OPCA Annual Awards of Excellence: Innovation & Transformation in Leadership
Arsalan Shah (he/him), Senior Director of Pharmacy, Central City Concern
Dr. Shah is the senior director of pharmacy for Central City Concern’s (CCC) community health centers at the Old Town Clinic and Blackburn Center in Portland, Oregon. Dr. Shah is an experienced pharmacist with PGY-1 and a Master of Business Administration (MBA) with a demonstrated history of providing clinical services in the community setting. CCC provides vital services to housed and unhoused patients in the Portland metro area with holistic innovative care models that meet people where they are. The core of our program is listening to a patient’s needs, stories, feedback and motivations. Forming responsive human relationships with our patients is the foundation of increasing access.
There is a well-known correlation between the injection of illicit substances and increased risk in contracting hepatitis C (HCV). In 2016, the Center for Disease Control (CDC) released a fact sheet stating, “sharing or reusing needles and syringes increases the chance of spreading the hepatitis C virus.” According to a 2022 article, published in the peer-reviewed scientific journal BMC Global and Public Health, 12 studies conducted between 1996 and 2019 reported the national average for link to care for HVC among those experiencing homelessness at 19% (Saha et. al, 2022). According to Dr. Andrew Seaman from our hepatitis C team, “To reach World Health Organization (WHO) Hepatitis C (HCV) elimination targets we must rapidly diagnose and treat HCV in people who inject drugs (PWIDs), including vulnerable and houseless individuals. We need streamlined care pathways addressing barriers including excessive provider appointments, laboratory workup complexity, and burdensome referral requirements.”
To respond to this critical challenge, CCC initiated its hepatitis C program in May 2017 and its Opioid Treatment Program on February 22, 2022, becoming the first opioid treatment program in the United States to implement dry blood spot testing. Since then, our link-to-care rate for all clients tested for HCV has been 85.5% and 40% for those in the opioid treatment pilot, double the national average. Of the 1,100 patients currently enrolled in CCC’s Opioid Treatment Program in partnership with CODA, 20% of them tested positive for HVC, (as opposed to 2% of all patient’s agency-wide) and 69 patients are currently receiving therapy. Figure 1 depicts the programs’ impact with a positive cut rate of >50% over time.
How did they do it?
First, Dr. Shah and the hepatitis C team saw an opportunity in the federal requirement that all opioid treatment providers engage in syphilis screening and chose to make HCV testing a matter of CCC policy. This made it possible for patients to get tested and treated for HCV at a location where they receive withdrawal management/point-of-care services. Dr. Shah and his hepatitis C team also adopted dry blood spot (DBS) testing as opposed to a traditional blood draw. This allowed the hepatitis C team to equip outreach workers with testing kits. The test uses highly portable dry blood spot technology, using a finger poke to test on-site, rather than asking patients to get tested at a phlebotomy lab. This process is trauma-informed, as some patients may be triggered by needles. This allowed the team to provide mobile testing kits out in the community, in our housing facilities and at our two community health centers.
Finally, the hepatitis C team also partnered with Transition Projects (TPI), CODA (one of Oregon’s largest non-profit substance abuse treatment programs), Acadia Health and others to integrate dry blood spot testing. In 2019, the hepatitis C team worked with community partners to loosen the prior authorization requirements allowing more people to start treatment. In 2020 to early 2022, CCC expanded from just clinic-based screening to testing with various community partners and eventually OTPs. Hepatitis C Medical Director Dr. Andy Seaman stated that the decrease in positivity rate (blueish line in Figure 1) “is due to testing people we have treated, therefore what we are seeing is true elimination.” Clinical Pharmacy Services Manager Marc Rizzo, PharmD stated, “The hepatitis C team is flexible and adaptable to various changes. As pioneers in our field, we show bravery by innovative and creative problem-solving while not knowing what obstacles we will face next. We also show a lot of persistence. A lot of patients start treatment 10-15 days after we find out they are positive, but we have success stories of linking patients to care after 500+ days.”
Examples of Success
Placing the principles of portability and adaptability into practice, one patient was tested at Belmont Comprehensive Treatment Center (BCTS) by our outreach team via DBS in November of 2021. The patient was discharged from BCTS before we could relay the results due to going back to active use and being houseless. The patient engaged with OHSU in March 2023, who alerted us. The patient was then discharged into CCC housing. Our CCC housing outreach worker retested the patient and was able to help them start treatment on June 13, 2023, after they were stabilized in the new housing location. Another patient tested positive via laboratory services in August 2019, so the hepatitis C team worked with the CCC Summit Team (a clinical team dedicated to complicated cases at CCC’s Old Town Clinic) to link the patient to care. Initially the patient was unmotivated to start hepatitis C treatment, but the CCC team along with TPI, a community partner, contacted them over 20 times in a 20-month span to see if they were ready. Persistence paid off and the patient enrolled in treatment. in January 2023, the patient completed their VR12 (test to see if the drug worked) and they cleared their infection.
We believe Dr. Shah and the hepatitis C team meet all the criteria for innovation and inclusivity and deserve this award. Not only were they first in the nation to use this testing method for opioid treatment patients, but they practically applied and shared that technology with community partners and achieved real results. They were so successful that the Substance Abuse and Mental Health Services Administration (SAMHSA) has indicated that CCC’s efforts will be included as an example of best practices in future publications. CCC was also a recipient of the Connecting to Care Award from the International Network on Health and Hepatitis in Substance Users in 2021. Dr. Shah and the hepatitis C team clearly led a unique effort to establish our clinics and outreach teams as centers of excellence through innovative community partnerships, clinical, operational, and administrative practices.
Submission written by Barbara Martin, Medical Director of Health Informatics, Central City Concern