Partnering for Pediatric Patients A vision of seamless transition to adult care

By Gail Luciani

Imagine you just turned 21. You have had ulcerative colitis since you were 8. It has been closely managed by your pediatricians, but now that you are an adult, they can no longer treat you. Your condition hasn’t gone away — but your medical support team has. What do you do? Where do you go for your healthcare needs? “

The department of pediatrics at Nemours/ Alfred I. duPont Hospital for Children is actually the academic home for pediatrics at Jefferson,” says Jay Greenspan, MD, professor and chair, Department of Pediatrics. “At the same time, Jefferson has incredibly strong divisions like gastroenterology. So for our pediatric patients with ulcerative colitis or who are diagnosed with liver failure and have a transplant at Nemours, the obvious place for the next stage of their care is Jefferson. But that handoff doesn’t exist today — so our goal is to help these patients make a smooth transition to adult care.”

Thirty Years of Partnering Pave the Way

Located in Wilmington, Del., Nemours began partnering with Jefferson in the early 1980s. Pediatrics is a core element of medical education, but at that time, the Jefferson pediatrics department was limited. Delaware had Nemours, a stellar pediatrics hospital located just a few miles south of Philadelphia on Interstate 95, but it didn’t have a medical school. Partnering answered the needs of both organizations. Today, Jefferson serves as the medical school of Delaware, and its students train at the department of pediatrics at Nemours.

“Students are very much embedded in day-to-day patient care,” says Greenspan. “The six-week pediatrics rotation is usually at Nemours, which has the largest patient base in the Jefferson system.* Students are our eyes and ears, and they present patient cases first in rounds.” In addition to training students on rotation, Nemours provides clinical experience for pediatric residents and fellows.

“The relationship is incredibly important for both sides,” says Greenspan. “For Jefferson, it allows us to train effectively with an appropriate caseload, which reinforces our reputation as a top-notch medical school, and for Nemours, it provides the opportunity to have a connection with a major academic medical center.”

Nemours and Jefferson collaborate on multidisciplinary pediatric programs for chronic or complex medical conditions, partner on important research studies and coordinate care as needed, such as facilitating the transfer of extremely ill patients from Jefferson to Nemours.

“It’s a vital relationship that both Jefferson and Nemours can be proud of,” says Kevin Churchwell, MD, chief executive officer for Nemours. “The continued development of our relationship is important for pediatrics in this region and nationally. Any way you look at it — from an academic standpoint, a patient-service standpoint or a research standpoint, Nemours being the pediatric home for Jefferson creates a great environment for success.”

A significant challenge for the two partners is the 25-mile distance between campuses. “We’re working on improving communication and collaboration to help solve that obstacle,” says Churchwell. “We want to be more intentional about how we continue to support clinical program development, academic development and research development.”

“The challenge of our physical distance from each other is one that we will never be able to change,” agrees Greenspan. “But we can overcome that hurdle as people recognize how strong both partners are in this relationship and how important it is to the future of both institutions to strengthen that relationship.”

Working closely together, the two institutions provide pediatric care to the region’s children both in Wilmington and at a satellite pediatrics site in Philadelphia. “By aligning our strategies and leveraging institutional strengths, we are advancing the care of children both at Nemours and on the Jefferson campus,” explains Pauline Corso, practice administrator at Nemours.

Women and Children Service Line Launched

In June 2012, Jefferson launched “women and children,” its sixth service line. An outcome of long-term strategy planning, it was born of a newfound focus on the future of health care for both women and children. Initiatives are currently in the development stage and include the participation of Nemours as the primary practice site for pediatrics. “All of our discussions start with ‘What’s best for the patients?’ then we work backwards to deal with logistical challenges. For example, which services should be on the Philadelphia campus, and which should be in Wilmington? Managing the geographic distance between the two campuses is a significant part of the discussion,” says William Schlaff, MD, the Paul A. and Eloise B. Bowers Professor and chair of the Department of Obstetrics and Gynecology. “And within a local context, we need to address programs like the expansion of obstetrical services and how that impacts pediatrics and neonatal intensive care.”

New perinatal programs will go beyond re-engineering obstetrics at Jefferson, given the opportunity to collaborate across the organization. “High-risk obstetrics tends to focus on caring for the fetus, and not the sick mother. So one of the initiatives we are looking at is integrating with the Department of Medicine to treat women with medical problems who are pregnant or who want to become pregnant,” says Schlaff. “We want to be the place that takes care of these patients most safely. By defining most of our initiatives as multidisciplinary — having the support of medicine, cardiology, neonatal ICUs and other specialties — we can leverage our institutional strength to provide something unique to patients that they couldn’t get somewhere else.”

Planning for the Future
The launch of the new women and children’s service line is just the beginning. In the future, tools like single medical records maintained across lifetimes could support continuity of care for pediatric patients entering the adult medical arena. Combined pediatric and adult centers of excellence, with partner institutions sharing space and other resources, could be positioned to provide the next generation of patient care.

Today, Nemours and Jefferson enjoy a collaborative partnership in their transplant departments, which sets the stage for other opportunities. “We see all sorts of possible connections between Nemours and Jefferson, and with a little bit of effort, we can make both institutions stronger,” says Greenspan. “For example, Nemours is a leader in pediatric orthopaedics, and Jefferson is a leader in orthopaedics, so if Jefferson has a pediatric patient with an orthopaedic problem, we should automatically refer him to Nemours rather than another children’s hospital in Philadelphia. Together, we can be number one in orthopaedics.”

Like most pediatric departments across the United States, transitioning pediatric patients to adult medical care is a critical issue for Nemours. “Children with chronic health conditions can find progressing to adult medical care very difficult after being cared for by a children’s hospital for most of their lives,” says Corso. “So our partnership with Jefferson positions us well to help make this transition smoother for patients and families.”

Learning to seamlessly transition pediatric patients to Jefferson will benefit the hospitals and patients alike. By taking advantage of connections in every specialty, from family practice to cardiac disease, adult care could be handled by a Jefferson provider. “This is important for our patients but also for Jefferson’s longevity, because that’s where many of our patients are going to come from in the future,” says Greenspan.

Children with chronic disease make up one of the most challenging patient populations to hit the triple targets of improving quality, enhancing access and reducing costs because they struggle with their conditions for a very long time. In the past, they wouldn’t have survived into adulthood. “Jefferson is uniquely positioned to manage them efficiently, and as we do that, we will improve the bottom line of our business,” says Greenspan. “If we leverage it properly, we can be the medical home for kids with complex disease throughout the world because partnerships between pediatrics and adult institutions are rare.”

In addition to partnering on pediatric training and clinical care, there is an expanding research relationship that spans basic lab work and clinical studies at both institutions. Jefferson professors, associate professors and assistant professors at all levels are working in labs, in the clinical arena and in the outpatient area of Nemours. One reason that research has been growing steadily since 2000 is that Jefferson investigators who want pediatrics to be part of a study’s population will reach out to Nemours.

A Business Case to Partner

As hospitals across the country wrestle with pressure to increase efficiency, healthcare partnerships are on the upswing, according to a March 2012 report by Moody’s Investors Service Inc. While hospitals have always looked to mergers as a way of becoming larger, some hospitals will join forces with once-unlikely partners — health insurers and for-profit companies — the report says. Pediatrics residents Matt Demczko, MD ’12, and Tracy Hills, DO, with a young patient at Nemours. Photo by Brad Gellman, courtesy of Nemours/ Alfred I. duPont Hospital for Children. Academic medical centers are not immune to these challenges, and strategic partnering is quickly becoming a key component of long-term planning.

“We don’t have the luxury of thinking in monolithic, self-focused ways, like we did 30 years ago,” says Schlaff. “Frankly, unless it’s illegal or unethical, we can entertain any discussion.”

One suggestion is to remake the relationship between center city academic medical centers and community-based teaching hospitals. “We need a hub and spoke model, where the quaternary care academic center is the hub and strong relationships with community-based teaching hospitals go out like spokes on a wheel,” says David Paskin, MD ’64, vice dean for graduate medical education and affiliations. “That way you can have patient care delivered at the academic center or the community-based teaching hospital while maintaining access to the academic medical center if requested. Our neuroscience network is an example of how this can work successfully. There is no sense economically with everyone having expensive technology and expertise in everything at every moment everywhere. The role of an academic center like Jefferson should be to provide those kinds of services and fortify the relationships that we have with the affiliates.”

Greenspan agrees. “In the future, complex, challenging cases that other hospitals don’t want to deal with are going to come to a major academic hospital. A large segment of that could be young adults with special healthcare needs that have weathered the storms of the children’s hospital but are now looking for medical homes in the adult arena. There could be a business case made for tracking complex patients because we do it better, we do it cheaper and we do it with better access,” he says.

“If we take care of these mothers and these children, if we do this well and build new programs, it will be good for Jefferson and will have positive financial implications. We can articulate a vision that’s unique to us,” says Schlaff. “We can do it.”
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