Date of Award
Projects: SPU Access Only
Doctor of Nursing Practice (DNP)
Christine Hoyle, DNP, ARNP, FNP-BC
Mary Segall, PhD, RN
Background and Significant: Hepatitis C viral infection (HCV) has silently become a public health concern in the past two decades, increasing its incidence among people who inject drugs (American Association for the Study of Liver Diseases [AASLD], 2020). While antiviral treatment provides the cure for HCV, millions of people remain infected (AASLD, 2020). Due to patient, provider, and system barriers, HCV patients have not benefited from these new treatment options. Common barriers include comorbid conditions like substance use disorders, lack of access to treatment, fear of cost, adverse effects, treatment duration, and lack of expertise in HCV treatment (AASLD, 2020; Bartholomew et al., 2019; Beste et al., 2017; Pourmarzi et al., 2019).
Problem and Purpose Statements: Patients fall out of the HCV cascade of care from diagnosis through cure, particularly at the point of the linkage to care of those affected to a system of care (AASLD, 2020). The linkage to care is defined as the patient diagnosed with hepatitis C, following the confirmation positive RNA test, linked to a provider by attending a follow-up appointment (Hep C Free Washington, 2019). The need to enhance linkage to and retention in care is magnified, especially for the vulnerable population in primary care settings. The purpose of this project was to enhance providers' expertise and engagement to provide treatment for patients and empower nurses to provide comprehensive patient education about HCV care. Ultimately, the multidisciplinary team approach has the potential to improve linkage to care among patients with chronic hepatitis C in primary care. Project aims were 1) to develop a process improvement in HCV care that is feasible and efficient for primary care providers, and 2) to increase the numbers of patients linked to HCV care.
Methods: This project was guided by the Ottawa Model and the Care Model to improve the process of linking HCV patients to treatment in a piloted urban federally qualified health center (FQHC). Three principal components: an evidence-based HCV care toolkit for the providers, an educational session for the nurses were built into the multidisciplinary team intervention, and utilization of clinical information to guide practice and increase charting efficiency. The Electronic Health Records (EHR) was utilized for retrospective data collection. The total number of confirmed HCV patients, linkage to care rate, interest in treatment, and treatment initiation rate were captured. The participants' perceptions and attitudes about the linkage of care in HCV were evaluated through a pre-and post-implementation survey and a post-implementation informant interview.
Results/Outcomes: The goal to improve the process in HCV care was met by providing an evidence-based toolkit to aid the providers' clinical practice and training the staff nurses through an educational presentation. Overall, this process improvement fostered a significant increase (26.4%) in provider competency to provide HCV care and an 18.4% increase in competency among the nurses. The aim to increase linkage to care as the primary outcome measure was met in this project. By the end of the implementation, patients who were successfully linked to a provider to discuss HCV treatment doubled (n=20), representing a 35.1% rate in linkage to care, where previously the linkage to care was 18.2%. There were also increases among the patients' interest in treatment and initiation to treatment.
Sustainability: Support from the organization's leadership team is essential to sustain the HCV program. This project only captured a small scale of the current HCV care cascade. A multidisciplinary team effort is necessary to ensure patients begin and proceed through the cascade's steps through clear care team responsibilities and buy-in from stakeholders. This project provided valuable evidence-based resources to enhance provider knowledge in HCV care. It offered EHR application with clinical informatics to guide practice and increase charting efficiency. Identifying the provider champions is essential to sustain this HCV care cascade practice and facilitate practice change. These champions are vital for ongoing data collection and promoting continuous process improvement.
Implications for Practice: Linkage to care bridges HCV diagnosis to cure. This project provided insight on the critical linkage-to-care step within the HCV treatment cascade provided by primary care providers at an urban FQHC. It highlighted the value of utilizing interprofessional teamwork and clinical informatics integration when providing comprehensive care to improve health outcomes. With additional support through tele-mentoring from specialists, primary care providers such as nurse practitioners were well-positioned to provide comprehensive HCV care to patients in primary care settings. The Care Model could be used to guide further process improvement to meet the HCV elimination goal. While addressing the barriers and promoting the strategies identified in the literature, this process improvement prevents delays in linkage to care. However, ongoing evaluation of the current best practice in HCV care is imperative for future research (AASLD, 2020). Further research in looking at the efficacy and effectiveness of different strategies and settings may maximize the current effectiveness of the direct-acting antivirals.
American Association for the Study of Liver Diseases. (2020, August 27). HCV testing and linkage to care. https://www.hcvguidelines.org/evaluate/testing-and-linkage
Bartholomew, T. S., Grosgebauer, K., Huynh, K., & Cos, T. (2019). Integration of hepatitis C treatment in a primary care federally qualified health center; Philadelphia, Pennsylvania, 2015-2017. Infectious Disease: Research and Treatment, 12, 1-7. https://doi.org/10.1177/1178633719841381
Beste, L. A., Glorioso, T. J., Ho, P. M., Au, D. H., Kirsh, S. R., Todd-Stenberg, J., Chang, M.F., Dominitz, J. A., Barón, A. E., & Ross, D. (2017). Telemedicine specialty support promotes hepatitis C treatment by primary care providers in the department of veterans affairs. The American Journal of Medicine, 130(4), 432-438. https://doi.org/10.1016/j.amjmed.2016.11.019
Coleman, K., Austin, B. T., Brach, C., & Wagner, E. H. (2009). Evidence on the chronic care model in the new millennium. Health Affairs, 28(1), 75-85. https://doi.org/10.1377/hlthaff.28.1.75
Hep C Free Washington. (2019, July). Plan to Eliminate Hepatitis C in Washington State by 2030. https://www.doh.wa.gov/Portals/1/Documents/Pubs/150nonDOH-HepCFreeWA-PlanJuly2019.pdf
Pourmarzi, D., Thompson, H., Thomas, J. A., Hall, L., Smirnov, A., FitzGerald, G., & Rahman, T. (2019). Outcomes of a tertiary-based innovative approach to engage primary care providers in provisions of hepatitis C treatment in community settings. BMC Public Health, 19, 1335-1342. https://doi.org/10.1186/s12889-01907604-5
Xia, Candice, "Expanding Primary Care Access to Hepatitis C Treatment by Improving Linkage to Care" (2022). Doctor of Nursing Practice (DNP) Scholarly Projects. 32.