A Trial of Post-Discharge Transitional Care for Patients With Chronic Liver Disease

Patients with complications of advanced liver disease often have difficulties after hospital discharge that result in early hospital readmission. Poor outcomes for these patients during this transitional time could be improved through the use of innovative transitional care models. This proposal aims to examine the effect of a transitional care model, The Transitional Liver Clinic (TLC), in reducing hospital re-admissions, improving quality of life, and improving patient experience.

Inclusion Criteria:Male or female age ≥18Diagnosis of advanced liver disease, defined as either (must meet either a or b)cirrhosis based on (either i or ii):biopsycharacteristic clinical, laboratory, and imaging findingsacute alcoholic hepatitis, defined by NIAAA Alcoholic Hepatitis Consortia, asonset of jaundice (serum bilirubin >3.0 mg/dL) in prior 8 weeksconsumption of >40 (female) or 60 (male) g alcohol/day for ≥6 months, with <60 days abstinence before jaundice onset,AST>50 IU/L, AST/ALT>1.5, and both values <400 IU/Lliver biopsy confirmation in patients with confounding factorsHas at least one of the following complications due to advanced liver disease occurring during hospitalization:ascites requiring diuretics or paracentesishepatic encephalopathy requiring lactulose or rifaximingastrointestinal bleeding due to portal hypertensionjaundiceHas planned discharge alive to home or a facility within 72 hours of informed consentAble and willing to provide informed consentExclusion Criteria:discharge under hospicelisted for liver transplant with MELD-Na ≥ 35unable or unwilling to participate in post-discharge follow-up either in-person or virtuallyunable to speak or understand English and/or Spanishlow hearing or communicative ability (examiner rated) that would interfere with interventions and outcome assessmentslack of access to a telephoneincarceratedconcurrent enrollment in an interventional research study