Home Ambassador in the clinic providing education regarding home treatment options, initiating referrals, and process to start home dialysis.
Educate patients and families about kidney transplant process, initiate referrals, and ongoing monitoring of patient's evaluation process with the hospital transplant teams.
Explain medical care options to help patients make informed healthcare decisions.
Formulate treatment plan strategies with interdisciplinary team to provide comprehensive and continuous care plan.
Complete psychosocial evaluations and needs assessments initially, quarterly, and annually.
Conduct, review, and assess quality of life results, develop patient goal setting, and complete appropriate follow-up to improve patient scores and quality of life.
Communicate with Interdisciplinary team regarding patient psychosocial issues affecting treatment and well being.
Arrange Care Plan Conference with patients, families, and interdisciplinary team.
Independently analyze, provide information, and facilitate referrals to community, private, state, and federal agencies (e.g. financial programs, medication assistance programs, vocational rehabilitation, transportation resources, mental health and chemical dependency resources, and home health or hospice/palliative care agencies.
Educate patients/families about grievance process and designee to monitor filed grievances.