Cirrhosis Medical Home

Inclusion Criteria

• •Age ≥18 years
• •Cirrhosis based on:
• •* biopsy
• •* characteristic clinical, laboratory, and imaging findings
• •Decompensated cirrhosis as denoted by either:
• •* active ascites requiring paracentesis during hospitalization or
• •* active overt hepatic encephalopathy requiring lactulose during hospitalization
• •Poor quality of life as defined by:
• •* SF-36 Physical and/or Mental Component Summary scale \<40 (1SD below the mean of healthy subjects)
• •Discharged to home, skilled nursing facility, sub-acute rehabilitation care, or long-term acute care
• •Able to be consented, either in person or through legally authorized representative
• •Access to a telephone
• •Age ≥18 years
• •Identified caregiver of patient
• •Able to be consented, either in person or through legally authorized representative
• •Access to a telephone