AATMC SESSION #5 GETTING PREPARED PART 2 Session Presenters: Cindy Mathews, RN, CCM Ronald G. Potts, MD
Content Pre-Transplant Preparation Transplant Admission Outpatient Care on Transplant Campus Transition to Home
Upon completion of this session, participants will be exposed to: Objective Content #1 Examine the role of the case manager in each transplant phase #2 Describe key components of the post-transplant regimen #3 Be familiar with immunosuppressant medication regimen #4 Understand the importance of ongoing follow-up care with the transplant hospital
Pre-Transplant Phase
Definition: Candidate is wait-listed as Status 1A. Case Manager, Jan Pearce is monitoring candidate s condition, adherence to pretransplant care plan, and assisting patient/family in preparing for transplant by reviewing and updating care plan.
Holistic Assessment Patient Care Plan VAD Maintenance Cardiac Rehabilitation
Patient education Length of stay in the hospital Transplant clinical care pathway Standard post-transplant medications Lodging post-discharge
Transplant Day
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Definition: Candidate has undergone transplantation. Patient is in the inpatient phase of the case rate contractual agreement.
Transitions of Care Cardio-Thoracic ICU Solid Organ Unit Outpatient Care 13
Cardiothoracic ICU Ventilator Hemodynamic Monitoring Lines Chest Tubes Pacemaker Wires
Solid Organ Unit Monitoring Education
Anti-rejection Medications Induction Maintenance Acute Rejection
Discharge Teaching with Patient and Family Immunosuppressant Medications Additional medications Drug-drug and food-drug interactions Home monitoring activities Biopsy schedule Signs and symptoms of rejection Prevention of potential complications When to call the transplant center Ohler & Cupples, 2008.
Case Manager Connections Transplant Coordinator Patient Family Local Providers Health Plan Reinsurer 18
Fever Rejection The Denervated Heart Infection Cardiac Allograft Vasculopathy Side Effects of Medications
Outpatient Care
Definition: Transplant patient discharged to outpatient setting. Medical services continued at the transplant clinic. Post transplant coordinator has educated you and family on contact needs and follow-up care.
What will happen in Clinic? Initial visits 1-2X/Week Physical examination by transplant physician Have blood tests drawn before taking AM dose of immunosuppressant medication(s) Review blood test results and medications with physician Meet with transplant coordinator Schedule or reports for any additional procedures or tests (biopsy, x-ray, Echo, etc.) Meet with other transplant team members (social worker, dietician, pharmacist) Attend support group meetings International Transplant Nurses Society, 2011.
Homeward Bound Maintain care coordination with transplant hospital and local providers Continue ongoing assessments which will lessen as patient progresses post-transplant 23
International Transplant Nurses Society (2011). A Guide to your health after heart transplantation. Retrieved from http://www.itns.org/patienteducation.html Ohler, L. & Cupples, S. (2008). Core curriculum for transplant nurses. St. Louis, MO: Mosby Elsevier. 24
1) Ask Questions & Seek Clarification 2) Complete The Post Test (Link in This Course s Section of Website) 3) Plan The Time For Your Next AATMC Session 4) Attend a Medical Roundtable (At Least Two Required)
Presenter Title Ext. Email Ron Potts, MD Cindy Mathews, RN, CCM Clancy Petersen Chief Medical Officer Vice President, Quality Programs Medical Programs Coordinator 421 Ron.pottsmd@interlinkhealth.com 208 Cindy.mathews@interlinkheath.com 224 aatmc@interlinkhealth.com