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M. E. B. de Lima et al.
15.7 Family Cares andPatient Education Using Technology
The COVID-19 pandemic has given digital educational pathways enormous visibility, as it was impossible to organise face-to-face support groups for patients and
carers worldwide. The term ‘eHealth technology’ is used to refer to digital support
(mobile applications, web-based platforms, virtual reality, etc.) that delivers digital
interventions or relevant educational content. Studies have found many positive
aspects of this approach and suggest that digital health tools can be an inexpensive,
easily accessible and time-saving option for addressing caregiver burden and mental
health. Further improvement and the development of commercialised digital health
tools that are scientically based but tailored to carers is needed [49].
Evidence suggests [50] that digital tools for caregivers (including web-based
solutions, mobile applications, or virtual reality; through video, audio, text, and
interactive content) that help to develop coping skills, emotional self-regulation,
caregiver education, skill building, and training using a well-structured approach
can be very effective in managing caregiver stress and burden. Due to their accessibility, adaptability, and the ability to provide structured and therapeutic interventions, digital health tools are an important means of support for informal carers.
Regarding the use of digital content among patients, it is important to consider
that the digital format is not an option for all patient proles (if they have cognitive
decits or are unfamiliar with devices such as smartphones, PCs, tablets) and healthcare providers need to explore the preferences and digital skills of each older adult
before offering this type of educational programme [49].
Summary and Main Points for Learning
• The aim of patient-centred healthcare is to empower patients to become
active participants in their own care, while also ensuring the empowerment
of the family when they play an important role in patient care. A key priority for patients is how their wishes and those of their families and carers are
integrated into the care process. Healthcare professionals are expected to
focus on working with patients and families of all ages, at all levels of care
and in all healthcare settings.
• Educating older adults with hip fracture about their injury and the best
treatments is an essential aspect of healthcare. However, the age of this
patient prole should be considered when designing specic patient education programmes to ensure an appropriate decision-making process, which
should include their carers.
• The needs of carers must be considered when designing educational content for them. Educational needs change according to the socio-economic
and anthropological conditions in which the patients nd themselves, and
according to the characteristics of the carers themselves. It is common to
nd informal carers who are of a different nationality from the patient and
who provide different types of care according to their own culture.
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249
15.8 Suggested Further Study
Ariza-Vega P, Ortiz-Piña M, Kristensen MT, Castellote-Caballero Y, JiménezMoleón JJ (2019) High perceived caregiver burden for relatives of patients following hip fracture surgery. Disabil Rehabil. 41(3):311–318. https://doi.org/10.108
0/09638288.2017.1390612.
Batista de Lima ME, Falaschi P, Eleuteri S (2020) Supporting family caregivers
of older adults with hip fracture: the role of educational courses. in Caregiving:
Perspectives, experiences and challenges. Nova Science Publishers. ISBN:
978-1-53616-889-1.
Guilcher SJT, Maunula L, Cadel L, Everall AC, Li J, Kuluski K (2021) Caregiving
for older adults with hip fractures: Exploring the perspectives of caregivers, providers and decision-makers in Ontario, Canada. Arch Gerontol Geriatr. 93:104321.
https://doi.org/10.1016/j.archger.2020.104321.
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Open Access This chapter is licensed under the terms of the Creative Commons Attribution 4.0
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adaptation, distribution and reproduction in any medium or format, as long as you give appropriate
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Discharge andPost-hospital Care
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16
MetteIreneMartinsen, MariaEduardaBatistade Lima,
andAlcindaMariaRudolph
16.1 Introduction
Fragility fracture is the result of a combination of bone fragility and a fall. Hip fracture and other signicant fractures are devastating injuries for both the patient and
their family, especially if the patient is older which nearly always requires admission to an acute hospital. The impact of such injuries and subsequent surgery on
mobility, function, and independence is immense and the recovery process requires
both physical and psychosocial care [1] which usually aims to return the person to
their place of residence before the injury. A well-planned discharge can reduce the
risk of adverse outcomes and readmissions. A multidisciplinary approach and good
communication both with the patient and family/informal caregivers as well as primary care throughout the process is essential for a safe discharge.
Patients’ and their families’ feelings of not being seen, heard, or given opportunity to take part in planning discharge and post-hospital care can negatively inuence their experience of transition to another level of care. Studies show that actively
[2]. Families and caregivers can play an important role in post-hospital care so
should be deeply involved in discharge planning. Studies show that patients have
lower readmission rates when caregivers are involved.
Case management models can be used to integrate services to meet the needs of
people with complex care needs. Such approaches can help in planning and preparing patients with hip fracture or other signicant fragility fractures for discharge.
M. I. Martinsen · A. M. Rudolph
Department of Anesthesiology and Surgery, Diakonhjemmet Hospital, Oslo, Norway
e-mail: Metteirene.martinsen@diakonsyk.no; Alcindamaria.rudolph@diakonsyk.no
M. E. B. de Lima (*)
Azienda USL Toscana Sud Est; FFN Education Committee; FFN Italy, Siena, Italy
e-mail: mariaeduarda.batistadelima@uslsudest.toscana.it
© The Author(s) 2024
K. Hertz, J. Santy-Tomlinson (eds.), Fragility Fracture and Orthogeriatric
Nursing, Perspectives in Nursing Management and Care for Older Adults,
https://doi.org/10.1007/978-3-031-33484-9_16
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One model that has demonstrated effectiveness in addressing the needs of patients
with fragility fractures is the Transitional Care Model (TCM).
This chapter aims to give an overview of best practice in discharge planning,
discharge, and post-hospital care following fragility fracture and describe different
case management models.
M. I. Martinsen et al.
16.2 Learning Outcomes
At the end of this chapter, the practitioner will be able to:
• Describe patient’s, families’, and caregivers’ involvement in planning discharge
• Describe different elements of a discharge plan
• Effectively plan discharge with the involvement of the patient, family, and
caregivers
• Describe different case management models
• Describe elements of post-hospital care
16.3 Patient andCarer Involvement inDischarge
fromHospital
Communication is a signicant factor in patient satisfaction and complaints about
care. Research shows that older people often feel anxiety, stress, and uncertainty
about the future after a hospital stay [3]. Lack of communication and involvement
when planning discharge and post-hospital care can increase these feelings, so
involving the patient in discussions and decision-making about the plan for posthospital care may decrease stress and increase their satisfaction. When planning
discharge, it is essential that practitioners assess what patients’ needs will be after
discharge is essential. One part of this assessment is asking patients about what help
they think they will need [4]. Patients who are given information about how to
evaluate symptoms, manage medication, and undertake activities feel better prepared for discharge.
The capacity to understand and execute discharge instructions is important for
patients for effective self-care [3]. They may have problems understanding the
information that is given and be reluctant to ask questions because they do not want
to bother the healthcare workers. Studies show that many patients forget information they are given and that the information they do remember may be inaccurate.
Informal caregivers, who are often family members, frequently participate in caring
for the older people following discharge. They are, therefore, an important resource
when helping the patient to understand information and asking questions on their
behalf; being in a closer relationship to the patient enables them to capture vital
information that the patient may miss. Family caregivers who receive adequate
information and feel involved in hospital-to-home transitions are likely to be more
satised, accepting of their caregiving role and experience less anxiety. For patients
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with cognitive impairment involving family from day one is essential. Supporting
patients and caregivers to take a more active role during care transitions may also
reduce rates of readmission.
The patient and family have a right to be involved at every stage of the process,
so collaboration and continuity of care are central. To prepare the person and their
family for discharge a structured conversation with them is vital to allow exchange
of vital information and clarify any elements of uncertainty. Written information
should support oral information and should be brief, relevant, and easy to read [5].
The conversation/meeting should consider the patient’s needs and abilities. Family
members should be given the opportunity to participate with patient permission,
especially if the patient has any cognitive impairment. The meeting should be
scheduled to give the patient and relatives time to prepare.
Communication failures between clinicians are the most common primary cause
of errors and adverse events in health care [8]. Communication between hospital
caregivers and caregivers in primary care or institutions is essential to clarify what
kind of care the patient needs post-discharge and what kind of care the place of
discharge can offer. This helps to avoid unrealistic expectations about the level of
care the patient can expect. Patients and their caregivers want to know how long
they are staying in hospital, and when they can expect discharge so beginning this
conversation early in the admission is essential even though rm plans for discharge
may be uncertain. Although a discharge date will not be denite, patients and caregivers should be given a tentative date for discharge early on so they know what to
plan for. All relevant information, including what is important for the patient, should
be given as early as possible so that the next level of care knows the discharge plan
and can put in place the resources need to follow it. Reassuring the patient about
their care after discharge may ease the transition.
Box 16.1 Case Study: Discharge from Hospital Following Fragility Hip Fracture
Mrs. da Silva fractured her left hip a week ago. The fracture was surgically
xed the day after admission. She is an 82-year-old widow who lives alone in
a one bedroomed apartment in a high rise building with a lift. Her son and his
family, who provide support, lives nearby.
You have ascertained that, prior to the fracture, Mrs. da Silva was fairly t
and well for her age. She attended a social group for older people once a week
as well as a weekly chair exercise class for elders at a local community centre.
She did most of her own cooking and housework although her family have
shopped for her and provided additional support with household activities
since her husband died 4years ago. However, she reports that she has had a
couple of falls at home recently and that she has been suffering from low mood.
At present Mrs. da Silva is slowly remobilising. She is nding this process
difcult as she says she seems to have lost her condence and she is struggling to get her appetite back.
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On admission, the plan for discharge was that Mrs. da Silva would be discharged approximately 10days after her surgery. At this point, you are starting to focus on a more concrete plan for her discharge.
Consider:
• What else do you need to know that will help you to plan Mrs. da Silva’s
discharge? How might you access this information?
• What options might there be for Mrs. da Silva when she leaves hospital,
given what you know about what is available in your own locality?
• With whom do you think you should discuss these options?
• Who, in your locality, can help you to make a discharge plan for Mrs.
da Silva?
M. I. Martinsen et al.
16.4 Preparing forDischarge
Discharge from hospital of an older person after hip fracture or other signicant
fragility fracture to the most appropriate setting is complex and requires careful
planning. The combination of higher clinical acuity and shorter lengths of stay,
places demand on the health services to plan discharge carefully to avoid unnecessary readmissions. Disorganised discharge can result from too much focus on rapid
discharge, not involving patients and other caregivers, and not having a standardised
patient assessment during care transitions [8].
Older people often experience lack of continuity of care after a hospital stay [9].
The aim is to secure a safe transition from the hospital to the next level of care and
make sure that the carers at next level have enough information to continue the
recovery and rehabilitation process. A rushed or poorly planned discharge may
result in a new fall, health deterioration, and/or hospital readmission. Increasing
evidence indicates that patients are particularly vulnerable and more likely to experience negative outcomes during these readmissions [10, 11].
Many factors can increase the risk of readmission including poorly planned dis-
charge, inadequate post-discharge care or follow-up, therapeutic errors such as
adverse drug events and other medication-related issues, inadequate transfer handovers, and complications such as infections, pressure ulcers, and new falls. Depending
on the length of the hospital stay some of these factors can be modied while the
patient is in hospital and some need follow-up after discharge in the primary/home
care setting. Investing in a well-planned discharge and making sure that the next
level of care receives the information about the patient’s needs is essential in preventing adverse events and readmissions.
The whole interdisciplinary team including patients and their families should be
involved in the discharge process to ensure a safe discharge. Frail older adults commonly experience a combination of mobility problems, complications, cognitive
decline, and psychological problems which require a carefully thought-through
individual discharge plan [12].
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Table 16.1 Elements of Comprehensive Geriatric Assessment (CGA) to be considered in discharge planning
Cause of fall and status
on admission
Comorbidities • Any known or new health conditions that will impact discharge
Pre-morbid ADL-status • Information about how the patient is able to function in daily
Cognitive status • Known dementia or cognitive impairment?
Social network and living
conditions
• Did the fracture happen due to an accident caused by dizziness,
illness, medication, or alcohol?
• Time from fall to hospital admission?
• Did patient need medical attention before the fracture could be
addressed?
• Skin and nutrition/hydration status on admission can be
indicators of how the patients are managing in daily life.
and post-hospital care?
• Have there been any changes in medication that need further
attention after the hospital stay?
activities
• Suspicion of cognitive impairment that needs following up
after hospital stay?
• Delirium during hospital stay?
• Living alone or with someone?
• Family or friends nearby who can help?
• Was there any help from primary care in place before the fall?
• Previously living at home or in an institution?
• Home: is everything on one oor or steps/stairs?
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Planning discharge should begin at hospital admission, by initiating a comprehensive geriatric assessment (CGA). A person’s pre-fracture status will be an indicator for what kind of care the patient will need after the hospital stay. Frail patients
leaving hospital following hip fracture and surgery will always need further care.
The aim of this assessment is to identify the patient’s physical, cognitive, and social
resources and dene what kind of help will be needed after the hospital stay to
ensure continuity of care. Continuity of care and the degree to which all involved
feel prepared to manage care following hospitalisation are the best predictors of a
person’s and caregivers’ satisfaction with discharge planning [13].
Table 16.1 identies the main elements of CGA to be considered and addressed
when planning discharge as these are most likely to impact the level of care the
patient will need after discharge. More detail relating to the elements of a full
Comprehensive Geriatric Assessment (CGA) can be found in Chap. 6.
16.5 Discharge Readiness
The length of stay in hospital following hip fracture, other signicant fragility fractures, and after surgery varies from hospital to hospital, and the health and social
care services offered to the patients after discharge will also differ locally depending
on the country and region. Whether the patient is ready for discharge will depend on
their discharge destination: to home, subacute care, post-acute care, or a long-term
care facility.
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