RENAL TRANSPLANT CLINICAL SOCIAL WORKER / 40 HOURS / DAYS - BWH CARE COORDINATION.
GENERAL SUMMARY/OVERVIEW STATEMENT
Provides psychosocial assessment, crisis intervention, mental health counseling, financial counseling, discharge planning, patient education, the provision of resources and linkage with community agencies to patients/families pre- and post kidney transplant. Identifies high-risk psychosocial factors of potential renal transplant patients/families, living related donors that impact social, emotional, financial and health status. Participates with physicians, nurses and pharmacists in the selection process before activating patients on the kidney transplant waiting list. Assumes care coordination responsibility for patients with complex psychosocial risk (domestic violence, protective services, mental health, substance abuse, etc.). Coordinates the financial aspect of care for all renal transplant patients and their living related donors. Assesses adaptation of families and donors to patients' illnesses and ensures maximum participation of patients/families in the transplant process. Provides consultation, teaching, research and program development within their assignment. Identifies, addresses and participates in the resolution of variances that affect the quality and/or cost of care.
PRINCIPAL DUTIES AND RESPONSIBILITIES
PATIENT CARE MANAGEMENT
A. Identifies and assists all transplant patient's/family's social, emotional, financial or legal concerns that affect patient care management and interacts with patient/family/interdisciplinary team to facilitate the patient care process.
B. Improves transplant patient and/or family understanding of and adjustment to the medical course of illness to maximize benefits of medical intervention, financial resources needed to enhance patient/family functioning throughout the course of illness. Ensures that the patient/family are involved in all phases of the patient care process.
B. Evaluates all potential and living kidney donors for genuine desire to donate and assess for any
psychosocial issues which preclude them from donation and communicate findings to transplant team.
C. Conducts psychosocial assessments, evaluation, counseling and interventions for potential transplant and living related donors and families to assist them in coping with:
Pre- and Post Transplant Evaluations
Financial aspects of transplant and medication costs
Evaluates current and secondary insurance options including Medicare entitlement forms after transplant
Pre certify all managed care and Center of Excellence patients
Advanced Directives Education
Violence and maltreatment including domestic assault, child, disabled and elder abuse/neglect
Mental health problems
Vocational concerns and re-entry to the job market post transplant
Environmental problems including financial, housing, medical alert bracelets, transportation and activities of daily living
D. Provides services across the continuum of care, including the provision of home health care, agency
services, medical equipment, rehabilitation, long term placement, hospice and referral to mental health
E. Develops and co-leads an outpatient support group with transplant nursing staff
F. Maintains confidentiality and complies with professional ethics according to Social Work Professional and Departmental standards.
As a member of the Renal Transplant Team:
1. Advocates for the patient to ensure quality outcomes.
2. Participates in interdisciplinary rounds, patient care conferences and team meetings.
3. Participates in the provision of emotional support to the patient/family during patient's illness.
4. Demonstrates an understanding of the impact of live threatening illness or injury on patients
of all ages, and their caregiver and significant others.
5. Identifies opportunities for service line process improvement.
Intervenes with appropriate individuals/departments/agencies regarding delays in service that may have an impact on quality of patient care, length of stay or inappropriate patient admissions.
A. Assesses patient's/family's adaptation to renal transplant and ability to provide for patient's care needs post transplant.
B. Coordinates care of transplant patients to the inpatient renal social worker/care coordinator
C. Serves as a resource to the interdisciplinary team for community based social service agencies.
D. Works with patient/family with process of addressing financial concerns, insurance and
medication issues, and billing issues.
E. Negotiates with care coordination team followup contact with transplant patient/family, community
agency or facility to evaluate the effectiveness of the discharge plans and identifies problems in
QUALITY ASSESSMENT/IMPROVEMENT ACTIVITIES
A. Ensures that renal transplant patients/families and living related donors are involved in all phases of the care coordination process to the greatest extent possible.
B. Maintains current knowledge of and identifies needs in service delivery within social, governmental and
C. Participates in data collection for Medicare guidelines and entitlement forms, and departmental quality assessment activities in collaboration with the renal transplant team and department.
D. Participates in quality assessment/improvement activities designed to evaluate the appropriateness and
effectiveness of the service delivery system.
As a member of the Renal Transplant Team:
A. Ensures that all renal transplant patients and families and living related donors receive consistent information regarding all aspects of care in all settings of care.
B. Maintains effective working and collaborative relationships with medical and nursing staff for the
health care needs of renal transplant patients.
C. Communicates and collaborates with renal transplant team to ensure that care coordination needs of assigned patients are met without duplication of efforts and there is adequate documentation in the patients ambulatory medical records.
A. Meets continuing education requirements to maintain licensure in Massachusetts.
F. Participates in supervisory conferences, staff meeting, in-services, continuing education programs,
research activities and performance improvement activities.
C. May provide field instruction for graduate social work interns.
D. Completes supervisory and examination requirements to obtain LICSW certification, if applicable.
D. May provide mentoring/clinical supervision for LCSW or LICSW.
A. Education: Masters of Social Work Degree from an accredited program.
2 - 5 years experience in an acute health care setting
Experience in working on interdisciplinary teams required.
B. Licensure: LICSW Current Massachusetts license required.
SKILLS AND ABILITIES REQUIRED:
Previous experience in a hospital or health care setting with dialysis or renal transplant patients, bilingual (English/Spanish) preferred/Cultural sensitivity and age-specific