A Model of Comprehensive Hepatitis B Care at a Community Health Center

Background: The Charles B Wang Community Health Center (CBWCHC) serves the API population in New York City (NYC) which has a high burden of chronic hepatitis B (CHB) disease. Because of CHB's significant morbidity and mortality, early identification and long-term monitoring of those infected are crucial for reducing complications. We adopted a collaborative care model to integrate CHB care guidelines into standard practice and meet challenges such as missing visits and poor patient understanding of disease.

Objective: Implement a collaborative care model for comprehensive CHB care.

Methods: Changes were made in delivery system design, decision support, clinical information system and self-management to address CHB. A hepatitis B collaborative care team coordinated delivery system design. Clinical information systems were tailored for CHB by creating a disease registry and care management databases. Decision support was implemented in electronic medical records (EMR) by creating hepatitis flowsheets and prompts for test ordering. Care managers intervened for patients who missed visits. A patient tracker was developed for self-management, and physician peer reviews were conducted.

Results: Of 37,800 EMR patient records 2006-2010, 12% (4512) had CHB. EMR decision support and patient trackers were implemented for all CHB patients. Care managers followed 450 CHB and 900 screening patients. Care quality measures improved, and providers and patients reported satisfaction with interventions.

Discussion: The collaborative care model is a promising approach for optimizing CHB care in the Asian community. The multifaceted approach requires additional resources, but can improve patient compliance and care quality.