The Role of NPs and PAs in Supporting HE Patient Care
Host: Christina J. Hanson, FNP, South Denver Gastroenterology
Featuring Mikhail Alper, PA-C, California Gastroenterology Associates
Welcome to Clinical Conversations: The Role of Nurse Practitioners and Physician Assistants in Supporting Hepatic Encephalopathy Patient Care
Christina Hanson and Mikhail Alper received payment from Salix Pharmaceuticals for their testimonies.
Christina: Hello, and thanks for tuning in to Clinical Conversations. I’m Christina Hanson, and today we’ll be discussing the role of nurse practitioners and physician assistants in supporting the care of patients with hepatic encephalopathy, or HE. I am here today with Mikhail Alper, a physician assistant with California Gastroenterology Associates in Fresno, California. Thanks for joining us, Mikhail.
Mikhail: Thank you, and I’m happy to be here.
Christina: I’ll start by saying that if you’re not familiar with HE or you aren’t sure how to recognize it in your patients with chronic liver disease, you may first want to watch our episode on managing HE, then come back to learn more about how you can support the care of your patients with HE. Whether we specialize in hepatology, gastroenterology, or primary care, it is our responsibility to recognize signs of HE and to routinely assess patients with cirrhosis for overt HE, and Mikhail, I’m sure you agree. Some practitioners may think that because they’re not specialists, they might not be able to help. There are a lot of stakeholders in the HE patient journey, and if everyone plays their part, it can help minimize potential delays in care. Mikhail, what are your thoughts?
Mikhail: You’re right, Christina. There are many different settings in which patients with HE are provided care: primary care, GI practices, the transplant clinic, and even the emergency department. Providers in all of these settings may have a different approach to managing these patients. There’s a huge opportunity for NPs and PAs to contribute to patient outcomes.
Research has shown that cirrhosis is on the rise, and many patients with cirrhosis will be affected by HE in some form. When a patient is discharged from the hospital after an episode of overt HE, a major challenge is reducing the risk of a recurrence that can result in hospital readmission. It’s been shown that 1 year after an episode of overt HE, patients have a 40% cumulative risk of overt HE recurrence. On top of that, patients with recurrent overt HE have a 40% cumulative risk of another recurrence within 6 months, despite treatment with lactulose.
So for the NP and PAs, it’s important to understand that, before we even think about a diagnosis of HE, we must recognize that the patient has cirrhosis of the liver. Then, we have to consider the fact that patients with cirrhosis have a high chance of developing HE at some point during their clinical course. Because of that risk, we have to take the time to ask the patient questions that help evaluate for signs of overt HE. We need to identify these patients. I think if you really know your stuff and focus on your liver cirrhosis patient, you might find signs of overt HE more often than you might think.
Christina: So if we can play this role and help identify patients with overt HE, we might be able to help minimize potential delays in care.
Mikhail: Yes! Keep in mind that a lot of patients with HE may present to their primary care provider, which presents a significant opportunity to identify these patients due to the number of NPs and PAs in primary care. When I speak at events, I try to identify NPs and PAs that have some interest in hepatology and encourage them to become hepatology-focused in their own practice. I will even encourage them to contact me by phone or text for any support they need, for example, with difficult case. Because there are so many stakeholders involved in the care of patients with overt HE, it can be helpful to develop a network of clinicians to whom you can reach out for advice regarding patient care.
I don’t know everything, but I am trying to know as much as I possibly can. I love to help. I love to gain knowledge and share that knowledge because no one person can see all of these patients—you really have to share knowledge and know that somebody else will be able to help you as well.
Christina: Mikhail, you have decades of experience working with cirrhotic patients and patients with HE, so what do you do when you see patients with liver cirrhosis who are at risk for HE?
Mikhail: Christina, I always ask the simple questions. “Have you noticed changes in your sleep patterns? Are you feeling fatigued or lethargic? Is your speech slurred?” It is important to ask not only the patient, but also the caregiver, if they are present. Questions like these should be asked routinely. If you have the sense that the patient is in the early stages of overt HE, I personally think that you should act right there. Don’t wait until they progress, potentially to a coma.
For patients with a diagnosis of overt HE, I always explain to them that the diagnosis is not something to take lightly. They have to be serious about understanding how to recognize symptoms of recurring overt HE. Maintaining communication with their doctor and adherence to the disease management plan are also important.
Discussing all the details of overt HE with patients and loved ones is very important. They will work with you if they know that they can trust you, that you will listen to them, and you will give them the right advice.
Christina: Educating these patients and their caregivers is so important and is certainly an area where NPs and PAs can provide support. So in terms of transition of care, and ensuring patients receive the continued support they need after an overt HE episode—for example after discharge from the hospital—what are some things providers can do to help?
Mikhail: Christina, there are several things we can do, some of which are in line with what I just mentioned. First, we can identify patients at risk for poor transition of care after a hospitalization or an outpatient visit, such as patients with frequent hospital admissions, patients who are taking multiple medications or have comorbid conditions, patients with poor medication adherence, and patients with cognitive or functional impairments. Secondly, we should verify with the patient and their caregiver, all the prescription medications, over-the-counter therapies, herbs, and supplements that they are taking and identify any potential barriers to adherence or access. Then make a plan for addressing those barriers. These are just a few things that can be beneficial for the patient and certainly fall within our areas of expertise.
Christina: That’s true. I think most of us would feel comfortable taking those types of steps. I also make a point to assess the patient’s self-management abilities and evaluate how well patients and their caregivers understand their current health situation. Patients and caregivers can sometimes receive conflicting or unclear recommendations as they move through the care continuum, and in cases of HE, they can certainly come in contact with several different providers. Sometimes, patients or their caregivers may even be excluded from the planning related to the transition process.
Mikhail: Exactly, Christina. Patients and the caregivers may be unclear about medication regimens, or they may lack a sufficient understanding of the medical condition of overt HE or the care plan. In other words, they may not understand the importance of following the care plan, or they may lack knowledge or skills to do so.
For patients being discharged from the hospital, validated surveys can be helpful. The 3-item Care Transition Measure identifies gaps in patient or caregiver understanding of the care plan. For example, consider asking how much the patient agrees or disagrees with the following statements: (1) The hospital staff took my preferences and those of my family or caregiver into account in deciding what my health care needs would be when I left the hospital; (2) When I left the hospital, I had a good understanding of the things I was responsible for in managing my health; and (3) When I left the hospital, I clearly understood the purpose for taking each of my medications.
I also like to make sure the patient and their caregiver understand how to take their medications appropriately.
Christina: Yes, especially when there are multiple specialists involved, providers may sometimes be unable to coordinate care or communicate effectively with one another, which may result in confusion for the patient as well as for those responsible for transitioning the care of the patient to the next setting or provider. Multidisciplinary communication, collaboration, and coordination between all care providers is essential for successful patient outcomes, and I think this is a place where NPs and PAs can really step in and help the patient.
Mikhail: Yes, Christina, and it is important to put processes in place to support the development of an ongoing care plan, which should include input from the patient, primary caregiver, and family. This plan should be accessible to all care managers and remain with the patient’s regular provider for continuity. It is also important to communicate essential transition information—such as diagnoses, medications, and follow-up appointments—to key stakeholders across the continuum of care. These stakeholders may include the patient, their caregiver, their regular primary or specialist care provider, and the care manager at the next care setting.
Christina: For patients and caregivers in particular, another way we can help is by making them aware of things that may precipitate an overt HE recurrence, so they can try to seek help before it becomes an emergency situation. These things could include gastrointestinal bleeding, infection, overdose of certain medications, and nonadherence to medications like lactulose. Patients with chronic liver disease should also be aware of the early signs of recurrence and what actions they should take in the event of a recurrence.
Mikhail: Adherence to the medication is an important discussion point. Nonadherence is common in patients receiving long-term therapy for chronic conditions—any condition, not just overt HE. We should educate patients with overt HE on the benefits and risks of their medications and how their medications should be taken.
Christina: I think, especially after a patient has an episode of overt HE, it’s important to educate the patient about the purpose of their prescribed medications. Our practice actually uses a little sheet that we give to our patients at each visit. It has all the important contact information at the top, and, below, it’s blank so I can write out notes for them—reminders of the medications they are on and when to take them, any tests that we’re running, things like that.
I always encourage frequent follow-ups to ensure patients are adherent and have enough refills to continue treatment. Frequent follow-up is also important to facilitate routine monitoring of neurologic manifestations in these patients, which can help us identify signs of overt HE recurrence.
Mikhail: Yes, exactly. And there are several ways to help assess cognitive function in patients with HE, including measures like the Animal Naming Test or mobile applications that track cognitive function like the Patient Buddy App. Early recognition of overt HE is essential for timely management of the disorder and can help us provide the best care possible for our patients.
Christina: Well, with that, I would like to say that it has been great having you here today, Mikhail. Thank you so much for sharing some of your insights on patient care.
Mikhail: Christina, it was my pleasure to talk with you today.
Christina: And thanks to our audience for joining us for this episode. You can find more clinical conversations around HE, available in both video and podcast format, on GastroHubAPP.com.