Hepatitis C Care Navigation

Infrastructure: Navigators will require access to the necessary IT infrastructure, including computers or laptops, any required software and computer functionality, and program databases. They will need access to client charts or electronic health records, secure storage files and the appropriate mechanisms for communication (email accounts, smartphones etc). 

Organisational support: Any organisation seeking to set up a HCV care navigation program should consider how navigators will be supported and under what frameworks. A supervisor should be appointed to oversee and discuss cases, troubleshoot challenges and celebrate achievements. Navigators should be supported to understand organisational policies and procedures, for example, the parameters around home visits. 

Helpful resources:

• Resources, tools, proforma 

Qualifications: These may vary but it is critical that navigators have experience with and comfort working with the population the program intends to serve. Some programs require navigators to have a college education and/or professional experience that includes working with at-risk populations while others have as their main requirement a lived experience of substance use and or HCV (peer navigation).

Experiential expertise: Ideally, a candidate will have a strong understanding of harm reduction and past experience providing low-threshold services to people who use drugs; a commitment to supporting marginalised communities to advocate for their healthcare and other services they need; and if applicable, be multilingual. Most programs seek to recruit Navigators with lived/living experience and/or who live in the communities where they will be working.

Identify existing, or develop, client education materials: These should be easy to understand, actionable and address common misconceptions and concerns related to HCV.

When developing resources, clients should be involved from the initial planning stage to ensure best practice.

Existing materials may be found through:

• Public health departments
• Health agencies
• National or regional bodies (organisations which represent the interests of a sector or the community to the government)
• Local, regional or national peer based or community organisations
• Harm reduction organisations

Materials may include: pocket cards, posters, brochures, videos or smartphone applications and should include information on local services for prevention, testing, linkage to care and treatment, as well as tackling stigma and discrimination, and barriers to testing and treatment. These resources are critical to help clients understand HCV and understand the importance of getting treated and cured.

When developing resources, clients should be involved from the initial planning stage. Prioritise educational materials that demonstrate that they are both accurate and relevant to the target populations. Particular attention should be paid to sourcing materials that are culturally acceptable to Indigenous communities and people from culturally and linguistically diverse backgrounds. 

Helpful resources:

• What does the evidence say?
• Resources, tools, proforma 

Supportive referrals: Programs must conduct ongoing assessments of client needs and barriers to care, and develop a list of the supportive resources available in the service catchment area to meet client needs, overcome barriers, and support successful referrals. Referral guides may not only be written — visit the services, identify champions within them who are willing to help facilitate access to your clients, invest in these relationships and nurture them. Supportive referrals can include:

• Primary care services
• Substance use treatment and harm reduction (including syringe exchange and safe smoking and safe snorting kits)
• Supervised consumption services
• Take home naloxone
• Alcohol treatment services
• Mental health services
• Health insurance and pharmacy benefits enrollment
• Transportation
• Housing and legal services 
• Food pantry
• Free or affordable phone plans
• Income assistance
• Probation and parole systems and other services.
• Family and carers services/support

Relationships: A robust referral network is important to successful HCV navigation. Formal agreements may be necessary to solidify referral relationships. Make sure the referral agreements outline expectations from your program and the referral agency, such as when clients can expect to receive services and what documentation is needed to release confidential client information for updates and to whom these record release rights are granted. Ensure the appropriate data protection laws and regulations are in place and adhered to.

Networking: Informal networking will also be critical to building relationships throughout the referral network. Formal or informal community mapping may help programs visualise the resources and potential collaborative opportunities near your site’s catchment area.

Helpful resources:

• Resources, tools, proforma 

Team composition: The Navigator needs to work collaboratively with a multidisciplinary care team to successfully navigate clients. The team should include some, or all, of the following: HCV navigator, people who carry out HCV testing, navigation supervisor, medical provider, mental health and/or behavioural health and/or substance use care provider, and other health care professionals and social services from within or outside of your organisation. In some instances, in particular in resource-constrained settings, these roles may be overlapping. It is important to remember that effective care navigation can occur across a variety of access levels — work with what you’ve got!

Collaborative practice: It is critical to establish a good working relationship between the Navigator and the care team, and to work with the care team to guide the client through every step of the process. The Navigator should speak with the care team on a regular basis and must be made aware of appointment dates to support attendance as well as the attainment of clinical milestones to track progress through HCV care. The critical relationship is between the care navigator and the client who work together to build an individualised care and navigation plan. This plan should identify a set of individualised interventions that cover a client’s journey through HCV assessment, treatment and post-treatment. This plan should identify named members of the care team, eg clinician (medical /nursing/counsellor), care navigator, and peer to support the client during assessment and treatment, and to prepare them for prevention re-infection post-treatment. 

Helpful resources:

• Resources, tools, proforma

Training provision: HCV care navigators and members of the care team will need training on HCV (which includes transmission, prevention, stages of liver damage, treatment options, and post-cure liver health). In addition, navigators should complete trainings on;

• Personal health information and data confidentiality
• The principles of harm reduction
• Trauma-informed and person-centred care
• Counselling techniques
• Local referral pathways

Depending on the context in which the program is operating, training might be required in overdose prevention, grief and loss, and options for drug treatment locally. Training can also mean providing opportunities for on-the-job mentoring and shadowing experiences. In some cases, navigators will need medical interpretation certification if they are bilingual and planning to translate for clients. As well, navigators will need up-to-date information on any changes to health insurance coverage or state-funded care and other benefits relevant to their client population and know what services are available in their area.

Supervision: Supervisors should support their staff and oversee navigation programs. It is recommended that the navigator meets with their supervisor weekly or every two weeks for one hour, either individually or in a group setting. This is to discuss things that are going well and any challenges, training needs, documentation needed for grant reports or organisation dashboards, cases that need special attention and other topics related to the navigator’s work.

Networking: Navigators should also be encouraged to participate in networking events such as coalitions of hepatitis and harm reduction providers and advocates, national and international conferences, and local HCV care navigator meetings, if available. Participating in these forums will provide opportunities to build stronger referral networks, troubleshoot challenges, and share best practices to ensure all clients can access HCV diagnostic testing and curative treatment. Navigators should be supported to undertake ongoing training opportunities on topics that emerge and are of relevance to the population served.

Helpful resources:

• Resources, tools, proforma

Documentation: Policies, protocols, and systems for documenting HCV care navigation services need to be developed to assure client progress and program outcomes are accurately tracked over time and to ensure the smooth running of the program. It is important to follow data confidentiality requirements in your area to protect private health information. Forms and databases should track information that will be used in reporting, and be as brief as possible for ease of use. Sample forms and templates can be found in the NASTAD Hep C Community Navigation Toolkit (see resource list below).

Confidentiality: The navigator should build the skills and competency necessary to be responsible for the documentation of their work while always protecting client information in accordance with the organisation’s policies and all applicable laws, rules, and regulations. Client confidentiality training should be conducted semi-annually (or as often as needed) to ensure navigators follow data privacy guidelines. Any Release of Information (ROI) forms should be reflective of the local privacy legislation in the jurisdiction in which the form is being used. ROI forms may include some or all of the following – consult your local privacy legislation for further information.

• Client information
• Receiving party’s information
• Information to be shared
• Purpose of the release
• Expiration of authorisation
• Disclaimers
• Date and signature 

Helpful resources:

• What does the evidence say?
• Resources, tools, proforma 

You should establish systems to assess the effectiveness of program activities. You can follow the ‘Plan, Do, Study, Act’ cycle or other methods to implement program changes designed to better serve your client population.

Questions to help guide this process may include:

• Did everyone complete trainings and a full induction (navigators and clinicians)?
• What workflow changes occurred and what remains to change (what worked well and what didn’t)?
• Are you finding and reaching the target population?
• Are you moving people forward on the care continuum (e.g. improving screening rates, treatment initiation rates, SVR testing rates, etc)? This can be accomplished by reviewing program implementation notes, assessing outcome data, conducting surveys and/or focus groups with the target population, or with local medical and other service providers

External bodies or agencies may be available to support this process.

Navigation services can be funded through local government special initiatives, grants from national government agencies and other funding sources such as pharmaceutical companies. If funds don’t allow for a robust internal team (people who carry out testing, navigator, navigator supervisor, data manager, behavioural health/ drug treatment provider, medical provider etc.) consider utilising your referral network to outsource services.  

In many jurisdictions, there is funding for services related to HIV/AIDS and for the overdose crisis. If that is the case, consider creating hybrid navigator positions that would work on HIV/AIDS, PEP/PREP and/or Harm Reduction and HCV. It may be possible to link in with existing health promotion programs and other local agencies.

When possible, the navigator should visit all referral sites and become familiar with the medical and service settings and staff. The goal is to find locations and staff who are affirming to all clients including but not limited to: LGBTQI+, people who use drugs, people from culturally or linguistically diverse communities, indigenous communities, and people who are unstably housed or who were formerly in prison. 

Many people do not seek medical care because they have felt stigmatised and judged by medical providers and other health care workers in the past. It is critical to acknowledge client concerns and past experiences and to determine which service providers are most appropriate. In some cases, accompanying clients to medical appointments will be necessary to advocate for their needs and may help them feel more comfortable getting care.

Training on how to tackle stigma and discrimination should also be provided.

Due to the price of oral direct-acting antivirals (DAAs), there continue to be restrictions on who may have oral DAA therapies covered or paid for by insurance in many parts of the world, and restrictions related to re-treatment eligibility. It is important that your organisation is familiar with any barriers to HCV coverage and potential strategies to address these barriers.

Some countries may look to provide treatment through their ministry of health or other cost-sharing programs.

Pharmaceutical companies and non-profit organizations that assist with co-payments and medication costs can be used, in some cases, to support people who are uninsured or underinsured.