Leading Better Value Care
Local vignette – Northern NSW LHD

Osteoporotic re-fracture prevention

Coordinator-led model – a clinician's perspective

By Stacey Kroehnert

28 Apr 2021 Reading time approximately

What is important to know about your service?

The Northern NSW Local Health District Clarence Network Osteoporosis Re-Fracture Prevention (ORP) service encompasses Grafton and Maclean. The Grafton Base Hospital is a level 3/4 rural hospital with 100 beds, an intensive care unit and specialist orthopaedic services. Maclean District Hospital is a level 3 rural hospital with 50 beds and a rehabilitation unit. The Clarence Valley has an aging demographic with many retirees residing in Yamba and Iluka. Medical governance for the ORP service is supported by staff specialist and rehabilitation physicians.

What organisational model do you use?

A coordinator-led model.

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 Clarence ORP program is coordinated by the fracture liaison coordinator (FLC). Patients with a minimal trauma fracture are identified from their hospital presentation. GP referrals are also accepted. The service offers a comprehensive assessment of a patient’s bone health, with follow up recommendations for appropriate treatment and management.

The assessment includes a risk factor questionnaire, a bone density scan and pathology testing prior to the ORP clinic appointment.

At the ORP clinic:

  • the patient and physician together discuss the identified risk factors and results and determine an appropriate treatment regime for improving bone health
  • the patient and the FLC discuss lifestyle modifications, set goals and make referrals to other services (hospital and community), as required
  • an individual bone health management plan is completed
  • letters are sent to the patient’s GP with the discussed treatment recommendations from the physician and FLC.

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

How does it make a difference?

Speaking with the patient after they have seen the clinic’s doctor and received their results is beneficial for the patient as it allows discussion to clarify the doctor’s recommendations and to answer any questions the patient may have.

What tips do you have for others?

  • Establishing good working relationships with the medical lead, physiotherapists, emergency department staff and orthopaedic staff is important.
  • Education is the key.
  • SMART goals are important.

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