Background

In 1984, The National Organ Transplant Act (NOTA) established that donated organs are a limited/scare public resource and created the Organ Procurement and Transplant Network. The OPTN is required to operate the national program in a systematic manner to maximize patient and organ graft outcomes, measured in years of survival following the transplant, and minimize the “waste” of donated organs.

The OPTN is administered by the U.S. Department of Health and Human Services Health Resources Administration (HRSA) and operated by the United Network of Organ Sharing (UNOS) under contract with HRSA.

QAPI and measuring outcomes

Patient and transplant graft outcomes are the most important measures of outcome quality that CMS uses to evaluate and certify new transplant programs and to cite and sanction an existing transplant program. CMS conditions of participation require transplant centers to have established and functioning Quality Assurance and Performance Improvement (QAPI) processes, guided by written policy with direct reporting and accountability to the hospital’s administration and medical staff governance. The primary purpose of a transplant center’s QAPI is to establish processes that measure, evaluate, report, and improve or protect patient and transplant graft outcomes.

All CMS certified transplant programs are required to report their recipient and graft outcomes to the Scientific Registry of Transplant Recipients (SRTR), which analyzes the data and provides a comprehensive report to the HRSA Division of Transplantation as well as the general public via its website (www.srtr.org/who.aspx). The Chronic Disease Research Group of the Minneapolis Medical Research Foundation administers the SRTR with oversight and funding from HRSA. The general public, including patients and their families, and health care payers use this information to compare transplant programs and select which one(s) to affiliate with.

In 2007, the CMS Conditions of Participation for Transplant Hospitals established that patient and organ graft outcomes are the result of the interaction between medical and psychosocial factors, and required transplant programs to have written medical and psychosocial patient selection criteria to use when evaluating candidates for transplant. CMS also required transplant programs to establish medical and psychosocial selection criteria to use in evaluating and selecting living donors.

The role of the social worker in the transplant program

CMS requires transplant QAPI processes to be multidisciplinary and to include qualified MSW social workers to address psychosocial issues in patient and graft survival outcomes. Social workers often collaborate with psychiatrists and psychologists on the transplant team and QAPI committee. Psychosocial factors affecting transplant outcomes include:

  • Poor social support, including absence of confirmed family caregivers during the immediate post transplant period
  • Mental health/psychiatric disorders likely to negatively affect post transplant adherence with medications and follow up
  • Dysfunctional personality traits and disorders
  • General poor adherence with medical and psychiatric follow up
  • Patient destructive behavior, such as alcohol or substance abuse
  • The patient’s inability or unwillingness to comprehend the need for post transplant adherence
  • Financial issues that could interfere with post transplant medication adherence.

Written psychosocial patient selection criteria are addressed prior to transplant and interventions provided before transplant listing. Most candidates for transplant readily meet selection criteria. Unfortunately some never meet criteria. And some patients remain high risk for poor transplant outcomes even though they eventually met the selection criteria after the early intervention. One example is the transplant candidate with a significant history of alcohol or substance abuse who completed rehabilitation, has attended ongoing relapse prevention, and demonstrated a minimum period of sobriety prior to placement on the wait list––and then relapses post transplant with negative consequences for survival or long-term outcome for the transplanted organ. Another example is the patient caregiver evaluated and confirmed pre-transplant that disappears and leaves the transplant recipient alone during the transplant surgery recovery period. One severe example is the transplant recipient or living donor who dies post transplant by committing suicide. Then there are patients with poor outcomes that did not have any contraindications to selection. This is true for both psychosocial and medical criteria.

Summary

Transplant social workers are actively involved with transplant center QAPI, evaluating the psychosocial factors involved in-patient and living donor candidacy, selection, and short and long term outcomes. This involves working closely with the other mental health and medical members of the transplant team and QAPI committee. It is important for transplant centers to incorporate psychosocial factors into evaluation of transplant patient and graft survival outcomes.