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Practical first steps towards development and implementation of an orthopaedic-geriatric co-care model are suggested below.

Identify ‘Service Champion’

Who will lead the process of development of an orthopaedic-geriatric co-care service? It is likely that one or two individuals will take this leadership role.

Review established models

The Best practice case studiesLiterature reviews and Global literature registrysections of this website provide details and links to publications from well-established high performing orthopaedic-geriatric co-care services. Relevant national clinical guidelines on the care of hip fracture patients should also be considered. Newly designated ‘Service Champions’ are strongly recommended to review the experience from these services to inform their own thinking.

Form a multi-disciplinary stakeholder group

A feature common to practically all published descriptions of effective service models is the involvement of a multi-disciplinary team. Accordingly, from the outset of service development, the Champion(s) needs to convene a group comprised of representatives from all the professional groups that have a role to play in the optimal care of fragility fracture patients. This is likely to include:

  • Orthopaedics, geriatrics, internal medicine, anaesthetics, radiology, haematology
  • Lead Clinicians for osteoporosis, falls and dementia
  • Specialist nursing (particularly orthopaedics and geriatrics)
  • Allied health professionals: physiotherapists, occupational therapists, dieticians, nutritionists, discharge planners
  • Institution management, business planning and finance
  • Quality improvement professionals

Identify current standards of care

Is audit data available on current standards of care for fragility fracture patients within your organisation? With respect to hip fracture patients, knowledge of the following information would be desirable:

  • How many hip fracture patients are managed by the hospital/health system annually?
  • What proportion of hip fracture patients are aged 60 years and over?
  • What is the speciality of the doctor with overall responsibility for the admission of hip fracture patients to the hospital/health system?
  • What is the average (mean or median) time to surgery for hip fracture patients?
  • How is medical care provided to hip fracture patients? Specifically:
    – What proportion of patients undergo a pre- and/or post-operative assessment of their medical
    needs by a physician (i.e. as distinct from a surgeon)?
  • What proportion of patients receive the following assessments before their final discharge from the hospital/health system:
    – Fracture risk, including osteoporosis?
    – Falls risk?
    – Cognitive function?
  • What is the length of stay for hip fracture patients (ideally, broken down into acute stay and subsequent stay in a rehabilitation ward or facility)?
  • What proportion of hip fracture patients return to their pre-fracture place of residence?
  • What proportion of hip fracture patients die during their acute stay?
  • What proportion of hip fracture patients are readmitted to hospital within 30 days

Redesign current care

The Service Champion(s) will lead the multidisciplinary stakeholder group through an analysis of current standards of care provided by the hospital/health system, making comparisons with outcomes for high performing orthopaedic-geriatric co-care models identified in the literature review suggested above and/or relevant national clinical guidelines for hip fracture care. LEAN methodology been used to facilitate redesign of several aspects of the care of fragility fracture patients, as has Plan-Do-Study-Act rapid cycle improvement processes. See:

Lean thinking: can it improve the outcome of fracture neck of femur patients in a district general hospital? Injury. 2011 Nov;42(11):1234-1237. PubMed ID 21227417

Redesigning the care of fragility fracture patients to improve osteoporosis management: a health care improvement project. Arthritis Rheum. 2005 Apr 15;53(2):198-204. PubMed ID 15818644

Long-term care

The Service Champion(s) should consider how outcomes can be optimised in the long-term. Local health system infrastructure will determine how long-term care is delivered. As an illustration, establishing protocols to optimise management of osteoporosis in the long-term will reduce the risk of subsequent fractures.

Useful resources

A suite of useful resources for those involved in developing orthopaedic-geriatric co-care services are available from the following websites:

  • U.K. National Hip Fracture Registry – www.nhfd.co.uk
  • Australian and New Zealand Hip Fracture Registry website – www.anzhfr.org
  • New South Wales Agency for Clinical Innovation Orthogeriatric Model of Care – Link

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