Bringing Hepatology to the People: How Community-Based Care Succeeds

When Mitchell L. Shiffman, MD, chose to leave an academic medical center after 20 years of directing a highly successful hepatology and liver transplant program and “hang a hepatology shingle” in Central Virginia, he forged a path to bring specialized hepatology care out of the academic medical center silo and into the community.

Prior to starting the Bon Secours Liver Institute of Virginia, “hepatology was a practice which existed almost exclusively within the confines of large medical centers associated with liver transplant programs,” Shiffman said. Today, there are a growing number of thriving community-based hepatology programs using the formula developed by Shiffman at the Liver Institute.

Shiffman joined the Bon Secours Virginia Health System and, along with April G. Morris, NP, who worked with him at the Virginia Commonwealth University Medical Center for 6 years, opened the first office of the Liver Institute in Newport News, Va., in April 2010. A second office in Richmond opened in September 2011.

“I honestly took a leap of faith,” Morris said about making this move. “The growth has been amazing. It’s more than what we could have imagined at the time.”

Liver Institute has grown more than 20% annually and added two additional nurse practitioners, a physician assistant, two nurse navigators and another hepatologist. The Bon Secours Liver Institute of Virginia is now the largest clinical practice whose primary purpose is to care for patients with liver disease.

The providers at the Liver Institute of Virginia treat about 1,000 patients with hepatitis C annually, collaborate with invasive radiologists to treat hepatocellular carcinoma and coordinate the care of pre- and post-op liver transplant patient, all while maintaining a robust research program with patients enrolled in clinical trials for HCV, metabolic liver disease and other liver disorders.

“Hepatology has finally reached the maturity level that allows this specialty to grow outside the academic silo and enter community-based practices. We now have the expertise in many communities to do everything we used to do only in academic centers. I was also very well aware of how far patients traveled to reach an academic center and how difficult it was for them to navigate the large institution. Our goal in setting up Liver Institute with two offices 70 miles apart was to bring the treatment of liver disease to the patient’s neighborhood and make it easier for them to access specialized hepatology care; and we have been very successful at doing that,” Shiffman told HCV Next. “I was very fortunate to recruit Nadege T. Gunn, MD, to our Newport News office. She was very well trained by prominent hepatologists, and has a great personality. The patients love working with her.”

Transplant Cooperation

A key factor Shiffman pushes with pride is his practice’s ability to manage patients in need of a liver transplant and who have undergone a liver transplant.

“Liver Transplantation is a critically important treatment for end-stage liver disease and incorporating pre- and post-liver transplant management into Liver Institute was a must if we wanted to help all of our patients with liver disease locally,” Shiffman said.

When Shiffman set up his practice, he reached out to several liver transplant programs in the area with whom he could collaborate and develop a successful working relationship; University of Virginia, Duke University, Georgetown University and the Carolina’s Medical Center are where Liver Institute patients are referred most often.

“We started by having meetings with key representatives from these centers and convincing them of two things: one, that it was in the best interest of the patient to receive the bulk of their pre- and post-transplant management locally; and, two, that we had the expertise to care for these patients outside the liver transplant center,” Shiffman said. “This is a very important concept for either new fellow graduates or established gastroenterologists with training in hepatology and interest in caring for patients with liver disease. Many of these physicians want to continue to take care of patients with liver disease but do not want to or cannot stay at the academic center where they trained. These physicians now have a model by which they can adapt to their own practice and hospital and remain involved in the care of patients with liver disease, including liver transplantation.”

Shiffman suggests that community hepatologists who wish to manage pre- and post-liver transplant patients start by setting up a face-to-face meeting with the transplant centers they wish to work with, and initially co-manage patients with the transplant program.

“Within a year or 2, they should be able to establish a good interactive relationship with a transplant program and be able to manage many of these patients independently,” he said.

Shiffman’s team has a weekly conference call with the University of Virginia Liver Transplant Program, where they send about 55% of their transplant patients. Each week, they review patients on the waiting list, patients in the evaluation process and post-transplant issues on patients that have had a liver transplant. They also have regular conversations with key members of the other liver transplant programs with which they work closely. These regular interactions facilitate the placement of Liver Institute patients on the transplant waiting list at these programs.

The key to managing patients with end-stage liver disease who require a liver transplant is the nurse navigator, Marti Burgos, RN, in Newport News and Staci Harpster, RN, in Richmond.

Once Gunn or Shiffman identify a patient in need of a liver transplant, they call upon the nurse navigator to facilitate the journey.

“The process begins with a conversation aimed at finding each patient the best transplant center where they can undergo a liver transplant,” Shiffman explained. “Family support and having family close by is an important ingredient to a successful post-transplant outcome. We therefore ask each patient where they have family. Sometimes it is better to go a little further to receive a liver transplant if that is where the patient’s family resides since that support has been shown to speed post-transplant recovery.”

The entire liver transplant evaluation process is organized by the nurse who summarizes all of the pre-transplant testing and sends it, in advance, to the liver transplant program. By doing this, Gunn explained, the transplant program knows a great deal about our patients before they arrive, and most patients only need to visit the transplant center once prior to being placed on the liver transplant waiting list. This significantly reduces the time that patients and their family members need to travel long distances for ongoing testing at the transplant center.

“The nurse navigators are excellent. They organize all the pre-transplant testing, and facilitate all interactions between the patient and the transplant center to ensure the patient knows exactly what to expect and has a smooth transition between Liver Institute and the transplant center. Once the patient is listed for transplant the nurse navigators keep the transplant center informed of the patient’s condition on a regular basis,” Gunn said.

Burgos told HCV Next about a patient who was not felt to be a good candidate at one center. Although despondent, she encouraged him not to give up, they reached out to other centers and he is now listed and waiting for a liver transplant at two other programs.

“I take it very personally. We are the patient’s advocate. You get close to these patients and their families, and you want to give them every chance to have a good outcome,” she said.

Patients speak glowingly of the service provided, explaining they were fully prepared for their visit to the transplant center by their nurse navigator, who walked them through each step, and was available to translate important medical information along the way.

Because the Liver Institute has arrangements with multiple transplant centers, patients can be listed with multiple programs, giving them a greater chance to receive a transplant.

“We always involve the patient in the decision making. The patient really is the driving force of the process,” Gunn said. “We try to do all of the testing and monitoring close to home where it is far more convenient and less daunting for the patient and their families.”

The Liver Institute also resumes post-transplant care soon after the patient returns from their transplant. Returning home sooner allows the patient to recover sooner.

“You have that joy that you helped and you facilitated everything the patient needed to have a successful post-transplant outcome,” Burgos said. “I made a difference in someone’s life. And that’s the most rewarding part about this job.”

Cooperation

Shiffman touts his cooperation with other specialties not only in managing transplant patients, but also in the management of patients with liver cancer.

“We have talented and knowledgeable physicians within our health system,” Shiffman said. “And they were very excited when I explained to them what we wanted to do here.”

One of Shiffman’s go-to persons for treatment of liver cancer at Bon Secours St Mary’s Hospital in Richmond is Gregg D. Weinberg, MD.

“Since Shiffman started his hepatology practice at the Bon Secours Health System, we see 20 times more liver cancers than before,” Weinberg told HCV Next. “We are seeing volumes that are typically seen only at transplant centers, which is great because radiologic treatment of HCC is an exciting and challenging field and we love to help these patients right here rather than have to refer them out.”

Weinberg attributed their success to the collaborative nature of Shiffman’s practice.

“He leaves it up to me to use the best liver-directed therapy options for each circumstance,” Weinberg said. “We have all the tools and are very aggressive in our treatment of HCC. We are getting the appropriate patients to transplant and the patients are doing as well here as any tertiary center.”

The nurse navigators are also essential in the management of patients undergoing treatment for liver cancer, Gunn said.

“The treatment of liver cancer is a long journey and involves a lot of appointments, radiologic treatments and MRI scans to monitor the response. It is our role as the RN navigator to keep the patients on track so they can achieve the best outcome possible,” Harpster said.

Radiology is one of the areas within the Bon Secours health system that benefits from an active hepatology practice, but Shiffman believes there is also a benefit to the health system overall. Data regarding this will be presented during the Clinical Practice Workshop at the AASLD annual meeting in November. Shiffman suggests physicians interested in developing a practice like The Liver Institute should take that data to their health system and say: “This is what a hepatology program can do for your hospital and your health system.”

Mid-level Providers

One of the ways in which Shiffman made patient care more efficient and successful is by incorporating non-physician providers into the practice.

“I strongly believe that nurse practitioners and physician’s assistants should act independently,” Shiffman said. “We have four very talented providers and for them to see the patient, review the issues with Dr. Gunn or myself and for us to then go in and see the patient behind them is not a good use of their knowledge base or patient care skills. It also does not give the NP or PA provider the feeling that you have confidence in their clinical abilities.”

And they agree, reflecting that same level of appreciation.

“We are definitely more independent and he is confident in us to be leaders and role models to our peers in the community,” Morris said. “I am lucky to have him as a role model and mentor.”

Sarah B. Hubbard, PA, PA-C, added that this practice model allows her and the NPs to expand and hone their skills in hepatology.

“From my standpoint, it allows the physician to do what they’re wanting to be doing in a more effective manner,” she said. “This subspecialty is uniquely poised to have a lot of success with NP and PA providers.”

The non-physician providers care for patients with a variety of liver disease diagnoses. Shiffman and his team agree that in-depth training puts them at an advantage in the hepatology sphere.

By providing each provider an appropriate level of training and a fairly in-depth knowledge of hepatology, Shiffman and Gunn create an environment where each NP and PA can succeed and give the best care to their patients while allowing the physicians to see more complicated and acutely ill patients.

“Each of our NP and PA providers is simply an extension of Dr. Gunn and myself. We see every new patient referred to the practice, but then transition care to either a PA or NP once the plan has been defined and the patient is clinically stable,” Shiffman said. “Our NPs and PAs are essential for HCV treatment and we could not possibly treat as many patients with HCV as we do without them.”

Amy James, NP, and Philip Alexander, NP, explain that prescribing HCV treatment and other medications to treat various liver disorders and complications of cirrhosis come with a lot of paperwork, insurance forms, specialty pharmacy interactions and appeals.

“We are the HCV experts in the practice when it comes to these issues,” James said. “Although the actual treatment of HCV is now easier, obtaining these medications has become a lot more complicated because there are now more options for treatment and we have to know which agents are preferred by each insurance carrier.”

Shiffman and Gunn maintain an open-door policy, knowing his providers will consult with them if they need a sounding board.

“We tremendously respect the knowledge base of our team and by working with them for so many years, we feel they have good judgment,” he said. “They’re equal members of the team.”

Technology in the Community

Despite removing himself from academic practice, Shiffman makes it a priority to have the latest technology on hand for his patients.

In Richmond, the practice uses Fibroscan (Echosens) in the office and many of the scans are performed by the NP or PA providers. In Newport News, Liver Institute partnered with radiology to purchase ultrasound shear wave elastography.

“We wanted to have both technologies available for our patients and simply looked at which technology would be most cost-effective and efficient for our practice and the hospitals we practice at our health system,” Shiffman said.

These less invasive technologies allow for less liver biopsies overall. However, Shiffman acknowledges that liver biopsy still plays a role in his practice to help with diagnosis and staging of certain liver diseases, and to allow for participation in clinical trials.

At The Liver Institute, Shiffman and Gunn perform all of the biopsies.

“We prefer not to refer the patients to radiology. Liver biopsy has certain risks and is a scary procedure for some patients,” he said. “They are our patients and it is important that we do these procedures.”

Clinical Research

Shiffman and his providers agree that metabolic liver disease is the next big frontier in hepatology. They have numerous studies ongoing in nonalcoholic fatty liver disease amidst studies for primary biliary cirrhosis and primary sclerosing cholangitis and others.

Patients respond positively when given the option to participate in clinical research just as they do in an academic setting, Shiffman said, but they are even happier when they realize they can participate locally.

“A lot of patients want to do everything they can for their disease, so we offer clinical trials as a way for them to be on cutting edge and do as much as they can,” Shiffman said.

And some patients do find their cure through clinical trials. Shiffman introduced one patient diagnosed with HCV in 1985. The patient began treatments via clinical trials at NIH where he received various forms of interferon. He moved under Shiffman’s care while still at VCU Medical Center and participated in HALT-C, then received telaprevir — which he said caused itching worse than “Chinese torture.” Once at Liver Institute, he was treated with sofosbuvir (Sovaldi, Gilead Sciences) plus simeprevir (Olysio, Janssen). Unfortunately, the patient failed to be cured by any of these treatments.

In 2014, this patient enrolled in the clinical trial for sofosbuvir/velpatasvir (Epclusa, Gilead Sciences) and found his cure, after four treatments and 15 years.

“We celebrated as much as he did,” Susan Volum, RN, one of the four research nurses at Liver Institute, told HCV Next.

That communal celebration adds to the feeling of family in the community hepatology practice.

“It’s a good model and I think you’re going to see more and more community hepatology practices in the future,” Shiffman said. “We and many others have proven we can do this very successfully. And it’s a very rewarding specialty.” — by Katrina Altersitz

• For more information:
• Mitchell L. Shiffman, MD, and Nadege T. Gunn, MD can be reached at The Liver Institute of Virginia, 12720 McManus Blvd. #313, Newport News, VA 23602.

Disclosure: Alexander, Burgos, Gunn, Harpster, Hubbard, James and Morris reports no relevant financial disclosures. Shiffman reports financial relationships with AbbVie, Bayer, Beckman-Colter, Bristol-Myers Squibb, Conatus, CymaBay, Galectin, Genfit, Gilead, Intercept, Immuron, Merck, NGMBio and Novartis.