Hospital @ Home Model of Care for Cirrhosis

The purpose of this study is to work with patients diagnosed with end-stage liver disease to understand their perspectives on the Health at Home (H@H) Program, including desired outcomes and expectations, perceived barriers, and drivers. H@H is an emerging model of home-based care, designed to extend traditional, inpatient hospital care which may address these needs. Through H@H, acute medical care services as well as ancillary care such as rehabilitation therapy can be delivered in the home. The study is divided into three phases: Phase 1 occurs while the participant is an inpatient. Phase 2 is when the actual H@H program takes place as part of the participant's clinical care. The study team will not be involved in the Phase 2 - H@H program as it will be conducted by the clinical staff. Phase 3, at which point the participant enters a rehabilitation phase to transition the patient to self-management, involves a research jam session with the participant and caregiver to assess the value of the program.

Inclusion Criteria: * Enrolled into IUH's H@H program * At least 18 years of age * Chronic liver disease/cirrhosis based on characteristic clinical, laboratory, and imaging findings * English speaking * Able to provide consent * Caregiver able to be present during the acute phase of care (first 48 hours post-hospital discharge) * Able to perform activities of daily living independently * Lives within IU Health Home service area Exclusion Criteria: * Unable to complete study questionnaires due to neurocognitive disease, legal blindness or hearing loss * Transplant of organ other than liver * Pregnant * Incarcerated * New hemodialysis * Blood pressure \< 90/60, Pulse \> 120, O2 \> 6L or \>2L above baseline * HIV+/CD4 count \< 200 * Receiving hospice services * Concurrent enrollment in a related research study