Qualified social workers with Master of Social Work degrees are required by the Centers for Medicare & Medicaid Services to be part of the transplant center’s multidisciplinary team. Social workers complete comprehensive psychosocial evaluations for all patients referred for transplant or live organ donation to determine if they meet psychosocial selection criteria.
CMS requires transplant centers to have written psychosocial and medical selection criteria to guide patient evaluation, acceptance for transplant or live donation, and waitlist maintenance. Centers are also required to have policies that address post-transplant discharge planning for transplant recipients and living donors. In addition to conducting psychosocial evaluation for living donors, social workers also function as the Independent Living Donor Advocate in many transplant programs. However, social workers functioning as Independent Living Donor Advocates are prohibited by CMS from routine involvement with transplant candidates or recipients. As members of the multidisciplinary team, social workers collaborate closely with the transplant surgeon, transplant physician (i.e.,. nephrologist), registered nurse transplant coordinator, nutritionist, pharmacist, as well as the in-patient nursing and allied health staff caring for the transplant patient or living donor. Psychiatrists and clinical psychologist may also be a part of the team. Of course, the patient and family are critical members of the team as well.
It is important for the psychosocial evaluation to include:
- Social, personal, housing, vocational, financial, and environmental support and strengths
- Cultural and language factors
- Identified and confirmed post transplant caregivers
- Post transplant medication plan
- Coping abilities and strategies
- Understanding of the risks and benefits of transplantation or live kidney donation
- Ability to adhere to a treatment regimen, and
- Mental health history, including substance or alcohol use and/or abuse and how it may impact the success or failure of organ transplant or the safety of the living donor.
The psychosocial patient selection criteria and psychosocial evaluation address psychosocial issues that affect patient and graft survival outcomes, similar to the medical patient selection criteria emphasis on the medical issues and how they affect patient and graft survival and outcomes. The National Transplant Act and CMS require transplant centers to operate in ways that maximize patient and graft survival and minimize “waste” of organs given the severe shortage of organs available for the 120,000 people on the national waiting list. CMS also requires centers to maximize transplant recipient living donor safety and protection of their rights. Both transplant candidate/recipient and living donors receive services from qualified social workers and both receive psychosocial evaluations. Transplant social workers role and involvement with living donors is entirely separate for the social workers working with patients needing transplant
A 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
Upon completion of the psychosocial evaluation, the social worker offers a preliminary conclusion about whether the patient met the psychosocial selection criteria, did not meet the psychosocial criteria or did not meet the psychosocial criteria at this time. This conclusion may be developed in partnership with others including psychiatrists, psychologists and/or addictionists. Social workers as part of the selection committee then meet with the other transplant team members to review and discuss. It is the transplant patient selection committee that formally determines the acceptance or denial of the patient to the transplant list or to accept a living donor candidate. If the patient needs more time to meet psychosocial criteria it is the social worker that follows up. Examples include patients with histories of substance abuse needing to complete rehabilitation or patients with serious mental illness needing to establish psychiatric stability.
Social workers are also involved with patient informed consent. CMS requires transplant centers to obtain informed consent from candidates for transplant and live donation prior to evaluation. This includes full disclosure of the center’s medical and psychosocial social selection criteria, that the information obtained during evaluation will be used to determine selection, and a review of the medical and psychosocial risks of evaluation and transplant or live donation. The psychosocial social risks include increased risk for depression, anxiety, dependence on others, emotional trauma, feelings of guilt, possible future health and mental health problems, impact of receiving a transplant, and the impact on future medical, disability and life insurance. Candidates for live donation must also be offered a “confidential out” should they choose not to proceed with live donation. The psychosocial risks become more acute as the transplant patient or living donor experience and cope with medical and psychosocial complications, such as rejection.
CMS requires the establishment of the center’s Quality Assessment and Performance Improvement (QAPI) committee to monitor and evaluate the performance of the transplant program. Key personnel for the transplant center are to be involved and the qualified social worker with the Master of Social Work degree is required. The social worker collaborates with other QAPI team members by participating in the QAPI committee, presenting psychosocial topics, writing reports that address patient and living donor outcomes, policy development, and process improvement. Social workers are also involved in CMS and UNOS survey readiness.
Social workers are involved with transplant patients and living donors throughout the transplant and donation process including pre-evaluation, psychosocial informed consent, transplant and living donor selection, hospital discharge planning, QAPI committee participation and short term and long-term follow up. Social workers also provide counseling and crisis intervention, patient and family education, information and referral to hospital and community resources and services, facilitate patient and caregiver support groups and mentor programs.