I interviewed Claudia Posadas, a clinical social worker at the National Institute of Pediatrics (INP) in Mexico City. She evaluates potential hematopoietic stem cell transplant (HCT) patients and their families for transplantation.

I met Claudia at an annual international conference in Puerto Vallarta, Mexico, in 2016. I was very impressed by her workshop on home visits and professionalism. The eligibility process for public HCT patients in Mexico differs greatly compared to institutions in the United States. Claudia’s insights present an interestingly unfamiliar perspective that I want to share with readers.

MM: How does the Bone Marrow Transplant (BMT) Social Work Services at INP interact with HCT patients?

Claudia: We work with families whose patients are candidates for HCT. The hospital's approach to patient health follows the concept of well-being of the World Health Organization, through which holistic wellness is sought in a bio-psycho-social context and not only to achieve eradication of the disease. To achieve these objectives, we use the ecological model by developmental psychologist Urie Bronfenbrenner.

MM: Can you tell me about this model and how you apply it?

Claudia: We use it broadly; it serves to analyze the micro, macro and exosystems around the patient. Our main objective with home visits is to understand the social, economic and housing conditions of the patient and patient’s family.

MM: What things do you analyze when you do a home visit?

Claudia: We look at many different things on three levels. We start with the patient’s microsystem, which is about the patient and family. We address cognition and the structure of beliefs of the parent or guardian in relation to the planned procedure. We analyze the functionality, resilience and involvement of the family in the treatment plan. If the family has characteristics of high social vulnerability, training is provided to the primary caregiver to help reorganize and improve family dynamics so the patient will receive the social support needed during recovery.  

At the exosystem level we seek to identify secondary social support networks during hospitalization and discharge. This is a stage where housing conditions come into consideration. At times it is necessary to work with private organizations that can provide temporary hostel accommodations to the patient and their caregiver. At the macrosystem level, we focus on family needs. If needed, we identify government institutions that may provide support for structural modifications of their house. An action and timeline plan is designed with the collaboration of all involved participants.

MM: Do you have certain guidelines for these home visits?

Claudia: Yes.The guidelines are quite specific and thorough. For example, we look for the following:
 

MM: How many visits do you make to these families?

Claudia: We make about three home visits in the pretransplant stage, before hospital admission. The number of visits depends on the characteristics and needs of each family. In some cases, families are so involved and functional that one visit suffices.

MM: Are families amenable to you coming into their homes to evaluate their environment and their interactions?

Claudia: When they enter the transplant protocol, we meet with them at the hospital as part of the initial counseling. We explain the responsibility they share as parents of a patient. We follow up with a first home visit (or a visit to the location where the patient will convalesce). Sometimes, family members must deal with improvements at home so their child is eligible to receive the transplant. HCT eligibility requires that the home presents no conditions that may impede the patient’s recovery. We work on the empowerment of responsible, informed and participatory parentage in social medical treatment.

MM: Can you provide an example?

Claudia: When we go to the homes, our greatest concern is hygiene—the patient must be in a clean environment so their new and weak immune system has the best chance of recovery. We provide onsite guidance about removing and storing unneeded items. For example, keeping clothes in a closet or transferring them to clean cardboard boxes. We might identify used furnishings that are hygiene risks and propose they be removed. We teach the families about sanitizing the home with disinfectant towels and gels and explain the usefulness of mouth covers. With poorer families, we work with foundations to get basic furniture such as beds, tables or a stove, all to improve household conditions for the patient and family. This approach is an application of the ecological model of Bronfenbrenner.

With some cases, the minor patient and caregiver must stay at a shelter for approximately 60 days after leaving the hospital. In other instances, a family member or friend will lend the patient and family a house. We also have participated in cases where relatives provide a room to isolate the patient, or they provide use of their kitchen while the other family members remain at home, trying to improve the conditions for when the child finally comes back home. There are many different patterns to use space, thus family organization may change.

MM: Do they listen to you? Is it hard to get cooperation?

Claudia: It can be difficult because we are often talking about critical changes that affect lifestyles of family members. However, we work with parents throughout the transplant process, which allows them to be sensitized and empowered in their behaviors, lifestyles, structure and family reorganization. Ultimately, families want whatever is best for their child, the patient, and will try their best to achieve that goal.

MM: And if they are not compliant?

Claudia: Then they will not be able to move forward to transplant. HCT is such an expensive treatment and is paid by the government in a public hospital. The money can only be allocated to compliant families who provide an environment in which patient recovery is likely. We do work so hard to help families understand the importance of their responsibilities throughout the process. We want families to be full participants in what is an arduous process.

MM: In conclusion, what do you say about home visits?

Claudia: The home visit intervention of Social Work Services serves to identify, create and manage an action plan with the patient’s family so the patient will access transplant. Our services also provide the cognitive and instrumental resources for therapeutic adherence, to reorganize habits and adopt new practices as a permanent lifestyle.

Maria: Thank you, Claudia, for this informative and interesting interview. If you have questions, you can contact Claudia Posadas directly at angelexa5@hotmail.com.