Multidisciplinary Osteoporosis Care: the Future is Now

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Ten years ago there was a vision. Could a unique clinical program be developed that would be based on a framework of excellence in clinical care, education and research, and be built upon a foundation of the principles of women’s health? This vision was reinforced on February 22, 2005 in a speech by the Hon. George Smitherman, Minister of Health and Long Term Care, entitled “Mending Ontario’s Fractured Care”, the launch of the provincial Osteoporosis Strategy, where he announced the recommendation of the “establishment of interdisciplinary teams in Academic Health Science Centres across the province to provide better integrated care for complex osteoporosis cases.”

Having been designed with input from women with osteoporosis, the Multidisciplinary Osteoporosis Program at the Women’s College Ambulatory Care Center campus of Sunnybrook and Women’s College Health Sciences Centre is celebrating ten years of providing care to individuals with, and at risk for osteoporosis.

The multidisciplinary ambulatory care model integrates clinical care, education and research in a single location. It includes the Clinical Program, Research Program and Education Program. This model allows for the dynamic process of the translation of clinical questions into research and then back to practice and education, ensuring best clinical practice in the field of osteoporosis.

The Osteoporosis Clinical Program uses a “one stop” patient-centred approach, which encourages and facilitates individuals to participate in all aspects of their care. Patients access the full team during an assessment, rotating through each health discipline individually. The clinical team includes physicians specializing in osteoporosis (rheumatologists and endocrinologists), a Clinical Nurse Specialist, Dietitian, Physical Therapist, Occupational Therapist, and Pharmacist. Patients attending the Clinical Program receive an individualized plan of care to address their bone health needs. Patients also have access to team members on an ongoing basis, and return to the program for scheduled follow-up visits. Bone densitometry provides an important service to both the Clinical and Research Programs.

The Osteoporosis Research Program reflects a broad spectrum of research – from program evaluation and practice-based research, to scientific peer-review research. Dr. Gillian Hawker, the Osteoporosis Program’s clinical and research director, has been member of the Scientific Advisory Committee of Osteoporosis Society of Canada (OSC) since the early 1990’s, and has facilitated ongoing interaction between OSC and Clinical and Research Programs. Close collaboration also exists with the Ontario Ministry of Health and Long Term Care; members of the Research Program were actively involved in the Ontario Women’s Health Council report and in developing the Ministry of Health and Long Term Care’s Osteoporosis Strategy.

Research is conducted by a large interdisciplinary research team (medicine, paediatrics, rehabilitation, pharmacy, nutrition, clinical psychology, orthopaedics, kinesiology). Graduate students and post-doctoral fellows are also affiliated with the program. This program has attracted substantial peer-reviewed grants. Individuals attending the Clinical Program have an opportunity to participate in research studies. The Research Program supports the provincial Osteoporosis Strategy of Best Practices – providing health professionals with tools to better use clinical practice guidelines, and Research – to expand our knowledge base about osteoporosis, allowing us to improve both prevention and treatment in the future.

The Osteoporosis Education Program provides a unique opportunity for medical and health discipline students to experience an interprofessional model of care. Each year the program provides a learning opportunity for many students from various backgrounds.

The program has been recognized for its leadership in multidisciplinary care. Several national programs have been modeled after this program. Team members are committed to sharing their expertise with colleagues from across Canada, and often participate in professional and community group presentations.

The Osteoporosis Program is currently testing new initiatives in the provision of care for individuals with osteoporosis. In support of the provincial Osteoporosis Strategy of the “integration of osteoporosis care throughout the various stages of treatment – primary care, post-fracture, rehabilitation – to ensure that patients receive the right care at the right time, by the right person”, the team is facilitating increased access to care by providing consultations by the entire multidisciplinary team for patients from Orillia and Timmins via telehealth through the North Network system as part of a research project.

In support of the Ministry of Health’s recommendation for the development of self-management programs and resources to help patients manage their osteoporosis and prevent its progression, the Osteoporosis Program is implementing an e-health initiative. This will enable program patients to access their own health information regarding their osteoporosis through an internet connection with the Osteoporosis Program. This will further enhance the current resources available on osteoporosis through the hospital website www.womenshealthmatters.on.ca and the Marion Powell Women’s Health Information Centre, located at the Women’s College Ambulatory Care Centre.