Outreach Rehabilitation Program Improves the “Chaotic Journey” After Hip Fracture

Abstract

A 4-week outreach rehabilitation program for nursing home residents after hip fracture repair appears to have provided hope and self-confidence as well as early mobilization and improved activity levels when compared with the usual care after hospital discharge. These findings come from a small qualitative analysis conducted in parallel to a randomized, controlled trial evaluating the efficacy and cost-effectiveness of the hospital team-led outreach rehabilitation program. Almost all the 28 residents included in the qualitative analysis had severe cognitive impairment. The larger trial recruited 240 older people in three hospitals in South Australia who had been admitted from nursing homes and were recovering from hip fracture surgery. The residents were randomized to receive either the usual care, which included physiotherapy provided by the nursing home staff and medical care provided by the residents’ usual general practitioner, or outreach rehabilitation in addition to the usual care. Outreach rehabilitation involved an average of 14 visits over 4 weeks from the local hospital team, including a geriatrician, physiotherapist, dietician, and, when required, a rehabilitation nurse. The physiotherapist focused on restoration of transfers and mobility, used positive motivational scripts to encourage engagement, and worked with nursing home staff to “encourage a rehabilitation approach between formal therapy sessions.” The qualitative subanalysis — as detailed in the report “The Chaotic Journey: Recovering from Hip Fracture in a Nursing Home” (Arch Gerontol Geriatr 2016;67:106–12) — aimed to understand the experiences and perceptions of 14 residents who returned to “usual care” and 14 residents who received outreach rehabilitation, through interviews and focus groups with family members and nursing home staff. Information on the 28 residents (out of the first 30 recruited for the randomized, controlled trial) was collected on average 5 weeks after each resident had returned from the hospital. The residents had a mean age of 87.5 years (range of 70 to 97 years), and each had been mobile before the fracture. Discharge occurred 2 to 19 days after surgery (a median of 4.5 days). Most of the residents (23 of the 28) had severe cognitive impairment after surgery and three had mild to moderate cognitive impairment, according to the scores on the Mini Mental Score Examination taken at entry to the trial. The challenges “started in the hospital with hospital staff ill-equipped to treat people with dementia and, following discharge home, nursing staff frequently reported poor handovers.” A dearth of information or guidelines from the acute hospital setting about how to handle and manage people after a hip fracture was reported by Maggie Killington of Flanders University and Repatriation General Hospital in Adelaide, Australia, and her associates in the same study. In the usual care group, “the nursing home staff lacked the knowledge and confidence to support [the residents’] recovery following hip fracture repair,” and the physiotherapists were unable to provide timely advice to the nursing home staff and were “unable to provide the intensity of therapy required to promote return of patients’ mobility.” Moreover, ongoing pain, malnourishment, and delirium — and a loss of hope and motivation to engage in activity — were more common among those who received the usual care. Eight of the 14 people who returned to usual care endured either ongoing pain or unacceptable medication side effects. By contrast, the caregivers and families of the residents who received outreach therapy “were positive about the experience and often surprised at the progress,” the investigators wrote. “In addition to good pain management strategies and improved activity levels, [they] were less likely to report anxiety and more often focused on improved quality of life.” Outreach physiotherapy was the most valued aspect of the outreach program, the investigators reported. Residents received psychological support in conjunction with mobility training and strengthening exercises, and the physiotherapists often “worked in conjunction with family members and nursing home staff to provide a safe environment with graduated challenges as the resident attempted to move in bed, get to stand, use stand lifting devices when necessary and undertake stand transfers.” The value of geriatrician input and improved nutritional status were also among the themes that emerged across interviews. “Ways need to be found for the appropriate expertise to follow the patient through post-operative recovery after hip fracture,” the authors said, calling for “integrated care pathways for people with dementia and hip fracture.” Christine Kilgore is a freelance writer in Falls Church, VA.