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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)

www.americanbonehealth.org

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. [https://doi.org/10.1002/jbmr.3836] 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. [https://lacunahealth.com/engaging-the-continuum/] 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

Lacuna-UL-Stroke-White-Paper.pdf

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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19 comments

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for more details visit the website
<a href="http://24qb.org/">Quickook Support</a>

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Kathleen Cody Congratulations on being selected as a Top Idea!!! Your tenacity in drilling down to just what an individual with a bone break goes through, along with a persistent openness to learning techniques of human centered design through this Challenge have been amazing. You're wonderfully positioned to further impact lives in the coming months. Best wishes in future developments! Susan

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Team

Thanks, Susan! I appreciate your help and advice along the way.

Spam
Photo of Susan Jackewicz
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You're welcome! Best of luck going forward:-))

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HI! Kathleen Cody Congrats on your latest idea update. Your presentation is now much stronger, articulate, and targeted...very clearly incorporating much of what you've read and heard on the platform. "Kudos!" for sticking with it and for all your hard work, patience, and moving the idea forward. Best of luck going into the finals round! Cheers, Susan

Spam
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Thanks, Susan. I am also the proud owner of new pens! BTW - do you see anything that I have missed in the submission?

Spam
Photo of Susan Jackewicz
Team

Hey Kathleen Cody Am happy to know you'll never have an ink-filled purse on an airplane:-)
Looking at your submission just before close of refinement it seemed to me you covered everything. Again, great job refining from the start....and best wishes through to the Final stage! Cheers, Susan

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Team

Hi Kathleen Cody 
Hope your idea prototyping is on in full swing!
In gratitude and in support of your future work, we would like to invite you to join the final Innovation Coach Office Hours as you continue your innovation learning journey:

Make, Try, Show, Test, Build
Ashutosh Biltharia, Designer and Engineer, MFA, Interaction Design, Umea Institute of Design, Sweden. 10am PST August 5th.

Building Partnerships in Design
Susan Jackewicz, Principal at Takhi Associates, Boston, Massachusetts. 10am PST August 9th.

Love the Problem, Scale the Solution
Chris Cochella, Managing Partner at Sequoia Group, Salt Lake City, Utah. 9 am PST August 12th.

Sign up here to attend
https://forms.gle/jPPAZvUfJ2u8oXuz5

Spam
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Kathleen Cody 
Great job revising your idea! The process as you describe it now is very clear, highlighting touchpoints of the patient journey. and explaining interventions at specific points to impact the care gap. Adding the storytelling makes it even more compelling!
Hopefully you saw the recent email about the deadline being extended another couple of days, to Saturday July 6 5PM PST...just in case you think of anything else!
Best,
Susan

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Photo of Kathleen Cody
Team

Thanks, @DeletedUser Susan, for your comments.

Spam
Photo of Susan Jackewicz
Team

You're welcome! With the Ideas phase closing shortly, the Next Step is for the Review Committee to generate the Short List of ideas moving forward. Everyone will be getting further communications. So, time to exhale a bit, and enjoy this summer weather! Thanks again for your submission and thoughtful edits.
Best,
Susan

Spam
Photo of Manisha Laroia
Team

Hi Kathleen Cody 
Thank you for being super-active through the Ideas Phase of the Healthy Bones Challenge.
Great work!
A reminder, to make any last minute tweaks you wish to, asap. Like adding images or changes in text. The DEADLINE for idea submission is Wednesday July 3rd, 2019 5pm PST.

A CHECKLIST to guide you is here:
Please make sure your idea does the following:
1) Clearly define the problem
2) Connects to at least one opportunity area
3) States how & when user accesses the solution
4) Tells the story

Let me know if you need anything.
All the best for the next phase of the challenge.

Manisha
OpenIDEO Challenge Team

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Photo of Kathleen Cody
Team

Thank you Manisha. I hope I got it right!

Spam
Photo of Susan Jackewicz
Team

Hello Kathleen,

I'm Susan, an OpenIDEO Innovation Coach for this Challenge. Thank you for posting your idea on how to address the "care gap" after a first bone fracture. You've identified and articulate well the opportunity to improve care and health at that particular post-hospitalization touchpoint. I've read your pdf proposal (great graphics!) and looked at your website (very informative and easy to navigate, thank you. I recently underwent a hip replacement, and while not challenged with osteoporosis, am keenly aware of challenges brought by aging and bone health, and saw immediately useful information!)

I'm curious about several things, which relate to the Challenge evaluation criteria of being patient-centered, post-first fracture, measurable, and scaleable. Might you answer please?

1) In your patient journey map, the first contact with your Bone Health program would be a brochure to read given to the patient from the hospital, at some point in their stay. I'm wondering about patients, esp. a couple decades older than 50, who might be challenged in reading, comprehending, or are too preoccupied with pain to make a decision about joining. Do they then have to sign an agreement and the hospital then does the enrollment, or do they enroll themselves? (Does this include permission for the hospital to give you their personal medical data?) You might be addressing this already, but it seems having an outreach mechanism including family members or care partners would widen your impact?

2) How long do you envision an active relationship with patients post-discharge? Is this something the patient/member has flexibility with? Do you envision providing the hospital with follow-up data a year or more after enrollment?

3) It's great you engage many peer educators who have personal or family experience with osteoporosis...empathy and tacit knowledge go a long way to making people feel comfortable and lessening fears. Your solution of a national call center is a good idea for scale - but I wonder (having run a call center myself in a past professional role) is 9 hours of training sufficient? What might be the strategy to keep those peers online continually supported? It's unclear to me from your proposal...would they be all located physically in the same place, or distributed but virtually connected? How might they know local resources - face to face interactions - to recommend, and how would you keep that information updated?

These are somewhat "in the weeds" questions....your overall idea is very well thought out and obviously supported by knowledge from your organization's board and scientific advisors. And you're able to translate the science into an easily accessible platform in your website. The opportunity with this Challenge is for utilizing the design process to go deeper into needs of everyone involved in the journey - from patient to care coordinator to hospitalist enables everyone to explore and see something maybe hidden in plain sight that would deliver more value for even diverse stakeholders. You're well on your way... (Pun intended!!)

If you have any questions, please ask. We have a team of coaches here ready with diverse experiences to help!
Susan

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Team

Hi Susan, thank you for your comments. I will try to tackle them!

1) We have an easy to read booklet called "You've Had a Fracture, Now What?" that 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 :/

In the case of an older patient, my expectation would be that their adult child would be involved in some way. (That's how it was in my case with my father - I was looking for any better understanding of what to expect and what I could prepare for.)

The patient would need to "enroll" in the program before discharge to make it most effective. I would hope that the process could be part of the discharge instructions. We would not need or want personal medical data, since the advocate is really there to help the patient (or adult child) navigate the next steps.

2) I would expect the most active connection to last through the healing process (first initiated contact at 3-4 weeks post fracture; second initiated contact within 3 months of the fracture depending on the patient). The relationship would continue until the patient (or adult child) 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 so they understand the value.

3) My plan is to work with an existing company that already does patient case management. These individuals already have a clinical background and would only need the additional training in bone health, osteoporosis and secondary fracture prevention. The advocates would be connected to the hospital so that if they got specific clinical questions from the patient or needed referrals to a DXA facility or physical therapy they would connect back to the hospital.

It's really helpful to have these conversations. Thank you.

Spam
Photo of Susan Jackewicz
Team

Hi Kathleen,
Thank you for wading through all the commentary - your thoughtfulness about our questions has pinpointed a differentiating factor drilling down to problems in the human-centered journey - that shift from a "medical" environment back into one's "normal" home surroundings.
1) Your booklet being easy to read and visually different in design from discharge instruction formats signals to the soon-to-be-former patient this is something that can help once the doctors and nurses and aides aren't around to answer questions. It becomes more a friendly educational format to explore vs. a medical directive. That could be very important for engaging people going forward in their healing process, and the design and format of the communication is something you could explore even further for additional impact and community building.
2) From your timing, it seems the most connection you foresee with former patients is an 8-week window, starting about 4 weeks after discharge. This helps clarify the break between being a connection requiring medical data permissions and being a community support system, while still providing valuable feedback for hospitals.
3) Re: the peer advisors...you might look at an idea just recently posted, Follow Your Calling by Z Morris (zarah morris). Her idea calls for tapping into a volunteer pool of pre-nursing certification studies or Masters in Social Work degree applicants who are required to show a significant volume of related volunteer hours. I know you've cited another organization to potentially partner with for call center resources, but it might be an idea for some collaboration!

Spam
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Team

very cool idea!

Spam
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Team

Hi Kathleen Cody 
Thank you for sharing your idea here.
We have a special Office Hours session coming up to interact with our Innovation Coaches and be part of a QnA.
We would love for you to join in and support you in refining your idea.

TITLE:
A story of two halves. Defining your problem and telling your solutions story. –with Alan Bryant, Senior strategist at Livity
DATE & TIME: Friday 28th June, 2019 10am PST
RSVP:
https://calendly.com/atillman-1/a-story-of-two-halves-defining-your-problem-and-tellin?month=2019-06&date=2019-06-28
DETAILS:
We'll start by workshopping how to clearly define and articulate the problem you are solving, then look at how to get to the root cause and the impact this has on your idea. Before we move on to talk about narrative structures and how to tell your ideas story in the most clear and engaging way for your audience.

Manisha
OpenIDEO Community Fellow

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Team

Dear Kathleen,

Like Susan Jackewicz, I'm an OpenIDEO Innovation Coach. I'm also intrigued by and impressed with your idea. You're building on your organization's expertise and existing network of peer educators while also drawing on the stroke patient model. You've built empathy into the ideation by conducting focus groups and quoting from participants. You've built empathy into the solution by planning to solicit peer eduators with their own bone challenges. And you've zeroed in on low-trauma fractures, which are more likely to be osteoporosis-related, and thus fit squarely in the challenge, which requires "solutions that support better connection of fractures to osteoporosis."

I also liked your considered "not too soon and not too late" calculation re: when, after a fracture, intervention should begin (at the hospital) and continue.

Building on Susan's comments, I wonder if you could strengthen your proposal by:

1) extending or deepening the relationship between peer educators and patients. Perhaps I missed it, but might these people meet in person? Might their term of connection last for a designated length of time - perhaps a year? Seems to me that anything to strengthen that relationship would serve to improve patient understanding, compliance, and quality of life.

2) broadening the network. Might you consider connecting patients to an online or in-person peer support group? I'm aware that people who are over about 70 are less likely to be online than younger people, but many people who are in the 50-70 age group - who are also prone to osteoporosis and first fractures - use computers daily at work and participate avidly in a variety of online chats, including those hosted by Inspire. (https://www.inspire.com) (That's based on personal observation rather than quantitative data.)

In-person peer support groups could feasibly be organized by hospitals, which increasingly offer community health programs. Fear seems to play such a big part in fracture experiences - as noted by your quote from the former cyclist who is too scared to ride again. Expression of those fears along with peer support in a psychologically safe environment could feasibly help people make good decisions about personal risks vs. rewards.

With both of these questions, I'm seeking longer-term support for post-fracture patients, which cannot always be ensured through the medical system's diagnosis and treatment of osteoporosis - a point your existing peer education network seems to support.

And, again like Susan, all of these comments are in a context of overall support for and enthusiasm for your idea.