Integration of pharmacist-led hepatitis C management into ......Background – SCF and Nuka System...

Integration of pharmacist-led

hepatitis C management into

primary care within

the Nuka System of Care

Matthew Begay-Bruno, Pharm.D.; Mike Beiergrohslein, Pharm.D., BCPS; Catherine

Arnatt, Pharm.D., M.S.; Christopher Chong, Pharm.D., BCPS; & John McGilvray,

Pharm.D., BCPS, FASCP

Southcentral Foundation, Anchorage, Alaska

Disclosure Statement

The authors are employees of the Southcentral Foundation,

otherwise, a vested interest in or affiliation with any

corporate organization offering financial support or grant

monies for this continuing education activity, or any

affiliation with an organization whose philosophy could

potentially bias my presentation.

Objective

Upon conclusion of the program, the participant should be

able to:

1. Identify benefits and challenges with proposed

assimilation of pharmacist-led hepatitis C medication

management into a primary care setting.

Purpose

The Alaska Native Medical Center (ANMC) presently has

all HCV cases utilizing specialty hepatology services.

Proposed assimilation of less complicated (treatment-

naïve, non-cirrhotic) cases into the management of

primary care

o Expected to enhance care through the Nuka

philosophy while enabling devotion of limited

specialty clinic resources to more complex cases.

Results of this report may assist both SCF and other sites

interested in pursuing similar projects aimed to expand

their clinical scopes of service

Background – SCF and Nuka System

of Care

Southcentral Foundation serves over 65,000 Alaska

Native/American Indian (AN/AI) people

Nuka System of Care: a relationship-based and

integrated health care system

Goes beyond the patient-centered medical home

model and focuses on physical, mental, emotional,

and spiritual wellness.1

Patients are called “customer-owners” (C-Os) to

signify that they are full partners in their health care

and that they in fact own the health care system.2

HCV Management – A Move from

Specialty to Primary Care

Epidemiology

Incidence of acute HCV cases in the U.S. steadily increasing

since 2009.

Incidence in AN/AI population disproportionally higher, 3-times

as many cases of acute HCV reported in 2016. 3

Mortality attributed to HCV accounts for more deaths than 60 other

infectious diseases combined.6

Direct-acting antiviral (DAA) therapy

Vastly improved cure rates compared to historical interferon-based treatments;

More options opportunities for increased pharmacy

involvement (consultative services) especially concerning

adherence and side effects.4,6-8

Results

Proposed Workflow

EHR Development and Education

o EHR Order Set (Cerner® Powerplan)

o Referral and Documentation Process

o Education Initiatives

**Rollout and approval still in progress – all plans proposed/tentative

Cerner® Powerplan

Discussion

Complexity of pre-treatment lab screening requirements potential delays in therapy initiation

Cost of DAA continues to be a large consideration

o Coordination of prior authorization and third party

reimbursement potentially highly time-consuming

A multitude of supportive services is needed to ensure

seamless transition to treatment initiation

Questions?

Acknowledgements

The authors extend their sincere gratitude to Callista

Carlton, PharmD & Stephanie Ogle, PharmD for assistance

with EHR process development; Solana Rollolazo for

assistance with process development; Hannah Espera,

MSN-Ed, Lisa Townshend, MSN, Brian McMahon, MD, & Joy

Callaway, BSN, for their dedication to the overall transition

of HCV treatment services from specialty to primary care

at the Alaska Native Medical Center.

References

1. Blash L, Dower C, Chapman S. Southcentral Foundation– Nuka model of care provides career growth for frontline staff.

Center for the Health Professions at the University of California, San Francisco. August 2011. Revised January 2012.

2. Gottlieb K, Sylvester I, Eby D. Transforming your practice: what matters most. Fam Pract Manag 2008 Jan;15(1):32-38.

3. Centers for Disease Control and Prevention. Statistics and Surveillance – Viral Hepatitis – United States, 2016. Updated

16 Apr 2018; Accessed 16 Nov 2018 via: https://www.cdc.gov/hepatitis/statistics/2016surveillance/index.htm#tabs-5-10.

4. Ahmed M. Era of direct acting anti-viral agents for the treatment of hepatitis C. World J Hepatol. 2018;10(10): 670-684.

5. El Khoury AC, Vietri J, & Prajapati G. The burden of untreated hepatitis C virus infection: a US patients’ perspective. Dig

Dis Sci. 2012;57(11):2995-3003.

6. Centers for Disease Control and Prevention. CDC Newsroom – Hepatitis C Kills More Americans than Any Other Infectious

Disease. Published 2016 May 4; Accessed 19 Nov 2018 via: https://www.cdc.gov/media/releases/2016/p0504-hepc-

mortality.html.

7. Strader DB & Seeff LB. A Brief History of the Treatment of Viral Hepatitis C. Clinical Liver Disease. 2012;1(1): 6-11.

8. Zuckerman A, et al. Increasing success and evolving barriers in the hepatitis C cascade of care during the direct acting

antiviral era. PLoS One. 2018;13(6):e0199174.

9. Sublette VA, et al. The Hepatitis C treatment experience: Patients’ perceptions of the facilitators of and barriers to uptake,

adherence, and completion. Psychol Health. 2015;30(8): 987-1004.