Identification and Linkage to Care of HCV-Infected Persons in Five Health Centers — Philadelphia, Pennsylvania, 2012–2014

Catelyn Coyle, MPH; Kendra Viner, PhD; Elizabeth Hughes, DrPH; Helena Kwakwa, MD; Jon E. Zibbell, PhD; Claudia Vellozzi, MD; Deborah Holtzman, PhD

Disclosures

Morbidity and Mortality Weekly Report. 2015;64(17):459-463. 

In This Article

Discussion

This project demonstrated that routine HCV testing can be successfully integrated into ambulatory care settings providing services for persons disproportionately affected by HCV infection. The project introduced six practices that could be replicated in other clinical settings. First, it tasked medical assistants with guiding patients through the HCV testing process, relieving the burden on clinicians and other health center staff. Second, reflex HCV testing technology was used to ensure that HCV-antibody positive patients received HCV-RNA testing necessary to detect current HCV infection. Such testing also allowed patients to receive test results and care referrals in one visit. Third, test costs associated with patients without insurance were eliminated as a barrier to testing. Fourth, modifying the HCV testing protocol to include HIV testing led to substantial increases in the number of HCV tests performed and currently infected patients identified (82.6% increase). Because more patients were eligible for HIV testing, the HCV test was easily added to the laboratory requisition.

Fifth, EMR modifications also improved patient care. The EMR prompted testing and the need for linkage-to-care services, all of which were monitored by the project manager and the linkage-to-care coordinator. Weekly reports tracked testing and patient progression through the HCV care continuum. EMR modifications also simplified the payment process for HCV tests performed on uninsured patients. Finally, intensive services carried out by the linkage-to-care coordinator increased the number of currently infected patients who received their results and were referred and seen by a specialist. This effort ensured that more patients received appropriate posttest counseling and medical evaluation for liver health and HCV treatment initiation.

The project successfully targeted patients at high risk for HCV infection; overall 8.6% of patients were infected with HCV, a higher proportion than previous estimates. Only 1% (0.8%–1.2%) of the general U.S. population is estimated to be infected with HCV.[1] A geographically targeted community-based testing program also carried out in Philadelphia found that 2.8% of persons were estimated to be living with current HCV infection.[8] The percentage of patients receiving an HCV-RNA test confirming their current infection status likewise was higher (92% versus 47%) than that reported by the Philadelphia Department of Public Health from routine surveillance of viral hepatitis.[9] The higher percentage in this project is largely attributable to the use of reflex testing,[10] which ensures that a greater number of persons are tested for current infection and can learn their infection status without returning to provide a second blood specimen.

A relatively small proportion of HCV-antibody-positive patients (7.6%) did not receive a confirmatory test during the project period. There are several possible reasons for this. Some patients submitted specimens early in the project, before the implementation of reflex testing, and might not have returned for confirmatory HCV-RNA test. Specimens submitted for confirmatory testing might not have met laboratory testing requirements because of insufficient quantity or improper handling. Providers might have inadvertently ordered the hepatitis panel that currently only includes an HCV-antibody test.

Linkage-to-care rates also were higher than those observed in Philadelphia surveillance data,[9] an outcome likely attributed to creation of the linkage-to-care coordinator position. Initially, linkage services included reminder phone calls, public transportation tokens for patients to attend appointments, or patient escorts. However, some patients were found to require additional services. The linkage-to-care coordinator provided intensive support services: following up with patients who did not keep appointments; conducting off-site (e.g., home, shelters, and halfway houses) visits as necessary; acting as an intermediary point of contact between the patient and the FQHCs; and helping identify and resolve any barriers patients experienced in attending appointments. These services fostered trusting relationships with patients. Additionally, the linkage-to-care coordinator remained a point of contact for HCV-infected patients that had fallen out of care because of addiction, unstable housing, or distrust of health care systems. The linkage-to-care coordinator worked with these patients until they were ready to reengage in care, linked them to social and addiction support programs, and provided specialized care plans to ensure they attended their HCV medical appointments. Similar intensive linkage services in community-based HCV testing and linkage-to-care programs in Philadelphia also have proven successful in navigating HCV-infected patients into care.[8]

The most successful linkage-to-care rates were seen at the PHMC Care Clinic, where HCV testing, care, and treatment are provided in the same setting. This test-and-treat model eliminates the need to refer patients to an outside care provider, except in extenuating circumstances (e.g., a patient with advanced liver disease or cirrhosis). Because of the high number of HCV-infected patients seen there, the Mary Howard Health Center plans to expand its services to include on-site HCV treatment. Linkage-to-care rates were lowest at health centers serving patients at low risk of HCV infection. Because they served fewer HCV-infected patients, providers at these sites might not be as aware of the HCV linkage-to-care protocol. To increase rates in these settings, HCV protocols will be updated and included in an automated centralized forum accessible by staff for training.

There were two main limitations of this project. The first was its relatively small size. HCV testing and linkage to care were integrated into a small network of health centers and therefore the practices and lessons learned from the project may not be applicable to larger settings, such as a large hospital system, or in other geographic areas. To address this, NNCC is exploring ways to replicate this model in larger health center networks in other cities. Second, the duration of the project did not follow patients through HCV treatment to cure. NNCC is working with offices of local HCV providers to collect data on treatment history and clinical outcomes.

The high rate of HCV infection among persons in disproportionately affected populations, like those seen at the five FQHCs, indicates a need for innovative models that can identify persons with HCV infection and ensure they receive appropriate care. Delivering care via trusted health care professionals at primary care settings can improve outcomes at every stage of the continuum of care, from reflex testing to providing timely test results and linking patients to HCV-focused care. In collaboration with public health agencies and other service providers, community health centers are optimally positioned to play an important role in expanding access to recommended HCV testing, care, and treatment for populations disproportionately affected by hepatitis C.

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