. 2018 Mar;35(Suppl 2):S14–S23.

Table 2.

Integrated Care Models From the Literature

Year; Etiology of Liver Disease (Mental Health Disorders, No.)	Definition of Integrated Care	Notable Results
2006; HCV (n = 184, of these 149 had positive screens for AUD, depression and/or PTSD)⁷⁶	Screening for MH/substance use disorders was conducted. Depending on scores, patients were referred to an established MH provider, a PCNS who was co-located in the hepatitis clinic, or both. Some patients had an existing MH provider.	38.3% had an existing MH provider, 47.0% had no MH provider and were referred to the PCNS, and 15.0% refused any psychiatric referral; 14% of 57 patients with existing MH providers started antiviral treatment; 48.6% of 70 patients with PCNS started antiviral treatment; 27% of 22 patients with no MH follow-up started antiviral treatment; 23.5% of 34 patients with positive screen seen by PCNS had treatment discontinuation; 35.7% of 14 patients with positive screen not seen by PCNS had treatment discontinuation.
2007; alcohol⁸⁷	Group meetings held with a psychiatrist specializing in substance use disorder, the PLN, and the liver clinic staff. Providers were given a multidisciplinary care assessment booklet with information about alcohol history taking and detoxification. Alcohol counselors and project nurses also conducted brief interventions with patients, including information-giving and advice.	Patients and their families appreciated the removal of the stigma and accepted the opportunity for a brief intervention and education; 88% seen by PLN vs 6% prior to the introduction of collaborative care; 84% had outpatient appointments vs 12% prior to the introduction of collaborative care; 96% of staff reported increased awareness about alcohol-related liver disease, and 83% felt more confident in caring these patients.
2007; HCV⁷⁵	A viral hepatitis clinical nurse specialist was employed in the local drug and alcohol action team. Patients were offered support at weekly hepatitis nurse clinics and by a local hepatitis support group, the Peacock-Project. Nurses created a pathway booklet for treatment of HCV and provided it to patients.	Prior to the project 17 patients received HCV treatment over a 3-y period vs 51 patients in a 4-y period after changes in care were made.
2010; HCV (n = 47, alcohol use)⁷⁷	Two psychiatrists and a later addition of PCNS were embedded in the hepatitis clinic. Actively drinking patient received brief alcohol counseling (5–10 min) by HCV clinicians and then were scheduled for outpatient follow-up with the PCNS, who used motivational and cognitive behavioral therapy.	Patients reported > 50% drinking reduction, 12 patients achieved or maintained abstinence; 8 refused referral, and among these only 1 maintained decreased alcohol use.
2011; HCV (n = 355, injection drug use within 6 months)⁹⁴	Both intervention and control groups were counseled to avoid alcohol, but the intervention group also received enhanced counseling focused on education about the natural history of HCV and alcohol.	Alcohol abstinence increased 22.7% in both groups after 6 mo.
2011; HCV (n = 101, initially deferred from antiviral therapy due to MH comorbidities)⁴⁶	Participants were randomized to intervention (50 patients) or standard of care (51 patients). The intervention group received counseling such as motivational enhancement techniques and case management for up to 9 mo. The intervention was guided by patient’s stage of readiness. Blinded hepatologists assessed treatment eligibility over follow-up.	Reasons for initial deferral included psychiatric issues (35%), alcohol abuse (31%), drug abuse (9%), or multiple (26%); 21 patients of the intervention arm became eligible for therapy compared with 9 in the standard care; Patients in the intervention arm were > 2 times more likely to be eligible for treatment at 9 mo.
2012; HCV (n = 76, on methadone maintenance)⁷⁴	An internist-addiction medicine specialist from MMTP was embedded in the hepatitis clinic. Staff psychiatrists were available for patient consultation, and a psychosomatic medicine fellow was available on request.	No control group; 24 patients initiated treatment with 19 completing and 13 (54%) achieving sustained response; Men who were engaged in the MMTP < 36 mo were less likely to be seen in hepatitis clinic then those engaged for > 36 mo.
2012; HCV (n = 120, referred by needle exchange program)⁸²	A free, community-based, nurse-led integrated care clinic established in 2008 including primary care and social work staff with a focus on HCV and drug treatment.	More than 70% changed alcohol use habits; 82.6% noted the clinic providing them with information to better manage HCV; 72.8% felt the clinic gave them confidence to better manage HCV; Patients noted to be very satisfied with the clinic and experiencing a discrimination free environment; Patients attending clinic > 6 mo were more likely to report planning for treatment < 6 mo.
2013; HCV (Interviews of 24 health providers and 24 patients)⁸¹	A free, community-based, nurse-led integrated care clinic established in 2008 including primary care and social work staff with a focus on HCV and drug treatment.	Participants gave feedback that the clinic was a good support mechanism for patients at all stages of their HCV illness; They noted that the clinic provides a “nonjudgmental” service leading to improved health outcomes.
2014; HCV (Interviews of 24 nonpatient stakeholders)⁸⁰	A free, community-based, nurse-led integrated care clinic established in 2008 including primary care and social work staff with a focus on HCV and drug treatment.	Described clinic as easy to access, nonjudgmental and non-threatening making it engaging to the “hard-to-reach” clients; Some participants expressed concerns of wasting resources with double handling of patients.
2013; NAFLD (n = 12)⁸⁴	Patients were prescribed personalized diet, physical exercise, and behavioral therapy for 3 mo. An expert cognitive behavioral psychologist provided support, counseling, and motivation at baseline, and after 1 and 3 mo. All patients underwent consultations by hepatologists, psychologists, and dieticians at each time-point.	No control group was included; There was a decrease in total caloric intake and increase in daily physical activity in all patients; 8% reduction of body weight; Reduction of aminotransferases; Liver fat decreased significantly by ultrasound.
2014; HCV (n = 139, AUD)³¹	Hepatitis clinics assigned 70 patients to MET and 69 to a control education with 6-mo follow-up. MET included 4 sessions that included feedback regarding liver testing and motivation to reduce alcohol use.	At 6 mo, MET group reported 73% of days abstinent vs 59% in control group; Alcohol use in the control condition decreased significantly at 3 mo but plateaued at 6 mo unlike MET where there was no plateau.
2015; HCV (n = 363, patients tested positive for depression, PTSD, and/or substance use)⁷⁸	Patients were randomly assigned to IC vs UC groups. A midlevel MH practitioner was embedded in the clinics to provide brief MH interventions and case management.	A greater proportion of patients in the IC group began receiving antiviral therapy (31.9%) vs UC (18.8%); The IC group achieved a higher rate of sustained virologic response (15.9%) vs (7.7%).

Abbreviations: AUD, alcohol use disorder; HCV, hepatitis C virus; IC, integrated care; MH, mental health; MMTP, methadone maintenance treatment program; MET, motivational enhancement therapy; NAFLD, nonalcoholic fatty liver disease; PCNS, psychiatric clinical nursed specialist; PLN, psychiatric liaison nurse; PTSD, posttraumatic stress disorder; UC, usual care.