RECRUITING Not applicable ClinicalTrials.gov

Hospital @ Home Model of Care for Cirrhosis

Sponsor: Indiana University • ClinicalTrials.gov ID: NCT06396897

Registry updated: 2026-09-22

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Description

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.

Interventions

Indiana University Health Hospital at Home Program (Other)
Structure of Care in IUH H@H Program: The IUH H@H program allows patients to be cared for at home using home remote monitoring devices, travel laboratory services and both in-person and virtual rounding by the health care team. The team includes registered nurses (RN), advanced practice provider (APP, nurse practitioner and physician assistants) and hospitalist physician. Care at home is divided into 4 consecutive phases after initial hospitalization: (1) evaluation/planning, (2) acute, (3) recovery, and (4) rehabilitation. All patients are sent home with a RPM tablet used to obtain vital signs, send messages between patient and RN, \& perform video visits. The device is Bluetooth enabled and does not require WiFi or a phone line. All data obtained is automatically pulled into the electronic medical record. The RN uses a device which enables remote physical exams, i.e., obtain heart, lung and bowel sounds, pictures (wounds, lines, etc.) for review by APP/MD.

Eligibility criteria

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

Conditions

Decompensated Cirrhosis

Locations

IU School of Medicine — Indianapolis, Indiana, United States

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Official Source

Data sourced from ClinicalTrials.gov, a service of the U.S. National Institutes of Health.

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