Relinkage Case Management for HBV and HCV is Needed
So far, sixty-five organizations have submitted proposals across three rounds of funding. Applicant organizations ranged from departments of health to large hospital systems, small clinics and non-profits of varying size and reach. Each proposal attests to the need for services focused on reconnecting people with chronic Hepatitis B or C, and who have fallen out of care, to the support they need.
The Relink program advisory board selected thirty grantees based on their comprehensiveness, innovation, and the potential impact on the communities they serve.
The Good News and the Bad News (Which Is Also Good News)
Fragmented data management systems and missing or incomplete contact information are notable barriers.
Program outcomes are revealing gaps in patient tracking across the Hepatitis B and C care cascades in the United States. By the start of the second year of implementation, available data revealed that over half of individuals believed to be lost to follow up are already receiving care, are cured, or are deceased and so, do not need care.
On one hand, this validates the effort invested into viral hepatitis elimination in the US since the introduction of interferon-free direct-acting antivirals (DAAs) to treat Hepatitis C in 2013. It also validates the efforts of organizations, many of which are community-based, working to prioritize the needs of Hepatitis B infected individuals whose care is still affected by widespread miseducation.
On the other hand, incorrect patient categorizations highlight critical disconnections in patient tracking and data management systems. This is even more so when coupled with other issues like incomplete or outdated patient information.
Our grantees are optimizing their care cascades and workflows, improving their data collection and management practices, as well as collaborating to connect fragmented patient management systems. This ensures accurate, up-to-date, and high-quality patient data to inform the care cascade.
Outreach outcomes vary. However, it is consistently clear that the chances of successful relinkage to care increase significantly with in person contact, peer support and telehealth options.
Grantees Are Charting New Courses for Diligent, Comprehensive, and Effective Patient Care
Round One grantee Philadelphia Fight’s Education, Outreach and Navigation Services(EONS) has implemented the “Call 2 Care” initiative. The program will direct intensive outreach and care coordination to any patient within the organization who has not been seen in over eighteen months. This new direction is based on the outreach and navigation model established during their relink program. It will ensure that all patients (not just chronic Hepatitis B or C patients) stay connected to their primary and subspecialty healthcare.
Similarly, Round Two grantee Iowa Department of Health and Human Services has created a permanent position for a Re-engagement Specialist to support a broader spectrum of patient re-engagement efforts.
Other grantees, recognizing that people whose basic life needs are not being met cannot prioritize treatment, are expanding their relink program services to offer cross-contextual support to people who need treatment. Yet others are presenting their program findings and winning research awards!
[[Iowa DHHS Video]]
Primary Investigator Eddie Brown of the Norton Healthcare relink program presenting at the 2025 Global Hepatitis Summit in LA.
Primary Investigator Maggie Beiser (L) and Patient Navigator Nikita Bhatnagar (R) of the Boston Healthcare for the Homeless relink program.
Project Manager Lauryn Ursey of the UNC relink program presenting their research at the UNC Evening of Scholarship.
Patient Navigator Victoria Jackson of the HBI-DC relink program making a house call to find a relink client.
“What I realized is that it’s far more effective to complete confirmatory testing, engage with clients through incentives, and secure accurate contact information at the start. The time and capacity required for re-engagement later is significant. Thankfully, through Relink, we now have the capacity to continue to do this critical detective work and help individuals return to care.”
— Sandra Marrero-Ashford, HBI CEO & Outreach Lead
Iowa Health and Human Services’ Experiences with Relink
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