for Health Care Providers
Integrated Mental Health Care for Patients with Chronic Hepatitis C and Liver Disease - Hepatitis C
Active mental health and substance use disorders (MH/SUD) among Veterans with chronic hepatitis C virus (HCV) infection are common barriers to treatment. These comorbidities affect diagnosis, linkage to and retention in care, disease progression, and candidacy for HCV antiviral treatment.
Given the high prevalence of MH/SUD in Veterans with HCV, increasing the availability of services to address this need is of critical importance in their successful treatment as clinical trials show that integrated mental health care can improve candidacy for HCV antiviral treatment, increase the likelihood of treatment completion, decrease problematic drinking, and increase rates of viral suppression for HIV patients on antiretroviral treatment. Many studies have found that HCV patients with MH/SUD can achieve sustained viral response rates similar to those seen among patients without these comorbidities.
"Integrated health care," often referred to as interdisciplinary health care, is characterized by a high degree of collaboration and communication among health professionals. What makes integrated health care unique is information sharing among team members related to patient care and the establishment of comprehensive treatment plans to address patients' biological, psychological, and social needs. The interdisciplinary health care team includes a diverse group of members (e.g., physicians, nurses, psychologists, social workers, and occupational and physical therapists), depending on the needs of the patient.
Addressing the high prevalence of MH/SUD in Veterans with HCV by increasing the availability of services for such disorders is critically important for successful treatment. Mental health providers in particular can add the following services to an integrated care team:
- Cognitive, capacity, diagnostic, and personality assessments that differentiate normal processes from pathologic states, side effects of medications, adjustment reactions, or combinations of these problems
- Behavioral health assessment and treatment that provide individuals with the self-management skills necessary to effectively manage their chronic conditions
- Diagnosis and treatment of mental and behavioral health problems (e.g., depression, suicide risk, anxiety disorders, addiction, and insomnia)
- Consultation and recommendations to family members, significant others, and other health care providers
- Contribution of research expertise to the design, implementation, and evaluation of team care and patient outcomes
- Development of interventions that are responsive to specific individual and community characteristics that may impact the treatment plan
Research shows that integration of mental health care with medical care can increase HIV treatment adherence and improve overall health outcomes. Ojikutu et al. (2014) have emphasized the following aspects of successful models of integrated HIV care:
- Patient centered with integrated or co-located services
- Diverse teams of clinical and nonclinical providers
- A site culture that promotes a stigma-reducing environment
- Availability of comprehensive medical, behavioral health, and psychosocial services
- Effective communication strategies
- Focus on quality
Based on literature on deployment of integrated care for HIV, integrating clinical psychological services into HCV clinical care settings can take many forms. Bonner et al. (2012) propose the following three models and encourage clinics to select the model best suited to local resources and expertise. These include:
|Convenience for staff||✓|
|Convenience for patients||✓|
|Most streamlined and efficient||✓|
|Maximizes access to MH/SUD services||✓|
|Strong and ongoing relationship with MH/SUD providers and clinics||✓||✓||✓|
|Providers use outpatient consultation||✓||✓|
|Staffed by nonphysician providers with training in MH/SUD care||✓|
|Brief screening and intervention||✓||✓|
|Assistance in case management||✓||✓|
Across all models of integrated care, a specialty staff is critical for improving treatment outcomes, retention in care, and quality of life for patients. Social work and case management staff are vital to facilitating communication among providers, monitoring treatment outcomes, recognizing concerns that may not present during clinic visits, and connecting Veterans to important resources necessary for continued engagement in care as well as overall health outcomes. Liaison with mental health and substance use staff also is crucial, as primary care is responsible for many patients with comorbid disorders who may not have been diagnosed or treated for MH/SUD.
Integrated care models also utilize Tele-Mental Health services to facilitate access to and delivery of MH/SUD services, especially with regard Veterans who face significant barriers to accessing care. Increased use of telehealth could significantly increase Veterans' access to mental health services by addressing critical barriers to care such as stigma, distance from care providers, and disability.
Specialty Care Access Network--Extension for Community Health Outcomes (SCAN-ECHO), which was created as part of VHA's commitment to transform its delivery of specialty care services, is an example of a current integrated care model in VHA. SCAN-ECHO is designed to allow specialists to electronically connect with primary care providers in rural and remote locations. The model utilizes teleconsultation via clinical videoconferencing equipment to allow health care specialists from a regional VA Medical Center health center to provide expert advice to VA providers in rural health care settings. SCAN-ECHO has made it possible for patients with complex medical conditions such as hepatitis C to receive health care from their local providers without the potential barrier of traveling to a referral center.
Serving Veterans: A Resource Guide
SAMHSA-HRSA Center for Integrated Health Solutions (CIHS)
Hepatitis C Support Group:
Initiating and Maintaining a Hepatitis C Support Group: A How-To Program Guide
Take Action against Hepatitis C: For People in Recovery from Mental Illness or Addiction
Resources from the Substance Abuse and Mental Health Services Administration (SAMHSA)
Reducing Alcohol Use
Medication-assisted Treatment for Substance Use Disorders
Substance Abuse and Mental Health Services Administration
Liver Health Initiative
The relationship between baseline Organizational Readiness to Change Assessment subscale scores and implementation of hepatitis prevention services in substance use disorders treatment clinics: a case study.
Hagedorn HJ, Heideman PW. Implement Sci. 2010 Jun 14;5:46.
Treating PTSD in the Context of Complex Medical Issues
Health Psychology/Behavioral Medicine
Tobacco and Health
Resources from the VHA Office of Public Health
Mobile App For Patients:
Stay Quit Coach
Make the Connection
Customizable website designed to connect Veterans, their family members and friends, and other supporters with information, resources, and solutions to issues affecting their lives
Pre-Hepatitis C Treatment Liver Clinic: Behavioral Health Screening
A questionnaire for providers
Combating the Silent Epidemic of Viral Hepatitis:
Action Plan for the prevention, care and treatment of viral hepatitis
Bonner JE, Barrit AS 4th, Fried MW, et al. Time to rethink antiviral treatment for hepatitis C in patients. Dig Dis Sci. 2012 Jun;57(6):1469-74.
Groessl EJ, Sklar M, Cheung RC, et al. Increasing antiviral treatment through integrated hepatitis C care: a randomized multicenter trial. Contemp Clin Trials. 2013 Jul;35(2):97-107.
Ho SB, Groessl E, Dollarhide A, et al. Management of chronic hepatitis c in veterans: the potential of integrated care models. Am J Gastroenterol. 2008 Jul;103(7):1810-23.
Knott A, Dieperink E, Willenbring ML, et al. Integrated psychiatric/medical care in a chronic hepatitis c clinic: effect on antiviral treatment evaluation and outcomes. Am J Gastroenterol. 2006 Oct;101(10):2254-62.
Ojikutu B, Holman J, Kunches L, et al. Interdisciplinary HIV care in a changing healthcare environment in the USA. AIDS Care. 2014;26(6):731-5.
American Psychological Association. Health Care Reform: Integrated Health Care.