NN&I - August 2010

Transplant August 2010 Nephrology News & Issues 25Subscribe to our free eNewsletter at www.nephronline.com Conditions of participation for transplant centers and implications for social workersBy Charlie Thomas, LCSW, ACSW Mr. Thomas is a social worker with the Liver Transplant Program at Banner Good Samaritan Medical Center in Phoenix, and is a member of NN&I's Editorial Advisory Board.Introduction In 2007, the Centers for Medicare & Medicaid Services (CMS) released the final rule for Hospital Conditions of Participation for Transplant Centers. The new regulations required all trans -plant centers participating in Medicare, including kidney transplant centers, to submit a request for "initial" approv -al. CMS had issued coverage decisions relating to heart transplants in 1987, liver transplants in 1991, and lung transplants in 1995. Coverage decisions for intestine transplants were issues in 2001 and updated in 2006. Kidney transplant centers have been regulat -ed by the Code of Federal Regulations since 1976 but had not been updated. The Final Rule for transplant centers differentiates between the role of the transplant social worker and the role of the dialysis social worker and empha -sizes the importance of psychosocial patient selection criteria in evaluation, selection and listing for transplant. CMS does not require psychosocial patient criteria for dialysis care. The purpose of the new rule was to improve the safety and quality of ser -vices provided by transplant hospital centers and to ensure transparency and non-discrimination in the evaluation, listing, and transplantation of patients. The regulation also created new stan -dards for the evaluation and care of living donors. With the implementation of the new regulation, social workers in hos -pital transplant centers have become increasingly accountable for the ser -vices they provide to patients referred for transplant evaluation. CMS requires that all transplant candidates receive a comprehensive medical and psycho -social evaluation prior to placement on the waiting list. The transplant cen-ter's formal medical and psychosocial patient selection criteria must be evi -dent in the decisions to place patients on the list. The evaluation includes whether the patient meets or does not meet criteria for transplant, or does not meet criteria "at this time." Examples of "at this time" are patients with histories of substance or alcohol abuse needing to complete rehabilitation or patients with serious mental illness needing to establish psychiatric stability. Additionally, CMS now requires hospital transplant centers to inform patients that they are being evaluated and that the results of the medical and psychosocial evaluations will be used to determine whether the patient meets selection criteria. Transplant centers are required to obtain informed con -sent prior to the initiation of the evalu- ation. This is in addition to the consent process for the transplant surgery. The requirements for informed con -sent prior to evaluation and the require -ment of a comprehensive psychosocial evaluation prior to placement on the waiting list have raised the standards of practiceand challengesfor social workers in transplant centers. A new approach to patient selectionThe concept of "patient selection" has its beginning in the early days of kidney dialysis (see page 27). Today, the new Conditions of Participation offer both transplant social workers and patients some assurance that trans -plant is the right therapy, and moves Medicare covered transplant programs to an "outcome" focused system. Both medical and psychosocial selection cri-teria are focused on positive patient and graft outcomes as measured by the Scientific Registry of Transplant Recipients (SRTR). Medical criteria addresses patient issues related to patient survival and long term quality of life (QOL), and psychosocial crite-ria focuses on implications for post-transplant adaptation and adjustment and QOL. This also impacts patient and graft survival. Transplant centers are required to have formal medical and psychosocial patient selection cri -teria which clearly state which groups of patients the center will or will not transplant. Transplant centers are required to follow their specific patient selection criteria policies to meet the National Organ Transplant Act (NOTA) goal to ensure the fair and nondiscrimi -natory distribution of organs. Every transplant candidate and every dialysis center has the right to know the center's patient selection cri -teria. Transplant centers are to give written patient selection criteria to transplant candidates upon request and transplant centers are to auto -matically provide the patient selection criteria to dialysis centers. Transplant centers have the autonomy to establish their own patient selection criteria. But each individual transplant center is responsible and accountable to follow their own policy and selection crite-ria in a manner that treats patients equitably. Exceptions must clearly be documented. The psychosocial patient selection criteria and psychosocial evaluation address psychosocial issues that affect Transplant_NNI_0810_3TK.indd 25 7/16/10 1:40:52 PM