What are the definitions of Open Model, Closely Aligned Model, and Closed Model in the context of health systems and Post-Fracture Care (PFC) programs?

From the Guidelines

The most effective organizational structure for Post-Fracture Care (PFC) programs is the Closed Model, which features full integration of fracture treatment and osteoporosis management within the same system, often with dedicated Fracture Liaison Services (FLS). This model is supported by a systematic review and meta-analysis that showed FLS to be the most effective approach for risk evaluation and treatment initiation 1. The Closed Model provides comprehensive care from identification through treatment and follow-up, reducing the risk of subsequent fractures through systematic identification and treatment of underlying bone health issues.

Key Characteristics of Each Model

• Open Model: minimal integration between fracture care and osteoporosis management, with patients referred to external providers for follow-up bone health assessment after fracture treatment
• Closely Aligned Model: partial integration with established communication channels between orthopedic services and bone health specialists, allowing for more coordinated care while maintaining some separation between services
• Closed Model: full integration where fracture treatment and subsequent osteoporosis management occur within the same system, often with dedicated FLS that provide comprehensive care

Evidence Supporting the Closed Model

A cluster RCT found that a nominated coordinator, a key element of the FLS model, significantly improves the implementation of osteoporosis treatment after a fragility fracture, with 45% of patients receiving appropriate management compared to 26% in the control group 1. This suggests that the Closed Model, with its dedicated coordinator and comprehensive care approach, is the most effective way to ensure patients receive complete post-fracture care and reduce the risk of subsequent fractures.

Implementation Considerations

The choice of model depends on available resources, existing healthcare infrastructure, and organizational capabilities within a specific health system. However, the Closed Model is generally considered the most effective approach for ensuring patients receive complete post-fracture care, and its implementation should be prioritized when possible, based on the evidence from the systematic review and meta-analysis 1.

From the Research

Definitions of Models in Post-Fracture Care

• The Open Model refers to a healthcare system where patients can freely choose their healthcare providers and services, without being restricted to a specific network or organization 2.
• The Closely Aligned Model is not explicitly defined in the provided studies, but it can be inferred that it refers to a model where healthcare providers and services are closely coordinated and aligned to provide comprehensive care to patients.
• The Closed Model is not explicitly defined in the provided studies, but it can be inferred that it refers to a healthcare system where patients are restricted to a specific network or organization, and have limited choices in terms of healthcare providers and services.

Characteristics of Models in Post-Fracture Care

• The Open Model is characterized by a lack of cohesion and consistency in care, making it challenging to maintain program effectiveness and cohesion when patients transition from acute care to primary care 2.
• Fracture liaison services and geriatric/orthogeriatric services are common models of post-fracture care programs, and have been shown to be cost-effective 3.
• Integrated-care models, such as the one developed in Ontario, Canada, aim to improve post-fracture care by enhancing communication between healthcare providers, and promoting investigation and treatment of osteoporosis 4.

Effectiveness of Models in Post-Fracture Care

• The efficacy of secondary fracture prevention programs correlates strongly with their intensity, with Type A FLS Models being the most successful in initiating diagnostic and treatment plans for fragility fracture patients 5.
• Patient-centered care programs, such as the PREVOST program, have been shown to improve post-fracture care by increasing bone mineral density investigation and treatment prescription 6.
• Creating a partnership with shared goals with primary care providers is a challenge for post-fracture care programs, but is essential for maintaining program effectiveness and cohesion when patients transition from acute care to primary care 2.