Webinar

Own the Bone Experiences: Three Different Models

This recorded webinar features three Own the Bone program coordinators who have found success running an FLS program within their different care settings:  an urban academic medical center, a community-based regional hospital, and an integrated health system.  Hear about each of their experiences implementing and expanding their program, what they are doing today, and future plans.

Moderator: Frederick C. Redfern, MD, FAOA

Speakers:

  • Laura Boineau, MSN, APRN, FNP-BC, Greenville Healthcare
  • Amanda Brown, PA-C, Sanford Health Fargo
  • Lynette Judy, RN, Jefferson Hospital

Originally recorded July 12, 2017

Laura has been a nurse practitioner for 20 years and has been in orthopedics for the past 7 years. She is the provider for the Greenville Health System’s Osteoporosis/ Bone Health Clinic in Greenville, SC. The program is certified, by the National Osteoporosis Foundation, as a Fracture Liaison Service. Greenville Hospital System has been using the American Orthopaedic Association’s Own the Bone FLS program since 2010.

Amanda has been a Physician Assistant in orthopedics for 7 years. She is the Provider for the Bone Health Clinic/FLS, based out of Orthopedics, in Sanford Health in Fargo. Amanda has been instrumental in the development and initiation of a secondary fracture prevention program and Bone Health Clinic for the past three years. She is a member of and recently became an Ambassador for the National Osteoporosis Foundation and has recently been nominated for PA of the year for the state of North Dakota. She is very passionate about helping her patients treat their bone health to prevent future fractures.

Lynette Judy is the osteoporosis coordinator and Own the Bone program coordinator for Jefferson Hospital’s Fracture Liaison Service. She has been an Orthopaedic nurse for 12 years and received her Orthopedic Nurse Certification in 2012. She is a member of the National Osteoporosis Foundation (NOF) and National Association of Orthopaedic Nurses (NAON). Jefferson Hospital has been enrolled in Own the Bone since 2012.

Own the Bone Site Highlights

Wake Forest Baptist Medical Center, out of Winston-Salem, NC, uses Own the Bone to supplement their existing fracture liaison service with information from the Own the Bone registry.

Benjamin Graves, MD
Benjamin Graves, MD
Program Champion
Anne Lake, NP
Anne Lake, NP
Program Coordinator
Betsy Southern, PA
Betsy Southern, PA
Back-up Program Coordinator

Wake Forest Baptist Health is a regional health care system with Level 4 trauma designation and an ACO that serves the entire Piedmont region in North Carolina. The main hospital is an 885-bed tertiary care in Winston-Salem, NC. In addition to the main hospital, there are five community hospitals in surrounding areas within the Wake Forest network. The total medical center workforce exceeds 20,500.

To improve quality and patient outcomes, the Fracture Liaison Service (FLS) was established in 2013 within the orthopaedic surgery department to address the growing problem of the treatment gap after fragility fractures and patients with osteoporosis. The program remains in the department of orthopaedic surgery and Anne Lake, DNP is the founding coordinator for the program and works as a clinician along with Betsy Southern, PA in treating patients within the FLS service line. The physician champion is Dr. Benjamin Graves, an orthopaedic surgeon who also specializes in upper extremity care and fragility fractures.

Since its inception, our FLS has grown and provides care at the Winston Salem location in addition to Davie Medical Center and Lexington Orthopedics. The goal of the program is to identify, evaluate and initiate appropriate treatment for patients that are high risk for secondary fractures. Referrals originate from the orthopedic service, primary care and other specialties as well as self-referrals. Currently, the program has served over 3300 patients.

As a nationally recognized program, “we saw the need to engage in the use of a registry for tracking our measures and to track outcomes as well,” says Dr. Benjamin Graves. “In 2018, we elected to implement use of Own the Bone to remain supportive of the AOA and congruent with other professionals utilizing this registry. For our program, Own the Bone provides a reasonable way to track data as it relates to our FLS program and encourages us to reach new goals in best practice by peer to peer program comparison.”

“Prior to using Own the Bone we had established protocols for identification, investigation and initiation of treatment for appropriate patients from the time of fracture to assure timely first visit and follow up visits as well. Since incorporating Own the Bone we have been able to utilize the resources and training provided and to see our data ‘come to life’ in a more concise and measurable platform,” says Anne Lake, DNP.

Wake Forest Baptist Health continues to grow in size and numbers. The Fracture Liaison Service is eager to educate the community and other health care providers about bone health, fracture risk reduction, and healthy bones for a life time. There are plans to expand our clinics into outlying communities as well, to serve more patients closer to their homes. The data tracking that Own the Bone can provide will help with housing this data for us as we continue to grow.

Published October 2018

Froedtert Hospital, located in Milwaukee, WI, implemented Own the Bone in late 2017. With support from an interdisciplinary team their program has grown to treat all fragility fracture patients.

Sara Arndt
Sara Arndt
MSN, APRN, ACCNS-AG, APNP
Erin Zepezauer
Erin Zepezauer
MSN, APNP
Can you tell us a little bit about Froedtert Hospital?

Froedtert Hospital is a 585-bed, academic medical center in the Milwaukee area. It serves as the region’s only adult Level I Trauma Center. Affiliated with the Medical College of Wisconsin, Froedtert Hospital serves as a major training facility for medical, nursing, and health tech students. Additionally, Froedtert and the Medical College of Wisconsin participate in nearly 2000 research studies each year.

How did you get started with your Own the Bone program?

Orthopaedic surgeon and current Own the Bone Program Champion at Froedtert Hospital, Dr. Joseph Schwab, became interested in creating an FLS program after attending an AAOS FLS Symposium where Own the Bone was mentioned. Both he and current Program Coordinator Sara Arndt, APNP, brought information regarding Own the Bone back to their Executive Leadership. This information was used to form an interdisciplinary team that would consult and manage the initiation of Own the Bone. The team included representation from Orthopaedics, Endocrinology, Interventional Radiology, Neurosurgery (Spine Care), Internal Medicine, nutrition, and therapy.

What does your current Own the Bone program look like?

Currently the day-to-day operations of the team are handled by Sara, and a second Program Coordinator, Erin Zepezauer, APNP. Sara focuses on seeing patients who are currently admitted to the hospital, while Erin focuses on seeing patients in the clinic. Both Erin and Sara share responsibilities of the program, such as entering data into the registry, which means that open and clear communication is important to the successful implementation of Own the Bone.

Initially, the program focused on capturing inpatient hip fractures through an automatic ED order set that also requested bone health screening labs. As our program has grown, we continue to update our processes in an effort to capture all fragility fracture patients. Once a patient is identified, Sara will try to see the patient by post-op day 1-3. During this time, Sara completes a comprehensive bone health assessment and gathers any information that could give insight to the patient’s risk for osteoporosis. She also goes over the two page Own the Bone Patient Education Flyer with each patient. Upon discharge patients are given a recommendation for calcium or vitamin D supplements and a prescription for a BMD test. After the initial meeting, Sara will either schedule a patient’s follow-up appointment or place a referral to have a scheduling coordinator contact the patient to help them arrange their follow-up appointment in the clinic with Erin. This appointment is usually around their 6-week surgical follow-up. We try very hard to arrange this on the same day as the appointment with their surgeon to avoid making the patient come in on multiple days. During their clinic appointment, Erin will review the results of the BMD testing, review calcium and vitamin D recommendations, and then discuss pharmacologic treatment options with the patient. Sara and Erin utilize a Sharepoint website as a communication tool to pass along pertinent patient information. By talking with patients while in the hospital and then again in the clinic, Sara and Erin have found that patients are able to retain more information about how they can improve their bone health.

How do you hope to grow your program in the future?

Although our program has seen such great success in the few short months since we’ve enrolled, we are already looking for ways we can continue to grow our program. While Own the Bone is currently housed in the academic medical center, Froedtert Hospital is part of a regional health network that includes community hospitals and clinics. Our team has been tracking where our patients are coming from to create a “heat map” of the community so that we can later provide a recommendation on where Own the Bone should be expanded to within the community.

What advice do you have for other sites?

The key is interdisciplinary support. In growing our program we had a lot of assistance from other departments, including Endocrinology. We routinely refer patients with complex needs to Endocrinology for their expert care. We also have a good relationship with Interventional Radiology and Neurosurgery (Spine Care); they will send referrals to our program if they notice a patient has not had a workup for their osteoporosis. Another important line of communication is with the patient’s primary care provider. We speak with them very frequently to make sure they are comfortable with our plan of care, and in return they have been a great help in reinforcing the continued need for osteoporosis care with the patient. Our various key stakeholders also didn’t stop being involved once the program came to fruition – they are still very much engaged with Own the Bone through monthly meetings in which the full team reviews program metrics, compliance with Own the Bone measures, and thoughts on how we can continue to grow the program.

Published April 2018

NYU Winthrop Hospital, located in Mineola, NY, has an Own the Bone program led by a clinical team of four who treat fracture patients over the age of 55 in an in-patient setting.

The Fragility Fracture Service Program at NYU Winthrop Hospital was established in 2013 to meet the comprehensive and unique care needs of community-dwelling adults that have sustained a ground level fracture. It is the first program of its kind on Long Island. The program is led by four clinical team members: Dr. James Capozzi, MD, FAAOS, Chairman, Sam Barzideh, MD, FAAOS, Director, Dina Chenouda, MD, FAAFP, Co-Director and Luz Gargiullo, APRN-BC, Coordinator who are all board-certified in their area of expertise.

The mission of the Fragility Fracture Liaison Service Program is to provide a compassionate, seamless, evidence-based, multi-disciplinary approach to the care and treatment of the adult at risk for a fragility fracture. The vision of the Fragility Fracture Liaison Service Program at NYU Winthrop is to be the healthcare leader in the management of osteoporosis and in the prevention of fragility fractures. Own the Bone serves as a starting point within the Fragility Fracture Liaison Service Program as the enrollment form guides what happens next in a patient’s care plan.

Currently the program serves an average of 300 hip and other inpatient fracture patients yearly. Patients admitted to the Fragility Fracture Service are co-managed by hospitalist and orthopaedic attendings. Co-management and a multi-disciplinary approach to care has reduced our length of stay from 9 to 5 days, reduced readmission rates and decreased the ED to OR time from 52 hours to 23 hours. Multidisciplinary rounds are held every morning to discuss the plan of care on all patients. The team also consults with other departments, for example, endocrinology and palliative care as indicated.

As the coordinator of the Fragility Fracture Liaison Service Program, Luz serves as the liaison between the inpatient clinical staff and the community physicians. Enrolled patients must be over the age of 55 and sustained a ground level fall resulting in a fracture. Patient and caregiver education regarding treatment of osteoporosis, fall prevention and home safety, nutrition counseling and diagnostic testing begins during the hospital stay and continues after discharge in the osteoporosis clinic. During the education and counseling phase of the program, patients are introduced to Own the Bone education materials, such as the “Take Steps to Better Bone Health” brochure, and additional resources through the NIH and NIA. These materials have also been introduced to clinician colleagues of the team, so other healthcare providers are familiar with the information. Luz uses an inter-system communication method with secure text and emails to communicate patient information and next steps to the patient’s primary care provider. In building a relationship with primary care providers (PCPs) the team has found that PCPs are often taking care of other patient concerns, but the team is able to provide co-management and support of patient care related to osteoporosis.

In an effort to raise awareness of osteoporosis as a major public health issue, Luz has participated in several community outreach programs sponsored by the Wellness Center at NYU Winthrop Hospital. Earlier this year, Luz presented a lecture on geriatric fall assessment to the clinical staff at NYU Winthrop Hospital and other health care institutions.

NYU Winthrop Hospital is a 591-bed, Level 1 trauma center located in Mineola NY. Founded in 1896 as Nassau Hospital, it was the first voluntary hospital on Long Island, NY. In the 1980’s, the hospital was renamed Winthrop University Hospital and became the teaching hospital for Stonybrook University School of Medicine. In April 2017, the hospital became affiliated with NYU Langone Medical Center and was once again renamed NYU Winthrop Hospital.

Published October 2017

Based in Louisville, KY, Norton Women’s & Children’s Hospital’s Own the Bone program is co-championed by two RN’s who treat fracture patients over the age of 50 in an in-patient setting.

Kim Kisegy, APRN, ONP-C Cynthia Preston, RN, Nurse Liaison
Norton Orthopedic Services Norton Women’s & Children’s Hospital
Can you tell us a little bit about Norton?

Norton Women’s & Children’s Hospital is the champion facility for the Own the Bone program within Norton Healthcare. This facility is a 373-bed acute care hospital with 2,100 employees providing care through the more than 139,600 patient encounters annually. The hospital is part of the Norton Healthcare system. The system overall has more than 2.6 million patient encounters in both adult and pediatric care annually. The physicians and advanced level providers through Norton Orthopedic Services support the initiative and are a leading force in the expansion of the program for both inpatient and outpatient encounters.

How did you get started with your Own the Bone Program?

Charlotte Ipsan, chief administrative officer at Norton Women’s & Children’s Hospital, is very passionate about improving the overall health and well-being of our patients. It is her vision to expand the orthopedic service line to include bone health education. In 2013, a multidisciplinary team composed of a project manager, a member of senior leadership, an orthopedic surgeon, and a nurse liaison, gathered to decide the direction of our program, particularly focused on improving fracture care through a fracture fragility program in our in-patient setting. This led us through a web search where we found the Own the Bone website. Own the Bone seemed to be the perfect fit for our goals. The program allows us to have access to patient education and speakers, while also providing us with a web registry to monitor our process as we collected data.

What does your current Own the Bone Program look like?

The goal of the program is to capture any fracture over the age of 50 in the in-patient setting.

Currently, our program is managed by our bone health champions, Kim Kisegy APRN, ONP-C, and Cynthia Preston, RN, nurse liaison. Our order set calls for either Kim or Cynthia to be consulted through our hospitalist group to see all patients with fractures over the age of 50; or Kim or Cynthia obtain referrals from orthopedic surgeons. While consulting with patients in the hospital, our nurse liaison provides patients education on bone health including the importance of:

  • Taking calcium and vitamin D supplements
  • Smoking cessation
  • Reducing alcohol consumption
  • Falls prevention
  • Follow up bone mineral density testing

Simultaneously our nurse practitioner will order the necessary lab work and make the out-patient referrals as appropriate to the patient’s primary care provider. If the patient does not have a primary care provider, our team will assist them in securing a provider and then work with our network of dedicated specialty providers such as non-surgical orthopedics, endocrinology or rheumatology to schedule the appropriate follow up appointments.

Research shows that successful recovery and a reduction in additional fractures is dependent on patients following up on their care with their primary providers. To support this effort, once a patient is discharged from the hospital, our nurse liaison calls the patient at 30 days and again between 60 to 90 days. The nurse liaison will ask the patient if they are taking medication if appropriate, checking to see if they had a DEXA scan or if they have followed up with a provider for their bone health.

How do you hope to grow your program in the future?

Norton Women’s & Children’s Hospital is part of the Norton Healthcare system. Overall there are four adult acute care facilities and it is our goal to expand our program into the remaining three adult hospitals. Future considerations for our program will include:

  • Broadening our program to emergency and outpatient services to capture the non-surgical upper extremity fractures and compression fractures.
  • Continuing our efforts to provide community education by providing community lectures as well as increasing our referral base for patients being seen in our non-surgical orthopedic offices for osteoporosis screening.
Any takeaways or advice for other sites?

As with starting any program, you have to have support. Our team was very fortunate to have support across all areas of the hospital from senior leadership and the medical staff.

Published July 2017

Jefferson Hospital, located in Jefferson Hills, PA and part of the Allegheny Health Network, implemented their Own the Bone program in early 2012 and was the first post-fracture care program in the area.

Jefferson Hospital is a 373 bed, community-based regional hospital facility dedicated to serving more than 280,000 residents in Western Pennsylvania. Their Own the Bone program, implemented in early 2012, was the first post-fracture care program in the area. The program is championed by orthopedic physician David Stapor, MD and run by Lynette Judy RN, who coordinates the in-patient education and post-fracture care and follow up. The initial program focused on in-patient fragility fractures and has since developed into a comprehensive program involving numerous specialties and departments in the care of fragility fracture patients.

According to Lynette Judy, Jefferson Hospital’s Own the Bone Program and Osteoporosis Coordinator, Own the Bone was implemented due to their continued involvement with fragility fracture patients; caring for their first fracture but also subsequent fractures. One of the main draws of the Own the Bone program was the education to physicians, nurses, patients, and families; education Jefferson Hospital’s team desperately needed but didn’t know how to provide. Lynette found the resources Own the Bone provided both easy to use and something that could be built upon as they grew their program.

“We followed the implementation guide provided by the Own the Bone program. From this guide we were able to start small and over the years we were able to grow the program into what we wanted it to be; and it continues to grow.”

There are several ways fragility fracture patients are identified for the Own the Bone program. Daily nursing assessments include a “Muscular/Skeletal” evaluation and a check box is available to indicate if the patient is over the age of 50, and has a fracture. If this box is checked the patient’s name and medical recorded are automatically sent through Jefferson Hospital’s EMR to Lynette’s computer, where it populates on a screen specifically for Own the Bone patients. Alternatively, a physician can order the consult; which will also send the patient’s information to Lynette’s computer. Finally, to catch any “lost” patients, Lynette will review the previous day’s operating room list and identify patients based on the orthopaedic surgeries. She will then use the census of the patients on the orthopedic unit to identify patient name, room number, and admitting diagnosis. Using these methods Lynette rarely misses eligible patients. As the program incorporates outpatient fragility fractures, Lynette will also receive a print copy of the patients that were seen in the emergency room and sent home with fractures.

In the infancy of the program, patients and families were educated on seven best practices; Calcium, Vitamin D, regular weight baring exercise, fall prevention, smoking cessation, limiting alcohol consumption, and DXA testing. They started with the basics, providing counseling to the patient, along with educational pamphlets detailing the best practices they discussed, and the osteoporosis nurse’s contact information if they had additional questions. At the time of discharge, letters were sent to the patient detailing the discussion that took place and reiterating the seven best practices. A letter was also mailed to the patient’s primary care physician describing the current fragility fracture, previous fracture, risk factors, medications that pose a risk for weak bone, any treatments initiated, DXA testing request, education that was provided to their patient, and any issues that may pose problems with osteoporosis medications.

Over the course of several years many changes have taken place within Jefferson Regional’s program. One improvement has been an increase in Physician involvement. Lynette credits the improvement to her effort of making the program easy for the physicians. Her messaging is “what can she do for them.” This has led to her role as a program consultant to the physicians.

Another growth of Jefferson Hospital’s program has been the edition of outpatient education. The physician, often the PCP, will call Lynette with the patient’s name and contact information; she will then call the patient to set up an appointment. Although, as an RN, Lynette cannot bill for her services, she can document that the patient was counselled. She has found that patients appreciate that this service is complimentary and that there is no co-pay for their visit with Lynette. Once counseled on their bone health, Lynette and the patient devise an easy-to-follow plan to help the patient meet their goals. Following patient discharge a nursing note is added to their online medical record and then faxed, along with the plan, to the referring physician.

A fracture board has also been instituted to help in-patients receive immediate care and oversee several complimentary initiatives including improving time from fracture diagnosis to surgery and decreasing the incidence of hospital acquired bed sores. The concept of a fracture board is fairly new to the AHN network and is currently only in place at Jefferson Hospital. The departments that make up their fracture board are emergency room staff, radiology, laboratory, bed placement, operating room staff, and the orthopedic care department.

Community outreach has become a core piece of the program. In part, due to Jefferson Hospital’s role as a community advocator which includes a community outreach program that identifies educational needs within the community. Lynette can be contacted by the Community Outreach Liaison to attend community events. Additionally, Lynette has facilitated her own community involvement throughout Jefferson Hills. Using a PowerPoint presentation created for the public Lynette has presented at local Libraries as part of their community outreach programs.

Lynette notes that the success of Jefferson Hospital’s Own the Bone program and fragility fracture care is largely due to the team surrounding her, including the immense support for program advancement she receives from the executive team including the Director of Orthopedics and Jefferson Hospital’s CEO. She also praises the program’s physician Champion, Dr. David Stapor, as “always looking for ways to make the fracture patient a priority. Dr. Stapor is probably the most committed physician I have ever met; he is always encouraging me throughout this whole process.”

As with any program, Lynette shares that there is still room for growth. One area that Jefferson Regional’s team is still looking to improve is the use of pharmacological osteoporosis treatment. So far, treatment has climbed from 3.9% to 16.6% since Own the was implemented. Lynette is also looking to collect data to demonstrate a correlation between time of admittance to surgery and fewer complications with a shorter stay overall. As far as expansion of their outpatient fracture population Lynette soon hopes to be able to contact the patients that were seen in the emergency department for a fracture, but discharged instead of being admitted.

Lynette explains their journey with fracture prevention and the Own the Bone program as climbing a ladder “you must start to climb the ladder to get to the top and to reach the top you must take steps to achieve the goal.”

Published April 2017