fls implementation – a national approach, rotterdam 2015
TRANSCRIPT
FLS Implementation – A National Approach
Friday 4 September 2015
Hilary Arden, Head of Service DeliverySonya Stephenson, Service Development Manager
Tim Jones, Commissioning Advisor
The National Osteoporosis Society• The only UK-wide charity dedicated to
improving the prevention, diagnosis and treatment of osteoporosis
• Vision: A future without fragility fractures• Mission: Working together for a brighter
future for people with or at risk of osteoporosis and fragility fractures across the UK, putting an end to preventable broken bones and helping people to live without pain and disability
• 300,000 fragility #• 85,000 are hip #• 1.8M hospital bed days• 20% die in 4 months• 33% become totally
dependent • £1.9B in hospital costs
Impact of Fractures in the UK
What is the solution?
A Fracture Liaison Service (FLS)• A proven model for fragility fracture prevention• All patients > 50 years who fracture are targeted• 50% of hip fracture patients have had a prior
fragility fracture• Where treatment is initiated, up to 50% hip
fractures could be avoided in future
• Clinically and cost effective
Find them
Assess them
Treat where appropriate Follow-up
National Osteoporosis SocietyPriorities and Plans for 2015Aim 1: Every person aged over 50 who breaks a bone is assessed for osteoporosis and managed appropriately.Priority 1:
Extend coverage of Fracture Liaison Services
Priority 2:Improve quality of Fracture Liaison Services and osteoporosis services
• FLS Implementation Group• UK FLS Clinical Standards• FLS Implementation Toolkit• FLS Implementation Workshops• Fracture Prevention Practitioner (FPP)
Training• Peer Review• Service Delivery Team
A National Approach to FLS
FLS Implementation Group• National stakeholders & Government• Provide strategic leadership and coordination
across projects• Ensure good communication and partnership
across FLS stakeholders• Plan and deliver agreed actions and
milestones• Ensure delivery of high quality, efficient and
cost-effective FLS
Definition of an FLS‘‘A Fracture Liaison Service (FLS) systematically
identifies, treats and refers to appropriate services all eligible patients aged over 50 years within a local population who have suffered a fragility fracture, with the aim of reducing their risk of
subsequent fractures.’’
• FLS Implementation Group• UK FLS Clinical Standards• FLS Implementation Toolkit• FLS Implementation Workshops• Fracture Prevention Practitioner (FPP)
Training• Peer Review• Service Delivery Team
A National Approach to FLS
Service Delivery Team
Sonya StephensonService Development
Project Manager
Will CarrService Development
Project Manager
Hilary ArdenHead of
Service Delivery
Tim Jones Commissioning
Advisor
Mayrine FraserService Development
Project Manager
Debbie StoneService Development
Project Manager
Fiona GardnerOperation Projects
Officer
Henry MaceProfessional
Development Lead
• Facilitate stakeholder engagement• Help establish patient/care pathway• Project manage commissioning/funding:
o The economic and business caseo Service specificationo Resource and capacity planning
• Work with commissioners to ensure services are sustained.
How We Help
• Provide input to enable the development of an FLS meets the UK FLS Clinical Standards
• Help establish data collection, analysis, evaluation and reporting
• Identify gaps in service provision, put in place improvement plans and monitor against agreed actions
• Peer review
How We Help
FLS: Some Localities
UK FLS Clinical StandardsThe 5IQ approach describes the key objectives of an FLS:
• Identification
• Investigation
• Information
• Intervention
• Integration
• Quality www.nos.org.uk/fls
UK FLS Clinical Standards Summary of Standards
CRITERIA RATIONALE MEASURES OUTCOMES Identification
1 All patients aged 50 years and over with a new fragility fracture or a newly reported vertebral fracture, whether managed as inpatients or outpatients, will be systematically and proactively identified.
Patients who have sustained a fracture are at higher relative risk of fracture than those who have not. Targeted interventions in this population will have most impact on reducing future fracture burden.
Proportion of fracture patients aged over 50 years identified by the FLS.
Denominator for all fragility fractures can be best estimated by multiplying total hip fractures in over 50 year olds by 5 (1).
Systematic identification of at risk patient population who would benefit from investigation.
Investigation
2 Patients will have a bone health assessment and their need for a comprehensive falls risk assessment will be evaluated within 3 months of the incident fracture.
Assessments need to be conducted promptly as the risk of having a further fracture is increased in the first year.
% of identified patients who have a bone health assessment within 3 months of incident fracture.
% of identified patients who have their need for a falls risk assessment evaluated within 3 months of incident fracture.
Improved identification of the population who will benefit from interventions leading to appropriate targeting of resources.
Information
3 All patients identified will be offered written information about bone health, lifestyle, nutrition and bone-protection treatments.
Anyone aged over 50 years who has had a fracture needs to be aware of the steps they can take to maintain healthy bones.
% of identified patients given information.
Improved patient understanding leading to confident self-management and engagement with recommended interventions.
Intervention
4 Patients at risk of further fracture will be offered appropriate bone-protection treatments.
Appropriately targeted interventions reduce future fracture risk.
% of assessed patients offered bone-protection treatment.
The right people receive the right interventions for bone health and falls leading to reduced fracture risk and fewer fractures.
Patient mobility and independence is maintained.
5 Patients at risk of further falls will be offered appropriate assessment or interventions to reduce future falls.
Evidence-based falls interventions are effective at reducing falls risk.
% of assessed patients offered referral for assessment or an intervention.
Integration 6 Management plans will be patient centred and integrated between
primary and secondary care.
Effective communication is essential to ensure that long-term management is achieved and that patients are supported to engage with recommended interventions.
Measure of communication – patients copied in/discharge letters
Written/verbal.
Patient feels supported.
Issues with treatment compliance and adherence are identified promptly.
Adherence to treatments is improved leading to greater patient benefit.
7 Patients who are recommended a drug to reduce risk of fracture will be reviewed within 4 months to ensure appropriate treatment has been started; and every 12 months to monitor concordance with the treatment plan.
Treatments must be taken consistently and appropriately over many years to be effective. Follow-up allows early identification of issues (side effects, compliance) with prescribed medications, reinforces need to take treatments and supports long-term concordance. Long-term management and follow-up should be carried out in primary care.
% of patients on treatment who are reviewed within 4 months
% of patients on treatment who are assessed annually.
Quality 8 Core clinical data from patients identified by the FLS will be
recorded on a database. Regular audit and patient experience measures will be performed and the FLS will participate in any national audits undertaken.
Data recorded will allow the FLS to audit and improve the service they provide ensuring that high standards are met and maintained. Initial data will provide a baseline from which improvements can be assessed.
Date of last audit against FLS standards.
Date of last patient satisfaction survey.
Excellent quality of care is provided and best practice is shared.
9 The FLS team will have appropriate competencies in secondary fracture prevention and supported to maintain relevant CPD.
All staff need appropriate knowledge, skills and experience to fulfil their role. Engagement with relevant CPD activities ensures that these are up to date.
Review of competencies and training needs in annual appraisals.
Assessment of CPD attained.
10 The FLS should engage in a regular peer-review process of quality assurance.
Clinical peer review facilitates quality standard assurance, equitable access to services and provides a means of benchmarking and sharing best practice.
Date of last peer review and progress against an agreed action plan.
UK FLS Clinical Standards
UK - Gap analysis All patients aged 50 years and over with a new fragility fracture or a newly reported vertebral fracture will be systematically and proactively identified.
outline process for identifying (include numbers seen where able)In-Patient hip fractures 50-75 75+
Outline process for identifying (include numbers seen where able)In-Patient hip fractures 50-75 75+
In-patient non-hip fracture50-75 75+
Out-patient fractures50-75 75+
Spinal fractures
Assist with Stakeholder Meetings • Lead clinician/local
champion• Consultants:
o Endocrinologisto Rheumatologisto Geriatriciano Radiologisto Orthopaedic surgeon
• Osteoporosis nurse specialists
• DXA radiographers• Service manager/s
• Pharmacist• Prescribing advisors• Physiotherapist• GPs/Primary care• CCGs• Commissioners• Health & Wellbeing
Board/s• Public Health• IT• Site services• Patient rep (NOS!)
Assist with FLS Pathway
FALLS RISKASSESSMENT
NEW CLINICAL FRACTURE
NEW VERTEBRALFRACTURE
(RADIOLOGY REPORT)
PREVIOUS FRACTURE OR FRACTURE NOT PRESENTING
TO ACUTE CARE
ORTHO IP
Virtual/#CLINIC
‘CASE-FINDING’ BY FLS‘CASE-FINDING’ BY COTE
‘CASE-FINDING’ BY GP/SEC CARE/CH
FLS RISK ASSESSMENTONE-STOP CLINIC
WITH DXA
EXERCISECLASSES
Rx FOR FRACTURE 2Y PREVENTION
EDUCATIONPROGRAMME
CARE OF THE
ELDERLY
4 & 12 MONTH FOLLOW UP
CLINIC
COMPLEX CLINIC
(IF REQUIRED)
25
FLS Implementation Toolkit1. Promotes commissioning of effective high-quality
services that are integrated within a system-wide approach
2. Ensures services are in accord with the evidence base and able to demonstrate outcomes
3. Stimulates provision of services that are sustainable
4. Make implementation easier, cheaper and more effective for commissioners and providers.
Contents Name Description Format
UK FLS Standards Clinical standards for FLS PDF
Call to action A summary of evidence for providers and commissioners PDF
Service Specification A part populated service specification suitable for use with NHS Standard Contracts
MS Word
Benefits Calculator A financial model demonstrating potential cost savings Web
Cost Calculator A financial model to calculate the service requirements Web
Service Improvement Guide A descriptive guide setting out step-by-step actions for providers to achieve a service improvement
Outcome and Performance Indicators
Practical, evidence-based indicators to demonstrate service improvement
MS Excel
Improvement Project Plan A list of tasks and activities for a development project MS Excel
Business Case Part populated case for investment in FLS MS Word
An FLS is both clinically and cost effective
FLS Benefits Calculator• Additional resource within the
FLS-IT• Designed for use by hospitals, community
services and commissioning organisations to help develop an FLS
• Estimates the benefits in terms of reduced fragility fracture incidence and cost savings that can be realised in a local health economy as a result of implementing an effective FLS.
What is the Impact of an FLS?Economic benefits in the UK:
• Reduction in hip fractures • Hip fractures cost £1.9 billion/year• For every 1000 FLS patients assessed in
FLS • 18 fractures are prevented• 11 of those are hip fractures
What Investment is Required?• Cost of staff required:
• Consultant• Nurse specialist• Clerical/admin
• Set up costs – FLS accommodation, IT, DXA scanner and other associated costs:
• DXA scans/reporting• Other diagnostics• Drug costs
FLS MappingArea Population
Salisbury 278,000
Stoke on Trent 215,000
Vale of York 348,000
Rotherham 255,000
TOTAL 1,096,000
Activity in 2015Aim 1: Every person aged over 50 who breaks a bone is assessed for osteoporosis and managed appropriately.Priority 1:
Extend coverage of Fracture Liaison ServicesPriority 2:
Improve quality of Fracture Liaison Services and osteoporosis services
Contact made
Implementation from no service
Quality improvement Intervention concluded
Total sites
Peer support Commissioning
35 34 30 12 6 117
How Good is Your FLS?
“You must be the change you wish
to see in the world.”
Mahatma Gandhi
