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The Transitional Liver Clinic (TLC): Reducing Liver Disease Readmission

Award Number: R01DK132390
ORGANIZATION: NATIONAL INSTITUTE OF DIABETES & DIGESTIVE & KIDNEY DISEASES
OPDIV: NIH
AWARD CLASS: DISCRETIONARY
AWARD ACTIVITY TYPE: SCIENTIFIC/HEALTH RESEARCH (INCLUDES SURVEYS)
PERIOD OF PERFORMANCE START DATE: 02/01/2023
PERIOD OF PERFORMANCE END DATE: 11/30/2027

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The Transitional Liver Clinic (TLC): Reducing Liver Disease Readmission - PROJECT SUMMARY/ABSTRACT Individuals with liver cirrhosis and alcoholic hepatitis often experience the complications of advanced liver disease: ascites, hepatic encephalopathy, and gastrointestinal bleeding. These complications frequently lead to hospitalizations, and after hospital discharge, disease complications can interact with medication errors and poor provider communication, resulting in frequent early hospital readmissions. Outcomes during the vulnerable post-discharge transition period could be improved through better transitional care (TC), focused on optimizing treatment regimens, improving communication, and facilitating access to community and other healthcare resources. TC addressing these issues has successfully improved outcomes in heart failure and other conditions, but there are few data on TC programs in patients with advanced liver disease, who suffer from unique clinical complications that can complicate TC treatment plans. To address this gap in our healthcare delivery system, we have developed an advanced practice provider (APP)-led TC program for patients with the complications of advanced liver disease: the Transitional Liver Clinic (TLC). In the TLC, patients discharged from the hospital with complications of advanced liver disease are contacted by telephone within two days of discharge, followed by a face-to-face or video telehealth visit with the APP within 7-14 days. During this time, TLC providers reconcile and manage medications, provide education and linkage to community resources, and facilitate necessary follow-up. This proposal aims to test the effect of the TLC on hospital readmissions, quality of life, and patient satisfaction with care. The hypothesis is that the TLC will improve patient outcomes across these domains. To achieve these aims, the TLC will be evaluated using a pragmatic stepped-wedge randomized controlled trial comparing the TLC to usual care at four high-volume tertiary care liver centers. Upon completion of the study, the investigators will have provided evidence for the efficacy of TC in reducing acute healthcare utilization and in improving quality of life and patient satisfaction for those with complications of advanced liver disease.


Issue Date FY	Funding FY	Legal Entity Name	Legal Entity Address	Legal Entity City	Legal Entity State	Legal Entity Zip Code	Legal Entity COUNTY	Legal Entity COUNTRY	Assistance Listing	Award Code	Budget Year	Action Date	Action Type	Action Amount

Issue Date FY: 2025 ( Subtotal = $643,003 )
2025	2025	TRUSTEES OF INDIANA UNIVERSITY	980 INDIANA AVE RM 2232	INDIANAPOLIS	IN	46202	MARION	USA	Diabetes, Digestive, and Kidney Diseases Extramural Research	001	3	6/11/2025	NON-COMPETING CONTINUATION	$64,300
2025	2025	TRUSTEES OF INDIANA UNIVERSITY	980 INDIANA AVE RM 2232	INDIANAPOLIS	IN	46202	MARION	USA	Diabetes, Digestive, and Kidney Diseases Extramural Research	000	3	11/25/2024	NON-COMPETING CONTINUATION	$578,703
														Subtotal = $643,003

Issue Date FY: 2024 ( Subtotal = $617,284 )
2024	2024	TRUSTEES OF INDIANA UNIVERSITY	980 INDIANA AVE RM 2232	INDIANAPOLIS	IN	46202	MARION	USA	Diabetes, Digestive, and Kidney Diseases Extramural Research	001	2	5/13/2024	NON-COMPETING CONTINUATION	$38,581
2024	2024	TRUSTEES OF INDIANA UNIVERSITY	980 INDIANA AVE RM 2232	INDIANAPOLIS	IN	46202	MARION	USA	Diabetes, Digestive, and Kidney Diseases Extramural Research	000	2	11/29/2023	NON-COMPETING CONTINUATION	$578,703
														Subtotal = $617,284

Issue Date FY: 2023 ( Subtotal = $707,588 )
2023	2023	TRUSTEES OF INDIANA UNIVERSITY	980 INDIANA AVE RM 2232	INDIANAPOLIS	IN	46202	MARION	USA	Diabetes, Digestive, and Kidney Diseases Extramural Research	000	1	1/17/2023	NEW	$707,588
														Subtotal = $707,588

Grand Total All Awards = $1,967,875

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The Transitional Liver Clinic (TLC): Reducing Liver Disease Readmission

Award Number: R01DK132390

ORGANIZATION: NATIONAL INSTITUTE OF DIABETES & DIGESTIVE & KIDNEY DISEASES

OPDIV: NIH

AWARD CLASS: DISCRETIONARY

AWARD ACTIVITY TYPE: SCIENTIFIC/HEALTH RESEARCH (INCLUDES SURVEYS)

PERIOD OF PERFORMANCE START DATE: 02/01/2023

PERIOD OF PERFORMANCE END DATE: 11/30/2027

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