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The Social Work "Expectrum"


Jill I. Giordano, MA, MSW, LCSW
Newark Beth Israel Medical Center
Newark, NJ
Jill.Giordano@rwjbh.org

Kathryn Carpenter, LCSW CCTSW, CCSW-MCS
Tampa General Hospital
Tampa, Florida
kcarpenter@tgh.org



The position of the Social Worker (SW) on the multidisciplinary team (MDT) is mandated by the Centers for Medicare & Medicaid Services (CMS) for Medicare-approved transplant centers. Similarly, The Joint Commission designates the SW as a necessary team member. The role of the SW on the multidisciplinary heart failure treatment team is to provide comprehensive social work services to patients and families across the spectrum of advanced therapies-from the date of initial referral, through hospitalization, and then during the lifespan of the patient and their support network. According to our professional organization, the Society of Transplant Social Workers (STSW), define this specialized role as "...providing patient education and emotional support, responsible for referrals to community agencies, coordinates patient care with other team members and assists with concrete services."

Social workers specializing in the care of heart failure patients requiring advanced therapies hold a Master's degree from a graduate school of Social Work accredited by the Council on Social Work Education. Social Workers also maintain professional licensure in their respective state of practice. Unlike the episodic care delivery model unto the inpatient social work role, our clinical work as part of the MCS/Transplant MDT is one of chronic care. We are tasked with assisting the MCS/Transplant team in determining a patient's psychosocial readiness for the demands and stresses associated with MCS/Transplant preparation, surgery, recovery, rehabilitation and lifestyle changes.

CMS and The Joint Commission designate the SW as a crucial part of the MDT in the care of these complex patients. There are numerous articles that reference patients with appropriate (or an abundance of) psychosocial resources/support showing improved outcomes over those with little or no psychosocial resources/support. Therefore, the SW role, while often overlooked on the MDT, provides critical support to our patients and caregivers.

The SW "Expectrum" is a term pointing out the large variation in role and responsibilities across teams and centers for SW specialists. Our psychosocial assessment includes a structured, comprehensive and evidence-based assessment of the patient's overall quality of life including, but not limited to, their physical, behavioral, psychological, social and spiritual functioning. The psychosocial evaluation contributes to the overall advanced therapies evaluation and helps establish patient-specific care plans to maximize optimal recovery and rehabilitation and ensure the best possible outcomes while reducing the impact of known psychosocial risk factors. MCS/Transplant social workers also contribute to patients, teams, and furthering of the specialty by:

While the Expectrum may be daunting, these specialist SWs proudly add to the richness of their respective MDTs. Understanding the specialist SW role and abilities on the MDT may further add to the enhancement of patient/caregiver outcomes in this complex population as well as the strength of the teams in which MCS/Transplant SWs play such a critical role. ■

Disclosure Statement: The authors have no conflicts of interest to disclose.




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