Transition of
Care: The Oxford Transplant Shared Care Programme
Senior Clinical Nurse Specialist,
Oxford Renal Unit
This session will discuss the
introduction of a “tripartite model” of care for renal transplant recipients at
the Oxford Transplant Centre.
Prior to
1995, all renal patients transplanted in Oxford also received their long term
care at the Oxford Unit. Oxford covers
six counties for transplantation and, therefore, many patients were taking a
day away from work and driving very long distances for routine follow-up
care. Clinics were becoming very large
with long waiting times and there was little continuity of care. Research suggests that transplantation does
not eliminate health-related stress from recipient lives and that empowerment,
continuity of care and trust in “major carers” is a fundamental requisite for
long term successful re-adjustment.
As the
clinics grew larger it became obvious that the unit was failing to meet the
necessary readjustment and long term needs of the recipients and therefore,
changes in the provision of the continuing care service were needed. After
discussions with transplant recipients a “tripartite” model of care was
introduced in which recipients with stable graft function and stable medication
needs could receive the majority of care locally in the primary care setting
with an Annual Review at the Transplant Centre.
This
programme was introduced in 1996 and has been audited at 3yrs and 5yrs and
overall satisfaction levels from clinical, recipient and primary care groups
have been high. The planning, introduction and audit of this service will be
discussed as will suggestions for future transitional and long term care
programmes.