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Beyond the Cast: Reimagining Osteoporotic Fracture Care

Empower patients to take charge of their fracture journey to reach optimal physical & emotional recovery & reduce risk of future fractures.

Photo of Patricia Salber

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

Fragility fracture care is often fragmented & incomplete. The bone gets fixed but osteoporosis isn't diagnosed, contributing fractures (balance) aren't identified, and emotional sequelae are ignored.

Fragility fractures can be devastating events in the life of a patient with osteoporosis. She didn't just break a bone, she suffered a significant emotional trauma - one that's often described like this:

  • "I am terrified of falling again" 
  • "I suddenly feel old and fragile" 
  • "I am afraid I will not get my old life back" 
  • "I keep reliving the fall and I can't sleep"


These symptoms are very similar to the ones described in PTSD

Too often, however, the healthcare system fixes her bone but fails to uncover why she fell or what can be done to prevent it from happening again. And the emotional sequelae that are engulfing her are almost always ignored.

It is also important to note that osteoporosis patients become much more expensive to a health plan/system once they have a fracture because of ER visits, ortho appts, PT, imaging studies. If the next fall is major, such as a hip fracture the costs go up exponentially because of surgical costs, nursing home/rehab stays, durable medical equipment (wheelchairs) and home care. Just like with other chronic illnesses that are currently aggressively managed in organized systems of care because it pays off to do so, these systems will also reap savings from preventing the next fall and fracture.

The Beyond the Cast (BTC) program is a comprehensive approach to osteoporotic fracture care that is based on principles of Population Health Management, an approach commonly used in organized systems of care. Much like the successful digital health management program, Omada Health, BTC involves the use of technology, human coaches, peer support, and data collection to ensure that what needs to be done, gets done. 

Here's how it works:

The patient is enrolled in the BTC program at the time of discharge from the ER or hospital.  Notification is also sent to the system's designated Bone Health Champion to help arrange follow-up. The patient is helped to download the BTC app and instructed on its use. 

The app is a comprehensive support tool that empowers the patient to take charge of their recovery and initiate changes that can reduce the risk of future falls. 

The BTC comprehensive fragility fracture management app includes

  • Info on home care (e.g., can you shower?) and safety (e.g., proper use of crutches) while immobilized
  • Info on physical therapy with links supporting a home PT program
  • Info about osteoporosis screening and treatment modalities with links on how to get screened
  • A tool to assess whether any contributing factors to the fall are present (e.g., balance or vision issues, orthostatic hypotension, neuropathy, poor shoes, home factors) with links for how to get evaluated and how to correct issues (e.g., Tai Chi for balance, grab rails in shower, secure loose rugs, etc.)
  • A detailed explanation plus screening tool to asses for PTSD-like symptoms common after falls/fractures (fear of falling, reliving the event, insomnia, anxiety, guilt) with links for support with symptom management
  • Links to connect with post-fracture care team including the Bone Health Champion
  • Symptom trackers that can easily be shared with providers or used as prompts during clinic visits
  • Links to peer group sites for people with osteoporosis fractures (e.g., American Bone Health)


The Bone Health Champion can be a case manager or other individual who is dedicated to managing the program. The program can be embedded into the health system's existing population health department. 

The Bone Health Champion manages the system's fragility fracture registry, provides outreach to patients with fractures but no evidence of screening for osteoporosis, facilitates follow-up, performs program QA, oversees app updates, and a variety of other program management tasks. One Champion could manage all of the cases in a moderate-sized organized system of care.

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

End users are older women and men who have suffered a first fragility fracture (low impact fracture in the setting of osteoporosis). These injuries are common; 1/2 of women and 1/4 of men over age 50 will experience one. Although almost everyone will receive care for their fracture (surgery, immobilization), not everyone will get screened for their underlying bone disease (osteoporosis). Even fewer will be assessed for factors that may have contributed to their injury (often a fall). Examples of such factors include balance problems, visual disturbances, neuropathies, other co-morbidities like diabetes or heart failure, and unsafe conditions in the home. And, unfortunately, almost no one gets assessed for debilitating emotional sequelae of the injury, such as insomnia, fear of falling, reliving the event, anxiety, and social isolation all of which may contribute to future fractures. See uploaded patient journeys and stakeholder descriptions to learn more

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

The solution is a population health management (PHM) approach to identification and treatment of patients with fragility fractures. The principles are the same as those commonly used to manage chronic conditions such as diabetes. This solution would be best implemented in an organized system of care (OSC) such as a health plan, hospital, ACO, that already has a PHM program that includes: 1. capability to develop the fragility fracture registry 2. Designated bone health champion (could come from existing staff) 3. Patient-facing application (in development) 4. Physician protocol that can be integrated into the EHR (optional) My solution is scalable because almost all OSCs already have PHM programs that have at least the first two components. They have already scaled the processes. They would have to designate a Bone Health Champion and customize the app. Cost of build-out & maintenance should be covered from savings related to fewer fractures as a result of using the program.

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

Short term: information from questionnaires/symptom trackers incorporated into the app will be used to see if the intervention reduced symptoms and documented improved functionality in four key realms of care: 1. Fracture recovery (improved range of motion, physical function self-reported via app) 2. Osteoporosis management (DEXA screening, referral for meds, non-med mgmt self-reported via app with confirmation via claims). 3. Evaluation and management of contributing factors (the app can eventually incorporate some eval tools) self-reports via apps questionnaire/symptom tracker. 4. Evaluation and management of emotional sequelae (initially off-the-shelf screening tools such as Primary Care PTSD Screen for DSM-5 can be used to track symptoms via the app. Long term: follow patients claims data over time to see if there are any recurrent falls or fractures. Eventually, a study with a usual care control group should be performed that includes costs so ROI can be calculated

What is the current stage of development of your idea?

  • Prototype: We have done some small tests or experiments with prospective users to continue developing the idea.

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)

Health Tech Hatch

Website (if applicable)

thedoctorweighsin.com

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

I am a UCSF endocrinology-trained former Kaiser Permanente emergency physician & health plan executive. Currently, I am a run the popular health news site, The Doctor Weighs In (http://bit.ly/2bmTsGy). I also am a contract consultant for CMS & a large Washington-based consulting group. I serve as an advisor to a number of health-tech startups and was recently appointed to the Board of MedShare. The members of my team include: -Kathryn Johnson (https://www.linkedin.com/in/kathryn-johnson-a833304/) -Meg Crofton (https://www.linkedin.com/in/megcrofton/) Meg suffered a fall/fracture and had significant PTSD-like symptoms afterward. - Francesca Nicosia (https://www.linkedin.com/in/francescanicosia/) -Ishita Jain (https://www.linkedin.com/in/ishita-jain-18278aa2/) - Leslie Rose (https://www.linkedin.com/in/leslie-rose-a04323a/) -Ann Bentley (https://www.linkedin.com/in/ann-bentley-42726a24/) Ann has untreated osteoporosis

Location (50 characters)

Larkspur, California, USA

What is your legal / organizational structure?

  • We are a For-Profit Startup or Startup Social Enterprise

Innovator/Organizational Characteristics

  • Female-led organization

How did you hear about the Challenge?

  • OpenIDEO announcement email

Why are you participating in this Challenge?

As I noted in my blog post, What Happened When I Broke My Shoulder (http://bit.ly/2apogKF), a fall is so much more than "just a fall." It is a life-changing event that can lead to decreased activity, social isolation, depression, & grief over the loss of a previously healthy, active life. My personal experience with my first fragility fracture (detailed in the essay) made it clear to me that treatment has to be so much more than just fixing the bone. That was my motivation to join the Challenge.

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

A systematic population health mgmt (PHM) approach triggered by the initial fragility fracture can ensure that everyone is offered screening for osteoporosis (e.g., DEXA scan). It can also be used to determine if patients actually got their screens. The program includes a designated Bone Health Champion (case manager) who can answer questions & help connect patients to their providers. The solution combines PHM with a patient-facing app that not only has information about the fracture, physical therapy, principles of medication and non-medication management, but also screening tools to evaluate whether there were contributing factors to the fall & whether or not emotional sequelae have occurred. Questionnaires and symptom trackers are incorporated to track progress and evaluate the effectiveness of the intervention. Multiple links will help people access a variety of high-quality resources that can help them return to optimal function. All info can be customized for the OSC.

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

My idea builds on the well-established principles of population health programs that are already being used by most organized systems of care (health plans, health systems, ACOs). This being said, most of these programs target high-cost, high prevalence chronic conditions such as heart failure and diabetes - not osteoporosis. The addition of an app that can be used for both patient education/support as well as to evaluate the effectiveness of the interventions would be a novel addition to many of these types of programs. American Bone Health (ABH) has many of the educational elements that are described in the program, however, Beyond the Cast is different because it will be built in the context of an organized system of care in collaboration with physicians and other providers as well as purchasers and insurers of care. A collaboration with ABH would be most beneficial.

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.

I have attached two journey maps. One is "without BTC". It traces the patient journey from the fall/fracture to the ER, discharge to home, follow-up in the ortho clinic, and referral to PT. For many fragility fracture patients that, is, unfortunately, the end of the story. The other journey map shows how BTC will positively impact the journey, starting with enrollment in the program at the time of discharge, connection to a Bone Health Champion and the BTC app to guide their journey.

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

I tested my idea with a variety of people including seniors, people with osteoporosis, one woman who had fragility fracture complicated by PTSD-like emotional sequelae, a personal trainer who works with people with osteoporosis, a business executive, the former CEO of a population health company, the former CEO of the Health Forum, and others. All of this is summarized in a written document that I uploaded at the beginning of this submission (It is titled "Prototyping Feedback." I also tested the app concept with Kathryn Johnson (the former CEO of the Health Forum), Ishita Jain (prototype coach) as well as Matt Jones and Akhsar Kharebov, serial entrepreneurs with digital health backgrounds. They provided detailed feedback on the concept and app wireframes. The feedback was incorporated into successive versions of the wireframes. I saved the iterations as different versions (labeled v1-v13) in Adobe XD. These are available on request. I also captured how the app functions in the uploaded video titled "Understanding the BTC Program and App." My prototype coach, Ishita Jain, also reviewed the concepts, guided me through the prototype testing. Medical anthropologist, geriatric specialist, and health services researcher Francesca Nicosia gave me feedback on both the concept and how it would fit into an organized system of care, such as the VA.

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

My solution prototyping took a number for forms: -In-person iteration at various stages of the idea -Zoom calls to discuss improvements, clarifications -Asynchronous iteration with both the program write-up and other materials (journey maps, the draft app, app videos, etc) I have captured some of the prototyping processes in a document that I uploaded (Prototype Feedback) at the beginning of this submission.

Please upload your Business Model Canvas

The business model canvas was initially drafted based on my personal experience as a Physician Executive at Kaiser Permanente, Chief Medical Officer of a Medicare Advantage health plan, an expert in population health management, and long experience working with employers. I worked with the former CEO of the Health Forum and the former CEO of a population health management program to expand and refine the model.

Please upload your team video.

My team video describes the motivation for joining the challenge and gives you a flavor of the prototyping processes used. I introduce you to my team. And most importantly, I tell fragility fracture stories I heard from many amazing women I met while working on the project. Finally, I reiterate what problem we were trying to solve. I hope you enjoy the video.
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Attachments (2)

App video narrative.docx

This document contains the narrative used in the video.

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Photo of Ashley Tillman
Team

Hi Patricia Salber really enjoyed reading about your work! I noticed your first video isn't working, if you send me the link I can fix it for you on the platform.

Photo of Patricia Salber
Team

https://youtu.be/mdYAyOHfYvw
It was working earlier. Wonder what happened. Thanks for fixing it for me.

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