Health Care Innovation Awards Round Two: Project Profile


Project Title: "Project INSPIRE NYC (Innovate & Network to Stop HCV & Prevent complications via Integrating care, Responding to needs and Engaging patients & providers"
Geographic Reach: New York
Estimated Funding Amount: $9,948,459


The Fund for Public Health in New York and the New York City (NYC) Department of Health and Mental Hygiene (DOHMH) are testing a model that will identify persons with Hepatitis C viral (HCV) infection utilizing the NYC DOHMH HCV surveillance database, electronic medical and laboratory records from participating facilities, and referrals from neighborhood organizations that perform HCV testing. Eligible persons will undergo an interdisciplinary, comprehensive medical and behavioral health assessment, for substance use and social support and benefits needs. Patients' behavioral health will be assessed using the Psychosocial Readiness Evaluation and Preparation for Hepatitis C Treatment (PREP-C), to identify areas of psychosocial functioning that require attention before and after beginning HCV treatment. HCV and related co-morbidities will be managed within an integrated, patient-centered clinical and behavioral health environment. Primary care and/or HIV providers will be supported by addiction medicine specialists, psychiatrists and hepatologists, who will be available for telemedicine-based consultation. Providers will be trained and mentored in HCV care and treatment by the institutions' hepatologists. Web-based teaching modules and weekly case management video conferences with hepatologists and providers from all participating clinics will be used. Patient management will be supported and facilitated by care coordination, defined as health system navigation and patient support to keep medical appointments, health promotion, medication adherence assistance, and coaching for improvement of self-sufficiency skills. Comprehensive care coordination programs and integrated care have been shown to improve health outcomes and reduce hospitalization and emergency department visits.

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