A new outpatient program for individuals with advanced liver disease who are not eligible for organ transplant offers multidisciplinary care for managing cirrhosis complications while decreasing ER visits and hospitalizations.
“We’ve been discussing how we can improve the care of these patients, specifically addressing their social determinants of health, such as difficulties with housing, transportation, and access to nutritious food,” said Simona Jakab, MD, associate professor of medicine (digestive diseases), who oversees the program. “It is not just the patients who would benefit, but also the healthcare system. We would like to offer better alternatives for outpatient care, so the patients don't have to rely on coming to the hospital for their cirrhosis care,” she said.
The program is called “The Liver Home.” Planning for it began in 2019, with support from the leadership of the Yale Medicine, Yale New Haven Health System Digestive Health Service Line.
“This new Liver Home model will truly elevate the way we deliver care in a coordinated patient-centered approach,” said Joseph Mendes, PA-C, Executive Director Program Development, Digestive Health, Yale New Haven Health. “Addressing the behavioral health needs of our patients is just the first step in our plan for the Liver Home program,” Mendes added. “It’s been great to see all of this come together, and I look forward to the growth of this program.”
Cirrhosis is a consequence of many chronic diseases of the liver when fibrous tissue accumulates, affecting liver function and potentially leading to liver failure. It can result from excessive alcohol use or infection with hepatitis B or C viruses, although the fastest growing indication for liver transplant is currently non-alcoholic fatty liver disease, seen in people with obesity.
“I'm very passionate about offering better care to patients with cirrhosis because they have so many health challenges,” said Jakab. “If somebody continues to use alcohol, drugs, or they don't have a good support system, or they don't have insurance, they will be declined for transplant,” Jakab added. “But they will still remain sick.”
A goal of the program is to decrease avoidable ER visits, hospitalizations, and inpatient length of stay. People with advanced liver disease often experience cirrhosis complications such as ascites (fluid build-up in the abdomen) or hepatic encephalopathy (confusion caused by accumulation of toxins not cleared by the liver). These complications result in recurrent hospitalizations and are associated with a high mortality rate. Most of the time, the only curative treatment is liver transplantation, but this is not an option for many people due to psychosocial barriers, substance use disorders, or other medical comorbidities.
This multidisciplinary program aims to provide patient-centered care to non-transplant patients. Through a three-year plan, it will facilitate access to social work services, addiction medicine, and nutrition, with the ultimate goals of improving patients’ outcomes such as transplant candidacy and survival. For example, the social worker would identify and address social barriers that limit patients’ engagement in their care, and also assist them with management of their substance use disorders. These interventions would impact not only the success of their medical treatment but increase their chance of being considered for liver transplant, Jakab said. The program will eventually integrate a community health worker and a nurse navigator, in order to increase patients’ adherence to outpatient visits, testing and treatment.
Jakab would like to start a remote patient monitoring program for blood pressure readings and daily weigh-ins at home. “We’ll get data transmitted through the electronic medical record, so we can be proactive about timely treatment changes rather than reacting when patients call because they’re getting sicker,” she said. Jakab is also working on opening an outpatient paracentesis unit. For patients with severe ascites, the only way to improve their symptoms is to have that fluid drained. “If we were to offer this service rather than sent the patients to interventional radiology, we can concurrently adjust their diuretics and other medications. So again, the idea is to optimize the outpatient care as much as possible to avoid preventable ER visits or hospitalizations,” Jakab said.
“We owe these patients a better outpatient experience, and I've seen it working very well in the VA setting where we have better access to remote patient monitoring, care coordinators, social workers, specialists in addiction medicine and palliative care,” she said. “And you can celebrate together if your patients’ liver disease improves, and they no longer need invasive procedures or difficult-to-tolerate medications. But even for patients who ultimately need end-of-life care, the transition is much smoother if all these resources are in place. We can provide better care and improve the quality of life for both patients and their caregivers, rather than simply putting off fires as the liver disease gets worse.”
Since forming one of the nation’s first sections of hepatology and then gastroenterology over 50 years ago, Yale’s Section of Digestive Diseases has had an enduring impact on research and clinical care in gastrointestinal and liver disorders. To learn more about their work, visit Digestive Diseases.