S2668 Navigating Cirrhosis Care: The Impact of Clear Goals and Seamless Transitions

Introduction: Hospital readmissions among patients with decompensated cirrhosis present a significant clinical and economic burden, with 30-day readmission rates ranging from 20–37%. While many readmissions are non-preventable, some may be avoided through targeted interventions. In 2023, the University of Kentucky reported a 21% 30-day unplanned readmission rate for patients with decompensated cirrhosis. In response, a quality improvement (QI) initiative was launched to reduce 30-day readmissions to 16% by June 2025, focusing on timely outpatient large-volume paracentesis (LVP) and improved transitions of care (TOC) via nurse navigators. Methods: This QI project included adults >18 years hospitalized under medical severity diagnosis-related group codes 432, 433, or 434. In August 2024, 3 primary interventions were implemented: (1) timely LVP scheduling, (2) referral to high-risk discharge clinics, and (3) nurse navigator-led follow-up coordination. An Epic discharge order set was developed to streamline ambulatory lab orders and follow-up appointment scheduling. The target was ≥50% adherence for each intervention. Data was extracted from Vizient and Epic. Results: In 2024, 474 patients met inclusion criteria and 104 (21.9%) were readmitted within 30 days. Following intervention in August, the average readmission rate fell to 19.3% by December. Monthly unplanned readmissions dropped from 9 to 7 (October–December), with estimated monthly cost savings of $29,675. However, rates rose to 32.5% in January–February 2025, revealing poor process adherence: only 30% had LVP scheduled, 46% were referred to the high-risk clinic, and 27.6% had nurse navigator coordination. Conclusion: Initial reductions in readmission rates suggest our interventions were effective, but sustainability was a challenge. A rise in readmissions in early 2025 highlighted gaps in process adherence, particularly in TOC through nurse navigators. In response, a dashboard was developed to help nurse navigators identify high-risk patients and proactively coordinate LVP and follow-up appointments with the primary team. As a result, 72% of patients had follow-up in March and 92.9% in April of 2025. A chart review of Oct–Dec 2024 readmissions showed 35% mortality within 3 months, an average MELD of 25, with 59% likely to benefit from palliative care and 18% deemed preventable. Future interventions will encourage early palliative care consults for patients with higher MELD to clarify goals of care and reduce avoidable hospitalizations.