The Development of a Hepatology Care Coordination Program: An Effort to Achieve Reductions in Hospital Readmissions

Abstract

Introduction: Due to the progressive nature of cirrhosis, patients are prone to frequent hospital admissions and readmissions. The period immediately after discharge is a ‘high risk’ one. Patients often carry new diagnoses, are on new medications, have received changes in the dosages of existing medications, and are deconditioned from their hospital stay. The aim of this endeavor was to create a sustainable care coordination program that would improve patient outcomes and achieve reductions in cirrhosis-related re-admissions at our institution. Methods: Our hospital is an inner-city quaternary care medical center with a dedicated hepatology inpatient service and an active liver transplant program that performed 53 orthotopic liver transplants in 2013. Based on an over 30% patient 30-day readmission rate to the inpatient hepatology service for cirrhosis-related complications, a care coordination program was created in February 2014. Patients at high risk for readmission (i.e. recurrent encephalopathy, refractory ascites with frequent need for paracentesis, failure to thrive, poor social support systems) are enrolled on an ongoing basis. Once these patients are recognized by the attending hepatologist, the inpatient liver transplant coordinator is notified. When appropriate patients are identified, monitoring equipment is installed in the patient’s home and education/medication reconciliation is provided to the patient and family before discharge. On arrival home and on a daily basis, the patient’s daily weight, heart rate, blood pressure, and pulse oximetry are monitored by a home monitoring company call center. The program also includes frequent phone follow-up post-discharge by the inpatient coordinator for continued assessment. Any identified clinical issues are discussed real-time with attending hepatologist enabling medication adjustments and/or rapid clinic follow-up. After regular office hours, clinical abnormalities and concerns are discussed with the on-call doctor by the call center. Additionally, all enrolled patients are seen in the outpatient hepatology office within 1 week of hospital discharge. As of May 8, 2014, 11 patients have been enrolled in the program. Conclusion: In an effort to respond to the frequent and costly readmissions for management of complications due to cirrhosis, we created an intensive care coordination program. Although still in its early implementation, it may be a tool to avoid hospital readmissions in select cases. This model of patient discharge care coordination can be replicated at other institutions.