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Post-discharge Advocate Program for Fracture Patients

The Post-discharge Advocate Program closes the care gap between a patient's fracture and their bone health evaluation and treatment plan.

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What challenges or opportunities are you trying to address within the problem? (200 characters or less)

Less than 20% of fracture patients are evaluated and treated for underlying bone health issues that could prevent another fracture. There is an opportunity to close this care gap after discharge.

From focus groups with fracture patients we conducted in 2014, we learned that fracture patients do not remember much of what they heard in the hospital and are consumed with their pain and disability during the acute healing process of the first few weeks. Patients reported that they do not remember much about the interactions they had with hospital or orthopedic staff about what they should do after their fracture except for work with the physical therapist during the rehabilitation process. The focus group participants believed that advocates – whether family, friends or medical professionals - could help them improve their bone health. 

Having experienced a debilitating fracture myself, I am personally aware of the healing journey. The first few weeks after the fracture were painful and frustrating as I tried to figure out how to get around and do my normal activities. I never wanted to go through that experience again! As I healed and the cast came off, I got back into my regular routine and didn't look back.  My primary care physician was not aware of my fracture and never discussed my bone health with me. The pain and inconvience quickly became a distant memory.

This "memory gap" that fracture patients experience can be closed by creating a mechanism to help them take bone healthy steps and reduce secondary fractures while their current fracture is top of mind. Our program would use a case management model inserted at the appropriate time during the fracture healing process - not too soon and not too late. 

In most cases, the hospital gives discharge instructions that include calcium, vitamin D, physical therapy and a bone density test, along with orthopedic follow-up and notification of the primary care provider. The instructions are detailed and speaking from my experience, relegated to the pile of "to be read" materials.

The fracture patient would be notified through their discharge instructions that someone from the Bone Health Team will be contacting them in 3-4 weeks to help them navigate the next steps.

When the patient is through the acute healing phase, about 3-4 weeks post fracture, a bone health advocate (health educator) would call the patient to review the discharge instructions provided by emergency department and help them follow-up with the steps outlined in the booklet. They would review patient's fracture risk factors to help the patient better understand their chances of breaking another bone.

As part of the program, patients would receive an easy to read booklet developed by American Bone Health called "You've Had a Fracture, Now What?" The booklet was designed to help the patient understand the journey they are about to start on. It's full of pictures and a timeline and is quite different than what discharge instructions look like. The booklet explains what the patient can expect over the next several months and outlines steps they can take during the process.

The bone health advocate would help the patient understand and complete the discharge instructions. This might include helping to schedule a bone density test, reviewing their calcium and vitamin D intake, fall prevention strategies, home safety and follow-up appointments with physical therapy, occupational therapy, orthopedics and primary care. 

The advocates would be connected to the hospital via a Fracture Liaison Service Navigator. The bone health advocate would report back on progress and share specific clinical questions from the patient or needed referrals. If the patient had any clinical concerns, they would be referred to their primary care provider.  

The most active connection with the patient and the bone health advocate  would last through the healing process. The first contact at 3-4 weeks post fracture; and the second contact initiated within 3 months of the fracture (depending on the patient). The relationship would continue until the patient feels they are back in charge of their life. There would always be the option for the patient to check back in. 

We would have a feedback loop to the hospital with metrics on the number of patients contacted and steps taken. This way the hospital could meet the Joint Comission measurement that requires all patients over age 50 with a low trauma fracture to be connected to a Fracture Liaison Service.

The goal of the program is to make it easy for patients to get the information they need to assess and manage their bone health to prevent another fracture.

Who is your target end user and why will they be interested? (650 characters or less)

In the US, nearly 20% of patients are readmitted within 30 days of discharge, associated with an estimated annual cost of 17 billion dollars. A case management method follow-up by trained health educators has been shown effective for stroke patients at the University of Louisville Hospital. The primary beneficiary of the intervention is the patient, who would reduce their chances of having another fracture. An initial 20-40 minute call with a bone health educator would set in motion the steps necessary for their bone health plan. The program is specifically targeting patients over age 45 seen in the Emergency Department for a low trauma fracture and discharged to home. This program would not follow patients who are admitted to the hospital and/or discharged to a rehab facility. Hospitals and health systems would also benefit by meeting Joint Commission measures and receiving a staff extender to help the fracture patient with their bone health journey once discharged.

How is your idea scaleable? (650 characters or less)

The model is based on a case management approach seen in other therapeutic areas, such as with stroke patients who are discharged from the hospital. Once the model is demonstrated to be effective in terms of cost savings and patient outcomes, adoption and payment for the service by hospitals and institutions would follow. Using a hospital- or health system- branded call-center with trained bone health educators allows for expansion as the program grows. The bone health educators would initiate follow-up calls that would be triggered from the date of discharge. An initial 20-40 minute call would allow the bone health educator to assess the patient's situation and help prioritize next steps for their bone health plan. A strong connection would be maintained with the hospital.

What do/will you measure to know if your solution worked? (500 characters or less)

1. Improve bone health and patient quality of life as assessed by patient reports. 2. Increase bone density screening among fracture patients from baseline. 3. Reduce secondary fractures reported from baseline at hospital or facility. 4. Reduce readmissions reported from baseline at hospital or facility.

What is the current stage of development of your idea?

  • Blueprint: We are exploring the idea and gathering the inspiration and information we need to test it with real users.

If you were to become a Top Idea, would you want to actively participate in piloting your idea?

  • I want my idea piloted, and I prefer to do my own piloting in collaboration with the health system and with assistance from the Challenge partner

Company / Organization Name, if applicable (140 characters or less)

American Bone Health

Website (if applicable)

Tell us about yourself or your team (500 characters or less)

American Bone Health uses insights from its Medical and Scientific Advisory Board to test models of care and stay abreast of the latest research. We support individuals, families and communities with programs and tools to help build strong bones and prevent fractures. We identify problems and seek solutions with the best science available, creating innovative responses to emerging issues and actively seek to collaborate to have the greatest impact for the most people. Over the years, we have worked with patients and learned the best strategies for engagement and activation. Our work has found that people don't pay attention to their bone health because they didn't know it was important. This program can change that perception among fracture patients.

Location (50 characters)

National footprint with HQ in Raleigh, NC, US.

What is your legal / organizational structure?

  • We are a registered NGO or Non-Profit Organization

Innovator/Organizational Characteristics

  • Female-led organization

How did you hear about the Challenge?

  • OpenIDEO announcement email
  • UCB website or social media

Why are you participating in this Challenge?

Our mission is to eliminate osteoporosis as a public health crisis in the US. We have been working collaboratively for solutions for over 25 years. We believe that the ultimate solution to the crisis in fracture management must include many stakeholders who will all gain from improved patient outcomes. We have learned that people learn best with they have personal interactions with their peers and can apply knowledge to their particular situation. Our interactive programs help people act.

How does your idea help more people who have had a first fracture either 1) discover they have osteoporosis or 2) access/navigate care?

This program would ensure that the fracture patients get a bone density test and complete a fracture risk assessment that is explained to them by the bone health advocate. The bone health advocate helps guide the patient through next steps. A recent study showed that patient who learn they have a compression fracture are 30% more likely to get treatment. [] In a similar way, when the fracture patient understands their risk of having another fracture, they will be more likely to engage in prevention and treatment strategies. Often when a patient gets a bone density test and learns that they have osteoporosis, the first thing they hear from their doctor is they need a medicine. A bone health advocate can create a bigger picture for the patient, ensuring they know about nutrition, using good posture and body mechanics in their activities and ways to modify their environment to prevent falls. Empowering the patient in this way gives them more control.

How is your idea new in the world or how does it build on existing interventions?

This program extends the Fracture Liaison Service (FLS) Program into the community by following patients who are discharged to home following their fracture. Many FLS programs work with fracture patients who are admitted to the hospital and do not follow patients beyond discharge. A similar model of managing a care gap was tested for stroke patients at Louisville Hospital by Lacuna Health. [] they found that most complications occur within 48 hours of discharge and an advocate can help preempt those problems. Our program is unique in its timing of execution. By engaging the patient after acute healing but before the memory gap has the best likelihood of acceptance by the patient. Interacting by phone with the patient allows the advocate to understand and address the barriers that the patient may perceive that they have, for example, denial, other health issues, family concerns other then themselves.

Please upload your journey map. Be sure your journey map shows when your user is introduced to the idea and when/how they access it, and illustrates which moments in the Challenge Journey Map your journey map touches.

Who did you test your idea with, what did you learn, and how did you evolve your concept?

We spoke with the founder and nurse navigator of the Strong Bones Program at Christiana Care in Wilmington DE. Their program focuses only on fracture patients who are admitted and they would welcome the opportunity to have a program to focus on fracture patients who are discharged from the emergency department (ED). They confirmed that the ED is not the place to try to engage the patients in bone health or give any materials. They also confirmed that patients are unlikely to "follow-up" on their own. They recommended that notification of the contact by a Bone Health Advocate be included in the discharge order set as a way to inform the patient. We also spoke with the CEO of Lacuna Health who runs a care gap management call center and who we hope would be our partner in this program. He noted the importance of hospital buy-in and especially the concern about return on investment by the hospital. He emphasized the importance of creating a robust program and ensuring advance preparation of the patient for best results. Their RN-led connection rate is 40-70%, depending on the acuteness of the disease they are working with. As a result of these conversations, we revised our program to focus only on low trauma fracture patients over age 50 who are seen and discharged by the ED. These patients will mostly present with wrist, shoulder and spine fractures. We also learned that the pilot programs will be best received in hospitals with a Fracture Liaison Service in place.

(Optional) Share documentation of your solution prototyping and testing, such as photos.

Please upload your Business Model Canvas

This canvas underscores the interdiscplinary approach of the program and the involvement of multiple stakeholders for its success. Key activities and resources all lead to the ultimate benefit for the fracture patient.

Please upload your team video.

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Attachments (3)

Advocate Program for Fracture Patients08212019.pdf

This presentation describes the program concept, logic model and components


This white paper describes the success of a similar call center approach after discharge for stroke patients. Most complications after discharge occur within 48 hours.

FINAL VERSION_170308_Had a Fracture Brock_FINAL.pdf

This is an easy to understand guide for fracture patients on what to expect after their fracture. Developed by American Bone Health

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