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A Fracture Care Program is Leveraging Nurse Insights to Improve Outcomes for Patients and Hospitals

Hip fractures can have serious health implications for patients and cost of care implications for hospitals. Meet the nurse duo who helped develop the pioneering Hip Fracture Care Program that is transforming fracture care for patients and health systems – Stacie Cox and Shandy Welch.

Hip fractures can be a frightening and debilitating event in an elderly patient’s life. About 90% of hip fractures occur in people older than 65, and often patients who arrive to the hospital with a hip fracture come with other medical conditions such as arthritis, osteoporosis and dementia that can complicate care.[1]

The year after a hip fracture can be difficult, as most patients are unable to perform normal daily activities and about 40% are unable to walk independently.[2] Research has shown that the mortality rate in the first year after a hip fracture can be as high as 20%.[3]

The Hip Fracture Care Program, offered by the Johnson & Johnson Medical Devices Companies (JJMDC), is an evidence-based care improvement program, aimed at creating better outcomes for both patients and the health systems by providing an organized, standardized system of care for elderly fracture patients.[4] This program has been driven and championed by nurses eager to change hospital culture around fracture patients.

In 2006, nurses Stacie Cox, AGPCNP-BC, and Shandy Welch, RN, FNP-BC, and several other clinicians were asked by JJMDC to lend their expertise to the redevelopment of their fracture program to help put better solutions in place for patients recovering from fragility fractures. Stacie, a nurse practitioner in the St. Francis Health System in South Carolina, and Shandy, a nurse practitioner and Implementation Coach for JJMDC, worked collectively with other nurses, physicians and healthcare professionals to bring the Hip Fracture Care Program to life.

“I believe a nurse’s perspective was crucial to the development of the Hip Fracture Care Program because nurses are the eyes and ears of the patients,” said Stacie. “Nurses were able to provide crucial information to help in the planning and implementation of the program, especially when we proposed a sample schedule for patients given key information of what works with medication time frames, assessments and therapy.”

Today, with Stacie embedded in the program at St. Francis and Shandy working as a consultant for JJMDC to disseminate the program to other health systems, they are leveraging their experience as nurse leaders to continue to innovate the program and adapt to the needs of the industry. Along with a third Implementation Coach, Rob Bruce, a physical therapist, they remain involved in the day to day planning behind the Hip Fracture Care Program, educating hospital staff on the urgency of hip fractures, tracking data and participating on the Implementation Coach committee that assists hospitals in the adoption of the program.

“We understand the importance of engaging all the staff members of a hospital to create a sense of ownership in patient care and to apply a patient-centered focus to their work,” said Stacie. “I think my favorite part of the program is the teamwork. Every single team member truly believes in the program and understands the crucial role they play in the outcomes of these patients.”

“We recognized the need to ensure the program be utilized by all eligible patients, not just the population that identified as geriatric,” said Rick Cirucci, Senior Manager, Solutions Commercialization, Health System Value Transformation at JJMDC. “We know this program can expand beyond hip fractures and the elderly and can provide value-based care to patients who have experienced a fracture.”

Today, hospitals are faced with several challenges when a patient comes in with a hip fracture, such as a lack of standardized protocols, having to determine proper pain management, having to assess patients for delirium and encountering instances of other hospital-acquired conditions, such as bed sores. A person who experiences a hip fracture can expect to stay in the hospital an average of 6.3 days, which can create great financial burdens on healthcare systems.[5] Every year, hospitals encounter over 300,000 hip fractures, and this number is expected to exceed 500,000 by 2040.[6]

The Hip Care Fracture Program offers tactical solutions that may provide reduction to length of stay and readmissions and improve clinician and patient satisfaction through the clinical standardization of protocols, more efficient coordination of care and an emphasis on monitoring key data. The JJMDC team offers hospitals multi-phased implementation support, resources that help hospitals through new protocols, patient education materials and access to clinical subject matter experts and other hospitals who have successfully implemented the program. Since the launch of the program over ten years ago, the Hip Fracture Care Program has since been implemented in over 170 hospitals and healthcare systems.

"Not only were nurses vital to the development of the program, but we have also applied those insights to our current work as Implementation Coaches as we disseminate the materials and support the hospital staff that are integrating these skills into their daily practice. We focus on not only tangible changes to improve programs, but also cultural shifts and leadership opportunities to ensure sustainability,” said Shandy.

By improving pre-operation patient optimization, creating clear and consistent communication with patients and their families, standardizing the treatment of pain and reducing instances of hospital-acquired conditions, patients recovering from hip fractures have seen improved health outcomes.[7] The Hip Care Fracture Program has also had demonstrative results on the financial health of healthcare systems by reducing the rate of inefficiencies and complications. Data from a regional community hospital showed that by implementing the program, they were able to save an average of $900 per orthopedic episode, a reduction of time spent in the emergency department before the OR by 17% and a reduction in post-operation length of stay by almost 1 day.[8]

“The Hip Fracture Care Program shows that having a good program isn’t always enough, understanding the dynamics of the patients and hospitals are key, and our Implementation Coaches have been very successful adapting our program to best help patients,” said Rick.

As nurses, a profession at the intersection of multiple healthcare stakeholders, Stacie and Shandy understood the importance of Implementation Coaches bringing together senior administration, nursing leadership, perioperative services, physical therapists, orthopedic surgeons, data/quality leadership and other teams to advise on clinical processes in their hospital. To guarantee the success of the program, they identify both physician and nurse champions within the hospital and work with them to get an interdisciplinary team on board.

“The only way to develop a successful program is by leveraging the perspectives of people who are actually doing the work with the patients,” said Shandy. “I think too often the business of medicine dictates how clinicians should practice, and it’s so important that multiple clinicians have a voice to communicate their needs and vision.”

“This is one of the most interdisciplinary programs that we’ve ever launched, starting from the emergency department and collaborating across more than ten other departments in the hospital,” said Rick. “And I think what has made the program so innovative is the unique partnerships we’ve developed with nurses, doctors and academic medical centers to disseminate this program to 170 hospitals across the country.”

As the Hip Fracture Care Program continues to expand and improve outcomes for patients and hospitals, the team looks forward to bringing the insights gathered from the success of this program to continue to help elevate the role of nurses as Implementation Coaches in the program.

“We’ll be looking at ways to digitize our content, improve delivery methods, create new partnerships and address other health challenges like osteoarthritis,” said Rick. “To meet the needs of tomorrow’s patients, we need to look at ways to enhance the ‘how’ of implementation, and without a doubt, nurses will be a part of those conversations.”

Stacie and Shandy hope that nurses can be empowered by the successful implementation of the Hip Fracture Care Program to voice their perspectives on solutions that improve care and share ideas for programs that can help health systems to operate more efficiently and cost-effectively.

“Nurses have a unique opportunity to promote change because they interact on a daily basis with many different specialties,” said Shandy. “Nurses are able to tap into the human side of a team and bridge the gaps between different departments. I think when nurses are able to play larger roles in developing healthcare programs, we are going to see dramatic improvements in care and the health of our healthcare systems.”

Pictured above are Implementation Coaches Stacie Cox, AGPCNP-BC (left) and Shandy Welch, RN, FNP-BC (right).

Learn more about the Hip Fracture Care Program, offered as part of the CareAdvantage platform from the Johnson & Johnson Medical Devices Companies here.

[1] Cooper. Am J Med. 1997; 103(2A):12s-19s
[2] Friedman, S. M. et. al. J Am Geriatr Soc. 2008 Jul;56(7):1349-56
[3] Friedman SM, Mendelson DA, Kates SL, McCann RM. Geriatric co-management of proximal femur fractures: total quality management and protocol-driven care result in better outcomes for a frail patient population. J Am Geriatr Soc 2008;56(7):1349-1356.
[4] Kates & Mears (2015) A Guide to Improving the Care of Patients with Fragility Fractures, Geriatric Orthopaedic Surgery & Rehabilitation, Edition 2 Geriatric Orthopaedic Surgery & Rehabilitation 2015,
Vol. 6(2) 58-120
[5] Dreyfuss, A. (2016, February 3). Study: Shorter hospital stay for hip fracture associated with increased odds of survival. Retrieved from https://news.vcu.edu/health/Study_Shorter_hospital_stay_for_hip_fracture_associated_with.
[6] Physician's Weekly. (2015, June 22). Hip Fracture Surgery: Costs & Benefits. Retrieved from https://www.physiciansweekly.com/hip-fracture-surgery-costs-benefits/
[7] Liem IS, Kammerlander C, Suhm N, et al. Identifying a standard set of outcome parameters for the evaluation of orthogeriatric co-management for hip fractures. Injury 2013;44(11):1403-1412
[8] Comprehensive Hip Fracture Care Program: Successive Implementation in 3 Hospitals https://journals.sagepub.com/doi/10.1177/2151459319846057 (These are examples only and do not guarantee or predict future results which will vary based on individual circumstances.)

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