Transplant Social Worker Job Description

PRIMARY PURPOSE:

The transplant social worker provides comprehensive social work services to patients and families through all phases of transplant—from date of initial referral through transplant hospitalization and for the duration of the post-transplant period.  As a member of a transplant team, the social worker provides patient education and emotional support, is responsible for referrals to community agencies, coordinates patient care with other team members, and assists with concrete services.  

The provision of these services in the United States is mandated by the Centers for Medicare & Medicaid Services (CMS) for Medicare-approved transplant centers.

                          

JOB PERFORMANCE STANDARDS:

1. Psychosocial assessment

      A psychosocial assessment is completed on each patient referred for organ transplant. This assessment is conducted to assist the transplant team in determining a patient’s psychological and social readiness for the demands and stresses associated with transplant surgery, recovery, and rehabilitation. The psychosocial assessment includes a structured, comprehensive, evidence-based assessment of the patient’s overall global quality of life including, but not limited to, their physical, behavioral, psychological, social and spiritual functioning. The psychosocial evaluation contributes to the overall transplant evaluation and helps establish specific patient care plans to maximize optimal recovery and rehabilitation and to ensure the best possible transplant outcome, while reducing the impact of known psychosocial risk factors. A psychosocial assessment is also required for patients being considered for re-transplantation.

 

The psychosocial assessment will include but it is not limited to:

    • Social History and Support System:
      • Obtain patients’ social history and assess the availability and stability of support for their transplant care. Specifically, ensure family or caregiver stability and emotionally supportive and committed relationships.
      • Assess for any domestic violence abuse and provide referrals as appropriate.
    •  Understanding of Transplant Process (Comprehension)
      • Assess patient and support system’s understanding of transplantation and required follow-up care and receptiveness to transplant counseling, education and teaching.
      • Assess ability to verbalize transplant risks and benefits and establish realistic goals and plans.
    • Self-Management with Medical Treatment (Compliance)
      • Assess patient’s adherence/self-management with medications, medical advice, medical appointments and general health surveillance.
    • Lifestyle Factors
      • Assess patient’s ability to adhere to important lifestyle behaviors that could affect short- and long-term outcomes including diet, exercise and stress-management. Assess patient’s receptiveness to counseling, education and teaching.
    • Mental and Psychiatric Status/ Past and Current
      • Obtain patient’s past & current mental/psychiatric status, including the presence of mood or anxiety disorders, evidence of personality disorders, suicide attempts or ideations, psychotic episodes and willingness to adhere to treatment.
      • Determine any past, current or pending legal issues such as history of arrests or incarcerations.
      • Refer for psychiatric treatment when appropriate and work collaboratively with the psychiatric service to assess patient’s mental stability and ability to manage a complex transplant regimen.     
    • Substance Use History
      • Assess patient’s history of alcohol, drug and tobacco/nicotine use.  Advocate and educate towards abstinence.
      • Provide treatment recommendations, supportive services and surveillance.  Refer to appropriate chemical dependency treatment programs as necessary.
    • Financial/Insurance/Work History
      • Obtain information regarding patient’s employment status, disability and insurance coverage for all medical expenses to determine areas of potential concern, making appropriate referrals for additional resources as needed.
      • Refer to financial transplant coordinator if necessary.
    • Relocation/Lodging
      • Review any relocation/lodging requirements and assess patient acceptance, ability and willingness to comply.
      • Identify potential barriers which may prevent patient/caregiver from relocating and address those barriers.
    • Motivation for Transplant
      • Assess patient’s ability to verbalize and comprehend risks and benefits of transplant.
      • Determine if patient has an advance directive and assess desire to pursue aggressive treatment.

2. Pre-Transplant

  • Meet with patient/family on a regular basis to assess and provide emotional support. Offer supportive counseling to help patient/family cope with the waiting period, declining health, death and dying issues, and/or lengthy hospitalizations.
  • Provide concrete services such as assistance with housing, transportation, and immigration issues.  Provide information and referrals for disability and retirement benefits, medical insurance coverage, and other financial issues.  Refer to community resources such as fund-raising foundations.
  • Facilitate and/or refer patients and caregivers to transplant support groups, and coordinate mentoring programs.
  • Make referrals to psychiatric/neuropsychiatric/psychological services as deemed necessary.
  • Maintain ongoing communication with multidisciplinary team members.
  • Obtain and monitor behavioral agreements from patients/families that address continued commitment to maintaining compliance with medical regimen, abstinence from nicotine, alcohol, illicit substance use.
  • Provide patients with support surrounding end of life issues. Educate patients regarding Advance Directive forms and refer to palliative care when appropriate.

3. Post-Transplant

  • Provide ongoing assistance with relocation housing needs, transportation, maintaining medical insurance, obtaining medications and support for the caregiver. 
  • Follow patient for psychosocial/mental health issues related to post-transplant adjustment (i.e. depression, marital or family issues, ETOH/substance abuse, changes in family. dynamics, concerns regarding rejection or body image). Facilitate referrals as needed.
  • Assist with return to work issues.
  • Provide support to transplant recipients as they explore feelings towards their donor and assist in the coordination for correspondence with donor family when desired.
  • Evaluate all post-surgical transplant recipients and living donors prior to discharge to ensure their needs are being met and collaborate with multidisciplinary team members as necessary.

REQUIREMENTS:

a.    Education, Licensure & Certification:

  • Master’s degree from a graduate school of social work accredited by the Council on Social Work Education 
  • Maintain professional licensure available to social work healthcare practitioners in the practice locale.
  • Certified Clinical Transplant Social Worker (CCTSW) credential is strongly encouraged.

b. Knowledge:

  • Physical and emotional impact of illness on patient and patient’s family support system 
  • Discharge planning and care management
  • Community resources
  • Role of state and federal governmental agencies as they relate to health care
  • Developmental issues related to populations served
  • Mandatory reporting requirements
  • End of life issues
  • Cultural diversity
  • Crisis management
  • Departmental and hospital policies and procedures

c. Skills:

  • Excellent interpersonal and written communication
  • Current clinical assessment skills
  • Ability to act in an autonomous, self-directed manner
  • Ability to receive multiple stimuli from multiple sources simultaneously
  • Good judgment, problem solving and priority setting
  • Decision-making
  • Active listening
  • Time management
  • Organization and delegation
  • Leadership
  • Ability to be a change agent
  • Critical thinking
  • Negotiation
  • Basic computer knowledge
  • Conflict resolution

d. Experience:

  • A minimum of two years of social work experience in a hospital or health care setting
  • Transplant experience is preferred.

e. Other Duties:

  • Participation in transplant team care conference and selection committee meetings
  • Active participation in transplant-related and social work professional organizations (i.e. OPO, NASW, STSW)
  • Professional presentations and/or research projects 

This information is also available to download in a word document or pdf


STSW Core Competencies

The content below describes the STSW Core Competencies as defined by the Council on Social Work Education. The practice behaviors listed are specific to the field of transplant social work.

Competency 1
Identify as a professional social worker and conduct oneself accordingly.

Social workers serve as representatives of the profession, its mission and its core values. They demonstrate professional commitment by taking responsibility for their conduct, practice and learning, with support through supervision. Social workers:

  • Advocate on behalf of their patients for fair and equitable access to services and demonstrate knowledge of community resources and funding possibilities
  • Practice personal reflection and self-correction to assure continued professional development
  • Demonstrate ability to work with the multi-disciplinary transplant team in a responsive manner while adhering to professional roles and boundaries
  • Engage in career-long learning and rely on supervision and consultation as adjuncts to ensure the competence of their work

 
Competency 2
Apply social work ethical principles to guide professional practice.

Social workers have an obligation to conduct themselves ethically and to engage in ethical decision-making. They are knowledgeable about values of the profession, its ethical standards and relevant law. Social workers:

  • Demonstrate knowledge of the NASW Code of Ethics and understanding of how social work ethics pertain to the medical ethics of transplant recipients
  • Tolerate ambiguity in resolving ethical conflicts, recognize and manage personal differences and then apply principles of ethical reasoning to arrive at an impartial and fair decision to determine patient selection for transplantation

 
Competency 3
Apply critical thinking to inform and communicate professional judgments.

Social workers are knowledgeable about the principles of logic, scientific inquiry and reasonable judgment. Critical thinking skills are enhanced by their creativity and curiosity, requiring the synthesis and communication of relevant information. Social workers:

  • Distinguish and integrate multiple sources of knowledge, including research-based knowledge
  • Demonstrate ability to conduct a comprehensive psychosocial assessment, specific to determining an individual’s capacity to receive or donate an organ
  • Demonstrate effective oral and written communication while interacting with patients, families, groups and colleagues

 
Competency 4
Engage diversity and difference in practice.

Social workers understand how diversity characterizes and shapes the human experience and is critical to the formation of identity. The dimensions of diversity are multi-factorial including: race, ethnicity, national origin, color, gender, sexual orientation, gender identity or expression, age, marital status, political beliefs, religion, immigration status and mental or physical disability. Social workers appreciate that as a consequence of difference, a person’s life experiences may include oppression, poverty, marginalization, and alienation as well as privilege, power, and acclaim. Social workers:

  • Respect an individual’s self-worth, human rights and dignity
  • Strive to eliminate the effect of biases in their work by never knowingly participating in or condoning discriminatory practices
  • Work with multi-disciplinary team to ensure there are no discriminatory practices

 
Competency 5
Advance human rights and social and economic justice.

Every individual has basic human rights including freedom, safety, privacy, adequate standard of living, access to health care and education. Social work values incorporate social justice practices in organizations, institutions, and society to ensure that these basic human rights are distributed equitably and without prejudice. Social workers:

  • Challenge social injustice
  • Strive to ensure full disclosure and equitable access of resources
  • Promote the opportunity for full participation in decision making

 
Competency 6
Engage in research-informed practice and practice-informed research.

Social workers use practice experiences to inform research, employ evidence-based interventions, evaluate their own practice, and use research findings to improve practice, policy, and social service delivery. Social workers comprehend quantitative and qualitative research and understand scientific and ethical approaches to building knowledge. Social workers:

  • Promote and facilitate program and resource development as well as clinical research and publishing
  • Critically examine and keep up to date with emerging trends in transplantation and incorporate evidence based research in their practices

 
Competency 7
Apply knowledge of human behavior and the social environment.

Social workers are knowledgeable about human behavior across the life span and the range of social systems in which people live as well as the impact of these social systems on achieving and maintaining health and well-being. Social workers:

  • Integrate both traditional and alternative perspectives for use in global practice, such as promoting projects which encompass problem solving and reflect the unique culture, politics, geography and economy of a region
  • Exercise critical thinking strategies and knowledge to ensure the best possible transplant outcome while reducing the impact of known psychosocial risk factors

 
Competency 8
Engage in policy practice to advance social and economic well-being and to deliver effective social work services.

Social workers understand that policy affects service delivery and they actively engage in policy practice. Social workers know the history and current structures of social policies and services, the role of policy in service delivery and the role of practice in policy development. Social workers:

  • Advocate for policies that advance the social well-being of transplant recipients, living donors and donor families
  • Are knowledgeable regarding departmental and hospital policies and procedures and collaborate with colleagues for effective policy action

 
Competency 9
Respond to contexts that shape practice.

Social workers are informed and resourceful while responding to evolving organizational, community and societal contexts at all levels of practice. They recognize that the context of practice is dynamic and use their knowledge and skills to respond proactively. Social workers:

  • Continuously seek knowledge and understanding of medical and technological developments and emerging social trends to provide relevant services
  • Provide leadership in promoting sustainable changes in service delivery and practice to improve the quality of social services

 
Competency 10
Engage, assess, intervene, and evaluate with individuals, families, groups, organizations and communities.

Professional practice involves the dynamic and interactive processes of engagement, assessment, intervention and evaluation at multiple levels. Social workers have the knowledge and skills to practice with individuals, families, groups, organizations and communities. Social workers:

  • Use interpersonal skills to develop a trust-based relationship with patients and families
  • Conduct psychosocial evaluations through information gathering
  • Work with patients, families and multi-disciplinary team to determine appropriate intervention strategies based on mutually agreed upon goals and objectives
  • Analyze, monitor and evaluate interventions, then communicate progress to multi-disciplinary team


Code of Ethics

The Society for Transplant Social Workers follows the National Association of Social Workers Code of Ethics.