Social Worker_Transplant

The Social Worker_Transplant 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 coordination of 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.

This position provides services/intervention for patients and families referred for Transplant services; demonstrating the ability to collaborate with patients’ and families physical, cognitive, emotional, and psychosocial needs specific to the population being served. This position provides a comprehensive psychosocial service to patients and support thru the three phases of transplant services: assessment, pre-transplant, and post-transplant.

Psychosocial Assessment

• Conduct a psychosocial assessment on patients 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 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.

• Develop individualized 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

• Reviews psychosocial assessment and care plans with the other members of the interdisciplinary team.

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.

• Refer to community 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.

• 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.

• Participation in transplant team care conference

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.

• Participation in transplant team care conference

This position documents all encounters in the patients’ medical record per program standards.

This position does provide patient care.

The foregoing description is not intended and should not be construed to be an exhaustive list of all responsibilities, skills and efforts or work conditions associated with the job. It is intended to be an accurate reflection of the general nature and level of the job.

Name

Description

Education:

Must have working-level knowledge of the English language, including reading, writing, and speaking English. Master of Social Work Degree from an accredited institution required.

Experience:

Requires minimum two years’ experience in a clinical social service setting. Transplant experience preferred.

License(s):

Masters prepared social worker degree at minimum. Ability to obtain and maintain a State of Nevada Social Worker license at time of hire. Requires valid Nevada license as an LSW, LISW, LCSW, LASW or is eligible for licensure in Nevada.

Certification(s):

Certified Clinical Transplant Social Worker (CCTSW) credential is strongly encouraged.

Computer / Typing:

Must be proficient with Microsoft Office Suite, including Outlook, PowerPoint, Excel, and Word and have the ability to use the computer to complete online learning requirements for job-specific competencies, access online forms and policies, complete online benefits enrollment, etc.