Melanie Cole, MS (Host): The benefit to rural communities of having nationally ranked academic medical center quality liver care close to home is invaluable for patients in these communities. We're talking about how Northwestern Medicine's Liver Transplant Care Clinics in Northern and Central Illinois and Rockford provide essential pre-transplant services locally right here on Better Edge, a Northwestern Medicine podcast for physicians.

I'm Melanie Cole. And joining me today is Dr. Sean Koppe, he's an Associate Professor, and Dr. Justin Boike, he's an Assistant Professor, both of Gastroenterology and Hepatology in the Department of Medicine at Northwestern Medicine. Doctors, thank you so much for joining us today. And Dr. Koppe, I'd like to start with you. What specific liver care challenges do patients in rural communities face? Can you give us a little bit about the inspiration behind establishing a liver transplant care clinics in urban areas?

Dr. Sean W.P. Koppe: Sure. I mean, I think the reality is that the farther away that you get from academic medical centers, the harder it is to sometimes get access to certain types of subspecialty care, such as Hepatology and Liver Transplant. And so, I think that's part of the inspiration for doing these clinics, is to bring the care closer to folks where they live. The other part of it too is, let's face it, people don't like driving downtown. That's true for our suburban patients that don't live as far away, and certainly very true for those who live 100 plus miles away. So, I think the idea of bringing clinics closer where they live is also good in that regard.

And I think finally, the most important thing too, is that the farther away that you live from a transplant center, the less access you oftentimes have to getting a liver transplant. It's been documented that patients who live farther away from transplant centers are less likely to receive transplants. So, I think the hope is that by bringing these clinics closer to people where they live, we also improve their access to services such as liver transplant.

Melanie Cole, MS: Access is so important. And Dr. Boike, what regions of Illinois do you currently see patients with liver disease?

Dr. Justin Boike: Yeah. So, we cover all aspects of Illinois. So within the Chicagoland area, we cover the North, Central, West, as well as South regions. We have hepatologists go to Northwestern-based offices, but we also go to private GI groups and see patients locally in their office who are not necessarily established with Northwestern. We also travel as far South as Champaign-Urbana, Peoria, Bloomington, as well as Dr. Koppe mentioned up to Rockford then too.

Melanie Cole, MS: Dr. Koppe, tell us a little bit about the clinics themselves, how they improve access to liver care for patients living in northern and central Illinois and Rockford. Tell us a little bit about the clinics themselves.

Dr. Sean W.P. Koppe: Well, I think the idea is that just the idea of being sort of present, you know, gives access to some of the patients where they live. I think we take it for granted a little bit in the Chicagoland area, how we have access to various academic medical centers. But for those who live farther away, it's not quite so easy to access.

And I think the other part of it too is just the geography-- or beyond the geography, I should say, you know, beyond the distances of the drives themselves is sometimes the support to have transportation to help you get to your appointments, for example. You know, there's some barriers in that regard as well. So, I think us coming closer to where patients live help give them more access. And so, it's probably more efficient for one of us to make one long drive once a month and see 15 patients rather than have 15 patients make 15 separate long drives to see one doctor.

Melanie Cole, MS: As we're talking about barriers, Dr. Koppe, how has telemedicine complemented the in-person liver care offered in these rural areas? How are you using telemedicine?

Dr. Sean W.P. Koppe: So, I think we all collectively do a mix of both in-person and telemedicine care. I think both patients and providers, you know, some prefer in-person visits. I would say the bulk of people still prefer in-patient or in-person visits. But, you know, having the ability to do telemedicine, especially for these farther off clinics, has been very helpful. So, I think most of our clinics are a combination of in-patient visits, and then, you know, followed up afterwards with some telemedicine visits as well. And it gives us a little bit of flexibility too with our schedules because these are clinics that are done pretty far away, many of them only one time a month. And so, you know, in order to maintain access to the clinic, we want to be able to accommodate all the in-person people that we can see that day, but also be able to get home at a reasonable time and also be able to still have access to other patients. And so, I think we use telemedicine to kind of complement that as well. So, it's a mixture of in-person and telemedicine visits.

Melanie Cole, MS: Dr. Boike, do you have some telemedicine stories to share?

Dr. Justin Boike: We do. Actually, we see a fair amount of patients with complex portal hypertensive issues. They actually come from all over the country, even as far as Germany at one point in time. So for many of those patients, we see them in person. We facilitate procedures to help manage. But then for followup, we're often doing telemedicine visits obviously because it's very challenging to travel multiple states and other places. So, we work in conjunction with local providers who are taking care of their patients to make sure that we have a good care plan. So as Dr. Koppe said, the telemedicine complements the component of seeing patients in the office too.

Melanie Cole, MS: Dr. Boike, then I'd like you to expand on what you just said about collaborating with local providers in these areas. Tell us a little bit about that.

Dr. Justin Boike: Yeah. So when we go out to other offices and see patients locally too, we're not just seeing them in a vacuum. So, we're often interacting with their local GI providers to come up with appropriate care plans. We interact with other service lines like interventional radiology who end up performing a lot of procedures on our patients, as well as even treating liver cancer in certain situations. And so, we often have multi collaborations with other providers locally, so patients can get a lot of their procedures and other testing locally and don't necessarily have to travel all the way downtown or to a Northwestern facility to have that done.

Melanie Cole, MS: As we're talking about access, barriers, telemedicine, and putting this all together for these clinics, Dr. Koppe, what challenges have you faced in setting up these clinics and how have you overcome them?

Dr. Sean W.P. Koppe: Probably some of the challenges we've encountered, you know, I had a flat tire one time going down I-55 just outside of Pontiac, so I had to change my tire and my suit and get back to clinic in time to see all my patients for the day. But beyond that, I think it just makes for some pretty long days on our part. You know, we have to leave kind of earlier in the day and go out and see a panel of patients. And then, you know, it makes for some long days between the drives and, you know, getting home kind of later at night.

I think the other part too is operating in clinic environments that are not our usual sort of home Northwestern clinics necessarily. So I think that in terms of some of the support staff and so forth that we kind of are used to with interacting at most of our other clinical locations, these clinics don't have those same people there. Now, that being said, we have an amazing group of people behind the scenes that provide us a lot of support. Our care coordinators, our MAs, our nurses, et cetera, that help us with sort of helping with the care of the patients, whether it's getting records, getting imaging uploaded, things like that, helping to answer patients' questions and provide them some continuity, you know, when we're away for that one day that we're in clinic as well.

And that being said too, even though we're not in familiar environments, I think the reality is we also do these clinics and locations. And the folks that host us are very accommodating and welcoming as well. So, we work with staff, as Justin mentioned, you know, collaborate with other groups and other practices and work with them as well. And so, they've been very helpful as well.

I think there's other issues too, such as having access to some of the, you know, specialized testing and procedures that we have very easy access to here at Northwestern. But one of the good things that's happened as time has gone on, as Justin mentioned, is that we've built these sort of collaborative relationships as well. So, we're familiar with a lot of the major medical centers downstate and up in Rockford and some of their capabilities and who to talk to, for example, if somebody needs a TIPS procedure with Interventional Radiology. We kind of know who to kind of go to with that type of thing, the ability to link patients, for example, with some of their local care, like liver cancer care, you know, those type of things.

So, I think one of the benefits is that, you know, we've done this for a while and we've sort of formed some of these relationships. So, there's some challenges, but I think as time has gone on, actually, you know, I would argue that things have actually gone relatively smoothly.

Dr. Justin Boike: I have had my share of flat tires as well too. It comes with the territory.

Dr. Sean W.P. Koppe: Yeah, one or two speeding tickets too.

Melanie Cole, MS: My next question is for both of you, Dr. Koppe, starting with you, as we think about these clinics and for referring physicians and other providers, can you mention some key components that you think if another medical institution is considering doing this kind of thing? What do you think is essential when you're looking at these institutions in the rural areas to meet the same quality standards as you would receive if you were at the Northwestern campus itself.

Dr. Sean W.P. Koppe: Yeah. I mean, I think it's a challenge. It also depends on the type of specialty you're talking about. You know, so for example, I think there's a lot of, for example, cardiac services available that are pretty strong in certain areas. Hepatology is kind of a smaller specialty, and so the reality is that there's not as many of us around. And so, I think there's not as many sort of kind of boots on the ground in terms of these locations downstate, et cetera. But I think that, again, getting back to the idea of these collaborative relationships, knowing when to sort of reach out and discuss some of these more complex patients, know when you need help and how to get that help.

 For us, I think we also serve to help educate, you know, some of the local providers as well and collaborate with them when they have a question. For example, you know, they will oftentimes curbside us on some patients as well. So, I'd like to believe that that also helps improve the quality of the care that they're delivering locally by providing them some support with their patients, even if it's not outright seeing their patients. Sometimes it's just even simply discussing cases and that type of thing.

Melanie Cole, MS: Dr. Boike, do you have some key components you'd like to mention?

Dr. Justin Boike: Yeah, I mean, I think the biggest emphasis is just on collaboration, so oftentimes when I'm seeing other patients in the office too, I'm talking with other staff and other providers and frequently discussing other cases for patients that I haven't even seen that day to come up with a unique care plan, determine, "Hey, do they need to see an additional expert? Should I see them next time I come down?" So, you know, those relationships are really important. And that's probably the biggest component here because, you know, we can influence and provide additional care for even patients that we haven't even seen yet. So, it does make a big impact.

Melanie Cole, MS: Well, it's a real multidisciplinary approach as we think about the other providers that you've mentioned. Dr. Boike, can you share any success stories or patient experiences that would highlight the effectiveness and impact of these clinics?

Dr. Justin Boike: I think the biggest success is really when we can identify a patient early in their disease course and intervene, prevent complications from occurring. But particularly for patients with cirrhosis, it's unique, liver transplant, right? And so, many providers aren't necessarily familiar with, hey, when should a patient be referred for transplant? And we're always trying to make sure that we see those patients as soon as possible early in the natural history.

So if we identify that they're heading towards needing a liver transplant, we can get them referred, get the evaluation completed, get them prepared and listed for transplant before they become too sick or before things unfortunately progress and the patients are in a point where they're not able to be transplanted. So, the biggest success is really being able to identify those patients early on, get them plugged in with us, get them evaluated, and ultimately get them listed if they're in need of a transplant.

Melanie Cole, MS: Dr. Koppe, what role does community outreach play in the success of these liver transplant care clinics? Tell us a little bit about community outreach and how people find out about you.

Dr. Sean W.P. Koppe: Well, a lot of it has to do with the relationships again, that we have with the local providers, and I think also maintaining good communication, not just with the GI specialists, but also with the primary care doctors as well. So, as the primary care doctors also become more and more aware of some of the opportunities to get liver care for their patients closer to home, we'll sometimes get referrals just even directly from primary care doctors for liver issues as well.

I think the communication is key to pretty much every relationship you want to talk about. And so, I think we really, you know, are pretty good about putting an emphasis on getting back to providers about what's happening with the patients, what the plan is, and also being accessible all the time. You know, we may go down for a clinic once a month, but the reality is we don't view this as a once-a-month type of a situation. The reality is that besides that, once-a-month in-person clinic day that we're there, the rest of the month, we're oftentimes always available as well for calls, quick curbsides, questions about management, questions about a transfer. You know, "Hey, I've got a patient I've got to link up and get seen pretty soon. Can you help me out?" And, you know, we make it happen as well. And so, I think doing those things has really helped engage local communities with some of the care that we provide.

We've also done some educational things, some dinners on some liver topics and that type of thing. And I've also participated in some of the educational programs that some of the local providers also have for their own local providers as well. So, for example, we engaged in a conference that one of the local gastroenterologists put on one time for some of the primary care doctors about things like fatty liver disease and that type of thing. And so, we've sort of engaged and participated in that with them as well, showing that, you know, we're truly invested in helping them also spread the knowledge about liver disease with their referring providers as well, their primary care doctors in the area.

Melanie Cole, MS: The education is such an important component to these clinics. And as we get ready to wrap up, Dr. Boike, looking ahead, what are your goals for expanding and enhancing these liver care services in non-urban areas? Tell us what you hope to happen and what you see in the future.

Dr. Justin Boike: Our biggest goal is to continue expanding. So, as Sean mentioned earlier, you know, as patients move further and further away from large academic centers, we know that, unfortunately, the quality of liver care diminishes, as well as the risk of death from liver disease, unfortunately, increases too. So, the more we can go out into the community and push this further and further, the more we can reduce that disparity and provide reasonable and excellent care for our patients. So, continuing to build the local relationships, but also expanding further and further throughout the state is really the overall goal.

Melanie Cole, MS: Thank you, doctors, so much for joining us today. This was such an enlightening conversation. Thank you again. And to refer a patient or for more information, please visit our website at breakthroughsforphysicians.nm.org/gastroenterology to get connected with one of our providers. That concludes this episode of Better Edge, a Northwestern Medicine podcast for physicians. I'm Melanie Cole. Thanks so much for joining us today.