Post-transplant coordinators serve as patients’ long-term advocate, supporterJan. 28, 2021, 9:51 AM
By Matt Batcheldor
When a patient receives a new heart at Vanderbilt University Medical Center, that person also gains a new family, so to speak — the heart transplant team. Among the patient’s biggest advocates and supporters on that team is his or her post-transplant coordinator.
From the moment of transplant, this coordinator will follow the patient from inpatient stay through discharge and to lifelong follow-up appointments, communicating with him or her every step of the way. Along the way, coordinators get to know their patients through life events — both good and bad — including weddings, birthdays and new children and grandchildren.
“We really do build special bonds and relationships with people,” added post-transplant coordinator Mary Stroud, RN. “They become part of our families. They’ll ask, ‘Oh, how’s the little one?’ And so, we become family. We really do. We’re checking in not only on their physical well-being but also on their mental well-being and on the well-being of those around them.”
Providing that level of care has never been more important as the number of heart transplants at VUMC has grown rapidly in recent years. Vanderbilt is now the No. 1 heart transplant center in the world by volume, with seven post-transplant coordinators who collectively manage more than 600 post-transplant patients. Heart transplants at VUMC never slowed down during the pandemic, and the coordinators are adapting, many working from home and interacting with patients virtually.
Patients first meet their post-transplant coordinators before they leave the hospital, at the time of transplant education. This is when patients learn what to expect going forward, including what medications to take, how upcoming appointments will work, when to call for help and much more. After hospital discharge, patients get a refresher education course.
All the while, coordinators are working with the rest of the transplant team, including transplant cardiologists and nurse practitioners, anesthesiologists and nurse anesthetists, pharmacists, social workers and case managers.
“If you just take the time to get to know someone and talk to them, it really humanizes you and it makes it so you can build that bond, build that trust, because it’s so important when someone has a transplant,” said post-transplant coordinator Katie James, RN. “It’s like going home with a new baby. I always tell my patients there’s no manual, you’re terrified, but we’re here to walk you through it.”
To better care for its rapidly growing population of transplant patients, the transplant team developed a patient advisory board and e-newsletter. The advisory board, which now meets virtually every quarter, “allows patients and their caregivers to have more of a voice in our program and to let us know how we can do better,” James said.
The e-newsletter is used to introduce new members of the team, reinforce education, and alert patients to programmatic changes taking place. According to Kelly Schlendorf, MD, MHS, medical director of the adult heart transplant program, the post-transplant coordinators were integral in making the patient advisory board and e-newsletter happen.
“Both these things are a reflection of our rock star nursing team,” she said. “Our nurses constantly amaze me with their dedication to these patients. While a lot of what they do occurs behind the scenes, this program thrives largely because of their efforts.”
In addition to caring for adults transplanted at VUMC, post-transplant coordinators also care for patients transferred from other centers, including pediatric patients who have reached adulthood and need to transition care from Monroe Carell Jr. Children’s Hospital at Vanderbilt to the adult side.
According to post-transplant coordinator Christian Haefele, RN, this can be a scary transition, especially for young adults who have previously had a parent or guardian largely manage their care. “We have to go in and respect that and also say, I want you to start assuming some of that responsibility now. I want to hear from you, from the patient. You tell us what you’re dealing with. It’s really important for these patients to develop some autonomy in their care, and to make sure they know that if they don’t know something, they can call us, they can ask.”
It can be an all-consuming job, but it’s one the post-transplant coordinators wouldn’t trade.
“I think one of the coolest things that we get to do is see someone go from end-stage heart failure to being able to reach their goals,” James said.
“I have one patient and I was talking to him yesterday and he was just so tickled. He said he walked a mile around the block, three weeks post-heart transplant. Before transplant, he couldn’t even walk to his mailbox. What we get to be a part of every day is pretty amazing.”
In addition to Stroud, James and Haefele, other post-transplant coordinators include Yvonne Turner, RN; Sherrie Adams, MSN, RN; Haley Smethers,RN; Olivia Palmer, RN; and Stephanie Dixon, RN.