Impact of a Chronic Disease Management Model in patients with decompensated liver disease: The Australian Liver Failure Trial (ALFIE)

The intervention will include multiple components. Coordinated care and management by a registered nurse with at least 2 years experience in hepatology will be provided to patients randomised to the intervention group. This will include a home visit (within one week of discharge from hospital) of varying duration (it is expected that the assessment will take around 1 hour), weekly telephone reviews for 3 months (from 5-30 minutes depending on the symptoms for review), reminders prior to appointments, planned admissions for paracentesis, and close biochemistry monitoring, protocol driven diuretic titration and extensive education, Content of the contact will include monitoring and management of signs and symptoms, medication review, education and self-management advice, care coordination and education and involvement of family. There will be enhanced communication with GPs post discharge and ensure that assessment by a hepatologist occurs within 1 month of discharge from hospital. After 3 months, contact will reduce depending on stability and symptoms. An individualised care plan will be developed signed off by the specialist and communicated to the GP. The intervention will continue until the study end which will be 24 months from the first patient randomised. As recruitment will stop 12 months from first randomisation, the maximum intervention is 24 months and the minimum is 12 months.