Peter A. Nigrovic, M.D. Assistant Professor of Medicine Harvard Medical School Division of...
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Peter A. Nigrovic, M.D.
Assistant Professor of Medicine
Harvard Medical School
Division of Immunology
Children’s Hospital Boston
Director, Center for Adults with Pediatric Rheumatic Illness (CAPRI)
Division of Rheumatology, Immunology and Allergy
Brigham and Women’s Hospital
April 27, 2012
CAPRICenter for Adults with Pediatric Rheumatic Illness
Managing transition: CAPRI
• Center for Adults with Pediatric Rheumatic Illness at the Brigham and Women’s Hospital (January 2005)
• Goals– Smooth the transition from pediatric to adult
rheumatology (mostly from Children’s Hospital)– Primary/second-opinion consultation for young adults– Long-term care of adults with JIA and other
rheumatologic conditions– Training of adult and pediatric rheum fellows
Clinical niche #1 Transition
Pedi rheumatology patients need to transition
– Diseases often persist into adulthood• JIA: 50% • SLE, scleroderma: 80-100%• Dermatomyositis, vasculitis : ? 20-40%
– 12/03-11/04: 107 pts >18yo followed at CHB rheum– from elsewhere
• college students from out of town• young professionals
Clinical niche #1 TransitionSpecial issues affecting our patients
– Medical• Growth disturbance (global and regional)• Uveitis in JIA• Calcinosis in juvenile dermatomyositis• Osteoporosis• Long-term effects of immunosuppression
– Functional• Autonomy• Anxiety/depression• Vocational goals
– Unknowns!
http://www.rheumtext.com/content/0323024041/suppfiles/chapters/Chapter85.pdf
Age: 14 years
Dr. P. White
e-bility.com/articles/ images/ben.jpg
Dr. P. Whitehttp://www.rheumtext.com/content/0323024041/suppfiles/chapters/Chapter85.pdf
Clinical niche #1 TransitionChallenges in transition
– Making it to the first visit• new system• long time to first new appointment• anxiety/wishful thinking
– Pedi adult culture shock– Establishing new network of providers (esp. PCP)– Insurance– Medical records– Vocational challenges
Clinical niche #2
Consultation for specialized topics
– Pediatric-onset illnesses – Autoinflammatory diseases/periodic fever
syndromes– Adult onset Still’s disease– Second opinions within BWH– Patients who have rejected Children’s
Additional niche: education
• Fellows– High density of complex cases– “Hands-on” teaching style– Continuity of care with 1 attending
• Rheumatology staff– Educate adult providers re: pediatric diseases– External: grand rounds, case conferences, CME
CAPRI: clinic practice model
Referral from
pedi rheum
Initial CAPRI visit
•nurse evaluation - vaccination status
•MD evaluation - disease activity - medication review - specialist referrals - bone health - reproductive health
•? PT/OT referral
•? social work referral
Follow-up
Initial meetingat Children’sHospital
RN watch for “falling through the cracks”
RN monitor compliance
Specialprograms
CAPRI: clinic staff• Rheumatologists: P. Nigrovic (director)
– Fellows: Derrick Todd (now CAPRI staff), J. Ermann, R. Ishiziwar, L. Gedmintas
– 2 sessions per month, 12-15 patients including 4-5 new patients
• Nurse coordinator: Fran Griffin– “point person” for patient contacts– initial intake for new patients (establish rapport)– obtain medical records, chase down no-shows, medication
teaching, care coordination, support for patients/families
• Social worker: <variable!> – insurance and social issues, care coordination, counseling
including vocational counseling
• PT/OT coordinator: Janice McInnes
• Specialist referral providers – small network for improved communication
CAPRI: specialist providers
Orthopedics:General: Dick ScottSpine: Mitch HarrisFoot: Chris Chiodo
Anesthesia: Mercedes ConcepcionAnne Schools
Ophthalmology: George Papaliodis
Nephrology: Ajay Singh
Cardiology: Mike Singh (BACH)
ENT: Nalton FerraroNeil Bhattacharyya
Rheumatology in pregnancy: Bonnie Bermas
OB/GYN: Kathy Economy
Neurology: Shah Khoshbin
Pulmonary: Manuela Cerñadas
Physiatry: ???
Psychiatry/psychology: ???
Primary Care: ???
CAPRI: progress so far• 1/3/05-4/27/12: 273 new referrals
– Typical age 18-23 – range 10-60s– mostly Children’s referrals, a few outside docs
from around New England (MA, NH, VT, NY, RI) and elsewhere (Puerto Rico, Bermuda, ID, TX, VA)
– Handful of internal second opinions– Very interesting patient population!
• 4 Fellows• 1 publication• Talks
– 10-15 internal case conferences– 6 grand rounds (BWH PT, BU, BIDMC, Children’s, MGH)
– 5 CME lectures
Summary
CAPRI: Center for Adults with Pediatric Rheumatic Illness
• Ad hoc model built to fit a particular set of circumstances and personnel
• Occupies unique clinical and educational “niches”
• Would benefit from more structured transition work at Children’s – but in most cases transition is uneventful
• How to study? How to improve?