1. How Belcourt Started a Hepatitis C Clinic
Authored and Presented by: LCDR Jonathan Owen, PharmD
LT Neelam Gazarian, MS, PharmD
Quentin N. Burdick Memorial Health Care Facility
Indian Health Service
Belcourt, ND
12/14/2017

2. Objectives
Describe use of tools to manage complex care of hepatitis C patients, discuss workload capabilities.
Share resources of NICE Project with participants to help manage hepatitis C clinic.

3. Who are we?

4. Prior to HCV Clinic With Insurance (Pvt./Federal) Without Insurance
Referred to Medical Specialists
$10,000-$15000/referral
Distance
Lost to follow-up
Without Insurance
Very Few Options
Rationing Care
Poor outcomes
Lost to follow up/less documentation
No tracking of patients

5. Inter-collaborative Approach
Patient
Primary Care Provider
Pharmacist
Laboratory Services
Benefits Coordinator
Behavioral Health
Public Health
Patient centered interprofessional collaboration to Policy making
Education and awareness

6. Identifying Patients with Hepatitis C
iCare
168 patients
25% screening rate
VGEN
155 patients
Getting a sense of how many patients with diagnosis of hcv. Jessica and David huge help
Patients with visit in past year
Screening rate with a denominator of patients born between 1945 and 1965 (baby boomers)
From reports from vay, based on old labs. Often patients deceased, moved away

7. EHR Documentation Referral Initial Visit Treatment End of Treatment
Consult from PCP
Walk in
Initial Visit
PHQ-9
AUDIT-C
Education
Labs
Immunizations
Comprehensive
visit
Project ECHO
Start Medication Authorization
Treatment
Counseling
End of Treatment
SVR
Patient is cured!
Counsel about re-infection and prevention
Comprehensive visit usually done on the phone.

8. Consult Template

9. EHR Note Templates

10. EHR Note Templates

11. Hepatitis C Labs Order Menu

12. Hepatitis C Labs Order Set

13. Patient Management Tools
iCare Panel
Consults
Excel Panel List
NICE Hep C Tool

14. Managing Patients Hepatitis C Patient Panel List
Excel document for patient management
Created by Jessica Leston, Brigg Reilley, and David Stephens
Automatically calculates APRI, FIB 4 scores
Excellent for helping to prioritize patients based on liver function and viral load
Respective stages for fibrosis or cirrhosis
Excellent for helping to prioritizing patients based on liver function and viral load

15. Managing Patients Hepatitis C Patient Panel List
New panel created by Nelly to help manage patients referred to the clinic
Spin-off of previous panel, automatically calculates APRI, FIB 4 scores
Organized by stage in the treatment processes
Reminders for labs while in treatment, immunizations, notes
Respective stages for fibrosis or cirrhosis
Excellent for helping to priorityzing patients based on liver function and viral load

16. Managing Patients
Snapshot of stage in treatment process drop down menus (these can be adjusted)
Reminders for labs while in treatment, immunizations

17. Patient Panel

18. Individual Patient Data

19. Appointment Calendar
Reminders for labs while in treatment, immunizations

20. Navigating Insurance/Prior Authorizations
Comprehensive Visit Clinic Notes
Project ECHO
Recommended regimen
Lab Values
Chem 14, CBC, anemia panel, Vit D, AFT, HIV, Hep A & B, pregnancy
Viral load and genotype
Fibrosis Score: APRI, FIB4, Fibrotest
Abstinence requirements
Urine drug screens and/or clinical notes
Compliance
Differs by state

21. Patient Assistance Program
Gilead’s Support Path
Harvoni®, Epclusa®
iAssist:
AbbVie Patient Assistance Foundation
Mavyret®
Type 1: Epclusa ( sofosbuvir/velpatasvir, with ribavirin in cases of decompensated cirrhosis) , Harvoni (ledipasvir/sofosbuvir), viekira pak, zepatier
Type 2: Epclusa, sovaldi (sofosbuvir) with ribavirin
Type 3: Epclusa only given with ribavirin in cases of decompensated cirrhosis
Type 4: Epclusa, Harvoni, zepatier
Type 5: Epclusa, Harvoni
Type 6: Epclusa, Harvoni
Mavyret (glecaprevir/pibrentasvir): 1, 2, 3, 4, 5, 6
Mavyret still not on abbvie patient assistance program list, soon hopefully?
ND Medicaid just added as preferred non-formulary

22. Patient Assistance Programs
Tribal ID card
Income documents
Max income allowed differs by program
Proof of no insurance
American Indians/Alaska Natives (AI/AN): Indian Health Coverage Exemption
“American Indians and Alaska Natives (AI/ANs) and other people eligible for services through the Indian Health Service, tribal programs, or urban Indian programs (like the spouse or child of an eligible Indian) don't have to pay the fee for not having health coverage. This is called having an Indian health coverage exemption.”

23. Time Investment and Workload (Minutes)30
Initial Visit
ECHO
Prior Authorization 60
Treatment
Counseling
Almost 3 hours per patient

24. 28 26 22 Current Status 14 8 3 4 2 11 8 Pending Project Echo ETR
Medication Approval Pending
Treatment
ETR 4
SVR “cure” 2
Current Status 8 11 14 22 26 28
Appointment with PCP, more labs pending (possible self clearers)
ETR: end of treatment response 3 months
All current ETR pts due for SVR Mid January to mid february

25. Patients Enrolled in Clinic

26. HCV Screening Rate

27. HCV Screening Rate

28. Cost Analysis: Cumulative
$1,123,776
Flat rate reimbursement from ND Medicaid and expansion to IHS, outsource for cost avoidance

29. Next Steps
Leading efforts in the Great Plains, Bemidji and Billings Areas
Sharing experiences and resources with other service units

30. Next Steps POC Testing (>14 years) Behavioral Health Public Health
Clinic
Pharmacy
Dental
Emergency Room
Public health: community events

31. Success Story ND Medicaid and Expansion
12-months abstinence requirements remains
Drop minimum fibrosure score requirements
Zepatier; Elbasvir; Grazoprevir
Elbasvir: Not Predicted
Ledipasvir: Not Predicted
HARVONI; Ledipasvir; Sofosbuvir
$630, takes 1 to 2 weeks
No NS5A resistance test required unless prescribing Zepatier®

32. Medicaid Letter – Balancing Act
STATE
CLINIC

33. Share info via text HCV to 97779
Hepatitis Listserv
Share info via text HCV to 97779
Create a NICE Project Listserv to continuously improve and grow resources
Create a MAX.gov to share resources

34. Patient’s Story
First patient enrolled in HCV clinic summer of 2017, achieved SVR mid-November
“I have been waiting for this for so long. I know I have made some mistakes in the past, but I had started to turn my life around. I am very thankful to them for not being judgmental and for treating me with respect. I am finally able to start a family. God bless you!”
- First patient to attain SVR in HCV clinic
Young 26 y/o female, unable to start a family for a very long time due to her diagnosis and fear of infecting her baby and her husband.

35. Recorded Webinars http://www.npaihb.org/hcv/#clinical-resources
How to create an iCare panel
How to create a quick order menu for required labs
How to use the NICE patient management tool
Hepatitis C clinic workflow
Medicaid Letter, appointment cards

36. Special Thanks
Jessica Leston , HCV/HIV/STI Clinical Programs Director for the Northwest Portland Area Indian Health Board
Brigg Reilley, National HIV/AIDS Program
David Stephens, BSN, RN, Case Manager for the Northwest Portland Area Indian Health Board.

37. Questions

38. Thank you
Contact Info:
Ext 8426