The following are broad recommendations, based on the knowledge that many patients do not have easy access to specialist care and that availability of transportation and other issues can be challenging.

Key Recommendations

Patients with Compensated Cirrhosis

For all patients with compensated cirrhosis, at a minimum, coordination between the generalist (PCP) and Gastroenterology(GI)/Hepatology specialist is recommended. The goals of coordination should include:

• to determine whether the patient needs to be seen in-person and if so, how often
• to determine which issues will be managed by the specialist and which issues will be managed by the PCP/generalist; for example, which provider will be responsible for ordering ultrasound for HCC screening every 6 months, which provider will manage beta-blockers (note: if specialist is not available locally, PCP/generalist is responsible for screening and other issues)
• consultation could be face to face or via telehealth technologies, depending on the location and ability of the patient to travel

Patients with Decompensated Cirrhosis

For all patients with decompensated cirrhosis, referral for an in-person evaluation by GI/Hepatology is recommended. Patients with decompensated cirrhosis should be seen regularly by GI/Hepatology at an interval determined by their clinical course and severity of liver disease. These patients must also be seen regularly by their PCP for their health issues other than cirrhosis. The specialist and generalist also both benefit from a co-management plan, clearly outlining which provider will manage which issue. In general, ascites, pulmonary hypertension, use of beta-blockers, HCC screening, etc. should be managed by the specialist; other chronic conditions such as diabetes, hyperlipidemia, joint disease, COPD, etc. should be managed by the PCP.

Patients with a Focal Hepatic Lesion

Any patient with cirrhosis with a suspicious hepatic lesion should be referred for a consultation with GI/Hepatology and ideally reviewed at multi-disciplinary liver tumor board. An in-person examination should be scheduled, if possible.