Residential Aged Care Research Articles

Knowledge, Attitude, and Practice of Care Providers Toward Non-Pharmacological Intervention for Managing Behavioural and Psychological Symptoms in Australian Aged Care Residents with Dementia: A Cross-Sectional Survey

ABSTRACT Objectives This study aimed to assess the knowledge, attitude, and practice of the healthcare professionals and paid caregivers toward non-pharmacological interventions (NPIs) for managing behavioural and psychological symptoms of dementia (BPSD) in Australian residential aged care homes (RACHs). Methods A cross-sectional, online survey was completed by RACH staff and physicians over the period 6 March-31 August 2023. Descriptive statistics were used to present the results. Results Ninety-six respondents participated (41.7% aged 35–54 years, 80.2% female, 38.5% nurses). While 50–65% of the respondents were extremely familiar with 15 of NPIs, only 22% believed there was a sufficient funding for their implementation, and 6% felt there were sufficient human resources. Although 66% of the respondents viewed NPIs as more useful than medications, only 46% expected consistent positive outcomes from NPIs. The most used NPIs were redirection, behaviour management, and validation therapy. Conclusions The study highlights that barrier such as inadequate funding, limited human resources, skepticism about NPIs’ effectiveness, unfamiliarity with certain NPIs, and unfavourable attitude toward NPIs are likely to slow NPI adoption for BPSD management. Clinical implication To improve practice, it is essential to address these barriers through targeted education, and training, increased funding, and enhancement of the workforce.

The use and usefulness of the Peninsula Health Falls Risk Assessment Tool (PHFRAT) process in residential aged care: a mixed methods study across 25 aged care facilities

BackgroundFalls remain a persistent problem in residential aged care (RAC) facilities. Fall screening and assessment tools such as the Peninsula Health Falls Risk Assessment Tool (PHFRAT) are widely used to inform falls risk and guide fall prevention interventions. However, it is unclear how it is used in practice and whether clinicians believe it supports resident care. This study aimed to measure the extent of use of PHFRAT to understand clinicians’ perceptions of its value and usefulness.MethodsThis mixed method study involved an analysis of PHFRAT assessment from 25 RAC facilities in New South Wales, Australia, and interviews with seven RAC staff about how PHFRAT information is used in practice. In the quantitative component, descriptive statistics were applied to PHFRAT data to summarise how RAC staff use the PHFRAT including the completeness and content of the three parts. In the qualitative component, thematic analysis techniques were applied to interview data.ResultsThe sample included 215 RAC residents with 703 PHFRATs, of which 617 documented fall prevention interventions. Among these 617 PHFRATs, 593 (96.1%) included strategies related to staff assistance and 283 (45.9%) recorded strategies related to device provision. While nearly all residents (96.74%) received at least one PHFRAT assessment over the study period, many PHFRAT assessments were incomplete (part 1: 11.5% of information missing; part 2: 10.8%; part 3: 17.1%). There were few variations in fall interventions prescribed to individual residents by their fall risk level. Interviews with RAC staff indicated that PHFRAT assessments are the responsibility of registered nurses with limited input from other staff or residents. While the structured process was viewed positively in guiding risk assessment and intervention assessment, a lack of input from others prevented strategies from being tailored to residents’ specific needs and preferences. A shortage of resources, lack of communication, and limited staff education were identified as the main barriers to PHFRAT guideline implementation.ConclusionThe PHFRAT provides a useful structure for clinicians to assess falls risk factors and plan falls prevention strategies. In the future, increased multidisciplinary input into fall prevention strategy development may improve the comprehensiveness of fall prevention plans.

Public health rapid response in managing COVID-19 outbreaks in residential aged care facilities: a regional public health unit perspective.

We describe here the impact of managing coronavirus disease 2019 (COVID-19) outbreaks, during January-August 2022, in residential aged care facilities (RACFs) in Central Queensland, Australia, following the deployment of a public health rapid response team (PHRRT, comprising a medical officer, a communicable disease nurse, and an epidemiologist) from a regional public health unit (PHU). Our existing vaccine preventable diseases surveillance framework was used in identifying any symptomatic resident, triggering a PHRRT response. We found that the Hospital in the Home (HiTH) admission and death events were significantly lower after the introduction of the PHRRT than in the outbreaks that occurred before. Based on our experience with a PHRRT-led approach in mitigating the burden of outbreaks, we recommend regular reflection on optimising resources and practices in RACFs. Effective communication from PHUs can improve the RACFs' preparedness and capacity to respond, and can inform the best practice model to protect the highly susceptible elderly residents and their staff.

Having to ‘go beyond’: Staff perspectives on activity programs for older people living in nursing homes

Activity programs are run by many nursing homes (also known as residential aged care facilities or long-term care facilities) however little is known about how activities are chosen or how well they meet the needs of residents. The aim of this study was to learn more about activity programs currently offered to older people living in nursing homes in Victoria, Australia. Interviews were undertaken with 13 activities/lifestyle staff working across six nursing homes. Staff were asked about their role and training; how activities were chosen, run, and evaluated; and barriers to providing social participation opportunities for residents. Thematic analysis of interview transcripts revealed six main themes: the role of the activities staff is to make people happy and meet their needs; activities staff largely choose (group based) activities; evaluation of activity programs is mostly informal; activity programs are poorly resourced; staff are often required to ‘go beyond’; and catering to the unique needs of residents is challenging. Given the established importance of social interaction to physical and psychosocial health, it is essential that activity programs and staff are viewed as integral to resident wellbeing; that staff are trained and supported; and that programs are funded and resourced adequately to deliver programs that are person-centred and meet the needs and preferences of residents.

A Focused Literature Review of Missed Care in Residential Aged Care

Missed care is any aspect of required care that is omitted (either in part or whole) or delayed. Residential Aged Care Facilities (RACFs) are susceptible to missed care due to a range of factors, including residents’ complex needs, workforce composition, and constraints placed on resource availability. This focused literature review aims to evaluate the current evidence on missed care, including an analysis of the concept, causes, and outcomes of missed care in residential aged care in Australia. Within most of the available literature, missed care is typically considered only within the context of nursing. It is noted that although the nature and identification of missed care were discussed extensively to provide a broad picture of the phenomenon, including possible prevalence and outcomes, they need to explicitly discuss the impact of missed care on residents, families, and other clinical and operational staff. Further research is needed to inform and improve the care of the elders in RACFs, considering this gap in the literature. This review has identified potential areas for enquiry into missed care to inform policy and practice to improve the care of elderly residents in RACFs.

Both Ends of the Leash: Animals in Australian Residential Aged Care Facilities, Views of Experienced Animal Trainers/handlers Working in Residential Aged Care Facilities

ABSTRACT Research on animals in residential aged care facilities (RACFs) mainly focuses on the residents with little concern for animal welfare. Australian RACFs cannot care for residents, making it unlikely they can maintain animal welfare. The One-Health/One-Welfare frameworks support developing animal policies in RACFs. However, inadequate policies places residents and animals at risk. To understand animals’ lived experiences in RACFs, experienced dog-trainers who worked in RACFs were interviewed. These experts were recruited using snowball sampling, with nine participating in semi-structured interviews providing opinions and experiences of visiting and live-in animals in Australian RACFs. The initial inductive coding produced six themes (residents, animals, handlers, staff, facility and policy). However, they noted animal welfare issues and explored them further using deductive coding, re-coding the quotes into four areas: handler, environment, participants and intervention. When residents were the focus of animal interactions, animal welfare became compromised, with dogs being frightened and one accidentally poisoned. Animals in RACFs could suffer poor welfare because of inadequate staffing, training and oversight. To provide safe, ethical animal contact, legislation and guidelines must support policy development for animals in RACFs.

The Attitudes, Beliefs and Perspectives of Registered Nurses on Sleep Health Management in Residential Aged Care Facilities: A Qualitative Study.

To explore the attitudes, beliefs and perspectives of registered nurses (RNs) regarding sleep health and sleep health management of residents living in aged care settings in Australia. Qualitative inductive thematic analysis of semi-structured interviews. Semi-structured interviews were conducted with RNs working in residential aged care facilities using a topic guide between August 2021 and April 2022. Participants were recruited using a convenience-based and snowball sampling approach. Interviews were audio-recorded, transcribed verbatim and inductively analysed for emergent themes. Eighteen interviews were conducted with RNs working in aged care. Thematic analysis of the data derived three main themes: (i) Awareness and observations of sleep health, (ii) assessment and management of sleep disturbances and (iii) barriers to implementing evidence-based sleep health management. It was found that the most common barrier to providing evidence-based sleep health practices was related to workplace constraints. Participants detailed the limitations of the RN's professional role and ability to work autonomously in sleep health practices. Despite the intentions of RNs to implement evidence-based non-pharmacological strategies for sleep health management, pharmacological interventions prevail. Systemic efforts to address organisational constraints in aged care may improve sleep disturbance management and assist with shifting the current attitudes around sleep health in aged care facilities. This study highlights that current sleep health management of residents in residential aged care is inadequate. Upskilling nurses in sleep health care techniques and improving organisational commitment to such care provision are issues urgently required to enhance the sleep health of residents. Current sleep health practices are not evidence-based in residential aged care. Optimising sleep practices in residential aged care that are person-centred is likely to improve quality of life and healthy ageing. No patient or public contribution.

Perspectives of Australian professionals who support younger people in residential aged care without access to individualised funding

Previous research demonstrates that living in residential aged care (RAC) has negative effects on the wellbeing of younger people (<65 years). This research reports on the barriers and enablers to avoiding or leaving RAC for younger people in Australia who do not have access to individualised disability funding packages. Interviews and focus groups were conducted with 18 staff who worked in an Australia-wide Program supporting younger people, and 24 stakeholders. Participants reported barriers to avoiding or leaving RAC that included a lack of funding, lack of appropriate housing, lack of transitional and rehabilitation services, and the preferences of family members. Enablers included having help to navigate alternative options, and effective collaboration across services. Participants reported that some younger people wanted to remain in RAC because they had no other option, were hesitant of change, or felt safe there. Funding and housing are required, as well as long-term, complex case management.

The Careful Project: Evaluating the acceptability of local virtual reality experiences as a leisure activity for residents in aged care.

The aim of this project was to evaluate the feasibility and acceptability of virtual reality (VR) as a leisure activity for people living in residential aged care. Virtual reality experiences may offer alternatives for residents with limited mobility, or during times when older people are unable to leave residential care. The intervention used VR videos delivered via a head-mounted device. Video content was created by a local artist specifically for use with older Western Australian adults and used local content. VR sessions were videotaped for analysis. The evaluation included structured observation of video content to assess mood and engagement and post-intervention interviews with participants. Mood and engagement scores indicated overall favourable mood and considerable positive engagement with the VR experience. Interview content analysis reflected the enjoyment participants took in visiting places they had once been and the surprising ways that the experience made them feel and act as though they were actually there. Videos featuring coastal visits were the most popular and videos featuring music were the most engaging. Some participants found the head-mounted device uncomfortable. VR was considered potentially beneficial for residents with limited mobility or living with cognitive impairment. Overall VR is a feasible and acceptable leisure activity for older people in residential care. The use of local content has the potential to prompt memories and generate new conversations. Future use of VR may consider different modes of video delivery and advancements in evaluation.

The Psychosocial Impacts of Co-Designed Healing Gardens Among Aged Care Residents With and Without Dementia in Nigeria

Healing gardens are green spaces that support the interaction of humans and elements of nature to improve well-being and quality of life. However, little is known about healing garden use and outcomes in African countries. This study aimed to design a healing garden intervention and measure its impact on psychosocial factors and quality of life of residents and care staff within two residential aged care facilities in Lagos, Nigeria. Each facility’s staff completed the psychosocial measurement tools by proxy for participants between ages 60 and 99, with or without dementia, at baseline and three months following interaction with the garden and completed the garden use observational survey to determine the effect on and use of the garden by care staff and residents. Results revealed an improvement in the quality of life and experiences of agitation but no beneficial change in depression among residents with and without dementia. Further, care staff reported a positive benefit of the garden on their work-life experience and the residents’ well-being. This study provides the base for future research on assessing the impact of healing gardens on persons living with dementia in Africa.

Experiences and Perceptions of Medication Management Communication During Transitions of Care for Residents in Aged Care Homes and Their Caregivers: A Qualitative Meta-Synthesis.

To explore the experiences and perceptions of communication about managing medication across transitions of care for residents living in aged care homes and their family caregivers. Effective medication communication across transitions of care involves exchanging information, resident, and family caregiver's participation in decision-making, and shared responsibility. A qualitative meta-synthesis. This review was conducted in accordance with the PRISMA 2020 guidelines and the accompanying 27-item checklist. A systematic search of seven electronic databases (Embase, PsycINFO, Medline Ovid, Scopus, CINAHL, EmCare and Web of Science) was performed from inception to December 2023. Studies eligible for inclusion in this review were required to be published in peer-reviewed English journals and focus on medication communication among healthcare providers, residents and family caregivers during transitions of care for aged care residents. The JBI Critical Appraisal Checklist for Qualitative Research was employed for the critical appraisal of the studies, and the COREQ checklist was used to evaluate their quality. Of the 2610 studies identified, 12 met the inclusion criteria. No study was excluded based on quality. Two main themes were generated: (1) Medication information exchange involving residents and families, and (2) resident and family factors influencing medication communication engagement. The findings revealed a lack of supportive structure for effective communication and collaboration among residents, family caregivers and healthcare providers during transitions of care, marked by one-way interactions and limited evidence of shared decision-making or family caregiver engagement in medication management communication, despite varying individual needs and preferences. Communication about medication management during transitions of care focused on sharing details rather than active engagement. Residents and their family caregivers have individual needs and perspectives regarding communication about medication management, which are not well addressed by healthcare providers during transitions of care. Healthcare providers' communication remains limited, and family caregivers are underutilised.

Intersection between person-centred practice and Montessori for dementia and ageing in residential aged care.

Internationally, person-centred care (PCC) is embedded in the language of regulations and mandated to be practised in residential aged care (RAC). Despite this, PCC has not been fully adopted in RAC in Australia and internationally, and concerns about the quality of care persist. Over the past 2 decades, Montessori for dementia and ageing has been introduced in RAC to support and inform a cultural change towards PCC. This study aimed to examine the intersection between the goals and approaches of Montessori and PCC in RAC. This qualitative descriptive study reports on a secondary analysis of qualitative data from focus groups (FGs) and interviews with residents, family-members, staff, and volunteers from eight RAC homes in Victoria, Australia. Sixteen FGs and 36 interviews were conducted. A qualitative deductive approach using researcher-developed Montessori for dementia and ageing framework for data analysis was applied. Findings provide support for the intersection between PCC and Montessori with participants' descriptions of PCC aligning with many of the goals and approaches of Montessori. Participants most commonly described Montessori approaches of engagement in daily tasks with purposeful roles and promoting cognitive abilities through multi-sensory stimulation. Least frequently-described approaches included focusing on residents' strengths/abilities, maintaining function, using familiar objects, and guided repetition. Findings have important implications for practice to use Montessori as a vehicle that supports and upskills the workforce to deliver care that is person-centred. Future research must examine the resources required to support the implementation and sustainability of Montessori as a vehicle for PCC.

A community within social and ecological communities: a new philosophical foundation for a just residential aged care sector.

A community within social and ecological communities: a new philosophical foundation for a just residential aged care sector.

The rate, causes and predictors of ambulance call outs to residential aged care in the Australian Capital Territory: A retrospective observational cohort study.

Older people in residential aged care are susceptible to acute illness or injury which may necessitate an ambulance call out, assessment/treatment by a paramedic and transfer to a hospital emergency department. Understanding the case mix of residential aged care ambulance attendances is important for prevention strategies and for planning services. A retrospective observational closed cohort study was designed to investigate the characteristics of emergency ambulance call outs to 15 residential aged care sites in the Australian Capital Territory over a 12-month period. Data were collected from the local ambulance service and the aged care sites. Case load data were analysed to determine rates, clinical characteristics, ambulance attendance outcomes and the temporal distribution of call outs. A Poisson regression model was developed to investigate demographic, morbidity and medication-related risk factors associated with the number of ambulance call outs per resident. Annual ambulance call out costs were estimated. There were 1,275 residents, with 396 (31.1%) requiring at least one ambulance call out over 12 months. Of 669 ambulance attendances, the majority (87.0%) were transported to emergency departments. Trauma (23.9%), pain (16.9%) and infections (9.4%) were the most common primary assessments by the ambulance attendees. Cases/day were similar throughout the year and on weekdays compared to weekends/public holidays. The main predictors of ambulance call out were multi-morbidity, taking regular anticholinergic medicines, being male and younger age. Estimated costs of ambulance call outs/year were $475/resident and $40,375/residential aged care site. The most frequent primary assessments (trauma, pain, infections) may constitute priorities for developing prevention strategies and for treatment initiatives within residential aged care. Strategies to reduce anticholinergic medication prescribing may also be a potential intervention to decrease ambulance call outs and hospital emergency department demand. The ambulance usage data from this study may be useful to compare with future datasets to measure the impact of the introduction of new services.

Exploring the Safewards Programme to Reduce Restrictive Practices in Residential Aged Care: Protocol for a Pilot and Feasibility Study.

Restrictive practice use in residential aged care homes internationally is unacceptably high. Although policies and legislation mandate the reduction or elimination of restrictive practices, there remains a gap in knowledge regarding strategies that have been effective in achieving a sustained reduction in restraint use. There is an urgent need to identify effective and feasible interventions that aged care staff can implement in everyday practice to reduce restraint use. Safewards is an evidence-based programme that has demonstrated effectiveness in reducing conflict and restrictive practice use in inpatient psychiatric settings and has the potential to address the issue of restraint use in aged care homes. This study aims to evaluate the feasibility of Safewards in reducing restrictive practices in residential aged care homes. This pilot and feasibility study will adopt a mixed methods process and outcomes evaluation. Safewards will be implemented in two Australian residential aged care homes. The Reach, Effectiveness, Adoption, Implementation and Maintenance framework will be used to evaluate implementation outcomes. Additionally, the Consolidated Framework for Implementation Research will be used to guide qualitative data collection (including semi-structured interviews with residents/family members, aged care leaders and staff) and explain the facilitators and barriers to effective implementation. This study will provide pilot evidence on the feasibility of the Safewards programme in residential aged care homes. Understanding the processes and adaptations for implementing and evaluating Safewards in residential aged care will inform a future trial in aged care to assess its effectiveness. More broadly, the findings will support the implementation of an international aged care policy of reducing restrictive practices in residential aged care. A person with lived experience of caring for someone with dementia is employed as a Safewards facilitator and is a member of the steering committee. Residents and family members will be invited to participate in the project steering committee and provide feedback on their experience of Safewards. ACTRN12624000044527.

Modified Oral Health Assessment Tool (M-OHAT) for Residential Aged Care: A Co-Design Protocol

Background: Older adults in residential aged care facilities (RACFs) experience disproportionate levels of poor oral health relative to other groups in the general population, affecting their physical and mental wellbeing. The Oral Health Assessment Tool (OHAT) is a validated and widely used dental assessment tool; however, recent systematic reviews have identified shortcomings with respect to its measurement properties. Objective: The objective of this protocol is to provide a detailed overview of a multidisciplinary qualitative study that aims to (a) co-design and develop a modified OHAT for RACFs and (b) inform the development of an OHAT training package and implementation strategies. Methods: This study will utilize a co-design methodology with aged care residents, caregivers, staff members, and health professionals. The co-design workshops will: (1) investigate the barriers to and enablers of optimal oral healthcare in RACFs; and (2) co-design a modified version of the Oral Health Assessment Tool and a referral to treatment pathway that is appropriate for use in RACFs. The co-design workshops will facilitate group discussion and involve interactive activities using, for example, mind mapping and Sticky Notes. Qualitative data (transcripts and artefacts from co-design activities) will be analyzed in NVivo using an inductive codebook thematic analysis, specifically a template analysis. Conclusion: The findings of this study will inform a modified OHAT (M-OHAT), as well as future study phases regarding training and implementation strategies. It is expected that the M-OHAT will have enhanced usability and relevance to RACFs, facilitating the identification of poor oral health and timely referral to dental treatment.

COVID-19 and Its Influence on Prevalence of Dementia and Agitation in Australian Residential Aged Care: A Comparative Study

Agitation is one of the most common and persistent behavioral and psychological symptoms among persons with dementia (PWD) in residential aged care facilities (RACFs). While most studies have explored the general impact of COVID-19 on the mental health and well-being of aged care residents, there has been limited research on the pandemic’s impact on agitation in dementia within RACFs. This knowledge is crucial to ensuring that RACFs are better equipped to handle future public health emergencies. Therefore, this retrospective cohort study investigates the impact of the pandemic on agitation incidents within 40 Australian RACFs. Using Python, we extracted agitation symptoms from nursing notes and compared the frequency and percentage of symptom occurrence pre-pandemic versus during-pandemic. Chi-square tests examined any significant change in the prevalence of dementia and agitation in dementia between the comparative groups and periods. Dementia prevalence dropped significantly during the second year of the pandemic, with a concurrent increase in early-onset dementia cases. Overall, agitation symptoms decreased by 20.1%, but six symptoms significantly increased: resisting (28.98%), wandering (11.78%), restlessness (3.19%), complaining (10.1%), arguing (2.36%), and outbursts (1.74%). Conversely, pacing decreased by 15.88% and speaking loudly decreased by 10.9%. Over half of the care recipients with dementia experienced agitation symptoms 2–5 times each year, increasing from 50.56% in 2019 to 58.28% in 2021. Despite the co-occurrence of symptoms such as falls, confusion, and weakness, there was no evidence to suggest that these comorbidities were specific to COVID-19; rather, they appeared to be prevalent even before the pandemic. Persons with agitation in dementia had a significantly higher death rate during the COVID-19 pandemic than otherwise.

Medicine communication from hospital to residential aged care facilities: a cross-sectional survey of aged care facility staff.

Continuity of medicines management can be compromised when older people are transferred between hospital and residential aged care facilities. This study explored medicines management practices at facilities during patients' transfer of care from hospital, and staff experiences with medicines information handover from hospitals. An electronic cross-sectional questionnaire sent to all residential aged care facilities within a metropolitan region in Australia, in February 2022. The questionnaire comprised 23 questions covering facilities' profiles, medicines management practices, and medicines management at transfer of care from 2 public hospitals. Of 53 listed facilities, 31 [58.5%] responded. Facilities varied in size ranging between < 50 and up to 200 beds. Twenty-seven [87.1%] facilities offered more than one level of care. Of those 27 facilities, 26 [96.3%] offered dementia care, and 23 [85.2%] offered palliative care. Six (19.4%) solely used hardcopy medication charts. Handover from hospitals to manage patients' medicines at transfer was inconsistent with only 15 [48.4%] reporting consistently receiving appropriate documentation. Residential aged care facilities varied in size and level of care. Diverse processes exist for medicines management. There is inconsistency in information received when residents transfer from hospital to facilities, potentially compromising patient safety.

Health professionals’ and caregivers’ perspectives on improving paramedics’ provision of palliative care in Australian communities: a qualitative study

ObjectivesParamedics have the potential to make a substantial contribution to community-based palliative care provision. However, they are hindered by a lack of policy and institutional support, as well as targeted...

Adherence to clinical care standards and mortality after hip fracture surgery in New South Wales, 2015-2018: a retrospective population-based study.

To determine whether adherence to hip fracture clinical care quality indicators influences mortality among people who undergo surgery after hip fracture in New South Wales, both overall and by individual indicator. Retrospective population-based study; analysis of linked Australian and New Zealand Hip Fracture Registry (ANZHFR), hospital admissions, residential aged care, and deaths data. People aged 50 years or older with hip fractures who underwent surgery in 21 New South Wales hospitals participating in the ANZHFR, 1 January 2015 - 31 December 2018. Thirty-day (primary outcome), 120-day, and 365-day mortality (secondary outcomes) by clinical care indicator adherence level (low: none to three of six indicators achieved; moderate: four indicators achieved; high: five or six indicators achieved) and by individual indicator. Registry data were available for 9236 hip fractures in 9058 people aged 50 years or older during 2015-2018; the mean age of patients was 82.8 years (standard deviation, 9.3 years), 5510 patients were women (69.4%). Complete data regarding adherence to clinical care indicators were available for 7951 fractures (86.1%); adherence to these indicators was high for 5135 (64.6%), moderate for 2249 (28.3%), and low for 567 fractures (7.1%). After adjustment for age, sex, comorbidity, admission year, pre-admission walking ability, and residential status, 30-day mortality risk was lower for high (adjusted relative risk [aRR], 0.40; 95% confidence interval [CI], 0.30-0.52) and moderate indicator adherence hip fractures (aRR, 0.61; 95% CI, 0.46-0.82) than for low indicator adherence hip fractures, as was 365-day mortality (high adherence: aRR, 0.59 [95% CI, 0.51-0.68]; moderate adherence: aRR, 0.74 [95% CI, 0.63-0.86]). Orthogeriatric care (365 days: aRR, 0.78; 95% CI, 0.61-0.98) and offering mobilisation by the day after surgery (365 days: aRR, 0.74; 95% CI, 0.67-0.83) were associated with lower mortality risk at each time point. Clinical care for two-thirds of hip fractures attained a high level of adherence to the six quality care indicators, and short and longer term mortality was lower among people who received such care than among those who received low adherence care.