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Viral Hepatitis and Liver Disease

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Integrated Mental Health Care for Patients with Chronic Hepatitis C and Liver Disease

for Health Care Providers

Integrated Mental Health Care for Patients with Chronic Hepatitis C - Hepatitis C

Background

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.

HCV patients often present with complex psychosocial issues at statistically higher rates than the general population. They are 90% more likely to have a history of IV drug use, 35% more likely to be homeless, 25% more likely to be co-infected with HIV, 25% more likely to have a history of incarceration, and 19% more likely to present with a mental illness. 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. Several 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 Care

Integrated health care teams work together to establish treatment plans addressing patients' biological, psychological, and social needs. The interdisciplinary health care team can include many types of providers, such as physicians, psychologists, social workers, and occupational and physical therapists, etc. The team makeup is dependent on the patient's needs.

Mental health providers in particular can add the following services to a 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

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.

IntegratedCollaborativeHybrid
Co-located services
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 is 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. Telehealth can help address critical barriers to care such as stigma, distance from care providers, and disability.

SCAN-ECHO

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 specialists from a regional VA Medical Center to provide expert advice to VA providers in rural settings.

Clinician Tools

Serving Veterans: A Resource GuideLink will take you outside the VA website.
SAMHSA-HRSA Center for Integrated Health Solutions (CIHS)

Hepatitis C Support Group:
Initiating and Maintaining a Hepatitis C Support Group: A How-To Program GuideLink will take you to our Viral Hepatitis and Liver Disease internet site

Reducing Alcohol Use

Tools for Reducing Alcohol UseLink will take you to our Viral Hepatitis and Liver Disease internet site

Medication-assisted Treatment for Substance Use DisordersLink will take you outside the VA website. VA is not responsible for the content of the linked site.
Substance Abuse and Mental Health Services Administration

Treating PTSD in the Context of Complex Medical Issues

VHA's National Center for PTSD

Health Psychology/Behavioral Medicine

Medication Adherence

AIDS.govLink will take you outside the VA website.

NIHLink will take you outside the VA website.

CDCLink will take you outside the VA website.

Crisis Intervention

Pain Management

Tobacco and Health

For Patients:
Make the ConnectionLink will take you outside the VA website. VA is not responsible for the content of the linked site.
Customizable website designed to connect Veterans, their family members and friends, and other supporters with information, resources, and solutions to issues affecting their lives

Sample Protocols

Pre-Hepatitis C Treatment Liver Clinic: Behavioral Health Screening
A questionnaire for providers

HCV Telephone Support Follow-Up Clinic Provider Manual

Journal Articles

Bonner JE, Barrit AS 4th, Fried MW, et al. Time to rethink antiviral treatment for hepatitis C in patientsLink will take you outside the VA website.. 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 trialLink will take you outside the VA website.. 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 modelsLink will take you outside the VA website.. 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 outcomesLink will take you outside the VA website.. 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 USALink will take you outside the VA website.. AIDS Care. 2014;26(6):731-5.

References

American Psychological Association. Health Care Reform: Integrated Health Care.Link will take you outside the VA website. VA is not responsible for the content of the linked site.

Workforce Issues Related to: Physical and Behavioral Healthcare Integration