Leading Better Value Care
Local vignette – South Eastern Sydney LHD

Osteoporotic re-fracture prevention

Multidisciplinary shared care model – a clinician's perspective

By Daniel Wu

29 Apr 2021 Reading time approximately

What is important to know about your service?

About 4.7 million Australians over 50 have poor bone health. As many as four out of five people with osteoporosis don’t even know they have it. After a minimal trauma fracture, people are likely to have another in the next two years.

The Osteoporosis Refracture Prevention Program (ORP) identifies patients who have had a previous fracture and takes measures to try and prevent another from occurring. It covers St George Hospital, Sutherland Hospital and the Royal Hospital for Women at the Prince of Wales Hospital.

What organisational model do you use?

Outpatient clinics.

Identification and triage
leads to
Assessment and diagnosis
leads to
Treatment initiation
leads to
Coordination of ongoing care

What is special about the way care is delivered that is valuable for others to know?

The program identifies patients over 50 who have had an initial minimal trauma fracture through emergency department admissions, special radiology programs and by direct referral from general practitioners or specialists.

We adopt a multidisciplinary care model which involves a specialist medical officer, fracture liaison coordinator and physiotherapist. This is important so we tackle the many aspects of this disease to improve and protect our patients’ quality of life.

A companion document describes options for organisational models in osteoporotic refracture prevention. One option is outpatient clinics – this vignette describes the model from a local perspective.

How does it make a difference?

We are able to engage patients who have had a fracture and provide holistic, multidisciplinary and patient-based care. We aim to improve their bone health, increase their health literacy and reduce the risk of future fractures by tackling the multiple complex factors associated with this chronic disease.

What tips do you have for others?

  • Keep in mind patient-centred care.
  • Develop relationships with external service providers and adopt it into your own business model (e.g. private nuclear medicine centres, external rehabilitation providers).
  • Understand the frames of reference of all other stakeholders. This includes managers, other clinicians, general practitioners and patients.
  • Engage with the community to increase awareness of the service (e.g. HealthPathways).

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