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Becker’s Healthcare Podcast
Back in Action: Managing the Inpatient to Outpatient Transition in Post-Fracture
00:15:30
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- [00:00]
A
Welcome to the Becker's Healthcare Podcast. Today's episode explores best practices in managing postmenopausal osteoporosis patients as they transition from the inpatient to outpatient setting in post fracture osteoporosis care. This episode is sponsored by M Gen as part of a podcast series on post fracture care. And with that, I'll turn the floor over to your host, Amgen's Kristin Buzeman.
- [00:26]
B
Hello, everyone. I'm Kristen Buzeman. I lead our health system strategy marketing team for Amgen for our Bone Health franchise. And what that really means is that my team and I get the chance to talk with health system leaders all over the country about population health and care gaps for osteoporosis patients and ways that we can work together to find solutions to fix them. I'm so excited to be here today. We've got two really great guests. I'm going to turn it over first to Dr. Aloya Kramer from St. Elizabeth Healthcare. Can you give us a little bit of background on yourself?
- [00:55]
C
Yes. Hi, I'm Aloya Kramer and I'm a sports medicine physician at St. Elizabeth, which is in Northern Kentucky.
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B
Excellent. And then I'm also here with Jackie Kernahan from Mainline Health. Jackie.
- [01:06]
D
Jackie Kernahan, happy to be here. PA outside of Philadelphia, practicing osteoporosis exclusively for the last 13 years. Previously with Crozier Health, now with Mainline Health Osteoporosis Center.
- [01:17]
B
Excellent. Thanks so much, guys for joining us. You guys have both done a lot of really tremendous work with your respective health systems. And we're really excited today to share with our listeners some of the things that you've been working on, especially thinking about care transitions for these patients and how we can manage those transitions from the inpatient to the outpatient setting. So firstly, I want to kind of get back to the roots.
- [01:37]
C
Right.
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B
So, Dr. Kramer, could you provide a little bit of context around how you established your Bone Health center, what kind of those driving needs were and how you address them?
- [01:45]
C
Yes. So the start of our Bone Health initiative is relatively recent. We got off the ground in late 2024, and it stemmed from a need that was identified of these osteoporosis patients needing to get into a specialist in a timely manner. So in conversations with primary care providers, we were finding that patients are waiting 3, 6 plus months to get into a specialist to treat their osteoporosis. So my concept behind starting this was, well, let's just treat these patients like we treat our athletes. And in sports medicine, kind of the Cornerstone of our specialty is accessibility. Athletes want to get in quickly after an injury to get evaluated, treated, and back on the field. And I think that our osteoporosis patients, especially those who are very high risk of fracture at imminent fracture risk, should be treated the same way. So we've really just folded them into our sports medicine clinic to get them in in a timely manner and also to give them a dedicated time where they have an entire appointment just to talk about their osteoporosis. We found in primary care, it can be difficult when they're going through screenings that are due, immunizations that are due, other chronic conditions to also tack on a comprehensive management of their osteoporosis. So we create an entire visit where we talk about that, and we can address the nutrition, exercise, vitamins, lifestyle changes, fall risk, and pharmacotherapy if it's indicated.
- [03:08]
B
Excellent. That's really great to hear, especially that focus on osteoporosis and really prioritizing care of this chronic condition. So, Jackie, I know that you also have spent, like you said, your. Your entire career focusing on osteoporosis. Can you tell us a little bit about the work that you did at Crozier Health to build that osteoporosis care program?
- [03:28]
D
Of course, at Crozier Health, my partner, who's a RET gynecologist, realized there wasn't much osteoporosis care being given to patients in our very, very populated county. So he started doing it once a week starting in 2005. It was a dedicated day for osteoporosis in his GYN clinic, mainly his own GYN patients initially. And then over time, the health administration and the hospital administration and physician leadership realized that what we were doing was so impactful that he wanted to expand it. So we started a fracture liaison service, which we actually called the Fracture Intervention Service. We weren't liaising them out to other providers. We were intervening to actually see them and to establish care with them. So that started in 2013. We started seeing patients in the hospital at the bedside, and then they would transition to our outpatient practice, which we expanded to four offices initially. Then we went out to seven offices, and then with COVID we actually restricted contracted back to three office locations. So that was both inpatient and outpatient osteoporosis care. As our FIS service expanded, we started giving referrals from not just the hospitalists and the orthopods, but rheumatology, endocrinology, physiatry, sports medicine, internists, gi, pulmonology everybody was referring to us in the inpatient setting for consultations for these patients as well. So then we would see them in the outpatient world and we would treat them. And I still see patients at my new practice, from my old practice that are still with us. And having met me at the bedside, and I can visualize where I met many of these patients. Like, I can see the exact same exam room where we met initially. Oh, wow. And it's been amazing to treat these patients exclusively. Treat these patients. My prior world was primary care for a number of years, and I love that. But I love being the expert on this, of this disease entirely and being able to answer these patients questions from the bare minimum basic information all the way to the mechanism of action of all of our drug options.
- [05:17]
B
That's fantastic. I think this is the first time I've heard fracture intervention service. So I love that. And it's a great reminder to us that we need to really intervene to help these patients, which they are so lucky to have had both of you along their journey. So speaking of their journey, I think I've heard from both of you kind of the inpatient to outpatient. How do we handle that? Jackie, I'm going to ask you to kind of follow up on some of what you were just sharing. How have you kind of helped manage that inpatient to outpatient care transition? And you mentioned a lot of the providers along the way that you're probably interacting with, kind of what role do they play?
- [05:50]
D
Yes. So once we get the consultation for the patients, and this is at my previous institution, we're still working on establishing at our new institution, but at our previous one, we would get the consult for the patient. We would see them at the bedside. Usually I would see them first in between patients at lunchtime, before hours, after hours. We just sort of made it work. And then my partner as the MD would see them and follow up in our information. We would give them a card. We also had a brochure with our pictures on it that had general information about osteoporosis and our practice. I could still. I could still visualize patients bringing that brochure with them and say, oh, this is the one I saw right here. Her pictures here, this. It helped them connect the dots from the very beginning. They would go home to their primary care provider. Oh, yes, we do want you to see Jackie and Dr. Jacobson in follow up. We would send them letters about two or three weeks after their discharge. But by then, most patients had already called for a follow up appointment some patients. We had already established their treatment plan in the hospital setting, so I would start the prior authorization process immediately so they could start therapy once they were discharged. Some patients would actually be put on some of their pharmaceutical drugs were started in the inpatient setting, but again approved through the outpatient setting and brought with them. Our goal was to get patients on therapy within six weeks. And some days that worked, and some days it would take a little longer. I still have a spreadsheet of every single patient we've seen since 2013. Wow. That I could easily pull them all up and see who I saw and who was treated. And when they were discharged, did they end up going to Sports Med for care or primary care? Again, we don't care where they went as long as they were getting treated.
- [07:15]
C
Sure.
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D
So it was a pretty inclusive process.
- [07:19]
B
Very ambitious. Dr. Kramer, I know you also have some partners that you've worked with, including the Fragility Fracture Clinic at Premier Orthopedics to help manage that care transition. Can you kind of describe how that works with your patients?
- [07:32]
C
Yes. So Premier Orthopedics is where I was prior to St. Elizabeth and we started, we called it there, the Fragility Fracture Clinic. And that was tied with inpatient side of things, which is my goal at St. Elizabeth is to bring the inpatient side coordinated with the outpatient care. But at Premier, the way that we did it was we had an APRN who would round on patients who were admitted with fragility fractures. So they come into the ED and at the time we were capturing hip, pelvis, proximal humerus and vertebral fractures. And the ortho team who was operating or managing the patient while they were there, had a resident who would enter an order set for our fragility fracture team to round. So the APRN would round and she did it in two batches on Mondays and Thursdays, which was able to capture everybody for their length of stay. And she would educate patients on osteoporosis, let them know that they have osteoporosis based on their fragility fracture alone, go over lab results, schedule them a DEXA for after discharge, and also schedule them while they were there in the hospital for them to have their follow up appointment outpatient after discharge. And then I would round on them on Mondays and Thursdays after my sports medicine clinic. So I batched that into those two evenings just to follow up, make sure that all their questions were answered. We did a split shared billing model there and then the patients would come for Their outpatient appointment goal was within 60 days of discharge. We, we wanted to allow enough of a buffer for patients who had to go to rehab facilities after a lot of times. Most times after hip fracture, patients are in a rehab facility for a time. So to give them time to get through with that and back home and then come to their outpatient appointment, that was our goal, was 60 days. I have one little tip for the inpatient outpatient coordination piece is to name it something. So when I was at Premier, I was with the orthopedic team, and if patients saw that they had an orthopedic follow up, they assumed they were coming in for fracture care for their fracture or for their pain. So we named it Fragility Fracture clinic. And at St. Elizabeth, if they see that they're referred to sports medicine. There's a lot of confusion there. Like, I'm not an athlete, why am I going there? Sure. So we named it Bone Health Clinic, and that has helped a lot.
- [09:48]
B
Yeah, that's really well thought out. And I love that tip, too. And I think both of you have come up with really great names to kind of describe some of the work work, both for your patients and I think also for your providers that you work with. So thinking about this idea of making sure we maintain care continuity for these patients that maybe initially start in the inpatient setting and then have to continue their care through the outpatient setting, how important do you think that is to overall successful treatment and maintenance of these patients? And can you just give a little bit of perspective on. On, like, why that should be a focus for our listeners as they think about building out their. Whatever they may call it, Bone Health Clinic, Fragility Fracture Clinic, Fracture Intervention Service, et cetera. Jackie, I'll start with you.
- [10:29]
D
I think that continuity of care where they saw us in the hospital, they're going to see us in the outpatient setting, we're going to follow them in the outpatient setting is really effective. I think it's harder for orthopedic clinics where they refer to rheumatology to be seen afterward. And then there are a whole new set of providers where they were previously kind of established. All my patients know about my children, they know about my pets. We have that relationship that we get. And again, I think a basis comes from being a primary care provider initially is that these patients are going to become mine forever, as long as I possibly can see them. And I think that the patients like that continuity because things are so, you know, the cardiologist takes care of just the heart and their pulmonologist takes care of their lungs. But to have that kind of continuity over time and caring about all of them and just making sure that they understand that this is a chronic disease. This is something. There was a reason that they broke their hip when they fell. And I still feel like a lot of patients still think, oh, it was a hard fall, it was cement. It would have happened to anyone. And trying to explain just the disease process to them, helping them get more involved in their care. Also in the hospital setting, seeing the patients with their family members makes a big difference because when they're in pain, they're not hearing all of it, but their family, their siblings, their spouse, their partners are there with them. They're also hearing the information, and they're going to process it a little bit better. So I feel like that was really impactful for our clinic to really get the patients to follow up and not just assume that, you know, the orthopedist that was like, like Dr. Kramer said that the ortho or sports medicine them now. But the Fragility Fracture clinic is really where they're going to have that continuity of care moving forward. I think it just really helped to see them from all angles in that way. That's great.
- [12:01]
B
That's great. And then they earn a spot on your spreadsheet for life. They do.
- [12:04]
D
And then also, like another part of it that the hospital found really beneficial was helping to reduce our readmission rates for additional fractures. There are patients I can tell stories about where they fractured again before we could even see them in the outpatient clinic and where we saw them again at the hospital bedside and really continue to emphasize the need for treatment and. But reducing those readmission rates, especially recurrent fractures, or even just the secondary prevention of further fractures, where they're going to cost more money to the health system. I know that we had hit our goal of reducing the hip fracture rate as well as reducing all overall fracture rate over time, but then also trying to get those patients so that they're helping get back to their primary. So they're meeting their goals in the primary care setting, as well as maybe GYN or rheumatology or whatever other quality metrics are picked by outpatient practices as well.
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B
Excellent.
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D
Very good.
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B
Thank you so much, Jackie. And Dr. Kramer, I'm curious, kind of on your thoughts on maintaining continuity of care. I know you've got perspective from multiple organizations as well, seeing this play out.
- [13:01]
C
I agree. I think it's paramount because the risk of subsequent fracture is so high so that continuity ensures that these patients don't fall through the cracks. It's also important from a system financial standpoint because the overhead cost of something like this is really so low. You just need really one champion provider to decide that they want to incorporate fragility, fracture care or osteoporosis care into their practice. For me, it was helpful that I was a new provider at both of the organizations so I had room on my panel to grow. But if we outgrow what I can deliver, then our backup plan is to hire another PA or an NP to help out with the clinic. So starting with one champion provider and then other than that, for overhead cost we spent a couple hundred dollars in marketing materials and then we used our EPIC support team to create some tools for the referrals and order sets. So really low over cost and it can have a really high financial reward for the system in cost savings from that post fracture morbidity and inpatient admissions for other medical issues after the fracture.
- [14:09]
B
Excellent. Well, thank you both so much for sharing your insights here today. I know that this is going to be extremely helpful for our listeners as they think through both the why why should they care about this patient population and improving the care transitions and care continuity for them, but also the how right how they might do it. So your input and your advice here is really very useful and we invite everyone that's interested in learning more about taking care of the fracture care gap to go to our website fracturecaregap.com to access resources, insights and tools might be helpful within their own health system as they look to establish better population health for the osteoporosis patient population. So thanks to Beckers for letting us host another podcast and stay tuned for more from Angen.
- [14:53]
A
Thank you Kristen, Dr. Kramer and Ms. Kernahan for this insightful conversation on navigating the inpatient to outpatient transition for post fracture osteoporosis patients. We also want to thank our podcast sponsor, M Gentlemen. This episode is part of our four part series sponsored by Amgen on post fracture Osteoporosis Care. You can tune into more podcasts from Becker's Healthcare on post Fracture Care and other topics by visiting the podcast page@www.beckerspodcast.com. participants were compensated for their time by M Gentlemen.