize patients such as those prescribed suboxone, or patients being treated for STDs.
  • Generalize testing such that all orders for HCV antibody testing reflex to HCV RNA and genotype to ensure supplemental testing needed to identify active infection, and to reduce treatment delays.

Resources

  • Guidelines for HCV Screening and Treatment in Primary Care – Sections 1-2 (Adapted from Community Health Center of Franklin County)
    The Community Health Center of Franklin County created a tool for clinicians and other staff to support implementation of HCV screening and treatment. The first two sections of the guideline address (1) Screening, and (2) Follow Up Testing.  Other sections of the tool address treatment initiation, management, and follow-up.
  • Bundling Antibody and Reflex Testing for Single Blood Draw (Adapted from SSTAR, Fall River)
    SSTAR of Fall River Massachusetts implemented reflex testing to ensure that all patients received the appropriate sequence of tests needed to identify current HCV infection, and to facilitate entry to treatment. This tool describes how they worked with the laboratory vendor to implement HCV antibody testing with reflex to HCV RNA and genotype testing.
  • Alcohol & drug use screening (SBIRT, DAST-10)
    • SBIRT (Source: University of Missouri-Kansas City, School of Nursing and Health Studies)
      This resource provides downloadable, validated tools for clinicians to use in screening patients for substance use and to deliver brief interventions (SBIRT Provider Card), and to make appropriate treatment referrals.
    • DAST-10 (Source: National Institute on Drug Abuse)
      The Drug Abuse Screen Test (DAST-10) provides a brief, self-report instrument for population screening.  It is designed to be used with adults and older youth.  This resource provides a downloadable, validated sample tool. 
  • Screening Guidelines
    • Recommendation: Hepatitis C Virus Infection in Adolescents and Adults: Screening (Source: US Preventive Services Task Force)
      USPSTF recommends one-time screening for hepatitis C infection to all asymptomatic adults, ages 18 – 79 years, and periodic screening to individuals with continued risk for HCV infection, such as those who use injection drugs (Grade: B Recommendation).  Supplemental HCV RNA testing is recommended for all HCV antibody reactive results.  This resource includes the recommendation statement and accompanying summary of evidence supporting the recommendation as well as links to tools to support clinical practice.
    • Recommendations for Hepatitis C Screening Among Adults - US, 2020 (Source: Centers for Disease Control and Prevention)
      CDC recommends one-time screening for hepatitis C infection for all adults 18 years and older; for pregnant women during each pregnancy, and routine periodic testing for people with ongoing risk factors, such as those who inject drugs.  CDC encourages use of reflex HCV RNA testing to ensure identification of active HCV infection and to expedite linkage to treatment. These recommendations are summarized in an infographic, CDC Recommendations for Hepatitis Screening Among Adults
  • Laboratory Testing Guidelines

HCV Treatment Uptake

Best Practices

  • Identify a staff champion.
  • Engage an interdisciplinary team, with specific roles and responsibilities.
  • If possible, have a dedicated “HCV Team” including physician, nurse (RN), NP, and MA (all with specific, identified roles/responsibilities)
  • Integrate a navigator, peer and/or community health worker (CHW) as part of the HCV team to provide intensive care coordination, and support linkage services for HCV positive individuals who require additional assistance to access and complete HCV treatment. This position can communicate with other agency departments to coordinate care for HCV and other services. Additionally, can provide resources such as bus passes, cab vouchers, food donation centers/drives, etc.
  • Accept without judgement and view addiction as an illness and young injectors as people.
  • Frame HCV treatment for patients as a way to have control over effects of addiction.
  • Reassure patients that they can be treated again should they ever be re-infected, whether they ask about this or not.
  • Lower barriers to treatment relative to stages in recovery. “If you feel that now is a good time to commit to taking this treatment and doing a good job sticking to it then I will commit to getting it for you and try to make the process as easy as possible.”
  • Work with patients around anxiety/misunderstanding about current HCV treatment.
  • Reduce number of blood draws needed before beginning therapy - set up reflex testing for HCV antibody to HCV RNA, and genotype to reduce number of blood draws before starting therapy.
  • Maintain a patient registry of all HCV positive patients – build into EMR, if possible.
  • Centralize referrals, so one person is outreaching to patients - leverage a patient registry to facilitate this process.
  • Establish a formal HCV treatment protocol, including written documentation of your sites HCV treatment workflows.  This can serve as a resource for providers to reference when needed and should be easy to access and share internally.
  • Streamline prior authorization (PA) process to one dedicated staff person. For example – RN or CHW handles the PA process. Once the provider submits the medication order, the RN/CHW uses an online system called “covermymeds.com” (CoverMyMeds is an electronic system connected with EHRs that includes provider tools such as prescription decision support, electronic prior authorization (ePA)and specialty support services).  A paper-based system works just as well, particularly when streamlined through one point person). With some cases, the site asks questions that are not applicable to the patient based on insurance plan so the RN/CHW must use a different form, but often a majority of patients have the same insurance, such as BMC or MA Health Standard. The RN/CHW writes the medication the provider chose, answer questions from the insurance company, and attaches appropriate lab work. If approved, the RN/CHW will send the approval to the specialty pharmacy, and if denied, the RN/CHW starts the appeal process.

Resources

  • Guidelines for HCV Screening and Treatment in Primary Care - Sections 3-6 (Adapted from Community Health Center of Franklin County)
    The Community Health Center of Franklin County created a tool for clinicians and other staff to support implementation of HCV screening and treatment. Sections 3-6 of the tool address treatment initiation, management, and follow-up. Earlier sections of the tool address screening and follow-up testing.
  • HCV Outline for Primary Care Providers (Adapted from SSTAR, Fall River)
    SSTAR of Fall River Massachusetts created a tool for primary care clinicians which provides a succinct overview of treatment for HCV infection, including the tests and actions to evaluate a patient for treatment, manage treatment, and treatment follow-up.  The tool also includes a treatment “checklist” It is available centrally for easy reference.
  • Hepatitis C Case Conference Vignette (Source: New England AIDS Education and Training Center and Family Health Center of Worcester)
    YouTube URL: https://youtu.be/aveK8C_IiVo
    Philip Bolduc, MD, Director of the HIV and Viral Hepatitis Fellowship at the Family Health Center of Worcester, and Thanh Thu Ngo, MD, HIV and Hepatitis Fellow, review a hepatitis C case and resources for HCV clinical decision-making. Recorded on 6/10/2021
  • Hepatitis C Treatment Patient Orientation (Adapted from SSTAR, Fall River)
    SSTAR of Fall River Massachusetts created a tool for HCV care team members to support patient education. This tool can either serve as a “script” for members of the care team to use in patient education, or it may be used as a patient educational “hand out”.
  • Hepatitis C: Getting Cured Is Easier than Ever (Source: National Coordinating Resource Center, AIDS Education and Training Center Program)
    This patient educational resource addresses current HCV treatment in comparison to older treatment regimens to address the reluctance patients sometimes feel regarding hepatitis C treatment initiation based on past experiences with older hepatitis C treatment regimens. This is a downloadable tool available in both English and Spanish. 
  • Frequently Asked Questions: Prior Authorization for Hepatitis C Virus (HCV) Treatment (Source: Center for Health Law and Policy Innovation, Harvard Law School)
    This resource addresses questions and concerns gathered from clinicians and other providers regarding the prior authorization process for hepatitis C treatment under MassHealth, the state’s Medicaid program.

HCV Treatment Retention and Adherence

Best Practices

  • Maintaining a patient list which includes dates of appointments, treatment status, lab results and other relevant information to help the care team keep track of patients as they make their way through the referral, workup, prior authorization (PA), treatment and follow-up steps.
  • Consider assigning care coordinator to monitor patients due for labs, appointments, and medication delivery.
  • Telehealth visits can be useful in providing care for most HCV patients who have early-stage disease and for whom treatment is straightforward, allowing for both frequent check-ins while not inconveniencing patients who may have transportation, work, or other challenges attending in-person appointments.  In-person initial and follow-up assessments are best for patients with compensated cirrhosis or significant medical comorbidities.
  • Provide HCV treatment education for patients to make sure the patient is following treatment course.
  • Provide “high touch patient interactions” to support patients e.g. through use patient navigators or others to help connect patients to resources for other needs, make weekly check-in calls, attend HCV care visits as support. 
  • Incorporate specialty pharmacists into patient management including prior authorization process, reminder calls, and to serve as a point of contact for patients.

Resources

  • Hepatitis C Navigator Job Description (Adapted from SSTAR, Fall River)
    SSTAR of Fall River, Massachusetts engaged a patient navigator to provide care coordination, and to support clients to complete treatment for HCV infection.  This tool is a sample job description for a patient navigator.
  • The two videos below provide more in-depth discussion of SSTAR’s use of patient navigators in the context of treatment of HCV infection and address the importance of and strategies for integrating HCV patient navigators into the care management team. 
  • The Importance and Integration of the HCV Navigator to the Case Management Team

    YouTube URL: https://www.youtube.com/watch?v=0pPPpg1pEds

    Discussion with Emma Newcity, Hepatitis C Navigator, Project Aware at SSTAR, about the importance and integration of HCV navigator to the case management team. Recorded on 4/21/2021
  • Hepatitis C Navigator Workflow

    YouTube URL: https://youtu.be/XqXrQDW55nM

    Emma Newcity, Hepatitis C Navigator, Project Aware at SSTAR, describes a workflow for hepatitis C navigators to link HCV positive individuals to care and provide case management services. Recorded on 4/8/2021
  • HCV Treatment using Telehealth.
    The Berkshire Harm Reduction Program at Berkshire Medical Center has fully integrated HCV testing and treatment into harm reduction programming, enabling provision of comprehensive health and support services, and facilitating continuity of treatment of HCV infection. Engagement with clinicians for HCV treatment, and ongoing support and navigation services are provided via telehealth.  The protocol used by the Berkshire Harm Reduction Program to deliver these services is available for download.  Through this service model  (accessible service model), testing, treatment, prevention services (including HIV PrEP), and support services are provided through and coordinated by the syringe services program and are facilitated through use of telehealth strategies.
  • Myth-Busting HCV Treatment: Interdisciplinary HCV Screening, Treatment and Follow-up (Source: New England AIDS Education and Training Center) – This part of the “Myth-Busting HCV Treatment” series focuses on the role of an interdisciplinary team in completing the essential components of HCV treatment assessment, service delivery for marginalized populations, and outreach to individuals experiencing SUD.   

Provider Education and Training

Best Practices

  • Regular distribution and review among staff involved in HCV treatment of current treatment guidelines.
  • Implement interdisciplinary care team meetings that include case discussions that foster discussion and questions.
  • Provide onsite educational sessions, including tailored HCV training to staff roles (accessible training).
  • Identify one or more clinical champions to serve as mentors and to provide consultation.  An infectious disease (ID) physician may serve as an HCV resource and a mentor to help train other providers to treat HCV.
  • Provide small group and 1-on-1 didactics for providers who wish to start treating HCV. Consider using these as opportunities to review cases and provide orientation to treatment guidelines.
  • Consider using apps such as Hep iChart (Apple, Google), HCV Treatment Path (Apple, Google), as well as clinical calculators.
  • Implement and document procedures/workflows and ensure that all members of the care team receive orientation to the procedures and that they are centrally accessible to all.
  • Get administrative support and provider buy-in across the clinic, recognizing the need to treat HCV in the medical home and the concordance with the health center’s mission.

Resources

  • Education and Training for Primary Care Providers
    The Bureau of Infectious Disease and Laboratory Sciences, Massachusetts Department of Public Health in collaboration with the New England AIDS Education and Training Center (NEAETC) offers training and education for primary care providers. Clinics interested in learning more about training opportunities may contact BIDLS at BIDLS.OHCP@mass.gov
  • Treatment Guidelines (Source: American Association for the Study of Liver Diseases, and Infectious Disease Society of America)
    HCV Guidance: Recommendations for Testing, Managing, and Treating Hepatitis C is a publication of American Association for the Study of Liver Diseases, and Infectious Disease Society of America.  The guidelines address all aspects of identification and treatment of HCV infection and are updated regularly.  A complementary tool for providers, A Simplified HCV Treatment Algorithm for Treatment Naïve Adults without Cirrhosis is available for download.
  • Hepatitis C Online (Source: University of Washington Infectious Diseases Education and Assessment program)
    Hepatitis C Online This is a self-study resource for clinicians regarding HCV, including the natural history, pathogenesis and treatment of HCV, including an in-depth review of HCV medications.  CME credit and CNE/CE contact hours are available.  Pharmacology CE for advance practices nurses is also available.  Clinical calculators such as the APRI and FIB-4 calculators are available. Continuing education credits are available, and the site includes many helpful calculators, illustrations and tables.
  • Hepatitis C Project ECHO (Source: UMass Chan Medical School, Center for Integrated Primary Care)
    Primary care doctors, nurses, pharmacists, and other clinicians participating in ECHO engage in a virtual community with peers to share information and learn from each other, and with the support of experts.  Learning is case based. UMass Chan Medical School is a Project ECHO Hub for HCV.

Sustainability

Best Practices

  • Cultivate support from key leaders:  CEO and CMO (mission match), COO (clinic operations, workflows), CIO (data support, patient registries) and CFO (financial planning).
  • Itemize necessary financial supports and resources, such as staff or IT time; pharmacy revenues may be used to fund support staff such as HCV navigators.
  • Build staff buy-in from front desk to prescribers, to leadership to ensure well-coordinated patient management.
  • Establish and maintain a multi-disciplinary team to manage HCV treatment.  Train, establish workflows, and support multiple prescribers who treat HCV to ensure sustainability and prevent treatment interruptions during absences or position vacancies.
  • Identify an on-site expert and an HCV champion to lead implementation and expansion of HCV screening and treatment in the clinic.  The roles of experts and champions might be the same person, but the latter does not need to be a clinician and/or prescriber.  If there is no prescriber with experience treating HCV but there is a motivated clinician, seek mentors through other clinics already successfully implementing HCV screening and treatment to develop this expertise in-house.
  • Establish access to a specialist for consultation or referral for challenging cases.
  • Develop team-based interprofessional systems of care.
  • Focus on efforts to address and reduce stigma.
  • Invest in IT to enhance EMR e.g., to create order sets, patient planning tools, integrate SBIRT, or other decision tools.
  • Create clear, written procedures and workflows on which all team members are trained, and which are centrally accessible.  Review these procedures periodically to ensure that the remain current.

Hepatitis C Infection Screening and Treatment Resources

This searchable tool allows users to easily locate additional information about the topic areas included in this toolkit from a curated collection of publications, tools, and other resources.

Comprehensive Resources

  • Patient-focused Hepatitis C Resources (Source: Massachusetts Department of Public Health)
  • HIV/HCV Co-infection: An AETC National Curriculum (Source: AIDS Education and Training Center Program, National Coordinating Resource Center)
    This curriculum provides the user with a roadmap of how to develop the skills needed to treat HCV, including which websites to use for self-education and point-of-care clinical references.  It is a good starting point, providing an overview of HCV treatment and a guide to the best web-based HCV resources.
  • Hepatitis C Online (Source: University of Washington, U.S. Centers for Disease Control and Prevention)
    This is a self-study resource on HCV, including the natural history, pathogenesis and treatment of HCV, including an in-depth review of HCV medications.  Continuing education credits are available, and the site includes many helpful calculators, illustrations and tables.
  • HCVGuidelines.org (Source: American Association for the Study of Liver Diseases, Infectious Diseases Society of America)
    This is the comprehensive, definitive, point-of-care reference for making treatment decisions.  It is updated on a continual basis and is organized in an easy-to-use format with clear, evidence-based recommendations and supporting information from clinical trials to help users make the best clinical decisions for their patients.

    Comprehensive guidelines, including:
    • Testing, Evaluation, and Monitoring of Hepatitis C
    • Initial Treatment of HCV Infection
    • Retreatment of Persons in Whom Prior Therapy Has Failed
    • Management of Unique & Key Populations
  • HealthHCV HCV 20X20 Resource Guide for Increasing Screening and Linkage to Care in Your Organization (Source: HealthHCV)
    This resource focuses on establishing effective programs for HCV outreach, testing, engagement in care and care navigation, with multiple links to evidence-based resources available to clinics seeking to create multidisciplinary HCV programs. 
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