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Becker’s Healthcare Podcast
Closing the Gap: Advancing Osteoporosis Care Across Practice Settings
00:21:52
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- [00:00]
A
Hi everyone, this is Lucas Voss with Becker's Healthcare. Thanks so much for tuning in to the Beckers Healthcare podcast series. It's great to have you. Today's episode explores how to optimize post fracture care across practice settings. And this episode is sponsored by Amgen as part of a podcast series on post fracture care. And with that, I'll turn the floor over to M. Gent's Kristen Buzeman, Director of IDN Strategy and Marketing.
- [00:27]
B
Hello everyone. It's a pleasure to be back here again on the Beckers podcast. My name is Kristen Buessman and I lead our health systems and key accounts marketing team for our bone franchise at Amgen. And what that really means is we work with health system leaders to understand where there are care gaps in managing the osteoporosis patient population that we can all work together to solve for. So I'm really excited today to be speaking with two folks that can share their perspective, particularly as it relates to the orthopedic practice setting. And today our guests are going to be Christina Yazdani from the University of Texas Physicians orthopedics group and Dr. Greg Mines from Florida Orthopedic Institute. So I'm going to turn it over to you guys. Christina, why don't you introduce yourself first?
- [01:09]
C
Hi Kristen. Yeah, I'm excited to be here. My name is Christina Yazdani. I'm a physician assistant and certified clinical densitometrist in orthopedic surgery. I'm part of the UT Physicians Group with University of Texas Health Science system in Houston, Texas. Texas.
- [01:26]
B
Wonderful. Thanks for joining us, Christina and Dr. Mines, how about you tell us a little bit about yourself.
- [01:31]
D
Hello Kristen and all the people listening. My name is Dr. Gregory Mines and I'm a medical physician from St. Petersburg, Florida, practicing with Florida Orthopedic Institute and I host the Post Fracture and Bone Health Clinic there, as well as non operative sports medicine.
- [01:45]
B
Wonderful. So thanks again for both of you for joining us. We're really excited about this conversation about how we can optimize post fracture care across the the practice settings. And I know that you both have really interesting, similar, yet different perspectives to share on how that can happen, especially in the orthopedic setting. So to start us off, Christina, could you share a little bit about what prompted the establishment of your bone health clinic at UT Physicians? Help us understand kind of how you were able to place post fracture care as a system priority.
- [02:17]
C
So our group, UT Physicians, is affiliated with a larger hospital system, Memorial Herman in the Houston area, and Memorial Herman is actually one of two Level 1 trauma hospitals in the Texas Medical center. And the Texas Medical center happens to be the largest medical center in the world. So as you might imagine, we see a very high number of trauma and that includes the fragility fractures and especially those hip fragility fractures. And so what our orthopedic trauma team was noticing was really the lack of follow up that these hip fractures and these fragility fracture patients in general were getting once they left the hospital. And that could be under treatment by their primary care providers or just really long wait times to get into specialists such as geriatricians or endocrinologists. And so with, with that poor follow up care, we just saw a bunch of repeat customers, lots of people that would have a hip fracture and then six months or a year later they're back for, you know, the other side. And so we just decided to kind of tackle it head on. And if we were the ones seeing the fractures, that we could form our own clinic to try to address that care gap. And that's how we formed our UT Bone Health clinic.
- [03:41]
B
Excellent. Thanks very much for sharing that, Greg. I'm going to turn it over to you. It would be great to get a little bit of context around the PFC or post fracture care program at your institution with which I know has a little bit of a different angle, especially incorporating the non operative sports medicine component.
- [03:59]
D
Yes, thanks, Kristen. So I think it's similar to Christina, but you know, slightly tangential at the same time that we too had a similar kind of recognition there. So I work for all Ford Orthopedics. Ford Orthopaedics, it's the new Ford Orthopedic Institute, St. Petersburg. And with that we're one of the larger practices in Florida and across the country in terms of private practices that are associated with a lot of hospital systems. And so with that we regularly handle the orthopedic care and the trauma call coverage for the local level one and level two trauma centers. Given Florida demographics with retirees and snowbirds, we saw a significant increase in fragility fractures and fractures as a whole due to the high risk populations that located in this area. Like Christina said, unfortunately we noticed repeat customers. We saw this cycle of fracture with great healing followed by an additional fracture. And so we unfortunately got used to these customers and saw that they did not have follow up of what was going on with their body, became clear that there was a deeper issue at play here in terms of systemic disease beyond the fracture initially. And so the bigger problem was osteoporosis and once we put a name and title on that, we began having patients not fall through the cracks. So originally where they were returning to the general public and seeing their primary care physicians, their OB GYNs, the rheumatologists and endocrinologists, no one really truly take control of the underlying osteoporosis. And it was each of their kind of physicians to handle, but neither or none of them really had a central indication for their practice. And so these patients were falling through the gaps until we generated this post fracture clinic. And that is why we did this, to have a home for these patients to turn to after their fracture.
- [05:38]
B
That's great. Thanks so much for sharing. Yeah. And so what I'm hearing from both of you is that in your respective organizations, you really notice that these patients were falling through the cracks. And we hear that time and time again. So kudos to both of you for your roles in helping to establish these post fracture care programs and clinics. And I know that you've both been very successful in getting these clinics up and running as well. So I'd love to hear a little bit about that journey from that initial insight that led to kind of starting your program to how you're growing and scaling today. So Christina, I'll start with you if you could just share a little bit more about how your program has grown.
- [06:15]
C
I can't take all the credit for the initial drive for it. Our program really started back in 2015. Two of our EPPs and orthopedic trauma took this on and started with a half day clinic once a week just addressing the low hanging fruit, the hip fragility fractures. It was only coming from our main medical center campus. It quickly grew and it was headed up by an orthopedic trauma surgeon who was a little bit older and not operating as much, but he had some experience at a prior position with a fracture liaison service. And so with his guidance, their half day clinic quickly grew and they all realized that they really needed a full time person to really own it and take it on and expand it. So I was doing some joint replacement with one of our within our department and I got the opportunity to take that full time position in 2017. So I have been doing full time bone Health since 2017 and really clearly developed a passion for it because I'm still here and talking to you guys today. But that half a day clinic quickly expanded and by about 2019 we had two full time apps and one dedicated medical assistant and we were seeing patients out of six different Clinic locations across Houston. So we were really full steam ahead, doing well. And of course Covid hit. So like probably most places, things scaled back a little bit and so we dropped a few locations and kind of had to hunker down for a few years. But I'm really happy to say that for the last two years we've been able to maintain two full time appointments, physicians in bone health, and we have another nurse practitioner who does one clinic a week or just bone health. And so we're across four different locations, but we've got seven full day clinics going per week and two half day telemedicine visits per week. So we've really been able to take our, our clinic from just one location and expand it to really reach a large patient base, not just from that one hospital, but to the more outlying community based based hospitals within the Memorial Herman system.
- [08:48]
B
That's excellent. Wow. What tremendous growth for sure. And to whether, you know, the growing pains, I'm sure, as well as Covid, as you mentioned, it sounds like you guys are on a great path and have a really great opportunity to serve a lot of patients. Greg, I'd be really curious to hear kind of how your clinic is going and how it has kind of grown over time as well.
- [09:12]
D
Yes, thank you very much. Well, just like surviving a fracture is a daunting test, starting a clinic, such as a bone fracture clinic or a post fracture clinic, is also quite daunting. And so, you know, we had to start with what we know and what we saw as the original problem, and that was the fracture patients that kept recurring within our own practice. And so we started as an internal post fracture clinic, initially seeing only our internal referrals. I work with 18 wonderful, wonderful colleagues. And so that's a large referral source coming from all the trauma centers and all the call that we take. And so starting off again, like Christina said, you know, hip fractures, the low hanging fruit, going from there to the wrist fractures, to the pelvis fractures, to the other fragility fractures, and moving along one by one as we grew that clinic enabled us to be successful. You don't want to take on too much too early because you don't want this to fail. Right? We want this to be successful. And so slowly kind of migrating this pathway as we prove the processes is key. So yes, after that, our reach broadened and we significantly started accepting patients from external referrals. These would be people that were post fracture from other orthopedic clinics. These were people from other practices, you know, coming from primary care Endocrinology, rheumatology, places that might have a long wait, and then of course, from the hospital systems themselves in the area. So, you know, generating emr, basically identification of patients that are high risk or fractures that may not be considered fragility fractures, but just, you know, could link together a bunch of fracture history for those patients. Those are how we identified additional patients that would be beneficial. Once we kind of shifted to the preventative side of things, and really that was the biggest shift that we had is we kind of went from this post fracture recovery to prevention on the side of people that didn't have fractures yet. And that's where we really want to hit this population and be aggressive. And so we are currently still seeing about six to 10 new patients a week that is growing actively, and we look to continue to grow this clinic in the right direction as we move through the future.
- [11:03]
B
Excellent. Wow. So two really great examples of really successful bone clinics treating osteoporosis patients. So again, congrats, guys. I know this is a lot of work, and despite all the successes that you've just shared, I am sure that you've both run into a bunch of challenges along the way. So I think it'd be really helpful for our listeners to hear some of those challenges and how maybe you address them. Christina, I can turn it over to you first.
- [11:28]
C
So one of our biggest struggles, being not connected in the same health system, with us being UT physicians and Memorial Herman being the hospital system, is bridging the gap between those two systems. Unfortunately, we're not even in the same emr, so what could just be a couple clicks and some. What seems like an easy referral just has never panned out that way. So when I first started in our bone health clinic, I was doing inpatient consults as well as the outpatient clinic. And so that was a little bit easier for the patients that I saw to then directly see me in clinic. But as I think most bone health programs grow, it became unsustainable to have both inpatient and outpatient services for one person. At the time. We did have kind of regular work groups between UT and Memorial Herman, providers, staff, some of the administrative partners, and they were focused on bone health. It became more about the metrics you see see around inpatient issues, such as length of hospital stay, time to the OR all cause readmissions. Instead of addressing directly how do we get these fracture patients to a bone health clinic so that they don't come back to see us again? And so that program kind of disbanded again. With COVID I am optimistic with one of our nurse practitioners that doing bone health. She also has an inpatient presence as well, and she is kind of regathering the troops with some of our interested hospitalist partners to refocus both the UT and the Memorial Herman sides on how can we really get that connection crossed between inpatient and outpatient? And we have a few more interests from our specialists like the endocrinologists and our geriatricians too. So I'm really hopeful that bringing everyone back together. We are now on a similar medical record system. Not the same, but similar. So I'm hoping that we can all put our heads together and maybe do a better job about bridging that gap now that we have more parties from different departments working together.
- [13:48]
B
Great. Yeah, it sounds like that's pretty complicated for a lot of reasons to coordinate that patient care across the continuum, especially with so many different parties in the involved in different sites of care. So sounds like you're well on your way. Dr. Mines, same question to you. What kind of challenges have you guys faced and how are you addressing them today?
- [14:09]
D
Yes, thank you. So I think we have a great referral source right now, but unfortunately we're still targeting and most of our patients are post fracture. And so we're really trying to address this and shift into that preventative care and really attack the patients that are very high risk pre fracture. With that being said, we're working on addressing the workflows, particularly our referral network beyond our practice, coming from the inpatient hospital systems, the outpatient hospital systems, and the other orthopedic and primary care and private specialties in the area. Additionally, on a personal level, we've had some staffing issues in our clinic. I originally had an app working very closely with me at some of the other office locations, seeing some of these patients with me. But since then she's moved on for personal reasons. And so really our hope is to hire another, either full time physician or another app that could take on the challenge as the response for this bone health clinic has been overwhelmingly great. But at the same time, it's taking over our practice in a way like we didn't imagine. And so with the amount of people out there that need the help and the care that we are providing, I do expect it to continue to snowball and grow, which is an excellent thing for both us and the patients. But at the same time, we need to find someone dedicated and who could be that champion alongside of me.
- [15:20]
B
Yep, that makes sense. Well, this is really helpful, guys. I think that you've both shown that you can make really great progress in terms of getting these clinics started and increasing the number of patients that you're able to see. So, again, congrats to you and your respective programs. I think that our listeners would really love to hear just advice that you have for somebody out there that would be considering taking a similar journey as you just described, from kind of the initial realization that this is a problem to getting a program up and started and growing that program through all the hurdles and barriers. Dr. Mines, I'll start with you. What advice would you have for our listeners that are looking to develop their passion and bone health just like you guys have?
- [16:05]
D
Well, I'd say the first thing is that make sure your team and yourself have the passion and dedication and the time to undergo something like this. So, you know, in my experience that like we mentioned earlier in this podcast, that, you know, there's a lot of different specialties that could take control of the situation. You have endocrinology, rheumatology, orthopedics, ob, gyn, family medicine, and the list goes on to even more that could all take control and provide the necessary care that's needed for low bone mineral density and osteoporosis. But at the same time, it requires them to push aside time specifically and dedicate time to go through that process. As we know, education is power, and by educating our patients, they take control of their health as well, which can lead to optimal goals for everybody. And so that requires education to the patient in order to get that done and ensure success. That requires time in the clinic set aside to discuss osteoporosis and when there's a lot of other diagnoses and problems to discuss that can be overlooked. And so with that, we need to curate a team that sets aside that time for the patient, creates that time for the patient, and also has the passion to fulfill the knowledge and impart that knowledge upon the patient and take ownership of that health condition. Lastly, the workflow. You know, it's very important to have a very solid workflow starting all the way from the front desk through your authorizations department, because this is a difficult field to manage in terms of you are working with medications that can be quite pricey but very useful. And so with that, you don't want to shoot yourself in the foot. We want to make sure that the patient has access to the care they need and we're documenting appropriately. So ensuring that the front desk is getting the right information. Your mas are obtaining the right information to Identify those high risk patients, ensuring that you're having the right conversation with the patient. And then on the back end, the authorizations department is doing what they need to do to be successful. It is key to have the proper positions in place, the proper people in place to really make this workflow and this clinic successful.
- [18:01]
B
Great, thanks for that, Christina. Any advice for our listeners on starting a post fracture bone clinic?
- [18:08]
C
Well, I completely agree with Dr. Mines. You do need to have a person and a team really that is passionate about making it happen. Because I always kind of compare it to starting your own business, which a lot of us come from, you know, medical schools where you've kind of got this big network going on and things just kind of kind of already seem to be in place. And so if you're trying to start off basically your own service line, but trying to start your own business, in a way you really are building it from the ground up. And you have to go out there and essentially market yourself. You're, you're marketing yourself to the other providers, to the other service line that's out there, to the nurse navigators, to the medical assistants. Kind of every person that might be part of this, you have to know that you're going to be putting, putting in significant, you know, non clinical, non billable face to face time with this stuff, especially in the front end of it, to kind of get those workflows up and going. And then I also think it's important that you circle back on those things too. For us, we've got new providers joining, people are shifting around to which clinics they're at and you kind of have to remind people that hey, we're still here. And guess what, we just opened a clinic at this location too. So it's always reintroducing yourself. And that's not something that when I was part of just general orthopedic surgery that I necessarily had to do, it was kind of already in place. So it's getting someone passionate that can help grow it. And I think those connections that you make between hospital outpatient, the other providers, that's really what's going to propel your fracture service, your fracture liaison service forward. I also think, at least in our area, that you have to make connections with infusion centers and you know, how are you going to actually get patients these treatments, like Dr. Mines was saying? Because I think we all wish it was as easy as they can start it tomorrow, but it takes a little bit more work than that and you have to kind of know all the ins and outs. So you need those partners and those connections, especially within your community, to really make it happen.
- [20:21]
B
Great. I love how you describe the entrepreneurial spirit and I can tell you've certainly embraced that, both of you. So hey, thank you very much again to both of you. It's really energizing to hear about all of the progress that you are making within your own organizations to establish post fracture care programs and bone health clinics across different practice settings, especially through the orthopedic perspective. So I know that our listeners are going to find your experiences very valuable as they consider, you know, making that first step forward themselves. As for us at Amgen, we appreciate, you know, all of the interaction with folks like yourselves and for our listeners. If you are interested in learning more about post fracture care osteoporosis population health management, please visit our website@fructurecaregap.com for more tools, resources and insights like we're sharing here today. Thanks to you both.
- [21:19]
C
Thank you.
- [21:20]
D
Thank you for having me.
- [21:21]
A
Thank you Kristen, Ms. Yazdani and Dr. Mainz for such a great discussion on adapting post fracture care programs across practice settings. It's so great to have you. This episode is part of a four part series on post fracture osteoporosis care sponsored by Amgen. You can find the full series and additional Becker's healthcare podcasts@www.beckerspodcast.com. this podcast was sponsored by M Gen. Participants were compensated for their time by M. Gentlemen.