Maximizing Organ Transplant Outcomes: TFC and Social Worker Relationship

1. Benefits of the TFC and Social Worker Relationship  Megan Maltby, MSW

2. VCU HF/Transplant

3. “Because donated organs are a severely limited resource, the best potential recipients should be identified. The probability of a good outcome must be highly emphasized to achieve the maximum benefit for all transplants”UNOS Ethics Committee

4. Background • 116,829 patients waiting for transplantation. (August , 2017) Of those, 75,572 people are active waiting list candidates. • 10-20% all heart, liver, kidney and lung candidates die on the waitlist. • Organ transplantation as a treatment of choice has increased in recent years due to concurrent advances in medical science. • Due to the limited organs available for transplantation, a thorough evaluation of transplant candidates is required to ensure each organ recipient will care for the organ and have the best possible post-transplant outcome. • In addition, there are significant financial and time resources involved in organ transplantation and subsequent care which highlight the importance of identifying appropriate candidates for transplant and ensuring before surgery that such resources are available to patients.

5. Review of the Literature Shows there are several psychosocial factors known to contribute to poor patient and graft outcomes. They include: • Poor social support/absence of family caregiver • Mental/psychiatric disorders likely to negatively affect post transplant adherence • Self-destructive behavior such as alcohol or substance abuse • A history of poor adherence with medical and mental health treatment • The patient’s inability or unwillingness to comprehend the need for improved adherence • Dysfunctional personality traits and disorders, and • Financial issues which could interfere with post-transplant medication adherence

6. Policy U.S. Department of Health and Human Services (DHHS) Transplant Center Process Requirements “Prior to placement on the center’s waitlist, a prospective transplant candidate must receive a psychosocial evaluation”. Centers for Medicare and Medicaid Services (CMS) • Transplant team: The transplant center must identify a multidisciplinary transplant team and describe the responsibilities of each member of the team • The transplant center must make available social services, furnished by qualified social workers, to transplant patients, living donors, and their families. Definitions for a qualified social worker included: • A qualified social worker is an individual who meets licensing requirements in the state in which he or she practices and • (1) has completed a course of study with specialization in clinical practice and holds a masters degree from a graduate school of social work accredited by the Council on Social Work Education, or, • (2) is working as a social worker in a transplant center as of the effective date of this final rule and has served for at least 2 years as a social worker, 1 year of which was in a transplantation program, and has established a consultative relationship with a social worker who is qualified under § 482.94(d)(1).

7. Goals of a Psychosocial Pre-Transplant Evaluation • Promote fairness and equal access to care • Maximize outcomesand use of scarce resources • Ensure that the potential for benefit outweighs risk by identifying factors that may result in non-adherence, morbidity and mortality • Provide information to develop treatment plan for those at high risk • Identify level of cognitive functioning • Address challenges • FINANCIAL • Support • Implement treatment to mitigate risk • Re-evaluate and adjust • Determine needs and help patients understand and cope with daily barriers • medical bills • money • transportation • return to work • Family responsibilities

8. VCU MCS/Cardiac Transplant SW Evaluation • Current family support structure, family history, and current and past family dynamics • Level of education • Employment • Current and past employment • Assessment of patient plans for return to work • Financial implications for transplantation • Insurance coverage • Insurance termination, if applicable • Applying for financial assistance • Patient assistance programs • Social history • ETOH history • Substance abuse • Smoking history • Legal history • Coping skills • Adherence history • Assessment of patient and caregiver understanding of the risks and benefits of transplant

9. The Many Roles of TXP SW • Initial screening and evaluation of patient and caregiver • Comprehensive psychosocial assessment of patient • Help patient/caregiver understand the illness and treatment options, as well as consequences of various treatments or treatment refusal • Help patient/caregiver adjust to hospital admission; possible role changes; exploring emotional/social responses to illness and treatment • Educate patient on the levels of health care (i.e. acute, sub- acute, home care); entitlements; community resources; and advance directives • Facilitate decision making on behalf of patient/caregiver • Educate hospital staff on potential psychosocial issues • Promote communication and collaboration among health care team members • Coordinate patient discharge and continuity of care planning; • Arranging for resources/funds to finance medications, durable medical equipment, and other needed services; • Advocate for patient/caregiver needs in different settings: inpatient, outpatient, home, and in the community • Champion the health care rights of patients through advocacy at the policy level. Almost are of these roles are tied to some financial obligation or resource

10. Because at the end of the day, what do patients really want to know from the SW….? How much is this transplant, hospital stay, medications, outpatient costs-what is cost me, the pt. asks?

11. So why is a collaborative relationship between the SW and FC important?

12. UNOS says…. • Social workers and financial coordinators collaborate to determine how our patients can best afford the costs of transplantation. • SW have some knowledge about insurance policies and funding but the financial coordinator has detailed knowledge of financial matters and hospital billing methods.

13. I say… • SW relies on the patient’s explanation of insurance • FC is able to confirm benefits for the SW • SW can explain in layman’s terms • The SW and FC share information • SW can test compliance- see if patients are actually following through • Truth seeking/finding when patients are not forthcoming or simply confused • Financial codes/assistance • Paying premiums • SW can help patients expedite Medicaid application • FC can provide bills, statements, access to insurance care managers • SW can educate others • SWs can’t help patients without financial knowledge and availability of financial resources • Benefits memo • Medicare info • We validate and support each

14. And Finally……. • Together we work on getting the whole picture

15. Thank You! And special thanks to Tami Topalu for recommending me

16. Shanda Ross, Director, MSN, RN Digestive Diseases & Kidney (DDK); TransplantOmaha, NE

17. Team; Together Everyone Achieves More • Each Team member brings their individual talents • A team’s foundation is formed by a mission and shared values • The Values and mission are the culture of the team • Myth or Fact; there is no I in team? MYTH! • Each Individual brings what is needed for our ENTIRE TEAM TO SUCCEED!! • Your Pt’s count on you to be fully engaged and bring you’re a game

19. The foundation of a Transplant Team • Transplant Teams are considered multidisciplinary • Each Transplant Team member has a responsibility to our pt..'s • The transplant cannot happen without financial clearance • Financial Clearance is a team effort between the TFC and SW • The TFC and The SW work closely together to assure all angles are covered

20. Role of the TFC • Work with the Medical Team to obtain demographics • Verify benefits; review the available benefits • Is patient eligible for Transplant • Do they meet criteria for Medical Team/Insurance • Is there a concern for SW or TFC, how can we partner together to get pt. transplanted? • Does the pt. require assistance? Additional coverage, exception to policy, etc.

21. Racing toward the end goal; forming relationships as we go!

22. Communication; As the Expert your Voice Matters SW TFC What medical benefits are available, any concerns If no lodging can we offer any assistance programs; collaboration with SW Are all medical needs met, any post transplant benefit concerns • Lodging Benefits • Psychosocial Concerns • Support System • Lifestyle • Transportation

23. Chain of Command/Communication; Normal Hours What is That? • Normal Pt coming in for eval; standardized process • Emergent Pt; standardization really counts • Did we capture it all, if not guess who suffers/pays for it?

24. Documentation; Assuring you Tell your Story • Team should have standard process of communication • OTTR and/or EMR • Dot phrases; efficient, set standard • Who is primary contact to send documentation to • What do you need for authorization, is it all there • Your documentation is your word

25. Regulatory and Compliance • UNOS and CMS assures we follow the same standards in each center • Monitor each program to assure safe pt. care • Must be followed or a program/pt.'s are at risk • How do we assure we are in compliance; PSC meetings, who needs to follow up and be sure documentation is in place • FQAPI; is the TFC and SW at the table

26. In the End; This is why we do it!!

27. A-game AKA; Accountability • Each team member is accountable for their role to assure there piece of the puzzle is done • If each team member stays in their lane=Best Patient Care/Satisfaction/Outcomes • Cy Wake man; the tool to utilize to keep your stress to a minimum and assure you are focused on your role as a TFC! https://www.youtube.com/watch?v=q6w_exHCvQ0

28. Staying your lane assures • You are focused on safe pt. care • You are functioning as a highly reliable and accountable team member • You are managing your energy • You are not stressed out about what you cannot do but on what you can do • Each team member is giving our patients exactly what they need to assure a safe, efficient transplant!!

29. References • The role of the social worker on a transplant team. (2009, October 24). Nephrology News and Issues. Retrieved from http://www.usatoday.com • https://www.unos.org/ • https://www.cms.gov • https://www.youtube.com/watch?v=q6w_exHCvQ0

30. Questions/Comments?????