1. Starting an HCV Clinic
Authored and Presented by: LCDR Jonathan Owen, PharmD
Neelam Gazarian, MS, PharmD
Quentin N. Burdick Memorial Health Care Facility
Indian Health Service
Belcourt, ND

2. Conflict of Interest Disclosure Statement
None

3. Objectives
Learn the tools to appreciate the scope of hepatitis C in their service area
At the end of this presentation, participants will have the knowledge and tool set to start a hepatitis c clinic at their service unit
number of people infected, awareness?

4. Prior to HCV Clinic With Insurance (Pvt./Federal) Without Insurance
Referred to Medical Specialists
$10,000/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. 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

6. Inter-collaborative Approach
Primary Care Provider
Pharmacist
Behavioral Health Public Health
Laboratory Services
Patient
Policy making
Education and awareness

7. Challenges in Starting Clinic
Labs do not exist
in system
NS5A Resistance Test
Fibrosure Test
Outsourced help to create this lab, currently working on NS5A resistance test
More info on this later

8. EHR Documentation Initial Visit Comprehensive visit End of Treatment
PHQ-9 screen
AUDIT-C
Order labs from Hep C Menu
Comprehensive
visit
Project ECHO recommendations
Start Medication Authorization
End of Treatment
Follow-up labs ordered throughout the process
SVR
Patient is cured!
Counsel about re-infection and prevention
Comprehensive visit usually done on the phone.

9. 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

10. Managing Patients Hepatitis C Patient Panel List
New panel created by Neelam ‘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

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

12. Managing Patients
Reminders for labs while in treatment, immunizations

13. Managing Patients
Reminders for labs while in treatment, immunizations

14. Stage of fibrosis score
Navigating Insurance
Stage of fibrosis score
APRI, FIB 4
Abstinence
Differs by state

15. Patient Assistance Program
Gilead’s Support Path
Sovaldi®, Harvoni®, Epclusa®
AbbVie Patient Assistance Foundation
Viekira Pak®, 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

16. Current Status 13 4 5 2 Pending Project Echo ETR SVR “cure” Treatment
Appointment with PCP, more labs pending (possible self clearers)
ETR: end of treatment response 3 months
First scvr labs due in November

17. Screening Rates

18. Investment Cost Analysis
Acquiring the medication
Case presentation
Education
Consultation request from provider
Approximately 2 hours needed per patient total

19. $110,046 $546,666 Direct cost of medications,
Includes patients that received medciations ….point of sale

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

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

22. Success Story Lobbied ND Medicaid 12-months abstinence requirements
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®

23. Acknowledgement
Quentin N. Burdick Memorial Health Care Facility Eliminate Hepatitis C Team:
Neelam Gazarian, PharmD. MS Pharmacology/Toxicology
LCDR Jonathan Owen, PharmD. USPHS
Thanks to:
Molly Steen, PharmD. Pharmacy Clinical Services Director
CDR Tyler Lannoye, PharmD. Chief of Pharmacy, USPHS

24. 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.

25. Questions

26. Thank you
Contact Info:
Ext 8426