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.