As documented by the Public Health Agency of Canada, there is a huge post-fracture care gap in this country; this care gap has negative impacts on patients’ quality of life, independence and mortality. Fracture Liaison Service (FLS) is the most clinically and cost-effective intervention in terms of improving patient care post-fracture and has been associated with improved patient outcomes and reduced health care costs. Less than 15% of Canadians who fracture currently have access to FLS. To ensure that all Canadians can access an FLS to receive optimal post-fracture care to prevent repeat fractures, Osteoporosis Canada (OC) is providing a free FLS consultation service.

Types of assistance provided

Due to a limited budget, OC can only provide in-kind support (not direct financial support), most often through the generosity of volunteers with expertise and experience in FLS. OC’s assistance will be subject to the availability of these volunteers.

Osteoporosis Canada (OC) may provide, to a new or existing FLS, assistance with the following:

1. FLS design

• Best location to start an FLS in your hospital (e.g. inpatient-only, outpatient-only or combined inpatient/outpatient FLS)
• Optimized FLS design for effectiveness and efficacy
• Templates for various FLS documents (job description, Care Directive, FLS protocols, algorithms, form letters, etc.)
• FLS data tracking tool (Excel)
• Connecting your team with an experienced FLS of similar design to yours
• In select cases, OC may be able to help facilitate the training of a new FLS coordinator

2. FLS sustainability

• Development of a business case for your FLS
• Preparation for important meetings with decision makers, including help drafting letters, presentations, etc.

3. Quality improvement

OC’s national FLS audits are utilized by FLSs across Canada in their on-going efforts for Continuous Quality Improvement. After participation in one of OC’s national FLS audits, your FLS team will receive a confidential report with your FLS’s results as per OC’s core FLS Key Performance Indicators. This report will include a comparison with other Canadian FLSs. This can help your FLS team identify areas where improvements may be possible. Where warranted, OC may also be able to connect you with other FLSs that have faced similar challenges to your own and have overcome them.

Absolute prerequisites

Three conditions must be met before OC will provide assistance. OC is available to help guide novice teams as they work through the steps needed to meet the three prerequisites.

1. A committed local FLS team

The local FLS team is absolutely critical to the success of any FLS. They alone have the intimate knowledge of their healthcare system and have the relationships which will be needed to facilitate the implementation of a new FLS or the improvement of an existing one. The FLS team must be committed to the longer-term efforts that are typically required.

2. FLS model is clinically effective

The FLS model must meet OC’s FLS definition as well as all of OC’s Essential Elements of FLS. The FLS would be expected to submit to OC’s FLS Registry shortly after implementation. Additionally, any available local care gap and/or FLS data must be freely shared with OC – such information would always remain strictly confidential unless OC is given express permission to disclose.

3. FLS model is cost-conscious

Well-designed FLS models are both clinically and cost-effective. Many well-designed FLSs are actually cost-saving by preventing very expensive hip fractures. An FLS’s cost-saving ability is a result of the combination of its clinical effectiveness and its attention to limiting costs. It is often a fine balance between spending sufficiently to ensure the model is clinically effective, but not going overboard such that the model is no longer cost-effective/cost-saving.

Most FLSs will not have access to the very specialized research resources necessary to perform a formal cost-effectiveness analysis. OC will preferentially support FLS models that are cost-conscious and which we would anticipate to be cost-saving. More expensive FLS models would only be supported by OC if they have clearly demonstrated improved patient outcomes that are significant enough to justify the extra costs.

FLS models will be assessed for:

1. Reasonable direct FLS costs including the salary/remuneration for the FLS coordinator, any FLS clerical assistance and the FLS medical lead who oversees the FLS’s operations.
2. Judicious utilization of healthcare resources (indirect FLS costs)
   FLSs utilize healthcare resources by initiating or recommending investigations (e.g. labs and Diagnostic Imaging), referrals to other services (e.g. osteoporosis specialists and falls prevention programs) and osteoporosis medications (costs vary). FLSs that preferentially favour more expensive therapeutic options and/or that go beyond the recommendations of OC’s Clinical Practice Guidelines will generate additional healthcare costs overall and OC may not be able to support (e.g. an FLS referring all or most fracture patients to an osteoporosis specialist).
3. Cost-competitive with other local/regional/provincial FLSs.
   Where a region/province has one or more established FLSs that have already been proven to be clinically effective, OC would only be able to support a more expensive model if it has clearly demonstrated improved patient outcomes compared to the existing FLSs.

OC recognizes that, in more remote regions of this country, extra direct or indirect FLS costs may be required to make up for lack of regional access to some osteoporosis services, e.g. lack of access to Bone Mineral Density (BMD) testing.

Please review these modules to find which one could be helpful to your planning depending on the stage of FLS implementation of your site.

MODULE 1: Initial exploration

MODULE 2: Determining FLS’s clinical setting and optimizing the local FLS team

MODULE 3: Detailed FLS design, typically done by the FLS’s medical lead

MODULE 4: Strategy to secure funding for your FLS

MODULE 5: Implementing your new FLS

MODULE 6: FLS sustainability: ensuring your FLS remains funded