The goal of this clinical trial is to learn about an intensive monitoring plan (transitional care program) in patients with cirrhosis and excessive swelling that are going to be discharged from the hospital.

The main question[s] it aims to answer are:

• How much time and what resources are needed to run such a program
• How well do patients follow up with the phone calls, bloodwork, and doctor appointments?
• Do the patients enrolled in the program have less need for hospitalization later, less kidney injury, better fluid control, and/or better survival compared to patients that are not in the program?

Participants will

• Be given a digital scale and a binder with educational material and a log to monitor their weights after discharge from the hospital
• Receive a phone call from the study team within 72 hours of discharge and weekly
• Be given a follow up appointment with hepatology within 4 weeks of discharge

Researchers will compare participants in this program to patients that receive normal care to see if there are differences in need for hospitalization later, kidney injury, fluid control, and/or survival.

Inclusion Criteria:

• Patients > 18 years of age.
• Inpatient at Penn State Health, Milton S. Hershey Medical Center.
• Diagnosis of cirrhosis.
• Hospitalized with fluid overload (ascites and/or significant anasarca/edema) requiring diuretic therapy.
• English speaking

Exclusion Criteria:

• Placement of a TIPS.
• Ascites from an etiology other than cirrhosis, such as malignancy, heart failure, pancreatitis, nephrotic syndrome.
• Non-English speaking