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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.