An ongoing six-year innovative osteoporosis disease management program: challenges and success in an IPA physician group environment.

The goal of this ongoing comprehensive osteoporosis disease management initiative is to provide the adult primary care physicians' (PCPs) offices with a program enabling them to systematically identify and manage their population for osteoporosis. For over six years, Hill Physicians Medical Group (Hill Physicians) has implemented multiple strategies to develop a best practice for identifying and treating members who were candidates for osteoporosis therapy. Numerous tools were used to support this disease management effort, including: evidence-based clinical practice guidelines, patient education sessions, the Simple Calculated Osteoporosis Risk Estimation (SCORE) questionnaire tool, member specific reports for PCPs, targeted member mailings, office-based Peripheral Instantaneous X-ray Imaging (PIXI) test and counseling, dual x-ray absorptiometry (DEXA) scan guidelines, and web-based Electronic Simple Calculated Osteoporosis Risk Estimation (eSCORE) questionnaire tools.