To catalyze and guide your thinking, we are providing journey maps that represent some commons paths of care. Please note that the journey maps do not represent real health care providers or real patients. These are guide points providing a representation of the challenges in the journey. The journey maps are certainly not an exhaustive illustration of who innovations may support or touch.

It’s important to note that while these maps point to potential solutions, there are many reasons why these solutions don’t exist at scale—from funding and resource constraints, to provider and patient awareness, to differences in actual lived experience. We encourage you to use these journeys as a starting point in understanding health systems, then discover opportunities through the Personas and your own investigation, and design around obstacles, realities, and insights you uncover.

Healthy Bones Healthy Aging Challenge Journey Maps

OverviewEmpathy is at the heart of our process. The journey maps

in this document are the reference point for the

people and experiences central to the Healthy Bones

Healthy Aging Challenge

HEALTHY BONES HEALTHY AGING CHALLENGE - JOURNEY MAPS

In the community

Meet Alice, a 70 year old woman living independently. She has an adult daughter that lives and works nearby.

Alice doesn’t know it yet, but she has Osteoporosis.

1. Introducing Alice

2. Community Center Visits

In the Hospital

Most days, Alice drives herself to the Community Center to have lunch with her friends and catch up on the goings on in the neighborhood.

She participates in Matter of Balance, a Tai Chi program (part of an Evidence Based Program on physical exercise).

Every so often she strolls past the resource library at the Community Center. Last time in she picked up a brochure on preventing falls in her home. A new ride share program called Go Go Grandparent looks interesting.

It has started to rain – as she leaves the resource library, Alice slips and falls on a slick spot on the stairs. Her left hip breaks the fall, and she experiences excruciating pain. She fears something may be broken.

The staff at the Community Center convince Alice this is a serious injury and a ambulance is called.

The next question becomes: What area hospital should she go to? Should it be the closest or best? Does Alice even have a choice based on the ambulance provider contract?

The next thought that enters Alice’s mind is “don’t call an ambulance!” Living on a fixed income, she worries about the expense. Even more troubling is the thought of losing independence and becoming a burden on her daughter.

The ambulance brings Alice to the emergency department and begins to fill out paperwork. She is admitted – imaging is ordered.

Imaging confirms her left hip is fractured. Because this is determined to be a non-emergent injury, Alice spends an uncomfortable night waiting for surgery the next day.

During the operation, the surgeon notices from the way the hip is broken, that Alice’s bone density might be lower than normal.

An orthopedic nurse helps Alice through her post surgery recovery period on the Orthopedic floor of the hospital.

The same day the surgery is completed, Alice starts in-patient physical therapy on the orthopedic floor. The therapist tells her about the practical do’s and don’ts for getting back to full use her hip. Alice thinks to herself “this is going to be a lot of work!”

Once Alice’s Primary Care Physician reviews her discharge papers, she orders a DXA scan to assess whether Alice may have OP. The PCP sends Alice back to hospital to get tested.

The DXA machine is the hospital’s imaging department is old and out of date.

After leaving the SNF, Alice is referred to an outpatient physical and occupational therapy clinic at the hospital.

The clinic is in the basement and difficult to find. It’s also inconvenient because Alice doesn’t live nearby and needs to find a ride each way. .

When the DXA results come back, the PCP sees that Alice's T-Score is -2.7 - in the zone for Osteoporosis. When the PCP provides the diagnosis, Alice feels her heart sink is fearful of losing independence and becoming a burden for her family.

Alice is assigned to a case manager who prepares her for discharge. Osteoporosis, a DXA scan, or treatment options may not have been mentioned. Instead, the discharge is focused on Alice’s surgery, mitigating the risk of readmission to the hospital.

Alice isn’t ready to be released home, as her break is severe with additional soft tissue damage. She’s discharged to a Skilled Nursing Facility.

Patients usually spend between 2-4 weeks at the SNF for a severe fracture.

The Osteoporosis Patient Narrative

Alice and her PCP discuss a treatment plan for her Osteoporosis, which includes weight-bearing exercise, a diet rich in calcium, and vitamin D supplements. After discussing risk and options, her PCP also starts Alice on an OP medication.

Alice gets a case manager through her Community Center. The case manager visits her home to assess fall risks, creates a care plan, and follows up monthly.

Case managers can follow cases for years if necessary, but a few months is likely enough for Alice.

A volunteer from the community helps Alice weekly to shop and take care of errands. She was referred to the service through her Community Center.

A friend tells Alice about Rebuilding Together. Rebuilding Together is a non-profit serving those who lack the means to make changes to their home. Alice doesn’t need much, but requests grab bars for her bathroom and new carpet that does not put her at risks for future falls.

3. Available Resources

4. A Big Fall… Ouch!

5. No Ambulance, Please

6. Ride to the Emergency Room

Scoping Workshop May 2018

14. Plan for Outpatient PT/OT 15. DXA Scan

16. Osteoporosis Diagnosis

13. Skilled Nursing Facility (SNF)

Out-patient Experience Reestablishing Routines

12. Discharge with a Case Manager

17. Osteoporosis Treatment Plan

18. Community Case Management

19. Senior Companion

20. Rebuilding Together

7. Arriving at the Hospital

8. Triage toConfirm a Fracture

9. Orthopedic Surgery

10. Post-Surgery Recovery

11. Acute Care Physical Therapy

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Coordinating the availability and distribution of educational materials in the Community

Patient / Caregiver / Program coordinator

IdentificationInformation

The Emergency Department experience for patients, including identification and tracking patients at the point of entry

Patient / Physician & Staff / EMT

Identification

Discharge from the hospital, including 1) streamlining case mgmt protocols 2) Selecting/referring patients to SNF 3) Handoff of patients to outpatient Ortho or PCP

Patient / Physician / Case Manager

Quality/Data

Investigation

Collection and analysis of data, including 1) reconciling data across systems 2) tracking patients using a manual process 3) analyzing baseline metrics for fracture patients

Identification

Patient / Physician & Staff

Intervention Integration

Coordinating w/ PCP post-surgery including 1) DEXA scans at O'Connor 2) Use of O’Connor outpatient PT 3) Supporting a diagnosis of Osteoporosis 4) Starting a holistic treatment plan to prevent a secondary fracture

Patient / Physician & Staff / PT

Identification

Preventing and mitigating secondary fracture impacts, including 1) Re-establishing routines in the community 2) Identifying patients who enter the hospital w/ a second fracture

Patient / Physician & Staff / Caregiver