HALO: Health and Liver Optimization, Partners in Care

Purpose: The purpose of the presentation is to disseminate knowledge and effectiveness of a unique model of patient care in chronic disease management. The Health and Liver Optimization (HALO) model of care provides an individual collaborative program with identified target goals for every patient who walks through the clinic doors, regardless of their condition.     

One of the greatest challenges facing the U.S. health care system is improving the care for patients with chronic illnesses.  Forty eight percent of all Americans and eighty-seven percent of senior citizens insured through Medicare have at least one chronic condition.  The Medicare statistics have identified two or more chronic conditions in 63% or more in individuals over the age of 65 (2010).  Traditional chronic disease management focuses on a single condition and does not meet the need of patients with multi-comorbidities. The client must seek multiple specialists to meet their health care needs.  

Liver disease is chronic in nature and may progress to cirrhosis with complications of end organ failure. Increasing rates of non-alcoholic fatty liver and viral hepatitis are being diagnosed with many of these patients showing evidence of advanced fibrosis and cirrhosis.  The liver, a major organ for metabolism and clearance, is affected thus influencing multiple systems of function. Long term care of the individual with a chronic liver disease will include management of other associated chronic illnesses, such as diabetes, obesity, chronic renal disease, cardiac disease, and hepatic complications. 

Care management is a holistic approach to the partnership between the patient/client and the provider.  As the patient with liver disease becomes more complex, careful monitoring and education becomes apparent.  Often this can be managed before it becomes overt, as the subtle changes are identified earlier with the partnership between client and provider. 

Methods: This collaborative care model was developed at Southern California Liver Centers, where we treat patients as partners in their own care bringing our unique perspective and experience with liver disease to our patients to optimize their health and wellness. The original concept of HALO was developed in partnership with experienced hepatology physicians, nurse practitioners and staff, primary care providers, the patients and a marketing team. Focus groups were conducted to identify themes and care needs of patients with long term chronic liver diseases. Health and wellness aspects and specific chronic care needs based on results of the focus groups were developed by a collaborative team and incorporated into the patient care model. The model of care was implemented in a large community based Gastroenterology and Hepatology practice in Southern California. Effectiveness of the model was evaluated by repeat focus groups and several long term patient health outcomes.   

Results: To address the multiple needs of the patients and address gaps in care, Southern California Liver and GI Centers developed a team approach to care management.  This community based clinic providing care to the patient with chronic liver disease developed a patient centered model of care entitled, Health and Liver Optimization (HALO). Findings from the patient focus groups included the themes of caring, safe environment, guardian angels, and knowledge empowerment. Patients identified a need for a long term partnership with their health care providers in order to support the life style changes many of them needed to make.  This partnership between the client and the provider is developed early in the care and optimized throughout the course or the patient’s liver disease.  The patient’s quality of life, chronic illness care, and family are addressed at visits, goals are established and “routine” tests are performed and maintenance of disease is managed. After implementation of the patient care model, patient satisfaction scores improved as well as several long term health outcomes. Individuals are currently being followed long term for disease management under this new model of care.    

Conclusion: The Health and Liver Optimization (HALO) patient centered model of care provides an effective collaborative chronic disease management approach. Patients are empowered to make decisions in their health and wellness journey with guidance from experienced healthcare providers partnered with them to impact their long term outcomes. Southern California Liver and GI Centers developed and adopted this new approach with effective utilization of the model for the care of the patient with liver disease.