1. (2)Consultation Unit and Ambulatory Care,
HEPATITIS MOBILE TEAM
Decrease of specific social score EPICES before and after direct antiviral agent treatment in HCV patients in France
Hakim BOUCKHIRA (1),
André-Jean REMY (1,2), Stéphane MONTABONE (1),
Nathalie BEURIER (1), BOULOGNE Guillaume (1, HAPPIETTE Arnaud (1).
(1) Hepatitis Mobile Team, Service of Gastroentrology,
(2)Consultation Unit and Ambulatory Care,
Hepatitis Reference Center, Perpignan Hospital, France
Hello everybody, my name is Hakim Bouchkira, I’m delighted and glad to talk about the work of the mobile team, I thank the organizing committee for allowing me to speak about people with hepatitis C in vulnerable situations along with collaboration of Dr andre jean rémy, Hervet Jeremy, Nathalie beurier, Guillaume Boulogne and Arnaud happiette Stéphane Montabone
Thank you for being present, he is the social worker of the mobile team he will speak to us about his work. So Today’s topic will be
Decrease of specific social score EPICES before and after direct antiviral agent treatment in HCV patients in France 1

2. French health insurance A high-level social model
French health insurance was created in1945 with 3 fundamental principles :
Equality of access to healthcare
Quality care
Solidarity
The health insurance allows each and everyone to be in care according to the needs, regardless of age and level of incomes
 With this social model almost all patients seen by the hepatitis mobile team can have access to a social insurance cover offering care and treatment of hepatitis by the new molecules

3. IN PRACTICE For a basic protection of health expenses
Universal health protection (PUMA)
Every person who has a permanent or temporary professional activity starting at the first hour of work
Or have been living in France in a stable and regular way for at least three months
No three months conditions for the asylum seekers

4. IN PRACTICE(2) For a complete protection : 3 possibilities
For all people in regular situation :
Complementary (Additional) universal healthcare coverage (CMU-C)
For all the care
With income conditions : less than 802$/month for 1 person (9629$/year)
Recognition for long-lasting affection (ALD)
Only for a specific disease
No income condition

5. IN PRACTICE(3) For people in irregular situation
State Medical Aid (AME)
For all the care
With same income conditions than CMU-C : less than 802$/month for 1 person ($/year)
With a residence condition of more than 3 months

6. Target population Drug users Inmates Homeless Excluded population
Migrants
Psychiatric patients
Hepatitis C was most frequent in vulnerable people who were insecure and had multiple viral risk factors.
HBV and HCV Infections are three times more frequent in people in precarious situation .
Vulnerable people included inmates, migrants, drug users, homeless and psychiatric patients. Accessibility of health system was not so easy, most part for these populations because of social, psychiatric and addictive issues.
Since July, twenty fourty the hepatitis mobile team is at the heart of this population which can sometimes be difficult to accompany.

7. Complex situations and difficult accompaniments
Absence of health care rights
Absence or low income
Absence of accommodation
Absence of identity documents
Isolation
Wandering
The factors which favorise the complex situations are
Absence of rights of Social Security
Absence or low income
Absence of accommodation
Absence of documents of identity
Isolation
Wandering

8. Complex situations and difficult
accompaniments (2)
Irregular situation on the territory
Linguistic difficulties
Addictions
Penal position
Psychiatric pathologies
Complex somatic situations
And Irregular situation on the territory
Linguistic difficulties
Addictions
Penal situation
Psychiatric pathologies
Complex somatic situations

9. Recommendations of the DHUMEAUX report
R 15-4 « Take a global approach to the disease and promote global patient management. - Improve continuing medical education for healthcare professionals.
- Create consultations on adherence or patient therapeutic education
- And involve social workers or psychologists to provide support to patients living hepatitis
In may 2014 French national experts published the Rapport Dhumeaux that recommends
1-to take a global approach to the disease and promote global patient management
2-Improve continuing medical education for healthcare professionals.
3-Create consultations on adherence or patient therapeutic education
4-And involve social workers or psychologists to provide support to patients living hepatitis

10. R 18-1 « Evaluate the social vulnerability of patients with hepatitis B and C and propose appropriate multidisciplinary support»
R « Facilitate the process for obtaining medical and social coverage when released from prison and increase social support after release »
the French report also recommends
1- Evaluate the social vulnerability of patients with hepatitis B and C and propose appropriate multidisciplinary support
And finally Facilitate the process for obtaining medical and social coverage when released from prison and increase social support after release

11. The hepatitis mobile team joins completely in these recommendations since September 2014 with the arrival of a social worker, a second social worker since July 2016 and also the use of specific social score allowing to estimate the precariousness
The hepatitis mobile team joins completely in these recommendations since September 2014 with the arrived of a social worker, a second social worker since July TWENTY SIXTEEN and also the use of specific social score Allowing to estimate the precariousness

12. Difference between pre and post treatment values were significant
On this slide, it’s the epices score (evaluation of individuals factors affecting vulnerability in health exams centers) Points indicated in the column YES allow to judge the importance of every question. The last line specifies that everybody starts with a constant of seventy five point one four points. The calculation of these points and this constant allows to establish a score at the individual level, varying from 0 (absence of precariousness) to one handred ( maximum precariousness).  The precariousness is proved true above fourty eight point five points.
Its application within the framework of the hepatitis mobile team allows us to facilitate the orientation towards the social worker then to estimate in therapeutic comments the evolution of the degree of precariousness of the patient. It is used in a informal way, without giving the score to the patient.
The EPICES score is done two times for every patient, one at first contact and one 3 months after treatment.
Difference between pre and post treatment values were significant

13. In twenty SIXTEEN , sixty four EPICES scores were done before DAA treatment with an average value of seventy seven.
In twenty sixteen , sixty four scores EPICES were done AFTER DAA treatment with an average score of fity two
Remenber that The precariousness is proved true above fourty eight point five, Red line
The people we meet in the context of the EMH has a high level of precariousness but after the social work
average scores spices post treatment is fifty two, there is a real differance between before and after treatment

14. Goals : To promote
Screening, Access to health rights Follow-up Access to treatment And its success as well as the insertion of the precarious patients affected by viral hepatitis C

15. For a social work
Punctual ...
Constant
Before
During
After treatment

16. Multiple ways of intervention ...
Checking, opening, renewal of health care rights
Finding accommodation solutions
Filling forms to help people integrate social structures, access to rights, to incomes documents of identity, residence permit for health reasons

17. Hotline No appointment reception Home visit  Connections with emergency & charity structures Form filling & follow up of requests to enter emergency and/or health structures Social accompaniment

18. Some figures … From September, 2014 till December, 2015
130 patients seen
More than 400 interviews done
3 interviews/patient as average but with an amplitude from 1 to more than 20
Outside “the walls” interviews in 40 % of the cases

19. 49 openings and/or renewals of health care rights 20 requests for accommodation
Therapeutic Coordination Apartments requests for Bed Stopping Care Health 9 files for Departmental House for the Disabled People

20. Seen in an day care health center Homeless, lives in a shed
CLINICAL CASE
Mr. L 57 years old
Seen in an day care health center
Homeless, lives in a shed
Has health rights
Wants to do a screening : (RISK FACTORS: precariousness, weaned drug user, important alcohool addiction (several times in emergency service).
Nurse does POCT/DBS (dried blood test) HCV + / HIV / HBV
With Fibroscan® Fibrosis F2 8,7 KPA
With the bloodtest Fibrosis (Fibrotest®) F4 cirrhosis
EPICES Score 75,14
Health records : STROKE
His wills : Cure his hepatitis C and work on his addictions, more globally taking care of his health and social situation
We are going to present you a clinical case to illustrate our way of working, We will talk about Mr. L, fivty seven years old. Patient who Worked as a gardener during ten years, he lost his daughter in a car accident. Had a partner and was not married, they would break up after the daughter’s death which had a big influence on Mr. Ls alcohol and drug addiction by injection during 4 years. There is a decline on the professional, relational and psychological sides. He finally gets in jail in ninteen ninty five during ten YEARS then when he was released he found himself on the streets.  At this time, he met a nurse from our mobile team in a day care health center for the homeless ( Every Friday morning we offer free POCT VHC VHB HIV and Fibroscan)
His POCT for HCV is positive and the fibroscan result is a moderate fibrosis
There is a discordance with the blood test which shows a cirrhosis

21. I suggest to accompany him to the Perpignan Hospital Center to :
CLINICAL CASE
I suggest to accompany him to the Perpignan Hospital Center to :
Do a blood test
Show him our premises
Screening of tuberculosis by lungs X-Ray
Do a social evaluation
I suggest accompanying him on the Hospital center of Perpignan to realize a blood test, present him our premises, realize a radio of lungs for the screening of the tuberculosis and to meet our social worker to realize a social evaluation and begin a social support.

22. Food support with weekly food parcels Mobile phone lending
CLINICAL CASE
SOCIAL WORK
Food support with weekly food parcels
Mobile phone lending
Social rights restoring (health insurance and minimum income)
Electricity and housing debts bearing
Psycho-social support
Rehousing support

23. CLINICAL CASE
Simultaneously to a social work the health care is done but without forgetting
Orientation towards addictology unit
Accompaniment in the care path
Educational therapeutic sessions during the treatment
Simultaneously to the health care, a social work is done but without forgetting
Orientation towards addictology unit
Accompaniment in the care path
Educational therapeutic sessions during the treatment
Need to remember him regularly his appointments but gets at the end to be autonomous regarding this point

24. FOR AN INTERESTING RESULT…
Score EPICES passes from 75 to 54 after the treatment
Clear improvement of the living conditions and the update of its administrative documents
Cured of hepatitis C
Weaned of his alcohol consumption but is still followed by the addiction unit
Wants to work
Pursuit of social work
FOR AN INTERESTING RESULT because
Clear improvement of the living conditions and the update of its administrative documents
Cured of hepatitis C
Weaned of his alcohol consumption but is still followed by the addiction unit
Wants to work
Pursuit of the social work

25. Conclusions
The Hepatitis Mobile Team is an innovative concept that promotes the come back of known HCV patients and new diagnosis patients in circuit of care by facilitating access to screening and FIBROSCAN*, but also for social worker and hepatologist consultation.
Training and coaching people with precarious situation, investment and adherence to project of our partners, increases the number of HCV patients supported, treated and cured.
The Hepatitis Mobile Team is an innovative concept that promotes the come back of known HCV patients and new diagnosis patients in circuit of care by facilitating access to screening and FIBROSCAN*, but also for social worker and hepatologist consultation. Training and coaching people with precarious situation, investment and adherence to project of our partners, increases the number of HCV patients supported, treated and cured 31

26. THANK YOU FOR YOUR ATTENTION!32