Transitional Care for Chronic Liver Disease Patients

Inclusion Criteria: 1. Male or female age ≥18 2. Diagnosis of advanced liver disease, defined as either (must meet either a or b) 1. cirrhosis based on (either i or ii): * biopsy * characteristic clinical, laboratory, and imaging findings 2. acute alcoholic hepatitis, defined by NIAAA Alcoholic Hepatitis Consortia, as * onset of jaundice (serum bilirubin \>3.0 mg/dL) in prior 8 weeks * consumption of \>40 (female) or 60 (male) g alcohol/day for ≥6 months, with \<60 days abstinence before jaundice onset, * AST\>50 IU/L, AST/ALT\>1.5, and both values \<400 IU/L * liver biopsy confirmation in patients with confounding factors 3. Has at least one of the following complications due to advanced liver disease occurring during hospitalization: 1. ascites requiring diuretics or paracentesis 2. hepatic encephalopathy requiring lactulose or rifaximin 3. gastrointestinal bleeding due to portal hypertension 4. jaundice 4. Has planned discharge alive to home or a facility within 72 hours of informed consent 5. Able and willing to provide informed consent Exclusion Criteria: 1. discharge under hospice 2. listed for liver transplant with MELD-Na ≥ 35 3. unable or unwilling to participate in post-discharge follow-up either in-person or virtually 4. unable to speak or understand English and/or Spanish 5. low hearing or communicative ability (examiner rated) that would interfere with interventions and outcome assessments 6. lack of access to a telephone 7. incarcerated 8. concurrent enrollment in an interventional research study