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.