Peter A. Nigrovic, M.D.

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CAPRICenter for Adults with Pediatric Rheumatic
Illness

• Peter A. Nigrovic, M.D.
• Assistant Professor of Medicine
• Harvard Medical School
• Division of Immunology
• Childrens Hospital Boston
• Director, Center for Adults with Pediatric
  Rheumatic Illness (CAPRI)
• Division of Rheumatology, Immunology and Allergy
• Brigham and Womens Hospital
• April 27, 2012

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Managing transition CAPRI

• Center for Adults with Pediatric Rheumatic
  Illness at the Brigham and Womens Hospital
  (January 2005)
• Goals
• Smooth the transition from pediatric to adult
  rheumatology (mostly from Childrens 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

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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 gt18yo followed at CHB rheum
• from elsewhere
• college students from out of town
• young professionals

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Clinical niche 1 Transition

• Special 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!

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Age 14 years
Dr. P. White
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Clinical niche 1 Transition

• Challenges 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

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Clinical niche 2

• Consultation for specialized topics
• Pediatric-onset illnesses
• Autoinflammatory diseases/periodic fever
  syndromes
• Adult onset Stills disease
• Second opinions within BWH
• Patients who have rejected Childrens

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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

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CAPRI clinic practice model

• 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

Referral from pedi rheum
Follow-up
RN monitor compliance Special programs
RN watch for falling through
the cracks
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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 ltvariable!gt
• insurance and social issues, care coordination,
  counseling including vocational counseling
• PT/OT coordinator Janice McInnes
• Specialist referral providers small network for
  improved communication

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CAPRI specialist providers

• ENT
• Nalton Ferraro
• Neil Bhattacharyya
• Rheumatology in pregnancy
• Bonnie Bermas
• OB/GYN Kathy Economy
• Neurology Shah Khoshbin
• Pulmonary Manuela Cerñadas
• Physiatry ???
• Psychiatry/psychology ???
• Primary Care ???

• Orthopedics
• General Dick Scott
• Spine Mitch Harris
• Foot Chris Chiodo
• Anesthesia
• Mercedes Concepcion
• Anne Schools
• Ophthalmology
• George Papaliodis
• Nephrology
• Ajay Singh
• Cardiology
• Mike Singh (BACH)

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CAPRI progress so far

• 1/3/05-4/27/12 273 new referrals
• Typical age 18-23 range 10-60s
• mostly Childrens 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, Childrens,
  MGH)
• 5 CME lectures

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SummaryCAPRI 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 Childrens but in most cases transition
  is uneventful
• How to study? How to improve?