San Francisco Health NetworkHepatitis CTreatmentEvaluationMay 2017Report prepared by

INTRODUCTIONAbo ut th e SF HNLike many communicable diseases, s, specifically people who injectdrugs, people who are homeless or marginallyhoused, people of color (most notably AfricanAmericans), and people living with HIV.The San Francisco Health Network (SFHN) isSan Francisco’s only complete system of care.In addition to cutting-edge specialty care, theSFHN, part of the San Francisco Department ofPublic Health, includes primary care in 10community-based and 4 hospital-based clinicsthroughout the city.The availability of highly effective HCVtreatment that is taken through an oral pillwith few side effects (known as direct actingantivirals, or DAAs) gives us the remarkableability to cure HCV in nearly all infectedpatients. Due to the high cost of DAAtreatment, originally the CA Department ofHealth Care Services (DHCS) restricted HCVtreatment for Medi-Cal patients to those withdocumented advanced fibrosis or cirrhosis(stage 3 or 4), and patients were typicallyexcluded based on active substance use or anumber of mental health conditions. However,a major DHCS policy change on July 1, 2015expanded treatment access to anyone inCalifornia with evidence of stage 2 or greaterAnyone who has Medicare, Medi-Cal, HealthyWorkers, Healthy Kids, or Healthy SanFrancisco (including through the San FranciscoHealth Plan) is eligible to receive primary carethrough the SFHN, if they have selected one ofthe SFHN primary care clinics as their medicalhome.Abo ut Hepa t it is CSan Francisco is profoundly impacted by thehepatitis C virus (HCV), a communicabledisease easily transmitted to others throughblood-to-blood contact. HCV is a significantdriver of morbidity, liver cancer, and death.1

hepatic fibrosis/cirrhosis, active injection drug use, or co-infection with HIV.Within the City and County of San Francisco, there is a strong commitment to providing HCVtreatment to all people living with HCV, unless medically contraindicated. For patients of the SFHN,this commitment has been realized through a comprehensive set of services to improve providerawareness and capacity to prescribe and facilitate successful treatment with DAAs.Examples of the efforts provided to date include two 4-hour trainings in 2016 about primary carebased HCV treatment, a detailed presentation of HCV treatment procedures for SFHN providersduring one of the quarterly SFHN Provider’s Meetings, establishment of an eReferral system tosupport treatment in specific patient cases, and a team of HCV champions providing clinic-basedtechnical assistance on an as-needed basis.Abo ut th is Eva lua t ionAlmost two years after treatment access was expanded to patients receiving care through the SanFrancisco safety net, the SFDPH hired an external consultant to evaluate the barriers still preventingsome SFHN providers from providing HCV treatment to their patients, and make specificrecommendations to facilitate increased treatment uptake.The landscape of HCV treatment support within the SFHN was assessed through a quantitativereview of clinical prescriber and patient data, a surveymonkey survey completed by 44 primary careproviders, in-depth, 1-on-1 intervews with 13 providers, running the gamut from those who hadnever prescribed treatment to those who were considered “HCV champions” in their clinics.eReferral System2

Who is prescribing HCV treatment in the SFHN?When comparing two full years of SFHN clinical data, it is clear that significant progress is beingmade in the area of HCV treatment. These numbers below only include accurate data for the PositiveHealth Program, Castro Mission Health Center, Tom Waddell Urban Health, and Southeast HealthCenter (with Southeast’s data being partially incomplete until March 1, 2016).Number of patients treatedNumber of providers prescribing942104277Oct 2014 –Sept 2015Oct 2015 –Sept 2016Oct 2014 –Sept 2015Oct 2015 –Sept 2016123%83%A total of 120 providers were trained during two HCV provider trainings in January and October2016. From March 1, 2016 through March 31, 2017, 17 providers from those trainings used theeReferral system, a total of 64 times (with an average of 3.8 times used per provider).44Total number of providers usingeReferral from March 2016 – March2017 (even if not prescribing)17Relationshipof prescribingproviders toeReferral33Total number ofproviders prescribingusing eReferralTotal number ofproviders prescribingnot using eReferralBetween their date of training and March 31, 2017, 74 prescriptions for HCV treatment were writtenby providers who attended either of the trainings in 2016. This was an average of 3.9 prescriptionsper trained provider; however, when excluding Royce Lin and Soraya Azari from the counts (as theywere “super-prescribers”) the total number of prescriptions drops to 30, with an average of 1.8 perprovider. During that same time period, 45 prescriptions were written by providers using eReferral,and another 152 prescriptions were written by providers who did not use eReferral (though 69 ofthose were written by Royce Lin and prescribers at OTOP).3

Wh o is cu rren t ly b ein g t reat ed in th e SFH N?When comparing the SFHN patients who have been treated for HCV to those who are HCV RNA but have not yet been treated for HCV, there are only slight demographic differences, as can beseen in the first two columns of pie charts, below. However, the overall age, gender, and ethnicitydemographics of SFHN patients who are confirmed HCV RNA (whether treated or not) areconsiderably different from all active patients overall (the third column of pie charts, below).Most notably, a disproportionate number of baby boomers (ages 50-69), males, African American,and White patients are HCV RNA or were recently treated. Almost 11% of adult African Americanspatients of the SFHN are living with HCV. Note that while trans women are known to have aconsiderable HCV prevalence in San Francisco (as high as 1 in 6), “transgender” gender is notcaptured in the clinical data of any SFHN clinics except Tom Waddell Urban Health. While 126 peopletreated for HCV (32%) were noted as having a history of injection drug use, this information ismissing for most SFHN patients, making a real comparison impossible.Treated for HCV sinceOctober 1, 2014Active patients HCV RNA but not yet treated as ofMarch 7, 2017*(2,183 people total)(389 people total)All active patients onApril 24, 2017(54,423 people total)AgeGenderEthnicity*Note that this middle column excludes 180 patients who are HCV antibody positive but had not yet had HCV RNAconfirmatory testing at the time of data analysis.4

S u rvey R esu lt sa n d In t erview sOut of the 120 providers whoparticipated in one of the 2016HCV prescriber’s trainings, 111had active emails at the time datawere collected for this evaluationand they were contacted to take abrief survey using SurveyMonkey.Of those, 44 providers completedthe survey, with a fairly broadspread throughout the SFHNprimary care clinics, as can be seenin the graph to the right. Of the 15providers who selected “other,”specified clinics included JailHealth Services, ZSFG UrgentCare, BAART Market Street, OTOP,SF HOT / Street Medicine, and anumber of supportive housingproviders.Almost 2 out of 3 surveyrespondents (28/44) were primarycareproviderslicensedtoprescribe HCV treatment directly.The remaining respondents wereRNs (18%), pharmacists (4%), andadministrative roles (e.g. programmanager, medical director, nursemanager) with one medicalevaluation assistant and oneurgent care provider.14 respondents completed theJanuary prescriber training, 25completed the October training,and 2 participated in bothtrainings. Three of the 44respondents did not answer thisquestion.5

When asked why they attended the training, 36 people (82%) said it was because there is patientneed/demand for HCV treatment in their practice and they needed to build skills in knowledge, 34people (77%) said they thought it sounded interesting and wanted to learn more, and 8 said it wasbecause their supervisor asked them to attend.Overall, participants had very positive things to say about the provider trainings (though many ofthe providers interviewed said it was so long ago they couldn’t remember enough detail to offerany constructive criticism). In the “additional comments” field of the survey, one respondent wrote,“The content of the prescriber training was useful and I have referred back to it several times in thecourse of treatment.” This sentiment was echoed by those interviewed; commentary wasoverwhelmingly positive, with one person suggesting more concrete information (i.e. an “algorithmhandout” that helps with decision-making around treatment) and another offering the idea that infuture trainings, the focus might be on clinical experience people have had with complications orside effects from treatment. One of the clinic champions interviewed explained that the training“didn’t quite do it for the nurses” and that it was very MD-centric, with some of the content goingover nurses’ heads. “When clinics are needing to beef up their whole team, it may be worth havingtailored trainings depending on what their role is,” she noted. Along those lines, a provider whohas treated about five people since the training said,When I went to the training I had zero HCV experience. I remember walking away fromthat training thinking, “That was great, but I don’t even know where to start about howto select a treatment.” Before I got into those detailed of writing a letter and all thatstuff, I feel like it would have been helpful to have the nitty gritty on the medical sidefirst. What labs to run, how to select treatment, what sort of potential side effects orbad outcomes could happen, what would you do in a situation where the medicationwasn’t working 4 weeks in, etc. Ultimately I think that’s a good use of eReferral, but Ialso think it’s good for providers to be aware of these things 0 like, you should be awarethat 4 weeks out you should have a zero viral load. And if that’s not happening, maybeyou check with eReferral about what to do but you have to know to check. Isubsequently went to an outside conference to learn that stuff.Before the training, more than 3/4 of respondents had never treated a patient for HCV. After thetraining, however, that number dropped below 50%, with 16 of the 34 people who said they hadtreated no patients before the training reporting treating at least one patient post-training. Thedistribution of the number of patients treated pre and post-training can be seen in the figure below.How many people have you treated for HCV?0%10%20%30%40%50%60%70%80%90%Before the trainingAfter the trainingNone1-34-869-1213 100%

Why still not treating?For those who said they still had not treated any patients for HCV post-training, there were anumber of reasons why. Eight people of the 20 who still answered “zero” post-training said theyhad no patients in need of HCV treatment, or were unable to prescribe (e.g. they were an RN, orpatients with HCV were already being treated elsewhere). Of the remaining 12, 8 said they don’thave any patients they think can complete treatment successfully, and/or that they can never focuson HCV as there are too many other “fires” for their patients. The other 4 said they didn’t know howto navigate the medication ordering process (2 people), they didn’t feel comfortable prescribingtreatments to their patients yet (3 people), or they know how to do it but there is no one at theclinic to assist and they feel like they can’t do it themselves (2 people).Of the 14 providers interviewed, all had begun treated except for one. That one said he had justbeen too busy, adding, “While I don’t think hep C care is beyond us, I query how realistic it is to getpatients and the system to come together for the necessary additional visits, to keep the visitsadequately focused on hep C .it’s been straightforward to get patients seen and treated at theLiver Clinic, so I don’t think folks are being denied access.” Two providers who were in the systemas having used eReferral but not yet treated actually had begun treatment with multiple patients;however, at their clinic (Tom Waddell Urban Health) patients going to begin HCV treatment areoften handed off to the “HCV treatment team” of NPs and RNs who guide the patient through theprocess and manage the official prescription, after referral from their primary care provider.eReferralOf the 35 prescribing providers who had patients who were HCV RNA post-training, 17 (about 1in 2) had never used eReferral; however, 9 of those 17 providers had prescribed HCV treatment toat least one person despite not using the eReferral system. Five people had used eReferral once, 9had used it 2-4 times, and two people had used it more than 10 times (one of these was someonewho had never treated someone before the training but had treated between 4 and 8 people posttraining, and the other person had gone from treating 1-3 patients before the training to treatingmore than 12 patients post-training).Of those who had used eReferral, 1/3 (6 people) found it to be very useful and very user-friendly (arating of 4 of 5 on both measures) and 2/3 (13 people) found it to be extremely useful and extremelyuser-friendly (a rating of 5 of 5 on both measures). No one rated it lower than a 4 on either measure.This was echoed by the providers who were interviewed for this evaluation; of the 9 intervieweeswho had used eReferral, no one had any complaints or suggestions for improvements at all. Rather,they spoke about it being just detailed enough (but not too detailed), with fast enough response,helpful answers, and ease of use. One provider did mention that the technology was “a little clunky,since it’s not the same system we chart in,” but acknowledged that had little to do with the eReferralsystem itself, which worked well.When asked on the survey to describe any improvements they would make to the eReferral system,only one provider had a suggestion: “I would have all the extra linked documents in the eReferralpage in one PDF, so we don’t have to click around.”7

As for whether they could foresee a future without eReferral, almost all providers interviewed saidthey hoped that would never come to pass. While one person said, “I would hope that I wouldn’tkeep using it every time I feel like in a few years it will seem funny that this is a big deal. I’m hopingit starts to feel easy and normal,” most saw it as a long-term solution, taking the responsibility offof them to stay current, especially because, as one noted, “I don’t see a world where any givenPCP is going to be doing enough HCV treatment to feel like they are always up to date.”Other support neededDuring the interviews, most providers were asked about their level of job satisfaction overall, andwhether there were things about their job that created barriers to HCV treatment. Unsurprisingly,many people interviewed cited short-staffing or a general lack of time being a main factor in theirwork environment. Many echoed the sentiments of one provider, who said,Our clinic is short-staffed overall. We have trouble getting people registered in anefficient way. We are down MAs, we are down nurses, we are down ancillary staff. Buteven if we had all that stuff, I think my clinic is so busy it wouldn’t really make adifference. Luckily it doesn’t have to, because we have this HCV team who takes [HCVtreatment] on, and they do such an excellent job.Along these lines, one clinic champion explained that they were trying to find ways to treat HCVwithout increasing the burden on PCPs, since in a public system so much of the work of telephonerequests and other administrative tasks are handled by doctors, instead of nurses or other supportstaff as might happen in a private system. Another provider spoke specifically about the support sheneeded for panel management, because she simply didn’t have time for that part of her practice.In general, when asked about clinic technical assistance, those in Tom Waddell Urban Health,Southeast Health Center, Curry Senior Center, and OTOP instantly referred to their HCV teams whoassisted PCPs or other prescribers to help make HCV treatment happen. As one of them noted,“Having dedicated people who are helping with this topic makes it easier. They can be the expertand you can feel like the consultant That’s the model we have here at Tom Waddell, we haveproviders who are experts on HIV medicine, or experts on trans medicine, and that makes it easierfor me to help with prescribing those things.”Another explained, “This would be MUCH harder if it wasn’t for these mid-level folks helping us tomake it happen. I feel like I get to write my prescription and then just take a step back. It would benear impossible with my tight clinical schedule to do two-week visits like this for multiple people ata time, without having the nurses help to follow people. I just couldn’t do it.” On the other hand,those providers at clinics with HCV specialty staff were often resistant to the idea of being integrallyinvolved with their patients’ treatment. One said, “They’re wanting more providers to take [HCVtreatment] on. But frankly I’d rather just have a specialty clinic to refer people to, rather than tryingto manage it myself. I’m just there part-time, and it seems hard to navigate the insurance stuff, thescheduling, the follow-up labs. I haven’t figured out how to do all that, so I just refer.” Similarly, aprovider at Southeast Health Center recalled, “I’ve heard other providers say they’re just going toask Colleen to treat their patients, because it’s so much stuff and we already have so much to do.There’s a spreadsheet where we have to enter everything in, and it’s a lot of stuff. So I’ve heard somepeople say that there’s a barrier there, and it’s easier to just pass it off to Colleen.”8

As for clinic-specific technical assistance for clinics that did not have dedicated staff to focus on HCVtreatment, feedback was positive – though some providers acknowledged it wasn’t enough on itsown. For those who thought the staff needed general education related to HCV and how to discussit with patients (such as at the Cole Street Clinic), the TA has been helpful and sufficient. A providerfrom Chinatown Public Health Center spoke happily about the work of Kelly and Ben to help withclinic workflow, along with his medical director’s encouragement to try out eReferral. Yet otherinterviewees noted that sometimes inexperienced providers needed more than education to begintreating; it was about needing support to “build muscle memory,” as one put it. This sentiment waswell-illustrated by one provider, who explained,I think for anybody who’s remotely complicated, most providers here would probablyrefer to the Liver Clinic for treatment at this point. I know when I made anannouncement about [the update] that if a patient had a history of HBV infection thenwe needed to do more tests to monitor their liver function, people were like, “Oh gosh,we’re not there yet. Let’s treat a few uncomplicated people first!”When interviewees were asked what more could be offered at the clinic level to increase the numberof clients treated, those from clinics with dedicated HCV staff (NPs, RNs, or pharmacists) immediatelysaid that increased capacity from those staff – in terms of longer shifts, the ability to do group visits,or the addition of new staff – were the most important way to increase treatment rates. Oneelaborated, “I kind of trickle in my patients, because I know that the nurse can only handle a panelof so many. If their capacity was more, I’d put those people on the launching pad more quickly.”Other providers mentioned a variety of ideas, including more case management options for clientsin order to improve adherence, and trainings and support around panel management. Numerousproviders said they would be willing to treat if it were easier to determine who was appropriate fortreatment; one provider noted, “I wish there were more of a real-time dashboard so I’m not combingthrough the same excel file week after week. It would be great to have more skills along those lines.”Another emphasized the importance of navigators who could support patients during thesometimes long wait for treatment authorization and testing to determine an appropriate regimen.In the survey, providers were also asked what more could be offered at the clinic level to increasethe number of clients treated; in general, respondents liked most of the options provided:9

In the survey, respondents were also asked what other learning modalities could be helpful to themas an HCV prescriber, in addition to the eReferral system. The two most popular options were“periodic HCV treatment update webinars/trainings that are pre-recorded and self-directed (27people) and “real-time access to an experienced provider” (20 people). Nine people said they wouldlike to have “periodic live webinars with HCV treatment updates,” and four said they would benefitfrom bi-weekly case conferencing.These ideas were echoed by interviewed providers, some of whom specifically noted the trainingsand resources that would be useful, including a convenient online CME that included updates aboutHCV treatment and nuances of treatment, such as information about racial/ethnic differences intreatment efficacy, or HBV and reactivation. One person suggested a teaching session, whereproviders could bring medical records or their computer, and sit with an experienced provider whocan walk through it with them, to “see where they are in the steps, what the next steps are, whatyou’re missing – build a plan .we need to show providers it’s just not that hard, but it IS timeintensive. Especially at first.” A provider at Chinatown Public Health Center pointed out that sincetheir providers are so experienced dealing with HBV, they could use some clinic-specific tools andtechnical assistance to point out the ways that HBV and HCV treatment differ, to help clear upconfusion in the moment and help providers feel more confident in their ability to treat both.Overall, there were two types of providers who participated in interviews: those who feltoverwhelmed by the whole idea of treatment, and those who were completely comfortable with it.The former were usually resistant to beginning treatment in patients unless it was exceedinglystraightforward or they could refer the patient to others to handle. As one explained, “I have donethree or four eReferrals, but on each of those people there were small things that needed followup, that have taken time. Having the time to figure out the logistics and weird insurance plans hasbeen what has limited me. It’s on my list of things to do that’s not urgent, and since I’m barelygetting through the urgent things, it just kind of sits there.” On the other hand, the latter groupwas almost exasperated by the challenge others felt, like the provider who said, “I don’t know, I findthese things to be incredibly easy. This is one of the easiest treatments I’ve ever taken on. I used todo the Ribavirin/Interferon combo, and that was the OPPOSITE of easy. To give someone aprescription and they just take a pill once a day, usually with no side effects, and it works? I mean,that’s so easy. It’s a ‘just do it’ kind of thing.”C o nc lu sion sOverall, SFHN providers who participated in this evaluation were optimistic about the future of HCVtreatment and were encouraged that their patients living with HCV could and should accesstreatment as soon as possible. While a few providers raised concerns about adherence for theirmost difficult patients, most found time to be the biggest barrier: time to determine which patientswere candidates, time to find them and get them in for the necessary visits, and time to negotiatewith insurance providers and others to successfully initiate treatment. A couple providers sharedtheir belief that patients who are asymptomatic, not cirrhotic, or otherwise “not sick enough” couldnot readily obtain treatment, showing that the need for education isn’t over. However, withenhanced specialty HCV teams and external support via pharmacies and eReferral, continuededucational options, and time, treatment rates in the SFHN will only continue to improve.10

The San Francisco Health Network (SFHN) is San Francisco’s only complete system of care. In addition to cutting-edge specialty care, the SFHN, part of the San Francisco Department of Public Health, includes primary care in 10 community