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Session Reading


Advanced Achievement in Transplant Management

Getting Prepared Part 1



Section Overview

This section of the AATMC will address the aspects of transplant management from a managed care nursing perspective. The world of transplantation is changing daily with new technology and protocols utilized for advancement in the field. This poses many challenges for nurse case managers to stay current in this ever-evolving specialty. The patient who has been advised that a solid organ or bone marrow transplant may be their best treatment option needs a nurse case manager advocate by their side. As the nurse case manager, you will be of assistance and a sounding board for the patient as he/she makes healthcare decisions of which among the first will be selecting a transplant program or possibly looking at the attributes of the recommended transplant program. The goal of Getting Prepared is to provide tools and information to ensure a successful transplant management plan of care.


Section Objectives

At the end of this session you will be able to:

       Understand the nurse case manager’s role within each transplant phase.

       List and explain the essential elements as to what constitutes a “Centers of Excellence”

transplant program.

       Present transplant program information to the patient in a logical manner.



More transplant programs exist throughout the country than ever before. As a result, there are many options available for transplant patients but there are also quantifiable differences amongst transplant programs. The nurse case manager must be prepared to determine the appropriate transplant facility, manage financial risk, and review time-intensive processes and treatments. Each of these steps requires considerable clinical expertise in transplantation and the skills needed to guide patients and their families through the transplant. Our Lung Transplantation Case Study will serve as our template as we proceed down the transplant continuum of care pathway. Throughout the transplant case management process there will be  ongoing  communication  of  patient  status  and  treatment  plan  among  the  nurse  case manager, transplant program staff, primary care physician, and the patient and her/his family.




Transplant Referral Phase


Receipt of Referral

Timing of the referral is one of the most important aspects in transplantation. The first step in the case management process is identification. Generally this step is done by an online program trigger alert when data is entered in the system (input of ICD-9 code) which could happen through a number of avenues: claims, utilization management, disease management or other sources.


Create Patient Profile

With referral in hand, the first step is to create our Patient Profile. The Member’s benefits, claims history and medical history are compiled in a systematic process. First is verification of  eligibility.  The  next  step  is  to  gather  plan  benefit  summary  information:  life  time maximum, exclusions and limitations. Specifically, examine the transplant benefit summary for limitations, exclusions, and enhancements such as benefit provisions for travel, lodging and meals when choosing a COE transplant program for care. Also, the nurse case manager needs to determine if transplant medications are included under the general health benefit plan provision or through a pharmacy benefit manager (PBM). Today it is fairly common to have a PBM as part of a medical benefit package.


A review of the medical claim history will provide: diagnosis codes, Providers, frequency of clinic visits, lab tests, diagnostic tests, procedures and inpatient hospitalizations. Utilization and case management history are useful in that they provide a detailed medical snapshot of events. The amount of information we are able to gather is dependent upon the health service package purchased by the employer group.


For the nurse case manager to be effective in their role, she/he needs to be knowledgeable of their patient’s disease process, treatment (with transplantation being an option) and COE transplant providers. This can be accomplished by doing one simple step – RESEARCH. With transplantation as a treatment option, the nurse case manager will obtain: diagnoses appropriate to transplant, indications and contraindications and patient selection criteria. During our Website Webinar, specific web links were shared that provide program specific post transplant patient and graft survival, volumes, facility and program accreditations, transplant length of stay, wait times and so on. These kinds of information are vital to collect on each transplant program (COE and non COE) but it needs to be taken one step further transferring the data into a meaningful organized report that can be presented to the patient and their family. Lastly, the nurse case manager needs to verify for each transplant case whether a facility is still considered a COE. It is common knowledge that facilities move in and out of COE status due to shifts in the transplant team, declines in outcomes or volume. With the patient profile and research information pieces complete, the nurse case manager is now prepared to contact their patient.


Contact Patient

At this point the patient is contacted to: advise of the case manager’s role, explain benefits and gather their clinical status along with the proposed plan of care. The case manager will inquire if the patient and family and her/his local physician have identified a center or if they are continuing to look at additional transplant facilities. In either case, this is the time to take a proactive approach in discussing the “Centers of Excellence” (COE) transplant concept. The case manager may need to educate both the family and referring physician about the best options available. COE Networks provide access to transplant programs that have been evaluated and identified as quality providers of transplant care. COE Networks provide qualitative as well as quantitative information about each program’s experience. At INTERLINK, our Facility Outcome Data Sheets provide a snapshot of each COE program’s transplant accreditations, outcomes, volumes, attributes, and ancillary services. The sample Transplant Comparison Worksheet is an excellent tool to compare and contrast transplant programs.  It  is  critically  important  for  the  case  manager  to  understand  the  data  being presented and be able to convey how this information demonstrates quality in a program. With the facility selection complete, the patient will proceed to the transplant evaluation phase.


Evaluation Process

Transplant Evaluation Phase


Patients are usually referred to the transplant program by their local specialist or primary care physician (PCP). Clinical information is sent to the transplant center for review. First and foremost is the pre-transplant consultation/evaluation. During this evaluation, many patients who are referred for transplantation are determined not to be a candidate for an organ transplant. Over the last several years one of the major changes in the field has been the opportunity of medical treatment options available to patients with end-stage organ failure. This may be a long-term option or delay the need for organ transplantation. For example, the patient who opts for VAD (ventricular assist device) destination therapy or the potential heart transplantation patient whom after pre-transplant evaluation is able to be medically managed by having a biventricular pacemaker inserted and fine tuning of their medication regimen. Unfortunately,  some  patients  will  not  be  appropriate  for  transplantation  nor  will  other medical treatment options be available. At this point, the patient’s physician will need to have a discussion around palliative care considerations.


However, those that are deemed a potential transplant candidate will proceed to the formal transplant evaluation process. Number of days needed at the transplant center for evaluation range from 2 – 4 days. Generally, evaluations are performed on an outpatient basis. There may be times an inpatient admission is appropriate; a classic example being the heart failure patient requiring close observation while their cardiac medications are titrated to achieve maximal effect. The transplant center conducts the appropriate specialty consultations, lab tests, x-rays, scans and so forth to confirm suitability for transplantation. These tests include such things as chemistry profile, CBC, serology screening, cardiac function testing (heart scans  and  stress  tests),  pulmonary  function  testing,  psychosocial  testing,  and  nutrition consult, among others. A question that arises is what tests can be conducted by the patient’s primary care physician (PCP)/specialist. Most transplant centers will coordinate with the patient’s PCP/specialist to have as much testing as possible performed locally. However, there are certain tests the transplant facility requires to be performed onsite, such as, blood typing and infectious disease panels to name a few. Also, keep in mind that ultimately it is the transplant center’s responsibility to ensure all testing is complete and accurate. Other subspecialists may be called upon to consult with the patient, e.g., dermatology, infectious disease, cardiology, etc. In essence, the goal of the formal transplant evaluation is to assure the patient is a suitable candidate and there are no contraindications to transplantation.



Activation on the Transplant List

Once the evaluation is complete at the transplant clinic, the patient’s case will be discussed at the Transplant Selection Conference. This is a multidisciplinary group that typically meets weekly. The group consists of transplant surgeons, transplant physician specialists, transplant coordinators, a social worker, financial coordinator, and if needed, psychologist, ethicist, and so forth. The patient will be notified of the group’s decision. If the decision is made to activate the patient on the wait list, information is provided to United Network for Organ Sharing (UNOS). They maintain the patient registry where all organ transplant candidates are listed. A notification letter will be sent to the patient from the transplant facility informing them  of  their  UNOS  activation  date  and  status.  The  web  link  to  view  organ  specific allocation policies is:


In the world of bone marrow transplantation, the review by the Transplant Selection Conference is similar. The BMT multidisciplinary group consists of oncologists/hematologists, sub-specialists, transplant coordinators, a financial counselor, social worker, and anyone else who is a stakeholder. The patient’s multidisciplinary team determines the patient is a suitable candidate for BMT. Patient notification process is the same as noted above. The patient will be informed of any next steps, e.g., additional chemotherapy.


Medical Necessity Review

The results of the evaluation tests are sent to the patient’s insurance company, accompanied by a letter of medical necessity that explains the reason for transplantation. It is a good idea for the nurse case manager to convey expectations of additional items required for review, e.g., patient selection criteria. The nurse case manager or designee will review the transplant medical records to ensure all required medical documents are on hand to proceed with the medical necessity review. A one page handout (solid organ and BMT) in the AATMC binder describes the elements to be collected to be able to perform the review. It is fairly standard for the medical necessity review to be conducted by managed care medical director or the case may be referred to an independent review organization (IRO).



With the transplant deemed medically necessary, the nurse case manager will notify the patient and transplant coordinator of the approval. A letter of correspondence is sent to the patient that outlines approval date and time frame (usually 6 months or 1 year) as to when their case needs to be reviewed again. The letter to the transplant center will contain the same information though it may contain additional items such as specific transplant benefits, etc. At this time it is a good idea to touch base again with the COE Network to verify correspondence has been sent to the facility to access the transplant contract for the patient. On the flip side, the nurse case manager should call the transplant financial coordinator or designee to verify that the COE Network contract is in place. It is of utmost importance with this many healthcare dollars at stake to ensure the contractual obligations are in place.


Other folks on the notification list are the local PCP/specialist, claims and underwriting contacts, reinsurer and COE Network. The nurse case manager will provide a current treatment plan, UNOS list date or tentative transplant date (in the case of BMT) and cost estimation to the insurance contacts. Remember, documentation  is vital to have a trail of your activities.


This concludes Getting Prepared Part I. The next course series will start with discussion  of the next phase of the transplant continuum, pre-transplant care.


Blood/Marrow Transplant Medical Necessity Review




To determine the appropriateness of a medical procedure or treatment plan is one of the most difficult and delicate challenges a payor can face.  We recommend that the following information be collected to perform a medical appropriateness review.


•     Current history and physical examination to include disease staging, chemotherapy/radiation therapy treatment history and chemotherapy responsiveness. In many instances, without this information a review cannot be completed.


      •     Facility transplant protocol.


      •     Copy of consent to be signed by patient or guardian.


•     CBC with differential, electrolytes, granulocyte count, serum creatinine, BUN, creatinine clearance, and liver enzymes.


      •     Results of infectious disease and viral titer laboratory studies, including HIV.


      •     Cardiac function report, e.g., MUGA scans, echocardiogram report, etc.


      •     Pulmonary function report.


•     Bone marrow pathology and radiology reports prior to and following conventional therapy.


      •     Chromosomal analysis, if applicable.


      •     Psychosocial profile and support system evaluation.


Solid Organ Transplant Medical Necessity Review



To determine the appropriateness of a medical procedure or treatment plan is one of the most difficult and delicate challenges a payor can face. Thus we recommend that the following information be collected to perform a medical appropriateness review.


•      Current medical history and physical examination, to include proposed treatment plan, prognosis and current medications. It should be noted that without this information a review cannot be completed.


•      Lab tests as follows: Electrolytes, BUN, serum creatinine, creatinine clearance, bilirubin, liver enzymes, CBC with differential and glomerular filtration rate (GFR) for kidney transplant candidates.


      •      Results of infectious disease and viral titer laboratory studies, including HIV.


      •      Cardiac function report, e.g. MUGA, echocardiogram report, stress thallium or Persantine reports, etc.


      •      Pulmonary function report.


      •      Radiology reports.


•      Psychosocial profile and support system evaluation, if appropriate. If history of substance abuse, describe the treatment for the substance abuse, the duration of abstinence and provide supporting lab work to confirm negative ETOH/drug screens.


•      For hepatoma, provide treatment protocol defining pre- and post-operative chemotherapy, liver ultrasound or CT, and metastatic staging.


      •      Heart, lung and/or liver biopsy, if applicable.


•      Ultrasound of gallbladder/biliary system; voiding cystourethrogram; and history of diabetic management, including glucose levels and insulin dosages, if applicable.


      •      Summary of current steroid therapy, including dosage, as applicable. If high dose, need plan to taper.