The Transitional Liver Clinic (TLC): Reducing Liver Disease Readmission

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PROJECT SUMMARY/ABSTRACT Individuals with liver cirrhosis and alcoholic hepatitis often experience the complications of advanced liver disease: ascites, hepatic encephalopathy, and gastrointestinal bleeding. These complications frequently lead to hospitalizations, and after hospital discharge, disease complications can interact with medication errors and poor provider communication, resulting in frequent early hospital readmissions. Outcomes during the vulnerable post-discharge transition period could be improved through better transitional care (TC), focused on optimizing treatment regimens, improving communication, and facilitating access to community and other healthcare resources. TC addressing these issues has successfully improved outcomes in heart failure and other conditions, but there are few data on TC programs in patients with advanced liver disease, who suffer from unique clinical complications that can complicate TC treatment plans. To address this gap in our healthcare delivery system, we have developed an advanced practice provider (APP)-led TC program for patients with the complications of advanced liver disease: the Transitional Liver Clinic (TLC). In the TLC, patients discharged from the hospital with complications of advanced liver disease are contacted by telephone within two days of discharge, followed by a face-to-face or video telehealth visit with the APP within 7-14 days. During this time, TLC providers reconcile and manage medications, provide education and linkage to community resources, and facilitate necessary follow-up. This proposal aims to test the effect of the TLC on hospital readmissions, quality of life, and patient satisfaction with care. The hypothesis is that the TLC will improve patient outcomes across these domains. To achieve these aims, the TLC will be evaluated using a pragmatic stepped-wedge randomized controlled trial comparing the TLC to usual care at four high-volume tertiary care liver centers. Upon completion of the study, the investigators will have provided evidence for the efficacy of TC in reducing acute healthcare utilization and in improving quality of life and patient satisfaction for those with complications of advanced liver disease.