Implementation of a Transitional Care Liver Clinic: Lessons Learned

Abstract

Introduction: Transitional care clinics help optimize inpatient-to-outpatient management in many chronic diseases, but there is limited data for cirrhosis. Our show rate for discharged patients booked in general hepatology clinics at a university health system used to be less than 50%. In March 2015, we opened a transitional care liver clinic (TCLC), targeting non transplant eligible patients with cirrhosis admitted to our inpatient liver service - a difficult population to engage. Our main goal for TCLC was to expedite outpatient follow up and to improve continuity of care in this vulnerable population. Our aim was to identify potential areas of improvement in our TCLC, by assessing the TCLC volume, show rate, and patient population characteristics. Methods: This is a retrospective review of patients scheduled in our TCLC from March 2015 to December 2015, with follow-up through December 2016. TCLC was staffed by a single transition provider who met the patients during their hospital stay. Subsequently, the patients were booked in regular liver clinics. We collected data on 1) TCLC volume: number of clinics, scheduled appointments, actual clinic visits; 2) patients: individual patients seen, patient characteristics. Results: Between March and December 2015, 412 encounters were scheduled in 69 TCLC sessions: 193 showed, 143 cancelled (48 hospitalized), 73 no-showed (details in Table 1). TCLC show rate was 73%. The clinic volume (Figure 1) increased gradually to 31 encounters/month. There were a total of 157 patients scheduled in TCLC. Although the majority (66%) were our “target” patients with cirrhosis, non-transplant eligible, and discharged from our inpatient liver service, other types of patients were seen (Table 2). For our “target” patients (61 showed, 38 no-showed, 4 cancelled), show rate was 62%, discharge-to-TCLC 8.3 days, 30-day readmission rate 33%, and 1-year mortality 36%.Figure: TCLC Volume.Table: Table. TCLC EncountersTable: Table. TCLC PatientsConclusion: TCLC had a high show rate considering the risk of readmission and mortality in our target population. There was a significant use of TCLC for patients discharged from non-liver services or without cirrhosis. Fluctuations in clinic volume were likely related to high cancellation rate, but also to vacation time. An additional TCLC provider could help with coverage for vacation and for other liver patients post-discharge. Increased administrative support could convert cancelled/“no-show” to “show” visits and optimize TCLC visits within 7 days from discharge.