ABSTRACT
IntroductionDistance from a transplant centre may present a barrier to liver transplant referrals and transplant recipients report disliking travel for long-term follow-up. A liver transplant outreach service based at Manchester Royal Infirmary (MRI) was established collaboratively between the MRI and a transplant centre in Sept 2019. We report the outcomes from this service.MethodsThe service runs one day/month and includes post-transplant reviews, transplant assessment triage clinic and a ‘working lunch’ complex case meeting. Baseline transplant assessment + listing data between April 2017- March 2019 for chronic liver disease indications were collected and compared with those between Sept 2019-Dec 2020, in addition to other service activity data.ResultsIn the 24 month period in 2017-19 there were 11 chronic liver disease (CLD), excluding HCC, transplant assessments from the MRI. Only 8 were assessed as outpatients. Median referral UKELD was 56. 7/11 were listed with an assessment:listing conversion of 63%.In the 15 month period Sept 2019-Dec 20 there were 27 pre-transplant reviews with 20 new patients, 4 with HCC and 16 with CLD. One CLD patient had associated HCC. The commonest liver disease indication for review was alcohol related in 8 patients. Nineteen (90%) patients were reviewed for transplant assessment suitability. 12 (63%) were referred for assessment with investigations done locally. 9 (75%) were for chronic liver disease indications and 3 (25%) were for HCC. Median UKELD was 53.5.9 assessments have been completed, with 8 wait-listed. None were converted to inpatient assessments. Overall assessment:listing conversion is high: 8/9(88.8%) overall. 3 transplanted to date. 2 HCC patients had bridging therapies locally.Of 7 not referred for assessment, 1 was suitable for a TIPSS locally, 1 needed pre-habilitation and is under follow-up, 1 was out-with HCC criteria + is managed locally (still alive). 3 were too advanced/frail + all have since died. 1 was initially thought suitable for assessment but did not progress due to alcohol relapse. During the period April 20-Aug 20 only 1 pre-transplant patient was referred as NHS services were curtailed due to the Covid-19 pandemic.112 post-transplant reviews have been delivered, in 82 recipients. 98% gave positive feedback. Post-transplant interventions delivered locally include 2 liver biopsies, 1venogram + the management of 1patient with acute rejection.ConclusionDespite the pandemic this service provided improved pre-transplant outcomes in a shorter time frame cf. the preceding 2 years and saved 139 appointments in the transplant centre. The service is efficient, popular with patients, and adds to the case for the widespread adoption of similar partnerships within liver transplant networks.
ABSTRACT
Background: Interprofessional Student Hotspotting addresses patients with complex medical and social needs. In 2015, Johnson et al found that 82% of these patients have multiple comorbidities, 41% have a serious mental health condition, and 30% report homelessness. High utilization patients have four times more inpatient admissions, four to eight times more readmissions, 30% longer and more expensive hospital stays than the average patient. Our project, a collaboration between the Camden Coalition, University of Montana, Montana Geriatric Education Center and Partnership Health Center, aims to decrease emergency department (ED) visits and increase primary care engagement. By using student teams, we aim to increase understanding of interprofessional collaborative practice (IPCP). Methods: Through home-based, non-clinical interventions to address social determinants, teams worked for 6 months to improve patients' quality of life, integrate medical, behavioral, and social care, and increase utilization of primary care. At the onset of COVID-19, faculty determined that ending services for these vulnerable older adults could be determinantal. Thus, students continued the program in a virtual format through mid-June. Patient utilization of the ED and primary care and PHQ-9 depression scores were monitored before, during and after program participation. The student outcomes were assessed using the Student Perception of Interprofessional Clinical Education - Revised (SPICE-R). Results: Patients decreased ED utilization, increased appropriate use of primary care, and improved depression scores. During the first months of the pandemic, patients in the virtual hotspotting increased their comfort in using technology for medical appointments as well as engaging in online social interactions. The students improved their understanding of and skills for IPCP as demonstrated by increased SPICE-R scores. Conclusion: Student Hotspotting is an educational tool to support IPE and training in patient-centered care while improving health outcomes and decreasing healthcare expenditures in patients with high utilization.