“If it wasn’t for them, I wouldn’t be where I am today. I’m so grateful.”
Last year, Alana Bown was fighting for her life, spending nearly 5 months in hospital after being diagnosed with liver and kidney failure. Severe abscesses on her legs made it impossible to walk, while her lack of organ function also robbed her of the ability to speak or eat. Several months after Bown was discharged from hospital, the gastroenterologist who cared for her referred her to the new Island Health Liver Care Clinic located at Royal Jubilee Hospital (RJH).
“Dr. Brian Mc Ardle and I care for many patients with severe liver disease and one of the most challenging aspects has been providing ongoing care once a patient is released from hospital,” says Dr. Jeremy Murray–Guenther, an internal medicine specialist at the RJH Liver Care Clinic. “Prior to establishing the clinic, we were seeing patients who were being readmitted to hospital time and time again, often visiting the emergency department 3 or 4 times before they could be seen by a gastrointestinal specialist.”
People experience liver failure for a variety of reasons ranging from alcohol intake and fatty liver disease, to metabolic inherited conditions or auto immune disorders. With severe liver disease, many patients experience similar symptoms, including accumulation of fluid in the abdomen that must be removed through a procedure called paracentesis, as well as malnutrition, jaundice, confusion and life threatening internal bleeding.
Early in 2021, Dr. Mc Ardle, Dr. Murray–Guenther, and Dr. Rohit Pai initiated a pilot project that eventually transitioned in October into a formal liver care clinic staffed by two internal medicine physicians, a nurse, social worker and dietician. Necessary procedures are carried out on site, as well as alcohol cessation counselling, dietary advice, home health monitoring, and other supports, including end of life care.
“We're the first clinic of its kind in the province. Our patients have very complex health issues and as a one stop shop we can help patients navigate the healthcare system, working with our partners to ensure patients are supported and connected to the services they need in a timely manner,” says Rozalyn Milne, nurse clinician. “Our goal is to see patients within two weeks of their referral to us, and so far we’ve been successful.”
Typically, there are three outcomes for patients with severe liver disease – it reverses or stabilizes to the point that they are discharged into the care of a gastroenterologist, they receive a liver transplant, or they are connected with end of life care.
The physicians at the clinic also regularly consult with a roster of other specialists including gastroenterologists and interventional radiologists to discuss the intensive needs required by their patients. An interim analysis is showing that the clinic has drastically reduced the health care utilization for its patients, translating into fewer and shorter hospital admissions, less emergency department visits, and fewer deaths.
“We are noticing that as the clinic progresses, many of our patients are getting and staying well and we're able to essentially de-escalate their care. This isn’t something we usually see with this form of disease,” says Dr. Murray–Guenther. “It’s incredibly rewarding to see the health of some of the sickest people that we meet actually improving. And even when they don’t get better, providing this kind of support, including linking patients with palliative and hospice care, makes such a big difference for our patients and their families.”
Nurse Rozalyn Milne agrees, saying that wherever a patient is on their healthcare journey, the Liver Care Clinic team is walking alongside them every step of the way.
“We really try to create that safe space for patients to visit so that we can engage with them and support them through all of these complex issues. I love that our patients and their families will email or call with their questions and we can provide them with comfort and security,” she says. “This is such an effective way for patients to receive quality care from an interdisciplinary team and everyone benefits, including the healthcare system.”
Alana Bown was one of the first patients to visit the clinic, an experience that she says was lifesaving. Her health has come such a long way that she has been discharged back into the care of her gastroenterologist, which means she will now visit the clinic every six months instead of weekly.
“Without the care I have received at the Liver Care Clinic, I would probably be back in hospital and not doing well. The team there is so wonderful, helping me get to a better place where I can celebrate my achievements,” she says. “Where I was once on 15 medications, I am now down to 3. And while I have had to rely on a walker to get around, I am now able to stand for much longer and go up and down stairs. Recently, I walked into the clinic unassisted - the first time I’ve been able to do that.”
“When Alana first came to the clinic, she arrived in a wheelchair and now she’s walking in on her own. It’s very emotional,” says Rozalyn Milne.
Another benefit of the clinic is an educational component where medical residents spend time learning about caring for patients with liver disease. In addition to patients being able to interact with residents for extended periods, Milne says it is an opportunity for Dr. Mc Ardle and Dr. Murray–Guenther to model their non-judgemental and compassionate approach to patient-centred care for a disease that can be highly stigmatized.
Patients are referred to the RJH Liver Care Clinic by internal medicine specialists, gastroenterologists, or emergency department physicians. The Liver Care Clinic team is working on expanding the RJH clinic with the potential for similar services to be available at other Island Health locations as well as offering virtual care for Island Health residents.