SummaryThe St. Luke's Texas Liver Coalition revamped its strategic approach to screening for hepatitis C, shifting from screening the general population at health fairs to working with and supporting community-based organizations that have contact with high-risk populations. Several partnership models exist, each focusing on making it as easy as possible for partners to integrate education, testing, and/or followup services into their everyday operations. The program has significantly increased the number of infected individuals identified, while simultaneously reducing testing costs for the coalition.Moderate: The evidence consists of pre- and post-implementation comparisons of key metrics, including the percentage of all tests that came back positive, the number of individuals testing positive, and screening costs.
Developing OrganizationsSt. Luke's Texas Liver Coalition
Date First Implemented2008
Race and Ethnicity > Asian; Black or African American; Hispanic/Latino-Latina; Vulnerable Populations > Homeless; Immigrants; Impoverished; Racial minorities; Substance abusers
Problem AddressedHepatitis (particularly the hepatitis C virus) is a common condition that tends to produce few if any symptoms until it progresses to an advanced stage and causes significant liver damage. As a result, most individuals with early-stage hepatitis remain unaware that they are infected. Because hepatitis is concentrated in several high-risk segments of the population, screening programs that target the general population can be costly and inefficient because they tend to have very low "hit rates."
- Highly prevalent condition: Roughly 1.6 percent of the U.S. population (representing an estimated 4.1 million individuals) have hepatitis C. The virus is approximately four times more common than human immunodeficiency virus (HIV).1
- Lack of awareness among infected individuals: An estimated 70 percent of those with hepatitis C remain unaware that they are infected.2
- Concentrated in high-risk populations: Using drugs and engaging in risky sexual behavior are strong risk factors for hepatitis C. Almost half (48.4 percent) of infected individuals have a history of injected drug use.1 Other high-risk populations include those who are incarcerated or homeless, as well as those who had a blood transfusion before 1992.
- Inefficiencies of general screening: General population screening programs tend to have low "hit rates" and therefore identify relatively few individuals positive for hepatitis C virus, making this approach costly and ineffective. The Texas Liver Coalition, for example, screened 1,461 individuals at health fairs in 2007, identifying only 40 (2.74 percent) who were positive for the hepatitis C virus antibody.2
Description of the Innovative ActivityThe St. Luke's Texas Liver Coalition revamped its strategic approach to screening for hepatitis, shifting away from screening the general population at health fairs to working with and supporting community-based organizations that serve high-risk populations. Several partnership models exist, each focusing on making it as easy as possible for partners to integrate education, testing, and/or followup services into their everyday operations. All diagnostic testing is provided free of charge. The coalition has implemented the project with four community-based organizations. Beginning in 2009, the coalition expanded the project to five additional organizations. Key elements of the program are described below:
- Wide array of potential partners: The coalition has identified as many as 150 community-based organizations that might be possible partners in its efforts. Potential partners include any organization catering to high-risk populations, including HIV/sexually transmitted disease clinics, methadone/alcohol clinics, recovery centers, treatment facilities, and jails. The coalition has also reached out to several organizations that serve low-income ethnic and racial groups that are at elevated risk for hepatitis, including those serving Mexican Americans, Asian Americans, and African Americans.
- Partnership models focused on needs of partner organization: The coalition will work with these organizations in a number of different ways depending on their needs. Two different types of partnerships have been set up, each designed to make it as easy as possible for partners to integrate hepatitis education, screening, and/or followup into their everyday operations:
- Awareness-building: Coalition leaders meet with representatives of a variety of organizations, educating them on the prevalence and risk factors for hepatitis and the need to educate and refer high-risk patients to the coalition for screening. Examples include an arrangement with a local counseling center and an organization that caters to Mexican Americans, both of which provide services to recovering drug addicts. The coalition has also partnered with local primary care physicians, particularly in the Asian community. For example, two Asian physicians have agreed to be advocates for hepatitis testing, educating their peers on the infection and encouraging them to refer high-risk patients to the coalition.
- Education and testing support: The Liver Coalition provides several organizations with training/education and all necessary supplies, thus allowing them to seamlessly offer hepatitis C virus antibody testing to clients free of charge as a part of their everyday operations. Examples are described briefly below:
- Planned Parenthood Houston: Liver Coalition staff educated six Planned Parenthood coordinators on hepatitis C and provided them with testing supplies, including needles, bandage, tourniquets, consent forms, and requisition forms/lock boxes designed by Quest Diagnostics (which is under contract with the coalition to process the tests) that identify samples as being from Planned Parenthood. Coordinators, who are already drawing blood for other tests, simply draw an extra vial for the hepatitis C virus test, place it in the lock boxes, and arrange for Quest to pick up the samples. (This program also included the local jail, where infection rates are quite high.)
- Asian-American organization: Under this arrangement, the Liver Coalition provides testing supplies (including requisition forms and lock boxes) for both hepatitis B and C. The organization's leader, a Vietnamese woman, works with local pastors to set up and promote awareness of church-based screening sessions.
- Local acquired immunodeficiency syndrome (AIDS) foundation: The coalition plans a similar type of partnership with a local AIDS foundation. Staff are working to get certified in needle sticks so that they can draw blood for the test.
- Integrated followup and confirmatory testing: The coalition continues to work with its partners during the followup and confirmatory testing phases, integrating these services into their operations as needed. With Planned Parenthood, coalition leaders access test results from Quest (either online or by fax), and then provide results to the Planned Parenthood care coordinators, who inform clients of the results. (This approach allows Planned Parenthood to maintain close relationships with its clients). Those who test positive are advised to contact the Liver Coalition for a second, confirmatory test. For those who fail to do so, coalition staff call the individual up to three times, and then send a letter to nonrespondents. The same basic approach is used with the Asian-American organization, with its Vietnamese liaison providing the test results and urging those who test positive to contact the coalition for additional testing.
- Arranging treatment for those confirmed positive: As part of its usual care, the Liver Coalition supplies those who have a positive confirmatory test with treatment options. Those with insurance are given the names of doctors near their homes who can provide treatment. For uninsured Harris County, TX, residents, the coalition provides information or an application for the Harris County Hospital District "gold card," an insurance plan for county residents. For uninsured individuals who live outside of the county, the coalition attempts to enroll them in local, free clinical trials whenever possible.
References/Related ArticlesMore information on the Texas Liver Coalition is available at: http://www.texasliver.org.
A poster abstract summarizing one of the partnerships is available at: http://www.hbvadvocate.org/news/reports/HBV_AASLD_2008/Abstracts/Epidemiology.htm.
Contact the InnovatorWayne Gosbee
Liver Outreach Coordinator
St. Luke's Texas Liver Health Outreach
6620 Main St., Suite 1505
Houston, TX 77030
Phone: (832) 355-5119
Fax: (832) 355-2312
Innovator DisclosuresMr. Gosbee has not indicated whether he has financial interests or business/professional affiliations relevant to the work described in this profile.
ResultsThe community-based partnership approach has enabled the Liver Coalition to significantly increase the number of infected individuals identified, while simultaneously reducing testing costs for the organization (as compared with the prior strategy of screening at health fairs).
Moderate: The evidence consists of pre- and post-implementation comparisons of key metrics, including the percentage of all tests that came back positive, the number of individuals testing positive, and screening costs.
- More infected individuals identified: In 2007, the coalition screened 1,461 individuals at health fairs, identifying 40 as being positive for the hepatitis C virus antibody, a 2.74 percent "hit rate." By contrast, using the partnership approach in 2008, the coalition has screened roughly 1,100 people, with between 20 percent and 25 percent (or 200 to 250 individuals) testing positive. In 2009, the coalition tested 1,344 individuals, with 16.3 percent testing positive. Results from specific partnership activities include the following:
- Planned Parenthood: As of 2009, 347 individuals have been tested through this partnership, 106 of whom (30.5 percent) were positive.
- Asian-American organization: Through this partnership, 647 individuals have been tested for hepatitis B and C. Roughly 11 percent of hepatitis B and 5 percent of hepatitis C tests were positive, with both figures being well above national norms.
- Awareness partnerships: Due to education and awareness activities with partner organizations, the coalition generated between 150 and 170 walk-in referrals in 2008 (156 had been served as of the end of November), with 29 percent of these individuals testing positive. By comparison, only 102 walk-ins were served in 2007, with between 12 and 14 percent testing positive.
- Beaumont and Houston community-based organizations: 20 percent of the individuals tested in these organizations received positive results.
- Federally qualified health centers: Two additional organizations implemented the project. One organization gained a positive test rate of 5.2 percent, the other, 2.8 percent. Testing was not continued at these sites due to funding issues.
- Lower costs: The total screening budget for coalition activities has fallen, from more than $56,000 in 2007 to just above $35,000 in 2008, largely because working through partners is a more efficient way to identify and test high-risk individuals. Under the old approach, the coalition absorbed significant labor costs, often paying Quest staff and/or nurses to draw blood at health fairs. In 2009, the total screening budget fell to less than $20,000 due to the formation of partnerships that led to lower labor costs, travel/mileage reimbursements, and zero cost for lab supplies, as they were free from a partner lab company.
Context of the InnovationThe Texas Liver Coalition is a not-for-profit organization formed in 1995 to work with liver disease patients and their families, providing education and other assistance, primarily through support groups. Over time, the organization branched out into initial and confirmatory testing and other activities. Facing a shortage of funds, the coalition became a part of St. Luke's Episcopal Hospital in 2002. Current services include a toll-free liver hotline, support groups, provider education and training, screening services, and help in learning about and applying for insurance coverage and in accessing treatment, including clinical trials. As noted, the community-based partnership program was developed in response to the high costs and low yield from the traditional approach to screening, which was to set up testing stations at health fairs.
Planning and Development ProcessKey steps in the planning and development process included the following:
- Initial meeting with potential partners: Texas Liver Coalition leaders invited representatives from a wide array of community-based organizations to attend a meeting in August 2007. During the meeting, the leaders explained the organization's goal of identifying more infected, asymptomatic individuals so that they could be treated before serious liver damage occurred. The goal was to educate representatives of these organizations about the risk of hepatitis and make them aware of coalition resources, including screening services. The meeting was attended by representatives of approximately 15 organizations.
- Educating and training partner staff: Liver coalition staff went onsite to organizations that expressed an interest in a more formal partnership. For example, the coalition's education coordinator and manager attended a staff meeting at Planned Parenthood, educating coordinators on hepatitis C and providing them with testing supplies. The coordinator explained procedures for sending the test into Quest, following up with clients about test results, and communicating and coordinating with the coalition throughout the process. Periodic meetings are held with Planned Parenthood staff to discuss any ongoing issues.
Resources Used and Skills Needed
- Staffing: The Texas Liver Coalition has two full-time staff—an education coordinator and a manager.
- Costs: The coalition's total budget for 2009 was less than $20,000, a significant decrease from the 2008 budget of $149,000.
Funding SourcesTexas Liver Coalition is funded internally through St. Luke's Episcopal Hospital, and through grants from St. Luke's Episcopal Health Charities, pharmaceutical companies, and private donors.
Getting Started with This Innovation
- Secure funding: Very little money is available for hepatitis testing at most community-based organizations. AIDS organizations, for example, are often unable to spend funds on hepatitis. As a result, potential partners will not be interested unless the costs of participation are quite low. Pharmaceutical companies, local foundations, and private donors may be interested in supporting this type of effort because 100 percent of donated funds go directly to patients.
- Educate potential partners: The leaders of local organizations may not be aware of the magnitude of the hepatitis problem. Sharing statistics on the prevalence and on the potential for high screening "hit rates" through partnerships can make them more amenable to working together.
- Address partner needs and integrate services into their operations: Some potential partner organizations may be concerned that client reimbursements will be diverted to the other partner, or that the partnership will place undue additional burdens on staff. To alleviate these concerns, set up systems and processes that allow partners to maintain close relationships with clients and to integrate any new services easily and seamlessly, with no meaningful increase in staff workload. For example, under the partnership with Planned Parenthood, coordinators draw blood for the antibody test as a part of other blood tests they are conducting (only one additional vial is necessary).
Sustaining This Innovation
- Monitor program impact: Keep track of testing "hit" rates and use these data to maintain strong relations with existing partners and to attract new ones.
- Cultivate community advocates: Physicians and other community leaders can be strong advocates for hepatitis testing.
- Continually seek funding: Faced with limited resources, organizations involved in hepatitis and liver disease are in constant need of funds.
Additional Considerations and LessonsHaving hepatitis data has proven to be beneficial in implementing and advocating for the program to other community-based organizations. It has also invigorated most partner organizations because the percent positives have been so high, they feel they are helping the individuals and the community. In addition, educating the organizations regarding the "ABC's of Hepatitis" has made organization staff more knowledgeable about the disease.
Armstrong GL, Wasley A, Simard EP, et al. The prevalence of hepatitis C virus infection in the United States, 1999 through 2002. Ann Intern Med. 2006;144(10):705-14. [PubMed]
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Service Delivery Innovation Profile
Original publication: April 27, 2009.
Original publication indicates the date the profile was first posted to the Innovations Exchange.
Last updated: September 25, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.
Date verified by innovator: September 19, 2013.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.