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Osteoporosis Model of Care

Hunter New England Local Health District
Project Added:
11 April 2012
Last updated:
5 January 2015

by Kerry Cooper, John Van der Kallen, Michelle Giles and Kerri GillBone and Joint Institute, Hunter New England Local Health District


The Osteoporosis Model of Care is a multidisciplinary team-based model. It has created efficiencies in detecting and management of osteoporosis with improved patient outcomes. This care model is designed for patients over 50 years of age, presenting to the Emergency Department (ED) with a minimal trauma fracture (MTF). The patients are identified, referred and managed with intervention and follow up.

Opening the Door on Osteoporosis (pdf 38 KB), abstract of presentation given at the Hunter New England Local Health District Nursing & Midwifery 6th Annual Showcase in Clinical Innovations, 28 March 2012.

Fracture Prevention Fact Sheet (pdf 63 KB), a summary of the project for health professionals.


  • A multidisciplinary fracture prevention team was established. The team included stakeholders from the osteoporosis fracture prevention clinic, ED, fracture clinics, orthopaedic wards, community health teams, physiotherapy, falls prevention team, allied health and General Practitioners (GPs) as well as consumer representation and health information technology experts
  • A fracture prevention Liaison Coordinator role was developed
  • An electronic report from patient information management system (Pims) was developed to identify all fractures presenting to the hospital
  • A fracture referral pathway was developed and implemented
  • A fracture prevention protocol was developed for the orthopaedic rehabilitation wards
  • The electronic discharge referral system was modified to include prompts for both GPs and hospital based medical officers to refer patients to the osteoporosis fracture prevention clinic
  • All minimal trauma fracture patients receive some follow-up for osteoporosis assessment and/or management
  • Management and follow up are recorded in a database.


Planning and Implementation Tools

Patient Information

Treatment Algorithms

Risk Calculators

Referral templates


A comparative prospective study with formal evaluation of this model of care was undertaken independently on identified patients over 50 years with a minimal trauma fracture. Patient interviews, phone surveys and electronic audits were undertaken.

  • Of 434 recruited patients, 214 were on fracture prevention pathway and 220 were not.
  • The osteoporosis clinic referrals of eligible people (excludes nursing home patients) increased from 6% in 2007 to 68% in 2011.
  • Patients reviewed in the osteoporosis clinic had a 65% decreased risk of subsequent fracture compared to those not reviewed.
  • Treatment rates in the clinic attendees are currently 72% vs 37% of non clinic attendees.
  • Re-fracture rates in clinic groups is 5.1% whereas those not attending the clinic has a re-fracture rate of 16.4%.
  • Mean time between fracture and attending clinic has improved from 136 days in 2007 to 35 days in 2010.
  • In this study of 434 patients, 43 bed days were required to treat subsequent fractures in the clinic attendee group whereas non clinic attendees required 313 bed days.

Considering the morbidity and mortality of patients post fracture, these improvements deliver better patient outcomes.


The strength of the model is that it has the ability to detect all patients who present with a minimal trauma fracture for referral and assessment of osteoporosis, thus reducing the numbers of subsequent re-fractures. This Model of Care has been implemented in three rural sites, as a result of this initiative, and is currently being evaluated by the NSW Ministry of Health for implementation in other Local Health Districts.

The improved outcomes have been implemented within existing services. Passion, enthusiasm and continual self evaluation drives the team for better outcomes for the patients and to build on the project successes.

Related Links


Fiona NiddrieActing Clinical Nurse Consultant in Rheumatology
Bone and Joint Institute, 3rd Floor, Royal Newcastle Centre
Hunter New England Local Health District
Lookout Rd, New Lambton Heights NSW 2305
Phone: 02 4922 3526

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