All team members are expected to be knowledgeable and compliant with Prisma Health's purpose: Inspire health. Serve with compassion. Be the difference.
Advocates for the patient and family as they navigate through the complex healthcare setting by providing resources and coordinating care. Empowers patient and family to actively participate in family centered rounds and medical decision making. Empowers the patient and family to problem solve and become independent in managing care for the transplant patient in the home setting.
Maintains thorough, accurate, and timely electronic documentation of all patient encounters to ensure safe transitions between all transplant/donation specific phases of care. Communicates effectively with patients, family and multidisciplinary team members, as well as referring and primary care provider and consultants regarding patient clinical findings and plan of care within a timely manner. Maintains/ensures communication with patient, referring physician, payors or other health care providers throughout the transplant/donation process. Collaborates with nursing staff, social work and other health care providers to establish and implement patient care plan according to current standards of care.
Maintains professional knowledge and clinical ability enough to provide evaluation and treatment of complex patients in one or more specialty areas including abdominal transplantation. Interprets relevant clinical data and is an active participant on the medical decision-making care team. Ensures comprehensive and complex healthcare needs (medical, psychosocial and economic), are continually monitored and addressed. Monitors and routinely updates the patient’s status on the national registry waiting list. Remains current on clinical policy, guidelines and regulatory changes. Maintains current knowledge of transplant center outcomes and performance standards.
Provides individualized patient/family education throughout all phases of care and provides an ongoing assessment of the effectiveness of education provided. Plans, conducts, and evaluates educational materials and activities provided for patients and families in response to educational needs. Educates candidate/family about the evaluation process, regulations, allocation, pre transplant/donation listing phase, transplant process, donor/recipient confidentiality, post-operative transplant/donation care, symptoms and surveillance of infection and rejection, risk and benefit of immunizations, potential financial issues and candidate/family responsibility throughout the transplant process. Assesses candidate and family educational deficits of transplant process. Reinforces education and follow up requirements needed for successful outcome.
Participate in, contribute to and promote continuing education around transplant and care of the transplant patient. Participates in improvement initiatives and projects within the institution. Serves as a resource to internal and external organizations to provide specific education appropriate to the needs of transplant professionals. Maintains current knowledge of and complies with institutional policies and procedures. Demonstrates knowledge/understanding of current regulatory oversight requirements for transplant centers including active participation in ongoing survey readiness and site visit process. Maintains current knowledge of transplant center outcomes and performance standards. Maintains knowledge of regulatory requirements for the transplant center and ensures required documentation is completed. Maintains knowledge of guidelines and standards and acts as a resource for internal and external health care providers.
Facilitates/coordinates evaluation and listing of potential transplant candidate. Identifies requirements and provides oversight of the candidate evaluation process. Interprets serological results and their implications for transplant. Gathers and communicates serological results and blood type in accordance with regulatory requirements. Identifies possible co-morbidities and absolute and relative contraindications for potential transplant candidate. Functions as candidate advocate by applying knowledge of growth, development, educational and cultural background during candidate/family interactions. Collects and evaluates medical, psychosocial and financial data for review by transplant team. Communicates with referring physician, other care providers, payors and transplant team members regarding the candidate status and evaluation outcome. Provides data to regulatory bodies for listing statistics.
Monitor and coordinate care of the candidate awaiting transplantation. Ensures monitoring per transplant center specific standards. Identifies and responds to the psychosocial and economic needs of the transplant candidate during the pre-transplant/donation period. Exhibits ability to maintain and update candidate listing status per regulatory regulations. Identifies the need for candidate re-evaluation and initiates process when appropriate. Acts as a resource for internal and external health care providers.
Participates in transplant/donation process according to specific standards. Shares pertinent information about the intended recipient including ABO compatibility with the transplant team. Facilitates admission or transfer of patient to the transplant facility. Notifies transplant team of pending medical and/or surgical procedure. Remove transplant recipient from list according to regulatory guidelines. Provides outcome specifics to regulatory bodies for donor family follow up.
Demonstrates understanding of post-transplant/donation management including medications, complications, interventions and discharge planning. Coordinate the care of the transplant recipient in the outpatient setting to achieve optimal physical, social and emotional rehabilitation. Identifies complications and considers interventions with the transplant team. Coordinates/ensures discharge planning to provide for continuity of care. Assess recipient's compliance with medication and medical regimen and collaborates with transplant team to attain and maintain compliance. Collects and reviews data pertinent to recipient/donor health (and if applicable the organ function) with transplant physician. Communicates adjustments in patient plan of care and drug transplant therapy as ordered by medical providers. Arranges for consults, diagnostic testing, and hospitalization when indicated. Coordinates emergent evaluation of transplant recipient when indicated. Assists in the reporting required data to regulatory bodies.
Performs other duties as assigned.
