A home-based, multidisciplinary liver optimisation program for the first 28 days after an admission for acute-on-chronic liver failure (LivR Well)

INTERVENTION: The 28 day intervention will be delivered through ‘Hospital in the Home’ (HITH), a medically‐led ambulatory care program supported by physical clinics and home‐visits by the nursing team. HITH is able to deliver many aspects of acute hospital care in the community, for otherwise stable patients. This includes diagnosis and management of acute conditions that would typically require bed‐based care Patients will have access to up to three, 1 hour home visits per week by nursing staff and physiotherapists. Nursing aspects of the home visits will include routine vital sign assessment (heart rate, respiratory rate, blood pressure, pulse oximetry and temperature), blood tests requested by medical staff (full blood count, urea/creatinine/electrolytes, liver function tests, international normalised ratio), administration of quality of life assessments at baseline/week 6/week 12 (Chronic Liver Disease Questionnaire and EuroQoL 5D), and general enquiry regarding concerns and wellbeing. Nursing staff can escalate to medical staff whenever a concern is raised. The patients will attend a hospital‐based ambulatory care liver clinic weekly, for up to 2 hours duration, for a medical and nursing review with dietitian, social work, addiction medicine specialists and pharmacist consultations as required. Patients could be referred to LivR Well from an outpatient context, the emergency department or the inpatient ward. All severity of liver disease is eligible unless the patient is receiving end of life care. There are no cut‐offs for MELD score or Child Turcotte Pugh score. The intervention will be personalised to the patient based on the criteria below. Intervention adherence will be assessed by attendance at scheduled appointments and undertaking of investigations requested. Adhe CONDITION: cirrhosis;acute‐on‐chronic liver failure; ; cirrhosis ; acute‐on‐chronic liver failure Oral and Gastrointestinal ‐ Other diseases of the mouth, teeth, oesophagus, digestive system including liver and colon PRIMARY OUTCOME: Primary composite outcome: death, waitlisting for liver transplantation or 30‐day readmission. This outcome will be assessed through access to the electronic health record for the health service. This is a multi‐site service spanning 3 tertiary centres, secondary hospitals and a catchment of more than 1 million people in south‐east Victoria. For patients referred to the statewide liver transplant service, this outcome will be assessed by directly requesting medical records.[90 days post‐intervention commencement] INCLUSION CRITERIA: Adult patients with previous or current hepatic decompensation complicated by organ failure Diagnosis of acute‐on‐chronic liver failure (ACLF) using the European Foundation of the Study of Liver Failure using the Chronic Liver Failure criteria (EF‐CLIF) and which includes age and white cell count. Severity is graded according to the number of organ failures Requiring consultation from at least 3 allied health clinicians SECONDARY OUTCOME: Changes in liver disease severity using Child‐Turcotte‐Pugh score[90 days post‐intervention commencement] Changes in liver disease severity using Model‐for‐Endstage‐Liver Disease Score (MELD)[90 days post‐intervention commencement] Changes in quality of life using EuroQoL 5D[90 days post‐intervention commencement] Cost‐effectiveness compared to standard care. This will be assessed with a cost‐effectiveness analysis to demonstrate absolute difference using admissions (including Hospital in the Home) data from hospital finance record reflecting cost to the healthcare system. Further economic assessment using the Incremental Cost Effectiveness Ratio and quality adjusted life years will be undertaken[90 days post‐intervention commencement] Quality of life using CLDQ[90 days post‐intervention commencement]