PRIMARY PURPOSE:

The transplant social worker provides comprehensive social work services to patients and families through all phases of transplant—from date of initial referral through transplant hospitalization and for the duration of the post-transplant period.  As a member of a transplant team, the social worker provides patient education and emotional support, is responsible for referrals to community agencies, coordinates patient care with other team members, and assists with concrete services.  

The provision of these services in the United States is mandated by the Centers for Medicare & Medicaid Services (CMS) for Medicare-approved transplant centers.

                          

JOB PERFORMANCE STANDARDS:

1. Psychosocial assessment

      A psychosocial assessment is completed on each patient referred for organ transplant. This assessment is conducted to assist the transplant team in determining a patient’s psychological and social readiness for the demands and stresses associated with transplant surgery, recovery, and rehabilitation. The psychosocial assessment includes a structured, comprehensive, evidence-based assessment of the patient’s overall global quality of life including, but not limited to, their physical, behavioral, psychological, social and spiritual functioning. The psychosocial evaluation contributes to the overall transplant evaluation and helps establish specific patient care plans to maximize optimal recovery and rehabilitation and to ensure the best possible transplant outcome, while reducing the impact of known psychosocial risk factors. A psychosocial assessment is also required for patients being considered for re-transplantation.

 

The psychosocial assessment will include but it is not limited to:

• Social History and Support System:
• Obtain patients’ social history and assess the availability and stability of support for their transplant care. Specifically, ensure family or caregiver stability and emotionally supportive and committed relationships.
• Assess for any domestic violence abuse and provide referrals as appropriate.
•  Understanding of Transplant Process (Comprehension)
• Assess patient and support system’s understanding of transplantation and required follow-up care and receptiveness to transplant counseling, education and teaching.
• Assess ability to verbalize transplant risks and benefits and establish realistic goals and plans.
• Self-Management with Medical Treatment (Compliance)
• Assess patient’s adherence/self-management with medications, medical advice, medical appointments and general health surveillance.
• Lifestyle Factors
• Assess patient’s ability to adhere to important lifestyle behaviors that could affect short- and long-term outcomes including diet, exercise and stress-management. Assess patient’s receptiveness to counseling, education and teaching.
• Mental and Psychiatric Status/ Past and Current
• Obtain patient’s past & current mental/psychiatric status, including the presence of mood or anxiety disorders, evidence of personality disorders, suicide attempts or ideations, psychotic episodes and willingness to adhere to treatment.
• Determine any past, current or pending legal issues such as history of arrests or incarcerations.
• Refer for psychiatric treatment when appropriate and work collaboratively with the psychiatric service to assess patient’s mental stability and ability to manage a complex transplant regimen.     

• Substance Use History
• Assess patient’s history of alcohol, drug and tobacco/nicotine use.  Advocate and educate towards abstinence.
• Provide treatment recommendations, supportive services and surveillance.  Refer to appropriate chemical dependency treatment programs as necessary.
• Financial/Insurance/Work History
• Obtain information regarding patient’s employment status, disability and insurance coverage for all medical expenses to determine areas of potential concern, making appropriate referrals for additional resources as needed.
• Refer to financial transplant coordinator if necessary.
• Relocation/Lodging
• Review any relocation/lodging requirements and assess patient acceptance, ability and willingness to comply.
• Identify potential barriers which may prevent patient/caregiver from relocating and address those barriers.
• Motivation for Transplant
• Assess patient’s ability to verbalize and comprehend risks and benefits of transplant.
• Determine if patient has an advance directive and assess desire to pursue aggressive treatment.

2. Pre-Transplant

• Meet with patient/family on a regular basis to assess and provide emotional support. Offer supportive counseling to help patient/family cope with the waiting period, declining health, death and dying issues, and/or lengthy hospitalizations.
• Provide concrete services such as assistance with housing, transportation, and immigration issues.  Provide information and referrals for disability and retirement benefits, medical insurance coverage, and other financial issues.  Refer to community resources such as fund-raising foundations.
• Facilitate and/or refer patients and caregivers to transplant support groups, and coordinate mentoring programs.
• Make referrals to psychiatric/neuropsychiatric/psychological services as deemed necessary.
• Maintain ongoing communication with multidisciplinary team members.
• Obtain and monitor behavioral agreements from patients/families that address continued commitment to maintaining compliance with medical regimen, abstinence from nicotine, alcohol, illicit substance use.
• Provide patients with support surrounding end of life issues. Educate patients regarding Advance Directive forms and refer to palliative care when appropriate.

3. Post-Transplant

• Provide ongoing assistance with relocation housing needs, transportation, maintaining medical insurance, obtaining medications and support for the caregiver. 
• Follow patient for psychosocial/mental health issues related to post-transplant adjustment (i.e. depression, marital or family issues, ETOH/substance abuse, changes in family. dynamics, concerns regarding rejection or body image). Facilitate referrals as needed.
• Assist with return to work issues.
• Provide support to transplant recipients as they explore feelings towards their donor and assist in the coordination for correspondence with donor family when desired.
• Evaluate all post-surgical transplant recipients and living donors prior to discharge to ensure their needs are being met and collaborate with multidisciplinary team members as necessary.

REQUIREMENTS:

a.    Education, Licensure & Certification:

• Master’s degree from a graduate school of social work accredited by the Council on Social Work Education 
• Maintain professional licensure available to social work healthcare practitioners in the practice locale.
• Certified Clinical Transplant Social Worker (CCTSW) credential is strongly encouraged.

b. Knowledge:

• Physical and emotional impact of illness on patient and patient’s family support system 
• Discharge planning and care management
• Community resources
• Role of state and federal governmental agencies as they relate to health care
• Developmental issues related to populations served
• Mandatory reporting requirements
• End of life issues
• Cultural diversity
• Crisis management
• Departmental and hospital policies and procedures

c. Skills:

• Excellent interpersonal and written communication
• Current clinical assessment skills
• Ability to act in an autonomous, self-directed manner
• Ability to receive multiple stimuli from multiple sources simultaneously
• Good judgment, problem solving and priority setting
• Decision-making
• Active listening
• Time management
• Organization and delegation
• Leadership
• Ability to be a change agent
• Critical thinking
• Negotiation
• Basic computer knowledge
• Conflict resolution

d. Experience:

• A minimum of two years of social work experience in a hospital or health care setting
• Transplant experience is preferred.

e. Other Duties:

• Participation in transplant team care conference and selection committee meetings
• Active participation in transplant-related and social work professional organizations (i.e. OPO, NASW, STSW)
• Professional presentations and/or research projects 

This information is also available to download in a word document or pdf