Assist patients of all ages in achieving the best quality of life possible, given their limitations, through provision of the following services:  psychosocial assessment of the patient/family needs, crisis intervention, supportive counseling to the patient/family, and mobilization of available community resources.  Assist in the development of post-hospital discharge plans appropriate to the patient’s age and development stage.  These tasks are performed in accordance with established transplant standards, policies, procedures, protocols and guidelines.  Embodies the Memorial Health System Performance Excellence Standards of Safety, Courtesy, Quality, and Efficiency that support our mission, vision and values.

1. Completes comprehensive assessment of potential transplant recipients and living donor candidates during all stages of pre-transplant evaluation. This would include assessment of coping skills, family and community support, mental health and patient compliance potential. This assessment would include when indicated, the recommendation for further evaluation by psychiatry.

2. Explains Medicare and the ESRD program to patient/family and how it impacts the options of transplantation.

3. Provides orientation, facilitates, and coordinates the living donor advocate involvement to ensure procedures are followed.

4. Communicates to the donor advocate any issues or concerns identified by the psychosocial evaluation of the living donor.

5. Embodies the Memorial Health System Performance Excellence Standards of Safety, Courtesy, Quality, and Efficiency that support our mission, vision and values:

• SAFETY: Prevent Harm - I put safety first in everything I do.  I take action to ensure the safety of others.
• COURTESY: Serve Others - I treat others with dignity and respect.  I project a professional image and positive attitude.
• QUALITY: Improve Outcomes - I continually advance my knowledge, skills and performance.  I work with others to achieve superior results.
• EFFICIENCY: Reduce Waste - I use time and resources wisely.  I prevent defects and delays.

6. Works collaboratively with financial coordinator to inform patient/family about insurance plans, supplemental programs for medication coverage and assistance and out-of-pocket expenses.

7. Acts as a liaison with dialysis social workers to identify potential recipients at high risk for poor outcomes.

8. Assists with the transportation arrangements for pre and post patient clinic visits.

9. Organizes and facilitates Memorial’s Transplant Support Group.

10. Responsible for producing quarterly newsletter for transplant patients.

11. Documents pre transplant information in transplant tracker and pre transplant chart as appropriate.

12. Completes post-op psychosocial assessment and intervention of transplant patients and living donor patients. This includes early post-op (inpatient stay) and beyond (post-discharge).

13. Develops inpatient discharge plans appropriate to transplant recipient’s age and development stage, and communicates and collaborates with the inpatient nurse case manager to assist with discharge planning.

14. Works closely and collaboratively with the inpatient social worker and patient care facilitators.

15. Participates in transplant patient rounds on inpatient units.

16. Provides social services to the inpatient and outpatient transplant population.

17. Learns and utilizes MIDAS program and Millinium to complete in-patient documentation. .

18. Works with patients to formulate an individualized plan to obtain medication, particularly, in light of Medicare coverage limitations. This includes facilitation of enrollment in various drug companies’ patient assistance programs.

19. Participates in transplant patient selection meetings, unit based council meetings, and quality improvement meetings.

20. Participates in pre and post-operative outpatient care clinics.

21. Completes follow-up psychosocial assessments with each transplant recipient per OPTN/CMS guidelines.

22. Provides crisis intervention and supportive counseling for patients and their families as needed.

23. Participates in continuing education and inservice training to support professional growth and expertise.

24. Participates in developing program policies and procedures that guide and support the provision of services.

25. Acts as a placement instructor for BSW/MSW students.

26. Participates in program outreach/community awareness building activities in order to raise awareness of organ donation and kidney/pancreas transplant services at MMC.

27. Performs other duties as assigned.

The intent of this job description is to provide a representative summary of the major duties and responsibilities performed by incumbents of this job.  Incumbents may be requested to perform tasks other than those specifically presented in this description.