Community health clinics (CHCs) are taking on greater roles in terms of screening and treating hepatitis C virus (HCV) patients, but new models of care are just starting to evolve to improve access and care for the high-risk, complex populations they tend to serve.
CHCs refer to federally funded clinics (Federally Qualified Health Centers, or FQHCs) which offer medical care to more than 27 million uninsured and underserved people in 9,800 rural and urban U.S. communities, according to the National Association of Community Health Centers (NACHC). CHCs deliver a wide range of primary and preventive care services, employ over 20,000 clinicians, and include community health centers, migrant health centers, healthcare for the homeless, and public housing primary care centers.
The NACHC reports that CHCs save the healthcare system about $24 billion annually, largely by reducing emergency department visits and hospital stays; and by providing a broad array of primary and preventive care services, including screening, diagnosis, and management of chronic illnesses. The NACHC also conducts research relating to population outcomes, best practices, and related topics.
Often CHCs have high rates of HCV infections in the populations they serve. A study in the Centers for Disease Control and Prevention’s Morbidity and Mortality Weekly Report conducted by the National Nursing Centers Consortium (NNCC) found a 13.2% HCV infection rate among patients in five CHCs in Pennsylvania. Another study by researchers in Hawaii looking at data from 2002 to 2010 found that the rate of HCV-positive people in 23 CHCs was 11.8%. According to data from 2011, HCV is more prevalent than HIV in patients seen in health centers.
Many CHCs lack the expertise to screen and treat patients with chronic HCV infections, as well as the infrastructure to provide assistance with services that complex patients often need. But in some parts of the country this is starting to change, largely triggered by the national Viral Hepatitis Action Plan, which recommends strengthening partnerships among health departments, community-based organizations, and healthcare providers for hepatitis services.
For example, in North Carolina, the Durham County Department of Health launched a program working in partnership with a variety of programs and an FQHC working with underserved populations.
Here, HCV testing was coordinated through the local health department in the sexually transmitted diseases (STD) clinic, the county jail, several community testing sites (including a residential substance abuse recovery program), and an FQHC homeless clinic. Findings were published in Public Health Reports.
Between December 2012 and February 2014, a total of 2,004 at-risk people were screened for HCV through this interagency approach. Of these, 241 people (12%) were found to be have chronic HCV infection. A total of 134 were referred for HCV, and of these, 123 attended the first appointment. Eighty-four individuals were homeless, with 19 (22.6%) being HCV positive.
The program showed that existing HIV/STD programs and provider networks can be successfully leveraged to deliver a coordinated system of care, said the lead author of the study, Arlene Seña, MD, MPH, of the University of North Carolina (UNC) Division of Infectious Diseases.
While the approach was able to capture additional people infected with HCV and help direct them to a treatment pathway, the experience shows there are still challenges. One is getting training for CHC clinicians so more can screen for and treat HCV. Seña suggested that CHCs could benefit from telemedicine approaches similar to the Extension for Community Healthcare Outcomes (ECHO) program.
ECHO is a telemedicine case-based training program in which primary care providers are mentored by specialists who treat HCV. The program was developed by the University of New Mexico to help enhance a variety of specialty services in rural and underserved areas. The North Carolina Division of Public Health recently developed a similar HCV telemedicine program in collaboration with UNC and Duke University to train CHC clinicians in the state.
Studies show that primary care providers (PCPs) are increasingly interested in treating HCV, with one study finding 22% of 129 PCPs from a variety of community clinics agreeing that HCV treatment should be provided by PCPs, and 84% saying they were interested in more HCV training. The willingness to provide treatment increased with higher proportions of HCV-infected patients in their practices.
Linkage to care is another challenge, with high-risk patients often needing help to successfully access services such as appointments with HCV providers, addiction counseling, housing, and other issues that can affect the success of HCV treatment.
“We developed an HCV bridge counselor program — a health educator or social worker who receives training in patient navigation services. This is similar to the bridge counselors or patient navigator programs in some HIV programs,” Seña told MedPage Today.
The navigator offers a wide range of assistance such as helping patients apply for Medicaid or Medicare; getting transportation to medical appointments; providing referrals to addiction or mental health programs; finding housing, food stamps, childcare, and translation services; or addressing other needs that can create barriers to care.
Patient navigators were also found useful in New York City’s Check Hep C pilot project. However, writing in Clinical Infectious Diseases, researchers said that while “evidence shows the effectiveness of patient navigation programs in improving health outcomes, including in diseases such as HIV and cancer … there is no ongoing national or state funding for HCV patient navigation programs.”
Another question: Do the high-risk patients involved want screening and treatment? The answer according to a study in BMC Infectious Diseases is a resounding yes. Here, researchers surveyed 140 patients from two homeless shelters, two drug rehabilitation centers, and a women’s drop-in center. A total of 99% said they would like free HCV services, 97% said they would undergo screening, and 90% said they would want to be tested even if they were unable to receive HCV treatment.
The researchers concluded that despite inconsistencies in access to care and treatment, high-risk communities want to know their HCV status. “Though baseline HCV knowledge was poor in this population, a brief on-site educational intervention improved both knowledge and acceptability of HCV testing and care.”
In an ideal world, Seña said, community health clinics would have more funding to support HCV treatment, healthcare providers trained in HCV management, patient navigators, a pharmacy infrastructure to assist with HCV medication approvals, and other social support for basic needs such as housing and child care.