Background Advanced liver disease (ALD) poses significant challenges, including high symptom burden, frequent hospital readmissions, and complex care needs for patients. Traditional models delay palliative care until end-of-life stages or End-Stage Liver Disease (ESLD), often missing opportunities for earlier intervention, holistic approach to care and ‘unmet needs’ that could improve patient outcomes (Valery et al., 2015).

Aim The Liver Supportive Care program aimed to enhance the quality of life and health outcomes for patients with ALD with early integration of palliative care to manage symptoms, reducing hospital readmissions, and providing comprehensive, patient-centred care through a multidisciplinary approach.

Methods Patients were identified from the Royal North Shore Hospital (RNSH) liver clinic or during hospital admissions for decompensated liver episodes. Eligible patients, meeting the SPICT criteria, were enrolled in the Liver Supportive Care program. The program included:

• Early integration of palliative care

• Regular follow-up via telehealth consultations

• Weekly multidisciplinary team meetings (MDMs) involving hepatologists, nurses, dietitians, psychologists, and palliative care specialists to develop individualized patient care plans

• Patient reported outcome measures (PROMs) and quality of life assessments prior to palliative care reviews to tailor interventions

Results Since June 2023, the program has reduced 30-day readmissions from 42% to 12.12% and 90-day readmissions from 50% to 15.15%. With a clear discharge follow-up pathway, the program has reduced the average length of stay in hospital from 16.1 days (statewide) to approximately 4.6 days (within RNSH). Additionally, 48% of patients received early palliative care reviews, with 25% referred to community palliative care for ongoing management. Of the 18% of patients that have deceased since being on the program, 50% of the patients were known to community palliative care teams and care was escalated to a palliative care unit for End-of-Life care (EOLC) or to an acute hospital for management of reversible causes. The program has achieved significant cost savings and improved patient outcomes by reducing readmission rates and improved linkage to community services, as appropriate.

Conclusion The Liver Supportive Care program demonstrates that early integration of palliative care and a multidisciplinary approach significantly improve health outcomes and reduce hospital readmissions for ALD patients. Its sustainable, scalable model offers a valuable framework for transforming chronic disease management, ensuring comprehensive and compassionate care that aligns with patient needs and healthcare efficiency.

Reference

1. Valery PC, Powell E, Moses N, Volk ML, McPhail SM, Clark PJ, Martin J. Systematic review: unmet supportive care needs in people diagnosed with chronic liver disease. BMJ Open 2015;5(4):e007451. https://doi.org/10.1136/bmjopen-2014-007451