1. Bringing Hepatitis C Treatment into the Medical Home A Pilot Program for Drug Users Dr. Joanna Eveland MS, MD, Clinical Chief for Special Populations Mission Neighborhood Health Center, San Francisco, CA

2. The Challenge: Hepatitis C Virus (HCV) in 2015 3.5 million infected New treatments which are safe and curative Opportunity to end the epidemic

3. Yehia BR, Schranz AJ, Umscheid CA, Lo Re V III (2014) The Treatment Cascade for Chronic Hepatitis C Virus Infection in the United States: A Systematic Review and Meta-Analysis. PLoS ONE 9(7): e101554. doi:10.1371/journal.pone.0101554 The National HCV Treatment Cascade

4. Mission Neighborhood Health Center FQHC in San Francisco Two clinical sites have high burden of HCV: HIV clinic Homeless drop-in center Began offering HCV Treatment 2014

5. HCV Pilot Program Goals Treat and cure HCV Include active drug users Build a sustainable model

6. Trauma Informed Care Harm Reduction Primary care Wound care Addiction counseling and linkage Behavioral Health Medication Assisted Treatment Case Management Hepatitis and HIV Treatment Conceptual Model: The Medical Home for Drug Users

7. Meet Our HCV Patients Albert: 65, completed treatment, cured Juan: 55, on treatment Juan: 55, on treatment DJ :40, awaiting treatment DJ :40, awaiting treatment

8. MNHC’s HCV+ Patient Demographics

9. Lead HCV Clinician Treatment Adherence Support Person Treatment Access Support Person PCP HCV Care Team Roles Behaviorist Assesses treatment readiness, stages liver disease and treats HCV in appropriate patients Consults with or refers patients to lead clinician for HCV treatment Educates patients on treatment, liver health and reinfection Dispenses meds Assesses and intervenes to support adherence Educates patients on treatment, liver health and reinfection Dispenses meds Assesses and intervenes to support adherence Consulted as- needed to assess for and help patients move towards treatment readiness Completes documentation for prior authorization of medications Communicates with pharmacy and patient to facilitate treatment access Completes documentation for prior authorization of medications Communicates with pharmacy and patient to facilitate treatment access

10. Patient ready for Hep C Treatment PCP consults with or refers to Lead Clinician Lead Clinician reviews chart and E-Consults with Hep C Pharmacist as needed Lead Clinician or PCP finalizes treatment plan & writes prescription Treatment Access Support Person obtains authorization for meds Adherence & Monitoring Person dispenses meds, orders labs, follows patient through treatment Lead clinician or PCP sees patient as needed and manages complications Patient completes treatment, monitored for reinfection by PCP Liver Clinic Referral for patient ineligible for community based treatment Liver Clinic Referral for patient ineligible for community based treatment Hepatitis C Primary Care Process Flow

11. Treatment Readiness Checklist  Patient wants Hepatitis C treatment  Patient generally keeps scheduled medical appointments  Can contact patient by phone or have another reliable way to reach them  If substance abuse and/or mental health issues, stabilized or engaged in treatment to the degree that patient can complete 12 weeks of Hepatitis C therapy  Other active medical issues (HIV, Diabetes, etc.) stable with adherence to other prescribed medications  Patient can articulate a plan to avoid Hepatitis C reinfection after treatment  Patient wants Hepatitis C treatment  Patient generally keeps scheduled medical appointments  Can contact patient by phone or have another reliable way to reach them  If substance abuse and/or mental health issues, stabilized or engaged in treatment to the degree that patient can complete 12 weeks of Hepatitis C therapy  Other active medical issues (HIV, Diabetes, etc.) stable with adherence to other prescribed medications  Patient can articulate a plan to avoid Hepatitis C reinfection after treatment

14. Conclusions Community based treatment works It’s easier than you think Challenge= Medication access Education is needed

15. Benefits to Community Based HCV Treatment Patient centered Promotes access Builds self efficacy Provider satisfaction

16. Next Steps Collaborate with local needle exchange to bring new HCV+ patients into care via “warm hand off ” Expand treatment to 2 additional clinical sites at MNHC Partner with community based researchers to study best practices Fall 2015 Winter 2016 Spring 2016

17. HCV Treatment Opportunities Specialty Clinic Primary Care Hospital SNF Inpatient Rehab Outpatient rehab Prison Jail Methadone Clinic Mental Health Clinic Needle Exchange Homeless Shelter TB Clinic Street medicine

18. The Hepatitis C Provider Group Monthly informal meeting at San Francisco General Hospital (SFGH) Open to all providers, nurses, pharmacists, and community members interested in supporting each other in treating HCV Join in person or by WebX http://bayareaaetc.org/resource- item/hepatitis-c-provider-group/

19. Thanks My Addiction Medicine mentors Drs. Paula Lum and Kenneth Saffier My team My patients Hepatitis C activists continuing to work for treatment access

20. Contact Information Dr. Joanna Eveland, MS, MD Clinical Chief for Special Populations, MNHC Clinical Faculty, UCSF Clinician Consultation Service (415) 552-1013 #303 Joanna.Eveland@ucsf.edu