Patients with ESLD in general have high rates of healthcare utilization, resulting in more than 250,000 hospitalizations at $9.8 billion annually in the United States (Ufere et al., 2019). Liver disease is a rising cause of death worldwide, affecting younger people, but palliative care is largely absent for these patients (Kimball et al. 2018). Early readmissions are common for patients with ESLD and in the U.S. alone, over 25% of patients are readmitted within 30 days of their initial diagnosis, rates that now exceed those seen for patients with CHF and COPD (Ufere et al. 2019). Evidence shows that early palliative intervention in severe chronic illness has been successful in decreasing readmission rates with effective outpatient symptom burden management. The Hospital Readmissions Reduction Policy (HRRP) aims to reduce unnecessary hospital readmissions by improving care coordination, and healthcare communication and improving patient and caregiver engagement in discharge planning (Hospital Readmissions Reduction Program (HRRP) Archives | CMS, n.d.). Reducing hospital readmission rates is an important health policy goal and as we know, Medicare payments are tied directly to hospital quality of care as evidenced by readmissions within 30 days. Studies show that the implementation of a nurse-driven palliative care program early in the ESLD diagnosis was effective in improving care coordination, anticipatory care planning, and quality of life for people with advanced liver disease and their caregivers. Coordination of care between hepatology and palliative care can greatly improve quality of life and decrease unnecessary hospital readmissions by proactively addressing the outpatient symptom burden of patients and caregivers by utilizing effective communication, education, and collaborative care planning and treatment (Kimball et al, 2018).

Date of publication

Fall 12-4-2023

Document Type

MSN Capstone Project



Persistent identifier



MSN Education

Included in

Nursing Commons