fracture liaison service in alberta

Fracture Liaison Service in Alberta Dr. Michael Mulholland, FLS - PowerPoint PPT Presentation

Fracture Liaison Service in Alberta Dr. Michael Mulholland, FLS Physician Beverly Bowles, FLS Nurse Clinician Disclosure Dr. Michael Mulholland and Beverly Bowles are paid by the Bone & Joint Health SCN which is funded through Alberta

  1. Fracture Liaison Service in Alberta Dr. Michael Mulholland, FLS Physician Beverly Bowles, FLS Nurse Clinician

  2. Disclosure Dr. Michael Mulholland and Beverly Bowles are paid by the Bone & Joint Health SCN which is funded through Alberta Health Services Dr. Mulholland has no pharmaceutical interests and no conflicts of interest 2 2

  3. Outline • The Problem • The Alberta Context • Creation of the Fracture Liaison Service (FLS) • FLS Processes • Current Status of FLS in AB • Challenges 3 3

  4. The Problem Osteoporosis Canada, 2015 4 4

  5. Key Facts • At least 1 in 3 women, and 1 in 5 men, will break a bone due to osteoporosis in their lifetime • 1 in 3 hip fracture patients will re-fracture within 1 year, and over 1 in 2 will suffer another fracture within 5 years without treatment • Typically >80% of patients who have suffered a fracture are neither assessed nor treated • Annual cost to Canadian Healthcare from osteoporosis and fractures in 2010 was > $2.3 billion 5 5

  6. The Alberta Context Red Deer specific • There are close to 3,000 hip fractures in Alberta yearly • To date 846 patients have been enrolled in Red Deer FLS (293 last year) • Of those patients we enrolled – 143 have died – 1/3 are on treatment 6 6

  7. Acute Care Catch a Break Secondary Provincially prevention scaled evidence- program to based best reduce Bone and practices for subsequent inpatient hip Joint Health fractures fracture care SCN Fracture Liaison Restorative Services Care Post-acute care, Dedicated post- emphasizing optimal acute team function level, quality proactively treats of life and underlying reintegration into osteoporosis and community prevents future falls

  8. Catch a Break EVALUAT ALERT INFORM IDENTIFY patients family E program fragility at risk physician fractures annually FOLLOW SCREEN EDUCAT patients for for E 12 months osteoporosis patients avg. cost to fractures $25 14 treat one hip avoided k fracture Acute avg. CAB hip Care 4 $44 cost/patient fractures Fracture Liaison Restorative avoided Services Care

  9. Acute Care Provincial Clinical Pathway + Order Sets STANDARDIZED PROVINCIAL CARE Developing Alberta BEST PRACTICE GUIDELINES for hip fracture care PROVINCIAL and SITE-SPECIFIC PERFORMANCE INDICATORS Early Time to EXAMPLES Surgery ≤ 36 Mobilization 30 Day Readmission Hours Catch a Break Length of Stay Return to Previous Re-fracture < 1 Year Living Environment Fracture Liaison Restorative Services Care

  10. Fracture Liaison Services Provincial ‘3i’ model: identify investigate initiate ASSIGN TRANSFER DISCHARG dedicated to family E from FLS team physician at 1 hospital year TREATMEN FOLLOW- T PLAN UP 3, 6, 9 Months Adherence and persistence to first line osteoporosis treatment - specialist referrals - falls prevention fractures avg. FLS Acute Care Catch a Break $1360 37 avoided cost/patient hip fractures Can be cost- Restorativ e Care 12 avoided savings with some changes

  11. Restorative Care Provincial Restorative Transition to Pathways COMMUNIT STANDARDIZED Y CARE PROVINCIAL CARE Pathways for: 1) Up to post-operative day 7 2) From post-operative day 8 to 28 Home +/- home care Long-term care Includes: Rural acute sites Catch a Break Acute Care Supportive Living Rehab/subacute/ transition Fracture Liaison Services

  12. What is an FLS? • A specific systems-based model of care for secondary fracture prevention • Closes the care gap between orthopaedic care post- fracture / patient’s underlying osteoporosis and return to primary care • 3i program: Identification (1i) Investigation (2i) Initiation (3i) 12 12

  13. Identification (1i) Inpatient Orthopaedic Unit Exclusions: • < 50 years old • out of province/country • pathological fracture • acetabular/pelvic fracture • distal femur or high impact Patient Care Census hip/femur fracture Hip Fracture Diagnosis • peri-prosthetic fracture from elective hip replacement • palliative patients • those with < 1 year life expectancy Patient ≥ 50 years old with identified fragility hip fracture 13 13

  14. Investigation (2i) FLS Patient Checklist Fracture and fixation Medical history Renal function Osteoporosis risks/history Nurse / Physician Fall risks/history patient review Supports Develop plan of care 14 14

  15. Initiation (3i) On First Line Rx Yes Must consider: No CrCl Swallowing issues Adherence Preference < Year > Year Coverage Complexity Defer till 3 months Continue Consider Start first and switching line Rx reinforce medication adherence 15 15

  16. FLS Algorithm 16 16

  17. Calcium and Vitamin D 17 17

  18. Patient Education • Osteoporosis, • Future fracture risk • Medications • Diet (calcium, vitamin D) • Exercise • Home safety & fall prevention 18 18

  19. Patient Education 19 19

  20. Patient Education 20 20

  21. Patient Education 21 21

  22. Q 3 Month Follow-up • Follow-up calls done with patient/family/caregiver at 3, 6, 9, and 12 months  Mobility, falls, fractures  Medication adherence if on OP treatment  Investigations (BMD, vitamin D testing as appropriate)  Referrals • Letter faxed to GP after each follow-up call if there is relevant information to pass on to them 22 22

  23. Secondary Fracture Prevention • We haven’t prevented the hip fracture, but the goal of FLS is to prevent further fractures by focusing on: – The reason for the fall and trying to reduce the risk for falling again – falling is not a normal part of aging! – Their bone health and treatment for osteoporosis – if they are osteoporotic and having falls, they will fracture 23 23

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