The Hepatitis C Self-Management 

Program

Erik J. Groessl, PhD

Kimberly R. Weingart, PhD

VA San Diego Healthcare 

System

University of California, 

San Diego
Overview

 Background – Hepatitis C

 HCV Care in the VA – past and present

 What is Self-Management?

 HCV Self-Management results

 HCV Self-Management Program

 Future Directions
Hepatitis C in the VA 

 HCV infects about 1.8% of the US 

population

 Infection rates are 5-6% in the VA system

 Leads to 

 cirrhosis, HCC, and liver transplants

 functional limitations, physical & psych 

symptoms, and reduced HRQOL
Hepatitis C in the VA 

 HCV-infected veterans have high rates of:

 substance abuse

 psychological comorbidity

 homelessness and impoverishment

 Other comorbidities (HIV)
HCV Care (past)

 2004 - low SVR rates for g1, side effects 

 2004 - low treatment rates (10% in care) 

 Many veterans either:

 were not good treatment candidates

 had failed treatment 

 refused treated 

 had low grade fibrosis → watchful waiting
Improving HCV Care

 How can we best help the 90% of HCV 

patients not being treated?

 Educate patients about HCV

 Facilitate lifestyle change

 Improve QOL of patients

 Prevent transmission

 Prevent progression of liver damage

 Prepare patients for treatment

 Increase treatment success
HCV Care (present)

 In 2011, % ever treated has doubled (22%) 

but can be further improved

 New triple therapies offer 

 increased chance of cure

 briefer duration of therapy

 slightly more side effects overall
Improving HCV Care

 How can we best help HCV patients?

 **Successfully Treat more people

 Prepare people for treatment

 Increase treatment initiation

 Maximize treatment efficacy - adherence

 Educate patients about HCV

 Facilitate lifestyle change

 Prevent transmission

 Prevent progression of liver damage
HCV Treatment

 New therapies are very expensive

 Interferon-free therapies may be available 

in 2-3 years, less side effects

 New therapies will be even more expensive

 Goal: To optimally prepare treatment 

candidates for antiviral therapy using low 

cost interventions
What is Self-Management?

 Patients take active role in managing their 

health

 Term used to be applied to informationonly patient education programs

 Beyond patient education - teach new 

skills, increase self-efficacy, encourage 

social support, activate patients (Lorig & 

Holman – Stanford University)

Self-Management skills

 Take action 

 Find and use resources

 Decision-making

 Problem-solving

 Develop and use supportive 

relationships
Self-Management Interventions

 Cognitive behavioral principles

 Empowerment/Motivational interviewing 

approach. 

 Holistic, comprehensive –

 use multiple modalities

 addresses global well-being

 mind/body connection stress

Depression Fatigue
Self-Efficacy

Figure 1. Structural model of the effects of self-efficacy on health behavior and outcomes

O Outcome Expectations

Physical

Social

Self-Evaluative

S Self-efficacy G Goals B Behavior

 Sociostructural Factors

Facilitators

Impediments

Health

Outcomes

Health

Outcomes

Bandura A, Health promotion by social cognitive means. Health Educ Behav, 2004. 31(2): p. 143-64.
Self-Management

 Shown to improve a variety of outcomes in 

many chronic diseases arthritis, diabetes, 

asthma, cancer, and many other diseases.

 CDSMP – Lorig et al. - widely disseminated 

via Kaiser Permanente, UK Expert Patient, 

Australia, British Columbia
Preliminary work

 VA HSR&D Career Development Award in 2004

 Qualitative interviews with 16 VA HCV patients and 

8 HCV care providers

 Group leader training - Stanford Chronic Disease 

Self-Management program 

 Piloted HCV Self-Management Program - 2004-05.

 HCV expert opinion (n=7) on developmental work -

2006
Intervention – New modules

 Began with Lorig’s Chronic Disease SMP

 Basic Hepatitis C Education – updated & 

added to VA HCRC slides 

 Alcohol and drug use

 Expand fatigue management

 Adherence to treatment recommendations 

 Discussion panel with vets who were treated
Intervention – changes

 Removed:

 advanced directives

 distraction from pain

 Reduced time spent on:

 exercise

 managing emotions

 Relaxation

 Added health professional to peer-leaders
Pilot Results

Measures (n = 8) Baseline Mean 

(sd)

Follow-up Mean 

(sd)

p –value (2-tail)

HRQOL - QWB 

score

.459 (.134) .480 (.131) .318

Self-efficacy 5.69 (2.02) 6.73 (1.68) .029*

Energy (fatigue) 1.93 (1.38) 1.70 (.99) .501

Depression –

CES-D 10

18.6 (6.0) 15.4 (6.1) .344

HCV knowledge 

score

8.6 (2.7) 11.1 (1.6) .038*

Health distress 2.00 (1.22) 1.71 (1.41) .547

Exercise – self 

report

4.4 (2.3) 5.0 (1.2) .553
Intervention Trial

 4-year HSR&D funded study 2006-2010

 134 VA patients w/ HCV randomized to selfmanagement or information-only

 Information-Only = printed packet of HCV 

information, resource guide, home self-study

 HCV – SMP = Groups of 8-10 patients coled by health provider and peer-leader, meet 

once/week for 6 weeks (2 hours each)
Patients

 Eligible for VA healthcare services

 Confirmed HCV positive

 No treatment currently or next 6 months

 Not terminally ill

 Recruited through

 Providers at VA Hep C clinic, ADTP, PC

 Flyers and in-person at satellite clinics, Vet orgs, 

American Liver Assoc, other non-profits

 Letters to those testing positive in last 2 years
Health Outcomes

 Assessments at baseline, end of workshop (6 

weeks), 6- and 12- month follow-up.

 Primary outcomes

 generic HRQOL - SF36 and QWB-SA

 disease-specific HRQOL - HQLQ

 Secondary outcomes

 Cost-effectiveness data
Secondary Outcomes

 HCV knowledge 

 HCV self-efficacy

 Fatigue/energy

 Depression

 Health distress

 Alcohol and Drug use
Secondary Outcomes

 Health behaviors and patient activation

 attendance of health care appointments

 medications and other utilization

 rates of antiviral treatment

 patient-provider communication

 vaccinations for hepatitis A and B

 dietary and exercise behaviors

 other misc. efforts to avoid transmission, manage 

symptoms, or avoid things harmful to the liver
Patient Characteristics

Information-only

n = 65 

Self-management

N =69

p-value

 Mean age (sd) 56.4 (7.2) 53.0 (5.2) 0.003**

 Gender 

 Male 95 96 0.909

 Female 5 4

 Residential % 0.577

 Homeless 13 15

 Group living residence 30 35

 With relatives 3 4

 Apartment 33 36

 Own house 21 10

 Homeless in the past 5 years % 59 38 0.015*

 Transportation % 0.241

 Drive own vehicle 40 26

 Public transportation 51 64

 Other 9 10

Years since contraction (sd) – self-report 25.1 (13.0) 21.6 (11.9) 0.152

Years since diagnosis (sd) – self-report 9.9 (8.9) 9.9 (9.6) 0.995
Patient Characteristics
HCV Self-Management results

 Attendance: mean of 5.2 out of 6 sessions (87%)

 At 6-weeks, workshop improved more on HCV 

knowledge, HCV self-efficacy, and SF-36 

energy/vitality

 At 12-months, effects were found for HCV knowledge, 

energy, and global QOL (QWB-SA)

 Trends found for physical functioning, CES-D 

depression, and health distress
HCV Self-Management results

Measure 1-year 

prior

1-year post Total 

change

p-value Effect size 

(d)

HCV Appointments Attended 0.344 0.24

 Information-only 1.9 1.8 -0.1

 Workshop 1.8 2.5 0.7

Appointment No-shows

 Information-only 1.8 2.0 0.2 0.600 0.13

 Workshop 2.4 2.2 -0.2

Inpatient Days less ADTP 0.390 0.22

 Information-only 1.7 1.8 0.1

 Workshop 3.4 2.0 -1.4

ER visits** 0.029 0.46

 Information-only 2.6 1.6 -1.0

 Workshop 1.4 1.7 0.3

Prescribed Medications* 0.877 0.02

 Information-only 5.0 3.9 -1.1

 Workshop 3.9 2.9 -1.0

Medication Refill Ratio

 Information-only 0.70 0.59 -0.11 0.282 0.24

 Workshop 0.73 0.83 0.10

 Total sample
Cost-Effectiveness results

 Our study delivered the intervention to 69 participants 

across 9 programs, averaging 7.67 participants per 

program

 The total mean intervention cost was $1806.00 per sixweek program and the total cost per participant was 

approximately $235.00

 The mean incremental increase in QALYs was 0.068 per 

participants, resulting in an incremental 

cost/effectiveness ratio = $3456/QALY

 *Stanford programs – effective with 20 people per 

program.
HCV Self-Management 

Program
Session 1

 Introductions - Identifying Common 

Problems

 Workshop Overview, Goals & 

Responsibilities – new treatment focus

 Hepatitis C information - general

 Acute & Chronic Conditions - HCV

 HCV antiviral treatment information -

updated

 Intro. to Action Plans
Parts of an Action Plan

1. Something YOU want to do

2. Reasonable

3. Behavior-specific

4. Answer the questions:

What? (for example, walking)

How much? (walking 4 blocks)

When? (after dinner)

How often? (for ex., 4 times; try to avoid “every day”)

5. Confidence level of 7 or more (0=no confidence to 10=total 

confidence; that you will complete the ENTIRE action plan)
Session 2

 Action Plan Feedback/Problem-Solving
Problem Solving

 Problem Solving –

 used in sessions 2-6 to review successes & failures of the previous 

weeks action plan.

 group members use discussion and brainstorming to help others 

be successful with action plans 

 7 steps to Problem Solving

 Identify the problem

 List ideas to solve the problem

 Select one method to try

 Assess the results

 Substitute another idea

 6. Utilize other resources

 7. Accept that the problem may not be solvable now
Session 2

 Action Plan Feedback/Problem-Solving

 Antiviral Treatment: Barriers and 

Facilitators – new

 Intro. - Cognitive Symptom Management 

 Benefits of Exercise 

 Alcohol and Drug Usage and HCV – new 

(brief interventions)

 Making an Action Plan
Alcohol Usage and Hepatitis C

 Discuss: HCV and alcohol consumption 

(http://www.hepatitis.va.gov/patient/alcohol/index.asp

 Brainstorm: Pros & cons of alcohol consumption

 Understanding triggers to promote abstinence and better 

decision making

 Change Plans

 Drinking Diary

 Brief Interventions & Motiv. Interviewing
Session 3

 Action Plan Feedback/Problem-Solving

 Dealing with Difficult Emotions

 Fatigue Management

 Hepatitis C Treatment Adherence - new

 Managing Treatment Side Effects - new

 Muscle Relaxation

 Making an Action Plan
Session 4

 Action Plan Feedback/Problem-Solving

 Antiviral Treatment Discussion Panel
Treatment Discussion Panel

 composed of 1 HCV healthcare provider and 2-3 

peers

 Goal: to provide an informal atmosphere for 

patients to ask questions

 3 parts to this module

 healthcare provider describes recent developments, clinic 

expectations, positive past experiences

 peers describe their experience & challenges

 Q&A for the Panel
Session 4

 Action Plan Feedback/Problem-Solving

 Antiviral Treatment Discussion Panel

 Making Informed Treatment Decisions

 Peer Support - new

 Communication Skills

 Problem-Solving
Session 5

 Action Plan Feedback/Problem-Solving

 Medication Usage/Adherence

 Healthy Eating

 Depression Management

 Self-Talk

 Guided Imagery
Session 6

 Action Plan Feedback/Problem-Solving

 Informing the Health Care Team

 Collaborating With Your Health Care 

Professional

 Longer-term goal setting

 Preparing for HCV Treatment – new

 Looking Back and Planning for the Future
Planning for the Future

 Participants are asked to:

 brainstorm all self-management techniques they 

have learned

 discuss how these techniques can help with HCV 

antiviral treatment

 share about their accomplishments & positive 

changes of the group as a whole 

 thank the other group members for their 

contribution & input

 group exercise “success visualization” 
Lessons learned

 Recruitment can be challenging

 Day vs. night

 No-shows

 Transportation?

 Those who show for first session attend well

 Good peer-leaders can be hard to find

 Two hour sessions are long, we provided 

refreshements
Future Directions 

for the HCV-SMP
Increasing Access to the HCVSMP via the Internet

 Funded by QUERI RRP

 Uses Stanford’s existing platforms for other 

Internet-based SM programs

 Can be accessed from any computer with 

Internet service

 Will be recruiting 40-50 VA patients for pilot 

study Oct-Dec 2013
Next Steps for the in-person 

HCV-SMP

 SDP – more evidence of impact on 

treatment outcomes before implementation

 Finalize revised sessions and pilot

 Resubmit for implementation? Dilemma of 

changing field
Tips for starting 

HCV self-management

 Contact us (Stanford Patient Education) 

 Find health professional to be trained and 

lead

 Locate organizations with CDSMP Master 

trainers http://patienteducation.stanford.edu/organ/

 Find a HCV-infected individual to be 

trained and be a peer-leader

 Locate space
Summary

 HCV-SMP has been shown to improve 

knowledge, self-efficacy, symptoms, & QOL

 Being adapted to focus more on improving 

antiviral treatment outcomes

 Being adapted for Internet-based delivery

 Is very low-cost, $235 per person vs $30,000
Thank you!

egroessl@ucsd.edu

Erik.groessl@va.gov