FLS Coordinators are no strangers to finding innovative methods to improve care for their patients. With the goal of ensuring that every fragility fracture patient is provided appropriate osteoporosis care, FLS Coordinators have often been successful at finding creative solutions when they identify significant barriers in care.

The national FLS audits have been most helpful in assisting with the identification of an FLS’s weaknesses, thus providing an opportunity to explore barriers that may be contributing to lower scores.  The barriers to optimal osteoporosis care may occur at any of the three key functions of an FLS: identification, investigation or initiation.

In the first national audit, some FLSs were surprised to discover they had a lower score for their “first i” compared to other Canadian FLSs.  In three of the FLSs, further investigation revealed that this was in large due to one of their FLS’ exclusion criteria:  they excluded all patients who did not have a family physician/primary care provider.  As the proportion of such “orphan patients” grew dramatically in that province, so did the number of “patients left behind” by those FLSs.  To date, an alternative solution has been put in place for “orphan patients” at 2 of the 3 FLSs.   A noticeable improvement was seen on their results for the first i in the recent second national FLS audit compared to their first audit results.

Completing an accurate fracture risk determination in a timely manner is critical to an FLS’s “second i”.  As Bone Mineral Density (BMD) testing is a key component of fracture risk assessment for many patients, FLSs have developed collaborative relationships with their local BMD departments and often are able to help coordinate point of care same day (as their orthopaedic clinic) appointments for their FLS patients.  The Covid-19 pandemic has also created a new barrier to most Canadian FLSs’ second i since most BMD sites were temporarily shut down, often for several consecutive months, during the height of the pandemic. OC has developed a guidance document (available here) to help BMD departments prioritize their BMD backlog as they resume operations. https://fls.osteoporosis.ca/wp-content/uploads/OC-BMD-prioritization-.pdf

In Canada, initiation of prescription medication is the most challenging of the 3i’s for FLSs.  Misinformation and misconceptions about osteoporosis and osteoporosis medications among patients, family members and occasionally in their primary care providers significantly reduces the number of appropriate treatment initiations.  Canadian FLS coordinators have worked with Osteoporosis Canada to develop communication tools to help patients understand the impact and prognosis following a first fracture and the risks and benefits of osteoporosis treatment.  Most Canadian FLSs have seen an improvement in their “third i” in this second audit compared to their results in the first one.

The pandemic has created new barriers to an FLS’s third i.  Patients have been reluctant to leave their home to go for blood testing and/or for administration of injectable osteoporosis medications.  FLS coordinators have spent extra time educating their patients on the importance of attending care appointments and how the healthcare system will ensure their safety.  There have been challenges accessing infusion clinics (e.g. for zoledronic acid administration) in some regions of Canada.   An innovative solution in one province was having local paramedics administer the zoledronic acid to patients within their own home. In some long term care facilities, shortage of personnel has led to temporary new medication administration protocols where all osteoporosis medications were removed from the list for all patients.  Long term care centres will often adapt their medication management protocols to include osteoporosis medications once informed of the importance of sustained, appropriately delivered, osteoporosis treatment to reduce the risk of new fractures.

As FLS Coordinator, Joyce Mammel, of Peter Lougheed Centre in Calgary, Alberta, says, “I consider each patient individually and try to overcome barriers they may have. Then, whenever possible, I use those learnings and solutions for other patients, thereby preventing similar circumstances from developing into barriers for them.” Canadian FLS coordinators are to be applauded for their dedication to their patients and their resiliency which has become even more evident during this pandemic.