Position Summary

The Transplant Social Worker is accountable for the overall Psychosocial needs of transplant patients at Jackson Memorial Hospital. The Transplant Social Worker is responsible for evaluating every pre-transplant patient being considered for an organ transplant. She/he is an integral part of determining a patients suitability for placement on the waiting list or a patients suitability for transplantation. The Transplant Social Worker also completes a psychosocial on potential living donors in order to determine the suitability of candidates for donation. Also, she/he provides needed support, education, and community networking for Post Transplant recipients.

Duties & Responsibilities

Complete a Psychosocial Assessment on all potential solid organ recipients and make a recommendation to the multi-disciplinary team as to candidacy for transplant factoring in risk/benefit analysis of each individual patient. Participate in the informed consent/education of transplant patients adhering to the program protocol on all components of education required for transplant candidates and living donors. Assess patients understanding of information presented and reinforce as needed. Complete a Psychosocial Assessment on identified living donors, assess for motivation to donate, any evidence of coercion, any valuable exchange for donation and make recommendations to the multi-disciplinary team as to candidacy to donate. Provide supportive counseling as needed to any patient who does not meet transplant listing criteria due to modifiable behavioral, support or economic reasons. Serves as patient/family advocate, and shall seek information, services and referral sources to heighten individual or family accesses to services in the community. Transplant Social Worker shall strive to provide optimal representation of patient in securing resources, information regarding federal and state guidelines as they impact patient's status as a transplant candidate, recipient, or as a potential living donor. Services may include the pursuit of up-to-date legislative and federal guideline measures impacting ESRD and Transplantation (e.g., ESRD Medicare guideline changes, and pursuant legislation). Participate in interdisciplinary listing committee meetings and provide recommendations to the team in terms of patient suitability for transplant, modifiable contraindications or absolute contraindications to transplant or donation. Liaison between patient and Transplant team on any issues relative to psychosocial assessment and recommendation for transplant and donation. Referral to needed community resources (i.e. drug assistance programs), follow-up on referrals, outcomes of treatment and make subsequent recommendation to the multi-disciplinary team on candidacy. Facilitate continuity of patient care through communicate with referring agencies (i.e. Dialysis Centers) and other entities both verbally and in writing. Assure compliance with CMS and UNOS regulations relative to the role of the transplant social worker, provision of mental health support in adherence to UNOS/OPTN and CMS regulations. Revises documentation forms and consent forms based on evidenced based practice, and changes in regulations and quality outcomes. Participate in the development and updating of clinical patient care protocols relative to social work services, psychosocial assessment and treatment outcomes using community best practices or evidence based guidelines. Attends (2) educational webinars scheduled via the MTI Quality Program throughout the calendar year. Attends and actively participates in program specific quality meetings. Provides substantive feedback from a psychosocial perspective during all multidisciplinary discussions. Attend patient selection committee meetings and other patient care related program meetings as indicated. Responsible for presenting feedback/findings of their psycho-social assessment during all patient selection committee meetings inclusive of coping skills, support, concerns, and compliance. Provides on-going interventional support post transplant. Assist program with quality metrics related to specialty as identified throughout the year. Served on a departmental or interdepartmental PI Team that has improved a process (PDSA-team). Participation in at a minimum of (1) performance improvement project during the calendar year. Collaborates with other team members while making recommendations for interventions. Assist with follow-ups to assess outcome of projects and/or improvements. Actively participates in the development of the Multi-Organ Transplant Center and its ongoing Operations Improvement (OI) and patient quality care plans. Responsible for following patients in all phases of the transplant process. Performs other related duties as assigned. Supervision of the daily Patient Care programmatic operations in the Jackson Health System/South Florida AIDS Network department; including the coordination and evaluation of referral systems for clients. Acts as a liaison to funded providers including Medical Case Managers and eligible patient care clients accessing services within the patient care network. Assists eligible patient care clients with access matters in addition to monitoring the quality of services delivered. Participates in the development, implementation and evaluation of the a continuous Quality Improvement plan that identifies improvement opportunities. Maintains knowledge of all systems required to facilitate the Medical Case Management process. Attends appropriate orientation and training courses to maintain competency in job skills and knowledge. Participates in required educational programs including Ryan White, JHS and Department of Health trainings. Knowledge of all funding sources for JHS/SFAN program eligibility i.e. Florida Administrative Code (F.A.C.) Chapter 64D-4, Ryan White Program Service Delivery guidelines, the Florida Department of Health HIV/AIDS Patient Care guidelines and JHS financial eligibility policy and procedures. Ensures Medical Case Managers are compliant to the clinical documentation, productivity and service requirements established by Ryan White, JHS and Department of Health. Responsible for the review and approval of Medical Case Managers Care Plans. Maintains the participation and act upon required recommendations of the Ryan White Technical Assistance (TA) reviews. Performs other related duties as assigned. Demonstrates behaviors of service excellence and CARE values (Compassion, Accountability, Respect and Expertise).

Education

Master's Degree in related filed is required.

Experience

Generally requires 3 to 5 years of related experience.

License/Certification

American Heart Association Basic Life Support (BLS) and any additional applicable life support certification for Healthcare Providers is required upon hire with at least 6 months validity and maintenance at JHS for the duration of employment.

Knowledge/Skill/Abilities

Knowledge of business and management principles involved in strategic planning, resource allocation, human resources modeling, leadership technique, production methods, and coordination of people and resources. Skill in monitoring/assessing the performance to make improvements or take corrective action. Skill in using logic and reasoning to identify the strengths and weaknesses of alternative solutions, conclusions, or approaches to problems. Ability to plan, implement, and evaluate programs. Ability to establish goals and objectives. Ability to recognize, analyze, and solve a variety of problems. Ability to assess a patients ability to adhere to therapeutic regimens. Ability to asses patients mental health history including degree of substance and alcohol use and how it may impact the success or failure of organ transplantation or the donors mental health post transplant. Ability to assess a patients and living donors(if applicable) coping abilities and strategies. Ability to assess the patients financial capabilities and resources. Ability to demonstrate literacy in using computerized information systems.

Physical Demands

Job function requires extended standing or walking. Must be able to carry objects weighing 21 to 50 pounds. Able to lift or move objects weighing 51 to 100 pounds with the use of appropriate devices. Jobs in this group require frequent visual acuity to perform activities related to extended use of computers. Additional information and provision requests for reasonable accommodation will be provided by the home unit/department in collaboration with the Reasonable Accommodations Committee (RAC).

Work Environment

Jobs in this group are required to function in a fast paced environment with occasional high pressure or emergent and stressful situations. Frequent interaction with a diverse population including team members, providers, patients, insurance companies and other members of the public. Function is subject to inside environmental conditions, with occasional outdoor exposures. Exposure to various environments such as: communicable diseases, toxic substances, medicinal preparations and other conditions common to a hospital and medical office environment. May also be exposed to needle sticks, airborne infections, medical gases, X-Ray, chemical exposures and other potential hazards. Must wear Personal Protective Equipment (PPE) when exposed to infectious/clinical hospital environment. Reasonable accommodations can be made to enable people with disabilities to perform the described essential functions. Additional information and provision requests for reasonable accommodation will be provided by the home unit/department in collaboration with the Reasonable Accommodations Committee (RAC).