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Multidisciplinary Patient Care Team (3.39)

Multidisciplinary Patient Care Team (3.39) - Policies, Administrative, UWHC, Department Specific, Transplant, Transplant - Solid Organ

3.39

Page 1 of 4

POLICY & PROCEDURE

Effective Date: September 2012
Revised Date: October 2016

Title: Multidisciplinary Patient Care Team


Policy Number: 3.39

I. PURPOSE

The purpose of this policy is to describe the members of the multidisciplinary patient care team that
supports the care of transplant patients throughout their transplant experience including evaluation,
inpatient stay, discharge, and post-transplantation. The purpose of this policy is also to describe their
role in the patient care process.

II. POLICY

It is the policy of the UW Transplant program to adhere to the University of Wisconsin Hospital &
Clinics (UWHC) standards of patient care, as well as the standards determined by regulatory and
accrediting agencies, such as The Joint Commission, the Organ Procurement and Transplantation
Network (“OPTN”) and the United Network of Organ Sharing (“UNOS”), and the Centers of Medicare
and Medicaid Services (“CMS”).

III. PROCEDURE
Documentation should include each team member's involvement as well as the patients' progress
through each phase of the transplant process. The following is a description for each member of
the multidisciplinary transplant team:

A. Transplant Surgeon – Transplant surgeons have been trained to perform kidney, and/or
pancreas, and/or liver and/or heart and/or lung transplant surgeries and trained in pre-, peri-,
and post-operative management, and management of immunosuppressant medication. The
surgeon is responsible for participating in the evaluation of potential transplant recipients, the
patient selection meeting, and in the management of patient care during the patient’s time on
the waiting list (as appropriate). The surgeon is also responsible for managing the immediate
post-operative care of the patient, the discharge process, providing management of post-
operative surgical issues, and participating in the long-term medical management of patients
after transplant, in collaboration with physicians.

B. Transplant Physician – Transplant physicians have medical transplant training and are
responsible for primary management of the patient care. The physicians are responsible for
participating in the evaluation of potential transplant candidates, the patient selection meeting,
managing medical conditions as appropriate during the patient’s time on the waiting list,
providing medical support during the transplant admission, participating in the discharge phase,
and participating in the long-term medical management of patients after transplant, including
immunosuppression medications etc.

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POLICY & PROCEDURE

Effective Date: September 2012
Revised Date: October 2016

Title: Multidisciplinary Patient Care Team


Policy Number: 3.39

C. Transplant Coordinator – Transplant coordinators are registered nurses trained in the field of
transplantation, and receiving ongoing education on transplant practice. The transplant
coordinator serves as the primary liaison between the patient and the clinical care team from
referral of the patient to long-term management post-transplant. The coordinator triages and
manages the patient’s care and assists with patient education at all phases of transplantation.
The transplant coordinator makes arrangements for the patient’s evaluation, assimilates and
presents patient’s data to the patient selection meeting, provides ongoing surveillance of
patients waiting on the transplant waitlist, assists the transplant surgeon in coordination of
transplant surgeries, participates in the discharge process, provides education on
transplantation to patients and families, sees patients in transplant clinic and assesses patient’s
current condition, provides evening and weekend phone triage support for patients with acute
medical complaints, and provides ongoing long-term management of the patient’s condition.

D. Social Worker – Transplant social workers are trained in the field of transplant and receive
ongoing transplant education. The social worker consults with every patient prior to wait-listing
for transplant to conduct a psychosocial assessment and documentation of psychosocial health.
The social worker will document any psychosocial concerns and the plan of care for support. A
psychosocial assessment will be performed again at the time of re-evaluation. A social worker
will participate in the initial assessment, care planning and discharge planning in the inpatient
setting. It is reasonable to expect different levels of intervention based on the needs of the
transplant patient. Any member of the multidisciplinary team may request an updated
psychosocial assessment if deemed necessary.

E. Dietitian – Transplant dietitians are trained in the field of transplantation and receive ongoing
transplant specific education. The dietitian provides a nutritional assessment (consult or chart
review) for every patient prior to waitlisting for transplant and is responsible for working with
the transplant team on the patient's ongoing nutritional status. The dietitian makes
recommendations on patient diet, tube feeding or TPN, instructing patients on dietary
restrictions or good nutrition, and providing education to the transplant team and patients
regarding food and medication interactions. The inpatient dietitian performs a nutritional
assessment during the transplant phase and documents the patient's nutritional status. The
dietitian will follow-up with any concerns and participate in discharge planning.




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POLICY & PROCEDURE

Effective Date: September 2012
Revised Date: October 2016

Title: Multidisciplinary Patient Care Team


Policy Number: 3.39

F. Pharmacist – Transplant pharmacists are trained in the field of transplantation and receive
transplant specific ongoing education. They work with physicians, staff and patients in
management and education of medications throughout all phases of the transplant process. The
transplant pharmacist participates in the medication administration and management process on
the inpatient units, patient discharge planning and instruction, participates in the development
of immunosuppressive medication protocols, provides education to patient and families,
administers the self-medication program, verifies medication lists with patients and provides
education to the transplant team with information about drug interactions, dosing guidelines,
etc., as required.

G. Anesthesia - A representative from anesthesia attends the liver multidisciplinary review meetings
to provide input on the medical work up as it pertains to patient's candidacy for transplant.
Medically complex heart, lung, kidney, pancreas and combined kidney pancreas candidates may
also be seen or reviewed by pre-anesthesia screening clinic prior to transplant as deemed
necessary by the physician involved in the patient’s care.

H. Financial Counselor – Transplant financial counselors consult with every potential transplant
recipient prior to transplant to identify adequate coverage for the transplant episode and
follow-up care, including medications. The financial counselors’ collaborate with social workers
to determine if patient is eligible for financial assistance and, if so, works to get patient enrolled
and approved. Financial counselors work with the multidisciplinary team to provide information
in order to obtain payor approval for treatment and procedures, whenever necessary. They
participate in the discharge process as necessary.

I. Inpatient Nurses and Clinic Nurses – Inpatient and clinic nursing staff are trained in the field of
transplantation and receive ongoing transplant specific education. They provide care to patient
during their hospital stay, or in clinic, either prior to, or following their transplantation and works
with multidisciplinary team to provide patient education. They also participate in the discharge
planning and instruction.

J. Coordinated Care Case Management Team – The coordinated case management team consists
of nurses, case workers, and social workers who coordinate and assist with discharge planning
for the patient’s inpatient stay including discharge planning and instruction.


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K. Histocompatibility Lab – The histocompatibility lab provides testing services for transplantation
including crossmatches, PRA, HLA typing and donor specific antibody identification.
Additionally, a member of the histocompatibility lab also attends the bi-weekly Luminex meeting
to discuss HLA results and serves as a resource for the multidisciplinary transplant team.

L. Transplant Pathology – The transplant pathologist provides assessment of biopsy specimens
and histological diagnosis.

M. Infectious Disease – The infectious disease team provides consultative support to the transplant
team for all infectious disease processes and recommendations related to patient’s risk of
contracting infectious diseases post-transplant along with treatment recommendation and
monitoring of disease processes diagnosed at any stage during the transplant process.

N. Other – Consults may be obtained from other services (i.e., health psychology, pathology,
psychiatry, hepatology, radiology, oncology, pulmonary, cardiology, alcohol and drug
assessment, etc.) as needed.

IV. COORDINATION

University of Wisconsin Transplant Program

V. REVIEWED AND APPROVED BY

Cardiothoracic Transplant
Manager
Kidney Transplant Manager
Liver Transplant Manager
Operations Director

VI. SIGNED BY



Jill Ellefson, MBA Dixon Kaufman, M.D., PhD
Director, Organ Donation and Transplant Service Line Chair, UW Transplant Program

POLICY & PROCEDURE

Effective Date: September 2012
Revised Date: October 2016

Title: Multidisciplinary Patient Care Team


Policy Number: 3.39