General Statement of Duties: Responsible for assessment of needs, education, and coordination of the care BMT patients and their families require throughout the transplantation process. Will communicate all aspects of the plan of care with patients, families and other members of the Transplant Team, other health care providers, and payers. Essential Job Functions: 1. Monitors patient/family before, during and after transplantation for physical, emotional, psychosocial, and financial needs and intervenes when appropriate. Refers patients to members of the BMT team (chaplain, counselor, nutritionist, oncology support team, and financial advisors) as needed, and/or utilizes community resources when appropriate. 2. Coordinates the patient and donor pre-admission work-up and visits. Gathers and reviews all pertinent clinical information (including past treatments and outcomes) and presents this to the transplant physician with special notes to abnormal results. 3. Collaborates with direct health care providers to establish plan of care, facilitates continuity of care across departments (both in-patient and out-patient) within hospital and home health providers. Coordinates all services for BMT patients, and oversees National Marrow Donor Program (NMDP) processes as needed. 4. Coordinates the transfer of patient care from Blood and Marrow Transplant Program back to referring physician and is responsible for long-term follow-up, which includes but is not limited to: periodic updates on patient condition, coordinating follow-up visits with Blood and Marrow Transplant physician and referring physician, and coordinating provision of post-discharge necessary services. 5. Educates patients, their families, and donors to assist understanding of the disease, and processes and procedures surrounding pre- and post-transplant issues. Acts as a resource for members of the interdisciplinary team on transplant care and protocols to promote positive outcomes for BMT patients. 6. Communicates with interdisciplinary team members, patients and families, and payers in a timely manner to ensure comprehensive documentation.
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