ELIMINATION PRIORITIES
OUR PROCESS
How Did We Get Here?
On World Hepatitis Day, July 28 2019, we partnered with the Hawai‘i Department of Health and the Hawai‘i Health & Harm Reduction Center to host the first meeting to develop Hawai‘i's Hepatitis Elimination Plan. It was attended by 45 stakeholders including patients, consumers, medical and social service providers, policymakers, among others. The meeting was also attended by Lieutenant Governor Josh Green, who proclaimed hepatitis elimination an important priority for Hawai‘i.
Over the following 12 months, we talked story with over 160 individual stakeholders in more than 24 formal meetings, multiple online surveys, and many more informal conversations to create the structure of this plan, establish its scope (viral hepatitis A, B, and C), and identify elimination priorities, strategic directions, and examples of micro-elimination opportunities.
What Does Micro-Elimination Mean?
Micro-elimination means that we will work on many different, innovative, community-driven projects at the same time. This allows us to tailor hepatitis elimination to the needs of each community and to change direction quickly if things aren't working.
After an intensive year of discussion, we collectively identified five priority areas to eliminate hepatitis in Hawai‘i. For each of these areas, we developed Strategic Directions that would help guide us over the next ten years, but still give us enough flexibility to adapt to changing resources and challenges (e.g., 2020 COVID-19 pandemic). Finally, we have highlighted some possible or existing micro-elimination opportunities to move step-wise in each direction.
Will this be a complete list of opportunities?
Not at all! The micro-elimination opportunities we list below represent only a fraction of the ideas we came up with. We decided to highlight a few that we thought were important and exciting. Since opportunities and resources may change over time, let's stay nimble!
Priority Area 1
AWARENESS AND EDUCATION
STRATEGIC DIRECTIONS
DIGITAL PRESENCE
By 2030, increase digital presence on multiple online and social media platforms to cultivate awareness and engagement around hepatitis and related issues.
CULTURAL ENGAGEMENT
By 2030, provide, support, and enhance culturally appropriate and in-language opportunities for community-based knowledge-sharing among people most impacted by viral hepatitis.
HUB FOR EXPERTISE
By 2030, position HFH “brand” as a local resource and expertise hub for viral hepatitis and related harms (e.g. harm reduction, drug user health, immigrant/ migrant health, LGBTQ health).
HEALTHCARE EDUCATION
By 2030, increase provider awareness and education to enhance the network of care for testing, immunizations, and treatment.
MICRO-ELIMINATION OPPORTUNITIES
DIGITAL PRESENCE
Social Media Influencers: Increase social media engagement within at-risk communities (e.g., baby boomers, people who inject/use drugs, youth, formerly incarcerated, Asians and Pacific Islanders) through online and community influencers.
Website Upgrade: Maximize website functionality by updating info and tools such as searchable maps.
Linked Partnerships: Increase website traffic by cross-linking with partner organizations via “Partner buttons.”
CULTURAL ENGAGEMENT
Storytelling Capacity: Empower communities and increase awareness through storytelling workshops to create a story bank and speakers bureau.
Health Ambassadors: Identify and empower local community influencers (including community health workers, social workers, but also patients, family) to become “ambassadors of health.”
Community-Driven Models: Create low-threshold “talk story” opportunities that are culturally/linguistically appropriate (e.g. Micronesian Education for Liver Wellness Program; youth for youth videos).
HUB FOR EXPERTISE
Media Campaign: Develop statewide awareness campaign to promote website and logo (e.g., PSAs w Olelo; paid/earned media).
Clear Branding: Clarify plan for brand visibility and positioning (logo).
HEALTHCARE EDUCATION
Learning Hubs: Develop and enhance provider capacity through mentorship and virtual learning hubs.
Promotional Materials: Develop and disseminate materials for use in healthcare settings (e.g., posters, flyers, etc.).
Provider Honor Roll: Promote non-discrimination and peer accountability through publicized provider report cards (similar to Bay Area Hep B Free).
Continuing Education: Provide ongoing continuing education programs, including annual convening, for all members of healthcare team, including social service providers.
Priority Area 2
ACCESS TO SERVICES
STRATEGIC DIRECTIONS
IMMUNIZATIONS
By 2030, develop a sustainable hepatitis A and B immunization infrastructure in Hawai‘i, especially for adults at risk.
TESTING
By 2030, increase awareness of and access to low-threshold, sustainable testing in high-impact venues and settings.
LINKAGE TO CARE
By 2030, increase awareness of and access to low-threshold, sustainable programs for viral hepatitis care coordination services, including integration with related linkage services such as housing, mental health, immigration, and harm reduction.
TREATMENT
By 2030, increase awareness of and access to timely and affordable treatment for viral hepatitis, primarily through engagement with insurance payers at all levels.
PRESCRIBER CAPACITY
By 2030, increase the number and capacity of medical providers to consistently screen for and treat viral hepatitis by creating a network of clinical support and mentorship.
MICRO-ELIMINATION OPPORTUNITIES
IMMUNIZATIONS
Community-Based Vaccines: Establish and implement evidence-based standing orders from statewide authority for hepatitis A/B immunizations in non-healthcare settings.
Pharmacy-Based Vaccines: Increase sustainable capacity of pharmacies to provide hepatitis A/B immunizations, especially adequate insurance coverage.
Vaccine Registry: Ensure implementation and use of a statewide immunization registry system among primary care, pharmacies, corrections, and community-based partners.
TESTING
High-Impact Settings: Increase HBV and HCV screening in high-impact settings, including primary care, FQHCs, corrections, syringe exchanges, substance treatment centers, homeless shelters, and community-based settings.
Universal Testing: Promote and ensure universal and risk-based adult screening for hepatitis, as recommended by U.S. Preventive Services Task Force (USPSTF).
LINKAGE TO CARE
HCV Care Coordination: Establish and support stand-alone or integrated HCV care coordination programs to address treatment and related issues, including housing, harm reduction, substance use, mental health.
HBV Care Coordination: Establish and support standalone or integrated HBV care coordination programs to address treatment and related issues, including immigration, language access, and chronic disease.
TREATMENT
Pharmacy-Based Treatment: Enhance and support pharmacy-driven treatment, especially with prior authorizations (e.g. collaborative practice agreements).
Co-infection with HIV: Develop and implement incentive models to promote testing and treatment of hepatitis among people living with HIV/AIDS.
PRESCRIBER CAPACITY
Project ECHO®: Launch liver health tele-ECHO® clinics for ongoing training and mentorship statewide.
Annual Summit: Establish and maintain an annual CME/CE event for providers and community members.
Priority Area 3
ADVOCACY AT ALL LEVELS
STRATEGIC DIRECTIONS
HEALTH DEPT. CAPACITY
By 2030, increase funding for health department infrastructure (e.g., staffing, programming) to address viral hepatitis elimination in Hawai‘i.
POLICY INTEGRATION
By 2030, integrate viral hepatitis language into strategic plans for related health and social issues, such as opioid misuse, homelessness, cancer, etc.
INSURANCE COVERAGE
By 2030, ensure consistent, affordable coverage of hepatitis immunizations, testing and treatment with limited pre-authorizations, as aligned with national and professional guidelines.
COMMUNITY ADVOCACY
By 2030, develop and maintain network of community and patient advocates to increase awareness of and access to services.
PROVIDER ADVOCACY
By 2030, develop and maintain network of clinical hepatitis advocates to increase awareness of and access to services.
MICRO-ELIMINATION OPPORTUNITIES
HEALTH DEPT. CAPACITY
Legislative Action: Draft and submit bills to local, federal, and/or global legislative champions to secure higher allocation in base budget within health department.
Departmental Action: Integrate viral hepatitis language into health department contracts and training to increase services in programs serving similar communities (e.g., HIV, TB, cancer).
POLICY INTEGRATION
Legislative Action: Draft and submit legislative resolution for strategic plan and legislative briefing to identify champions and discuss appropriations in future sessions.
Cross-Linked Policies: Identify strategies or policies for integration of viral hepatitis language, including plans for housing, substance use, mental health, non-citizen rights, sexual and gender minorities, incarceration, drug policy, Native Hawaiian health.
INSURANCE COVERAGE
Legislative Action: Draft and submit bills to improve access to hepatitis services, especially by reducing barriers to treatment (e.g., prior authorizations, prescriber requirements).
Pharmacist Capacity: Draft and submit bills to increase pharmacy scope of practice and reimbursement for hepatitis services.
Quality Metrics: Identify champions within insurance plans to develop and implement hepatitis-related benchmarks for reimbursement.
COMMUNITY ADVOCACY
Advocacy Training: Identify and train patients and allies to be local legislative and policy advocates (e.g., model used by National Viral Hepatitis Roundtable).
Advocacy Network: Coordinate ongoing mechanisms to share insights and consolidate efforts (e.g., speakers bureau; Circle model; correctional ECHO®; veteran matching in courts).
PROVIDER ADVOCACY
Advocacy Training: Identify and train healthcare providers to be local legislative and policy advocates (e.g., model used by National Viral Hepatitis Roundtable).
Advocacy Network: Coordinate ongoing Clinical Advocacy meetings to share insights and consolidate efforts (tie in with Awareness/Education).
Priority Area 4
EQUITY IN EVERYTHING
STRATEGIC DIRECTIONS
SHARED LEADERSHIP
By 2030, create and maintain opportunities for those most affected by viral hepatitis—especially people who inject drugs, are immigrants or migrants; are houseless; are LGBTQ+; have been incarcerated; live in rural areas—to have policy and leadership roles.
PEOPLE FIRST
By 2030, create and maintain opportunities for those most affected by viral hepatitis—especially people who inject drugs, are immigrants or migrants; are houseless; are LGBTQ+; have been incarcerated; live in rural areas—to have policy and leadership roles.
STIGMA REDUCTION
By 2030, develop and support efforts that change community norms around perception of viral hepatitis, especially regarding stigma of affected populations.
DATA EVALUATION
By 2030, integrate equity into evaluation metrics for all Priority Areas and Micro-Elimination projects via the Data Workgroup.
MICRO-ELIMINATION OPPORTUNITIES
SHARED LEADERSHIP
Leadership Development: Develop trainings and support for emerging leaders to plan and implement micro-elimination models (e.g., grant-writing).
Peer Mentorship Network: Coordinate ongoing mechanisms to share insights and consolidate efforts (e.g., speakers bureau; Circle model; correctional ECHO®; veteran matching in courts).
PEOPLE FIRST
Community Champions: Create “Ambassadors of Health” or “Hepatitis Champion” designation to identify and empower community liaisons to provide feedback (e.g., Paij w PWID; Kenson and Rensely w Micronesian families).
Feedback Loops: Create formal mechanism to receive and respond to community feedback, especially via Hepatitis Heroes.
STIGMA REDUCTION
Social Influencers: Create social opportunities to discuss hepatitis via Community Champions (above) (e.g., “Ask me about hepatitis” t-shirts; HIV models of engagement; incentives).
Community-Driven Materials: Disseminate visual, multi-lingual and low-threshold materials, developed by people affected by hepatitis (e.g., comic books).
DATA EVALUATION
Qualitative Measures: Develop evaluation metrics and mechanisms to highlight experiential, qualitative (“talk story) data, especially to determine impacts of stigma, culture, and other social nuances.
Community Feedback Loops: Create mechanisms for community participation in data collection, reporting, and messaging to ensure meaningful engagement and avoid unintended consequences (e.g., communities perceived as “diseased”).
Stigma Research Repository: Conduct literature reviews and create repository for stigma research, especially related to viral hepatitis and harm reduction.
Priority Area 5
DATA FOR DECISION-MAKING
MICRO-ELIMINATION OPPORTUNITIES
DATA TO ACTION
(CARE CASCADES)
By 2030, develop site- or population-specific care cascade reports for targeted programming, policymaking, and communication by identifying and utilizing existing data sources.
CROSS-CUTTING EVALUATION
By 2030, establish Data Workgroup to develop evaluation metrics/process for other Priority Areas and Micro-Elimination Projects.
SURVEILLANCE INFRASTRUCTURE
By 2030, improve health department surveillance infrastructure to determine statewide and county-level prevalence estimates for grant-writing, programming, and policymaking.
EQUITY
METRICS
By 2030, integrate equity into evaluation metrics for all Priority Areas and Micro-Elimination projects via the Data Workgroup.
MICRO-ELIMINATION OPPORTUNITIES
DATA TO ACTION
Standardized Care Cascades: Define and disseminate “best practice” for care cascade definitions and development for comparison across sites and populations.
Data Capacity-Building: Provide training and technical assistance for agencies/communities on best practice for data collection, reporting, and dissemination.
Quality Improvement: Develop and share care cascade reports to identify opportunities for improvement in clinical practice within and across agencies/communities.
CROSS-CUTTING EVALUATION
Multi-Level Evaluation: Develop metrics and processes to measure outcomes at various levels, from patients and providers to policies and systems.
Qualitative Measures: Develop evaluation metrics and mechanisms to highlight experiential, qualitative (“talk story) data, especially to determine impacts of stigma, culture, and other social nuances.
SURVEILLANCE INFRASTRUCTURE
Health Department Capacity: Identify local and federal funding and staffing opportunities for hepatitis surveillance within DOH.
Vaccine Registry: Ensure implementation and use of a statewide immunization registry system among primary care, pharmacies, corrections, and community-based partners.
Visualization Projects: Create capacity for data visualization, reporting, and dissemination for community use (e.g., geo-mapping, heat maps, infographics).
EQUITY METRICS
Qualitative Measures: Develop evaluation metrics and mechanisms to highlight experiential, qualitative (“talk story”) data, especially to determine impacts of stigma, culture, and other social nuances.
Community Feedback Loops: Create mechanisms for community participation in data collection, reporting, and messaging to ensure meaningful engagement and avoid unintended consequences (e.g., communities perceived as “diseased”).
Stigma Research Repository: Conduct literature reviews and create repository for stigma research, especially related to viral hepatitis and harm reduction.