Models of Post-Acute Care in Complex Older Adults with Fracture

Broken bones, or fractures, in later life are a leading cause of disability, need for long-term care, and death. Prior studies have shown that poor outcomes including death can be prevented by treating patients with bone-strengthening medications and stopping risky medications that cause falls. However, few patients receive this high-quality care because it is time consuming and requires specialized knowledge that primary care providers may not have. Many patients with a fracture receive care in skilled nursing facilities following a fracture, and these facilities offer an opportune time to engage patients and their caregivers in a review of medications. Patients may have a wide range of preferences about the importance of managing symptoms like pain, anxiety and depression after a fracture. Some may prioritize preventing future falls and fractures and others may not, especially those with other health conditions who are nearing the end of their lives. Patients, their families and providers need more information about how much benefit they will get from starting osteoporosis medications, and the risks versus benefits of reducing medications that cause falls but may relieve other important symptoms. 

This study will compare two care models that have previously been shown to improve care in skilled nursing facilities. One model is a Fracture Liaison Service, in which recommendations are given to manage osteoporosis (weak bones) with medications. The second model is a Deprescribing Care Model, which helps patients reduce medications that cause falls. Both models are led by a remote nurse who will review electronic health records and consult with an external team of experts to devise a personalized medication treatment plan. The nurse will provide information about osteoporosis treatment and/or reducing medications to patients and families by phone so that they can decide together what changes to make. The nurse will communicate recommendations to the skilled nursing facility staff and/or the community primary care providers. Involving patients and providers in the decision-making process will ensure that medication changes represent the values of the patient. 

Forty-two skilled nursing facilities will be enrolled in this study. In random order, the study team will provide the Fracture Liaison Service care model for six months, the Deprescribing care model for six months, or both models simultaneously for six months. All patients who are admitted to a participating facility after a broken bone will receive the model offered at that time. Patients will be followed for about two years using information that is already in their electronic health record and from Medicare to see if they have fewer injuries from falls compared to similar patients in facilities that don’t offer the care models. The study team will also ask patients or their caregivers if they would be willing to complete a survey 90 days after admission. The study team will compare whether important symptoms like pain, anxiety, sleep and medication side effects are different in patients treated with the different care models. They will look to see if the benefits versus risks of starting osteoporosis medication or stopping medications that cause falls are different in patients depending on how long they are expected to live, or if they have memory loss, or dementia. 
The study will help patients and families make personalized choices about starting medications to prevent more broken bones, stopping risk medications that cause falls or both based on their individual goals and preferences. It will also prepare the study team to spread the care models to health systems so that all patients can receive high-quality care after a broken bone.