Building a Team to Fight HCV

In 2019, Dr. Necito Montaniel, the Spirit Lake Health Center’s Medical Director, participated in a hepatitis C (HCV) elimination training offered by Indian Country ECHO. Inspired, he returned to Fort Totten, North Dakota, the heart of the Spirit Lake Nation, to gather data on how the community was doing with regard to HCV.

Upon returning home, Dr. Montaniel reached out to Joey de la Paz, a Spirit Lake Nation tribal member and Clinical Informationist. What the pair discovered when they looked at the data was alarming. HCV was trending upward in the community, and between 2015 and 2019 positive cases jumped from 8.1% to 22.7%.

At the time of this discovery the only patients being flagged for HCV screening were baby boomers (aged 55 to 73). However, boomers only accounted for 5% of the clinic’s positive HCV results. The median age of the majority of the clinic’s cases was much younger, only 32 years of age.

To create an HCV clinic that met the needs of the community, Joey and several colleagues within the Center’s pharmacy department united. The team consisted of Joey, Tana Triepke, and A.J. Wohlers. Tana, a commander in the U.S. Public Health Service and Clinical Pharmacy Coordinator, took the lead in developing the infrastructure of the clinic. A.J., a Clinical Pharmacist, grew his skill set to coordinate the care of HCV positive patients and provide one-on-one patient education.

The first step the HCV team took was to create buy-in with the Center’s medical providers. Tana requested that Indian Country ECHO train the medical and pharmacy staff on HCV elimination. Of this she said, “after attending the training many clinicians were excited to support the HCV clinic.”

In the meantime, Joey built out the digital infrastructure required of a functioning HCV clinic, including developing consult and lab order forms. He also began working to address the clinic’s electronic health record needs. According to Joey, “The greatest reward for me, that motivates me, is adding value to my tribe. The more value I add, the greater the impact I have on my people. I always keep that in perspective. I feel the path Creator has given me is to serve and help my people.”

Creating the HCV clinic would not have been possible without the high degree of collaboration done within and outside of the health center. Internally, Tana worked with radiology, the Center’s business offices, medical records, and lab staff to establish protocol for treating patients with HCV. She even worked with the Center’s behavioral health department to ensure transportation of patients to the HCV clinic. Then Tana worked to define policies and procedures for the HCV clinic, including creating a formalized billing procedure, as well as creating an EHR template to fit the needs of the clinic. In order to do so, she collaborated with the local IHS pharmacy in Belcourt who already had established an HCV treatment program, as well as North Dakota’s Medicaid office to ensure that the health center could receive reimbursement for HCV care.

While growing pains are typical with any new clinic, especially during COVID-19, Spirit Lake’s HCV clinic, which officially opened in October 2020, is adapting quickly. The clinic initially struggled with patient follow through on labs, vaccines, and appointments. To remedy this, the HCV team created an HCV patient next-step list. This tracking sheet lists the patient’s information, their provider, and then an HCV treatment checklist. Each list is updated by patients’ providers and peer workers so that everyone involved can stay up to date on patients’ progress throughout their treatment. Tana says this tool is instrumental in keeping the health care team on the same page and ensuring all preliminary tests and appointments are completed.

Currently, Spirit Lake provides universal HCV screening, such that anyone who is 18+ is encouraged to get screened for HCV at least once during their lifetime. For those who test positive, consults are sent to the pharmacy where HCV positive patients work with clinical pharmacists, like A.J., to discuss needed labs, connect with primary care, and receive critical education about treatment, recovery, and prevention.

As of now, one patient has completed treatment, five are in the process of being treated, and since the inception of the HCV clinic, the pharmacy has received twenty-nine consults. While the majority of the implementation of the clinic happened during the COVID-19 pandemic, Tana says that a large part of HCV treatment is destigmatizing a positive HCV diagnosis. For this reason, the HCV team hopes to do more outreach and education as spaces reopen and community events become commonplace.

Since its inception, the Spirit Lake HCV clinic has been working closely with Indian Country ECHO. According to Tana, “Indian Country ECHO has provided training for staff, vital patient form templates, and general technical assistance on HCV elimination.” Additionally, Spirit Lake has presented 13 cases on HCV ECHO virtual clinics, where they received insights from peers and clinical recommendations from experts in HCV treatment in Indian Country. According to Tana, “we would not be treating HCV without the training and support from the exceptional staff at Indian Country ECHO.”

For those interested in starting an HCV clinic, Tana says “At one point in my career, the thought of taking on HCV seemed very complex and daunting. Now, after jumping right into it, it is very doable. There is no better job satisfaction than being able to say that you cured a disease and helped change someone’s life for the better.”

To enhance your ability to screen, treat and manage patients with hepatitis C, join one of several hepatitis C virtual clinics. Here you will participate in didactic and case presentations, receive recommendations from peers and a multidisciplinary team of specialists, and join a learning community of dedicated I/T/U providers committed to growing clinical capacity so that every patient across Indian Country receives the care they deserve.