Chronic Hepatitis C and Mental Illness: Three Case Studies

Our patient navigator is the first-line team contact for patients with chronic hepatitis C enrolled in our interprofessional, team-based treatment model. Care integration for patients begins during the pre-treatment evaluation phase with a comprehensive health assessment, assessment of liver functioning, possible ongoing risk, behavioral health assessment and psychosocial assessment. The Psychosocial Readiness Evaluation and Preparation for Hepatitis C Treatment (PREP-C), a structured assessment interview focused on hepatitis C treatment, is a key part of our pre-treatment assessment. The PREP-C tool assesses nine areas of psychosocial functioning that are linked via evidence to successful hepatitis C treatment: motivation, information, medication adherence, self-efficacy, social support and stability, alcohol and substance use, psychiatric stability, energy level, and cognitive functioning. Our three patient exemplars had previously been treated leading to basic knowledge of but also apprehensions about treatment. The PREP-C is used as an opportunity for collaborative education and setting of expectations for both patients and team members. The assessment reveals areas for intervention in order for the team to optimize chances for successful treatment. In formulating a workable plan, patients are engaged as partners. Compromise and adaptation were made by the patients as well as the team. In the case of two of our patient exemplars, special arrangements were made in order for the patients to consent to the regular blood draws required while on treatment. In another case, the team accommodated the patient’s request not to have office visits with the nurse practitioner (who remained involved in the patient’s care) as an accommodation with the goal of preventing reoccurrence of a previous psychological trauma. Roles and team contributions were made evident to the patients so that they could understand the resources available to them and access them readily. The navigator in turn mobilizes appropriate team resources to address the patients’ needs. This structured approach led to expeditious evaluation and treatment and was reassuring for patients.  Using this method, we were able to avoid provider burnout and patients’ feelings of isolation by providing them with additional psychosocial support and ambulatory, emergency, and psychiatric care coordination. The team collaborated closely and communicated consistently with and regarding patients’ issues. Weekly case conferencing, with added conferencing as needed to address issues as they arose and to individualize care, led to speedy resolution of issues. In some cases, deviation from standard of care in order to address acute issues was also an effective tool to engage and support patients. When one of our patient exemplars developed psychotic symptoms while on treatment, team members guided the patient into emergency care and then to hospital admission. The team then worked with the patient’s family and the inpatient team to assure that treatment was not interrupted. To provide additional support, the patient navigator and social worker both visited the patient in the hospital but the nurse practitioner did not in order not to confuse the distinct roles of the inpatient and outpatient care teams. Similar rapid responses to acute symptoms and psychosocial issues allowed for treatment continuation and eventually to successful completion for all three patient exemplars.