The Community Paramedic HCV iLink (CP HCV iLink) program used community paramedics (CPs) and telemedicine to provide in-home hepatitis C treatment to rural Appalachian patients in South Carolina. CPs visited patients in their homes to initiate treatment via a guided telemedicine appointment with an infectious disease (ID) physician, as well as at four, 12 and 24 weeks for follow-up care. Of the 34 patients eligible for SVR testing at the end of the study period, 28 (82.4%) were cured and six (17.6%) were lost to follow-up. Patients were highly satisfied with the program and the care they received from the CPs.
Program description
As many individuals, especially in rural and remote areas, struggle to access or complete hepatitis C treatment due to significant geographic barriers, a novel treatment program leveraging CPs and telemedicine was developed to address these challenges. CPs are uniquely positioned to engage hard-to-reach rural and remote patients; they have specialized training and are comfortable providing healthcare services (e.g., physical exams, venepuncture) in homes.
The CP HCV iLink program incorporated CPs in a multidisciplinary care team (e.g., physicians, nurse), allowing all treatment activities to take place in a patient’s home. Patients were eligible for the CP HCV iLink program if they were aged 18 years or older, had received a positive hepatitis C RNA result through an opt-out emergency department screening program, had a telephone, and had either indicated they could not attend or had previously failed to attend clinic-based treatment. Those with decompensated liver disease or advanced cirrhosis and those with HIV or hepatitis B coinfection were not eligible to participate in the program.
Patient identification and initial visit
Patients were identified in emergency departments (ED) through an opt out testing program. Following identification, an appointment was scheduled for a CP to come to the patient’s home for an initial assessment and to initiate treatment. Coordinators worked with the CP and a nurse to identify which laboratory tests would need to be completed during the home visit. Either a coordinator or CP phoned patients within 48 hours prior to their appointment to confirm the patient would be at home for the visit. At the first visit, the CP used a mobile Wi-Fi hotspot in their vehicle to initiate a video call with an ID physician. This was used to boost the signal to ensure connectivity. The CP assessed vital signs and completed a physical exam guided by the ID physician, then performed venepuncture for required laboratory tests and documented all patient medications. Required laboratory tests varied by individual but included screening for HIV and hepatitis A and B, hepatitis C genotyping and additional liver function tests (e.g., metabolic panel). Once the laboratory tests were complete, the ID physician explained the process for hepatitis C treatment and provided patients with the nurse’s contact information in the event they had further questions.
Treatment follow-up
For most patients, medication delivery was coordinated between the patient and the pharmacy, although the CP, nurse and coordinator ensured the medications were filled and provided to patients. Medications were delivered to the patients’ homes once a month through postal delivery services for the duration of treatment. For patients lacking a permanent mailing address, medications were delivered by a CP. Patients received follow-up visits from a CP at four, 12 and 24 weeks after starting treatment. During these visits, the CP repeated the physical exam and completed required laboratory testing. They also asked about treatment adherence and side effects, helped resolve any issues the patient had encountered and connected patients to other resources (e.g., social services, primary care) as needed.
Results
Between July 2021 and June 2023, 52 patients were enrolled in the study; however, three dropped out before receiving medication, resulting in 49 people participating in the study. Thirty-four of the 49 patients were eligible for sustained virologic response (SVR) testing by August 2023. The remaining 15 were in various stages of active treatment but not yet eligible for SVR laboratory tests. Patients eligible for SVR testing were predominantly male (61.7%) with an average age of 56 years. Additionally, 64.7% of patients were White, 32.4% Black and 3.0% Hispanic. In terms of patients’ access to care, distance to the nearest outpatient treatment facility varied between 2.7 to 70.6 miles, with a median distance of 20.4 miles.
Of the 34 individuals eligible for SVR testing:
- 28 (82.4%) were cured
- 1 (2.9%) case of reinfection occurred where the individual was readmitted into the program and subsequently cured.
- Six (17.6%) were lost to follow-up
Of the 6 patients who were lost to follow-up:
- 5 received their first course of medications; 2 of these then refused to be part of the study, 2 were unable to be contacted and 1 moved out of state.
- 1 had received SVR testing at their 4-week visit and had undetectable levels of hepatitis C virus but was then unable to be contacted.
Patient satisfaction in this program was high; out of 18 patients who completed a satisfaction survey:
- 88.9% (16) strongly agreed or agreed they were satisfied with the overall care they received
- 83.3% (15) strongly agreed or agreed their health had improved
- 94.4% (17) strongly agreed or agreed they received an adequate number of visits for treatment
- 94.4% (17) strongly agreed or agreed the CPs were caring and empathetic during their visits
- 94.4% (17) strongly agreed or agreed they felt more informed of their medical condition following their visits
- 88.9% (16) strongly agreed or agreed they felt more comfortable addressing and improving their overall health
What does this mean for service providers?
This study demonstrated that integrating CPs into a multidisciplinary team is a feasible model for delivering hepatitis C care to patients located in rural and remote regions. Although other programs have harnessed telemedicine to provide care remotely, many of these programs still require patients to complete laboratory testing or pick-up their medications at or near the clinic where they’re receiving care. The CP HCV iLink program enabled all aspects of treatment to occur in-home. Patients in this program faced significant geographic barriers to accessing hepatitis C treatment. This program increased treatment accessibility and achieved high cure rates for hard-to-reach rural and remote populations who may otherwise have been lost to follow-up. While this program used ED opt-out screening to help reach vulnerable populations, this hepatitis C treatment approach could use other methods to test and identify patients (e.g., outreach testing).
High patient satisfaction indicates this model is not only effective but also well-received. Barriers that were mentioned were transportation and lost medication; thus, this model of service delivery met most of patients’ needs. Although the lost to follow-up rate was slightly higher compared to other programs serving rural patients or people who use drugs, the CP HCV iLink program successfully engaged vulnerable populations that are challenging to retain in hepatitis C care, many of whom had already failed to attend clinic-based treatment. Findings from this program demonstrate this is a promising model for improving access to care for rural and remote patients.
Related resources
Telemedicine hepatitis C care for rural and remote communities – CATIE News
Barriers to Hepatitis C Treatment – CATIE video
References
Gormley, Mirinda Ann, Phillip Moschella, Susan Cordero-Romero, Wesley R. Wampler, Marie Allison, Katiey Kitzmiller, Luke Estes, Moonseong Heo, Alain H. Litwin, and Prerana Roth. "No Patient Left Behind: A Novel Paradigm to Fulfill Hepatitis C Virus Treatment for Rural Patients." In Open Forum Infectious Diseases, vol. 11, no. 5, p. ofae206. US: Oxford University Press, 2024.