What to do after a hip fracture? The importance of transitional care planning for older patients.

Hip fractures are a significant health risk as result of the most common injury in older people - falls. Also compounded by factors like reduced physical strength, balance issues, and conditions such as osteoporosis and thinning of bones. These fractures not only represent a major medical event but also a pivotal moment in the lives of older people, when it results in loss of independence and quality of life.

The consequences of a hip fracture extend beyond the immediate physical injury often marking a challenging journey, including surgery, hospitalisation, and a lengthy recovery process. The physical and psychological impact on older people is particularly profound, affecting their mobility, independence, and overall well-being and underscores the need for effective and compassionate care tailored to the unique needs of each individual.

In September 2023, the Australian Commission on Safety and Quality in Health Care released the revised Hip Fracture Clinical Care Standards(1). This update represents a significant step forward in the standardisation and improvement of care for hip fracture patients. The standards provide a framework for healthcare providers to deliver high-quality, evidence-based care, ensuring that patients receive the best possible outcomes.

For patients returning to an aged care home, Dr Carolyn Hullick, emphasises the role that aged care providers play in ongoing care of individuals, and minimising their risk of future falls and fractures. An important focus given that a reported 27% of hip fractures occur within an aged care setting. (2).

So what stood out for us? Transitions from Hospital Care

The seventh Quality Statement, "Transition from Hospital Care", we see as critically important and addresses a common concern for families - the process for discharge and care post-hospital, which is often the point when many reach out to us for support. This transition phase is often complex, involving coordination between healthcare, social workers or discharge planners, care services, and of course, patients and their families to ensure a safe and supportive move from hospital to home where home can include an aged care setting.

Noting that before a person leaves the hospital after a hip fracture, an individualised care plan is developed that describes their goals of care and ongoing care needs. This plan, crafted in collaboration with the patient, their family, and healthcare team, outlines a comprehensive approach to address all aspects of the patient’s recovery. It includes details on mobilisation activities, expected functional outcomes, wound care, pain management, nutrition, fracture prevention strategies, and any specific rehabilitation services and equipment needed.

Challenges in Implementing Care Plans

Ensuring that all aspects of the plan are understood and followed by everyone involved can be difficult, especially when dealing with multiple care providers and the complexities of home modifications and ongoing medical needs. One of the most significant challenges in this process is the current delay associated with Home Care Packages (HCP). The time taken to apply for, receive approval and be assigned these packages can be substantial, often extending from 6 to 9+ months, followed by time to engage a chosen provider. This delay poses several issues:

Immediate or early Care Gap: Patients can be discharged from the hospital without the necessary care services immediately in place or when transitional care is offered is limited to between 4-12 weeks. This leaves many weeks or months to have an Aged Care Assessment via My Aged Care and the subsequent wait for HCP approval and final set-up.

Increased Risks: The lack of immediate post-discharge care services can lead to increased risks of further injury, delayed recovery, and a higher likelihood of hospital readmission.

Disjointed Continuity of Care: Post-hospital care at home can see care and health workers change from [1] transitional care services, to [2] multiple Commonwealth Home Support Program (CHSP) providers using interim codes (whilst on the national waitlist), and finally to [3] HCP providers. This is experienced by the care recipient as a revolving door of different care workers and services, multiple assessments which need significant coordination to stay on top of.

Stress on Families: The delay places additional stress on families and informal carers, who may not be prepared to provide the level of care needed. This can lead to caregiver stress and burnout, particularly if the carers are older themselves or have other responsibilities.

As highlighted by Dr. Hullick:

“When someone’s coming home from hospital with a hip fracture, [it’s about] recognising that it’s been a life-changing injury and recognising that getting them back on their feet and back to their best condition is important.”

This perspective is central to our approach at Ageing Well Sorted. In our experience supporting the journey of recovery from a hip fracture, ensuring a seamless transition from hospital or rehabilitation centre to home is incredibly important. We also support the immediate family and informal carers, tasked with continued care and a safe environment for recovery at home. Getting this right reduces the risk of further mishaps and looping back into the hospital system.

Here's how we help:

Coordinating Transitional Care: We take on the responsibility of coordinating care plans among healthcare providers, our clients, and their families. Our goal is to make sure everyone involved understands and effectively follows the care plan.

Bridging the Home Care Package Gap: We understand the delays in obtaining Home Care Packages and thus provide interim solutions and guidance to cover the care needs during the waiting period. This ensures our clients are not left without essential care.

Personalised Care Planning: Each client is unique, and we dedicate ourselves to creating and adapting personalised care plans that focus on their specific needs and goals. Our approach is tailored to each individual's journey to recovery.

Family Support: We believe in empowering families. By providing them with the right resources and education, we help them understand the care process. This reduces their stress and enhances their ability to provide support.

Through our expertise and compassionate approach, we ensure that our clients and their families receive the comprehensive support and care necessary for a successful recovery post-hip fracture.

If you’re looking for guidance or assistance putting together a plan for yourself or a loved one after a hip injury, get in touch today.

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References:

1. Australian Commission on Safety and Quality in Health Care. Hip Fracture Clinical Care Standard. Sydney: ACSQHC; 2023. (First released 2016, revised 2023).

2. Article_AgedCareHomesCrucialToHipFractureRecovery_NatashaEgan_www.australianageingagenda.com.au_20231109 Aged care homes crucial to hip fracture recovery - Australian Ageing Agenda