Clinical Team Leader: Gracie Moore-Greene, DrPH, LCSW-C
Patient Profile (age range-socioeconomic status)
Transplant patients ages range from pediatric to elderly. The large majority of the new transplant patients are middle aged (in their 40s or 50s). Post transplant patients age range is in the 50s to 60s with more elderly in this category. The patients are from a middle to low socioeconomic status (limited finances, limited social support and usually high school graduates). The transplant patients have numerous medical co-morbidities that complicate their medical and psychosocial treatment plans and compliance.
Scope and Complexity of Patient Care Needs
The transplant social workers provide clinical services across the continuum of care. Pre-transplant social workers provide psychosocial evaluations for recipients, living donors and kidney outreach dialysis patients. The inpatient transplant social workers provide automatic service to all inpatients on the medical and surgical kidney/pancreas transplant service, heat/lung transplant service and liver transplant service. Post transplant clinical service is provided based on referred patients. The following clinical social work activities include:
- Psychosocial Evaluations
- Patient and Family counseling
- Health education (individual and group)
- Counseling for victims of abuse
- Community referrals (shelter/housing, medical insurance and prescription benefits, substance abuse, outpatient counseling, hospice)
- Legal assistance (guardianship, advanced directives, illegal aliens)
- Support Groups
Strategies to Meet Patient Care Needs
Federally mandated evaluation of patient's psychosocial situation and risk for graft success and compliance with the treatment plan is completed by patient and family interviews. Treatment strategies include individual and family counseling, psychiatric consultation, patient and family education groups, community resource referrals and development and distribution of education brochures and booklets. The transplant social workers attend daily inpatient multidisciplinary rounds and weekly team meetings to list recipients and approve living donors. Documentation of psychosocial evaluations are required by the DSW and mandated by the federal government before new patients are listed and after transplantation.
Extent to Which Care Meets Patients' Needs
Transplant social work services are evaluated on a regular basis through performance measures, customer satisfaction surveys and outcome measures. Indicators used to measure if patient and family needs are met include documentation monitors, patient and staff satisfaction surveys, education group surveys, patient volume and complexity and clinical practice outcomes. Quality of service is evaluated based on established indicator thresholds.
Patient Care Providers
All transplant social workers are licensed by the state of Maryland and have obtained a master's degree from an accredited school of social work. Orientation to the hospital, DSW, Transplant Department and service area is provided for all new employees. Ongoing professional training and development to provide appropriate clinical intervention for patients and meet licensure requirements for CEU's is completed by all transplant social workers. Training is provided by the DSW, professional community and in-services by the Transplant Department specific to organ transplantation.
For patient inquiries or to make an appointment, call 1-800-492-5538.
This page was last updated: May 10, 2013