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.