Transcript CAPRI - Brigham and Women's Hospital

CAPRI
Center for Adults with Pediatric Rheumatic Illness
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
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 Transition
Special issues affecting our patients
– Medical
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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!
Age: 14 years
Dr. P. White
http://www.rheumtext.com/content/0323024041/suppfiles/chapters/Chapter85.pdf
e-bility.com/articles/ images/ben.jpg
Dr. P. White
http://www.rheumtext.com/content/0323024041/suppfiles/ch
apters/Chapter85.pdf
Clinical niche #1 Transition
Challenges in transition
– Making it to the first visit
• new system
• long time to first new appointment
• anxiety/wishful thinking
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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
Initial CAPRI visit
•nurse evaluation
- vaccination status
Referral
from
pedi rheum
Initial
meeting
at Children’s
Hospital
•MD evaluation
- disease activity
- medication review
- specialist referrals
- bone health
- reproductive health
•? PT/OT referral
•? social work referral
RN watch for
“falling through the cracks”
Follow-up
RN monitor
compliance
Special
programs
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 Scott
Spine: Mitch Harris
Foot: Chris Chiodo
ENT:
Nalton Ferraro
Neil Bhattacharyya
Rheumatology in pregnancy:
Bonnie Bermas
Anesthesia:
Mercedes Concepcion
Anne Schools
OB/GYN: Kathy Economy
Ophthalmology:
George Papaliodis
Pulmonary: Manuela Cerñadas
Nephrology:
Ajay Singh
Cardiology:
Mike Singh (BACH)
Neurology: Shah Khoshbin
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?