Transplant Center Staffing: Stabilizing the Team Kandis Schwartz, BSN, MBA Director Transplant Services Intermountain Transplant Svcs

Intermountain Transplant Center First kidney transplant performed 1983 Pancreas, Heart, Liver, Living Kidney and Liver Medium sized program 100 kidneys, 5 pancreas, 15 hearts, 45 livers 50 living kidney donors, 1 living liver donors History

Allocation Policy KAS Share 35 Increased waiting time Pre-emptive transplant to ESRD time Increased morbidity Marginal kidneys Long-term follow up Co-management to dedicated management Share 35 Import livers High MELD at transplant HCV is CURED Allocation Policy Life Happens

Snapshot of Impact The Big Ask 2014 2015 2016 Annualized 2017   2014 2015 2016 Annualized 2017 Δ 2014-2017 Referrals 362 366 347 376 4% Evaluations 293 230 330 216 -26% Re-evaluations 502 551 716 434 -14% Post-transplant 407 444 885 1226 201% Transplants 103 65 89 80 -22% Living Donor Evals 66 78 92 40% The Big Ask

Stabilizing the Team Kidney/Pancreas Program STAFFING FTE Transplant Assistants – Pre 4 Transplant Coordinators – Pre 6 Living Donor Assistants 2 Living Donor Coordinator 1 Advanced Practice Clinicians (New) 3 Transplant Assistants – Post Transplant Coordinator – Post Quality Manager 0.5 Financial Coordinators Data Coordinators Kidney/Pancreas Program

Stabilizing the Team Liver Program STAFFING FTE Transplant Assistants – Pre 1.5 Transplant Coordinators – Pre 3 Advanced Practice Clinicians 6 Transplant Assistants – Post 1 Transplant Coordinator – Post Quality Manager 0.5 Financial Coordinators Data Coordinators Liver Program

Staffing Best Practice Staffing Ratio? Staffing Mix? Roles and Responsibilities? My Quest

2018 Transplant Games in Salt Lake City

Staff Ratios Stabilizing your Team Jennifer M. Kerney, MSN, CRNP Assistant Director, Transplant UCSF Medical Center Carolyn V. Light, MPA Director, Transplant Services UCSF Medical Center

Staff Ratios Stabilizing your Team Increased: referrals  need more staff complexity  need more staff post transplant volumes need more staff regulatory compliance  need more staff

Staff Ratios Stabilizing your Team Increased: referrals  need more staff complexity  need more staff post transplant volumes need more staff regulatory compliance  need more staff Institutional budgetary concerns  manage labor costs!

LD application / eval per FTE post transplant visits per FTE UCSF LIVER TRANSPLANT ORGAN TYPE LIVER Referrals (per year) 561 Evaluations (per year) 318 Waitlist Size 750 Living Donor Applications (per year) 612 Living Donor Evaluations (per year) 115 Transplants (per year) 192 Post Visits (per year) 3484 Total Recipients Followed 2400 STAFFING FTE x/FTE x  Intake AA 1.5 212 referrals per FTE Intake RN 0.5 636 Waitlist AA 2 375 pts on waitlist per FTE Waitlist RN 4.4 170 Living Donor AA 1 LD application / eval per FTE Living Donor RN Inpatient AA 384 transplants per FTE Inpatient RN Inpatient AHP 96 Post Transplant AA 3 800 post transplant visits per FTE Post Transplant RN Post Transplant AHP 5.5 436 Financial Counselors 5 342 109 Data Coordinators

LD application / eval per FTE post transplant visits per FTE UCSF KIDNEY & KIDNEY/PANC ORGAN TYPE KIDNEY PANC/K.P. Referrals (per year) 2095 41 Evaluations (per year) 1211 35 Waitlist Size 4984 98 Living Donor Applications (per year) 1778 n/a Living Donor Evaluations (per year) 294 Transplants (per year) 353 (101) 16 Post Visits (per year) 5212   Total Recipients Followed 7000 465 STAFFING FTE x/FTE Intake AA 5.5 381 referrals per FTE Intake RN 5 419 Waitlist AA 4 1246 pts on waitlist per FTE Waitlist RN 6 831 Living Donor AA 3 LD application / eval per FTE Living Donor RN 5.6 52.5 Inpatient AA 0.5 706 transplants per FTE Inpatient RN Inpatient AHP 88.25 Post Transplant AA 2.6 2692 post transplant visits per FTE Post Transplant RN 2 3500 Post Transplant AHP 1400 Financial Counselors 342 109 Data Coordinators

LD application / eval per FTE post transplant visits per FTE UCSF HEART TRANSPLANT ORGAN TYPE HEART Referrals (per year) 150 Evaluations (per year) 151 Waitlist Size 24 Living Donor Applications (per year) n/a Living Donor Evaluations (per year) Transplants (per year) 20 Post Visits (per year) 485 Total Recipients Followed 196 STAFFING FTE x/FTE   Intake AA 1 referrals per FTE Intake RN Waitlist AA 25 pts on waitlist per FTE Waitlist RN Living Donor AA LD application / eval per FTE Living Donor RN Inpatient AA transplants per FTE Inpatient RN Inpatient AHP Post Transplant AA post transplant visits per FTE Post Transplant RN Post Transplant AHP Financial Counselors 2  10 Data Coordinators

LD application / eval per FTE post transplant visits per FTE UCSF LUNG TRANSPLANT ORGAN TYPE LUNG Referrals (per year) 311 Evaluations (per year) 199 Waitlist Size 24 Living Donor Applications (per year) n/a Living Donor Evaluations (per year) Transplants (per year) 49 Post Visits (per year) 1435 Total Recipients Followed 378 STAFFING FTE x/FTE   Intake AA 1 referrals per FTE Intake RN 2 155 Waitlist AA pts on waitlist per FTE Waitlist RN 12 Living Donor AA LD application / eval per FTE Living Donor RN Inpatient AA transplants per FTE Inpatient RN Inpatient AHP 4 Post Transplant AA post transplant visits per FTE Post Transplant RN 358 Post Transplant AHP Financial Counselors  2  25 Data Coordinators

Staff Ratios Stabilizing your Team UCSF Since 2014 Liver Transplant Adds: 2 Post Liver Transplant AHPs Kidney Transplant Adds: 2 Post Kidney Transplant AHPs 2 Pre Transplant (1 eval, 1 waitlist) RN 1 Pre Transplant RN 1 SW

Staff Ratios Stabilizing your Team UCSF Since 2014 YEAR LIVER TRANSPLANT ADDS Leverage Data UCSF Centers >150 Txs 2014 Post Transplant AHP Staffing Number of AHPs  2.5  4.8 Transplants per FTE  27.6  17.5 KIDNEY TRANSPLANT ADDS 2015 124 40   Waitlist RN Patients on waitlist per FTE 151.7 55.6 2017 Social Worker 2006.8 700.2 Evaluation RN - Referrals per FTE 500.3 259.8 1064.7 836.1

Staff Ratios Stabilizing your Team UCSF Since 2014 YEAR LIVER TRANSPLANT ADDS Results UCSF Centers >150 Txs 2014 Post Transplant AHP Staffing 2 additional AHPs APPROVED  2.5  4.8 KIDNEY TRANSPLANT ADDS 2015 124 40   Pre Transplant AA 2 additional Aas APPROVED 151.7 55.6 2017 Social Worker 1 additional SW APPROVED 2006.8 700.2 Evaluation RN - 1 additional RN APPROVED 500.3 259.8 Waitlist RN 1064.7 836.1

Staff Ratios Stabilizing your Team UCSF Since 2014 YEAR LIVER TRANSPLANT ADDS Leverage Data UCSF w/adds Centers >150 Txs 2014 Post Transplant AHP Staffing post tx visits per FTE  27.6  19.7  17.5 KIDNEY TRANSPLANT ADDS 2015 Transplants per FTE 124  74 40   Pre Transplant AA Patients on waitlist per FTE 151.7  143.4 55.6 2017 Social Worker 2006.8 1449 700.2 Evaluation RN - Referrals per FTE 500.3  398 259.8 Waitlist RN 1064.7  884 836.1

Staff Ratios Stabilizing your Team UCSF Since 2014 UCSF LUNG TRANSPLANT Staff Ratios Stabilizing your Team UCSF Since 2014 Lung Transplant Adds: 2 Post Lung Transplant AHPs 1 Medical Assistant LUNG TRANSPLANT ADDS Leverage Data UCSF Centers >150 Txs Post Transplant AHP Staffing Number of FTEs 2.5 4.8 Transplant MA Transplants per FTE 27.6 17.5

Staff Ratios Stabilizing your Team UCSF Since 2014 UCSF LUNG TRANSPLANT Staff Ratios Stabilizing your Team UCSF Since 2014 Lung Transplant Adds: 2 Post Lung Transplant AHPs 1 Medical Assistant LUNG TRANSPLANT ADDS UCSF Centers >150 Txs Post Transplant AHP Staffing 2 Additional AHPs APPROVED 2.5 4.8 Transplant MA 1 additional MA APPROVED 27.6 17.5

Staff Ratios Stabilizing your Team UCSF Since 2014 UCSF LUNG TRANSPLANT Staff Ratios Stabilizing your Team UCSF Since 2014 Lung Transplant Adds: 2 Post Lung Transplant AHPs 1 Medical Assistant LUNG TRANSPLANT ADDS Leverage Data UCSF w/adds Centers >150 Txs Post Transplant AHP Staffing Number of FTEs 2.5  4.5 4.8 Transplant MA Transplants per FTE 27.6  17.25 17.5

Staff Ratios Stabilizing your Team UCSF Since 2014

Future Considerations How do we continue to ensure sufficient staffing to provide high quality care for our growing volume of increasingly complex patients? Negotiate a rolling growth model with institutional commitment to expand – for every XX transplants, increase by YY staff Stable, long term post-transplants return to their hepatologist/GI/nephrologists for management of immunosuppression, etc.