O13 Liver care at home: development of a hepatology clinical nurse specialist led home service for patients with advanced chronic liver disease

IntroductionPrognosis for advanced chronic liver disease (CLD) is poor and for those ineligible for liver transplantation, management is supportive, aimed at relieving symptoms. The complications of end stage liver disease (ESLD) reduce quality of life, impacting negatively on both physical and mental health of patients¹ and can also contribute to difficulty attending clinic appointments, hence missed opportunities for specialist review and symptom control.MethodsWe developed a hepatology clinical nurse specialist (CNS) led home service, to support and manage symptom burden in patients with CLD, aiming to provide holistic care and avoid hospital admissions. Patients with poor prognosis or palliative care needs are identified either at their last clinic appointment or during a hospital admission, through discussion at the weekly liver MDT. The team visit and review patients in their homes. They assess frailty with the liver frailty index, involving dietetics as needed. They assess for ascites, either commencing or titrating diuretics or referring to ambulatory care for paracentesis. For suspected hepatic encephalopathy, critical flicker frequency assessments (CFF) are undertaken, and treatment modified accordingly.ResultsBetween October 2019 and Feb 2023, 249 home visits were made to 136 patients. Of these, 57% (n=78) were ESLD patients, with age range 48 to 90 years (mean 80 years). The remaining 43% (n=58) were for CFF only.Interventions included16% (n=13) referred to ambulatory care, 22% (n=17) required ascites management, 21% (n=16) required medication changes, 18% (n=14) were referred to dietetics, 7% (n=5) to community frailty services and 16% (n=13) to community palliative care services.In the 2 years prior to the development of this service, there were collectively 95 liver-related admissions and 481 days in hospital for the ESLD cohort. Following initiation of home visits, this reduced respectively to 30 and 144, a 68% reduction in liver-related hospital admissions and 70% reduction in-hospital bed days. Of the 40% (n=31) of these patients that have died since the service was established, 68% (n=21) died in the community, either at home or in a hospice, and 32% (n=10) during hospital admission.ConclusionA CNS home service has facilitated the management of ESLD in patients own homes as well as co-ordinating timely referral to other services. A greater percentage of patients died in the community than in hospital, suggesting increased community palli