Summary
The Cornish hepatitis C management model is an integrated model of care, incorporating partnerships between hospital-based hepatology and drug and alcohol services. Blood-borne virus (BBV) screening is performed in the community by all Addaction staff with each result reviewed by the BBV lead nurse. The BBV lead nurse then discusses the positive results with the patients and when ready for treatment takes each case to the monthly hepatology multidisciplinary meetings.
Addaction covers the whole of Cornwall with clinics in its own premises, GP surgeries, probation offices and pharmacies. The choice of treatment location is decided on where the patient lives and how accessible the service is to them.
Challenge
Cornwall is both rural and urban. Injecting drug users were being asked to travel up to 40 miles each way for treatment, prompting poor attendance. BBV screening was poor, so DBST was introduced in 2011. This increased both screening numbers and new HCV diagnosis.
Viral hepatitis treatment was provided at RCH (Truro) with some outreach clinics. In 2008, Penzance was identified as an area of need, and in partnership with Cornwall Drug and Alcohol Team, Addaction set up a one-stop-shop to complement secondary care treatment.
Objectives
The project has three objectives. The frst was raise the profile of BBV screening to patients and partner agencies across Cornwall. A business plan was put together to win funding for DBST kits, to roll out the DBST programme and give DBST training to drug and alcohol keyworkers. A DBST pathway was devised.
The second was to improve community HCT treatment, supporting hard to reach active injectors. A pilot project was to be set up in a GP practice for patients receiving substitute prescription for opioid dependence and a general nurse trained to manage HCV patients.
The final objective focused on multi-agency working, collaborating with partner agencies, discussing HCV patients at a monthly hepatology MDM and auditing patient outcomes annually.
Solution
All drug and alcohol staff had BBV training. DBST kit training was given to all drug and alcohol workers in Cornwall. The Penzance hepatology team, together with DAAT, devised a plan for HCV patients to be treated locally. Penzance’s Morrab Surgery was identified as willing to house the project. A GPSI and CPN with an interest in HCV were chosen, a general nurse was employed and the pilot started. The nurse was able to extend the project to North Cornwall, as a roaming nurse treating HCV in the community on the back of drug worker clinics.
BBV and HCV awareness events were run at GP practices. A pathway was set up, and HCV patients discussed at the monthly hepatology MDM.
Results
There are over 1200 patients in Addaction treatment service, 600 of them current or former injectors. Of those 600, 86 per cent have been BBV screened. DBST kits continue to be funded through the commissioning team.
The Morrab pilot was a great success. In 2008/2009, 10 chaotic patients were treated with standard combination therapy. They all completed treatment, with seven achieving an SVR. Two were non-responders and one relapsed post treatment. With nurse support, eight patients had a liver biopsy.
In 2009/2010 the roaming HCV community service treated 42 HCV patients. Twenty-three achieved an SVR, while 10 stopped treatment due to medical problems.
Learnings
Screening high-risk patients across a geographically challenging county was challenging. Implementing DBST was the answer, but many drug and alcohol workers were not clinically trained, and found offering and performing it difficult. Once trained and offered support, they were competent and confident. Numbers tested have dramatically increased.
Building rapport with chaotic HCV patients was difficult. Running awareness sessions and being visible at drug clinics encouraged them to talk to the BBV nurse. Once the first patient was treated, others were more willing.
High quality appropriate care is essential in this patient group. A nurse-led community service with governance from secondary care via monthly MDM is the way forward, especially in light of the radical changes in HCV treatment medication.
Evaluation
The 10 patients treated at the Morrab GP clinic were regularly asked about their treatment experience. They welcomed the opportunity to be treated locally, having previously failed to attend hospital appointments.
Patients said they felt at ease and were pleased that they could combine their HCV treatment with their substitute prescribing for their opioid dependence. They received text reminders before appointments. One of the key points that these patients have made is the flexibility of appointment times, especially during treatment. The Morrab clinic is still treating patients in Penzance.
