Outcomes for older adults in an inpatient rehabilitation facility following hip fracture (HF) surgery

Abstract

The purpose of the study was to evaluate patient and system outcomes regarding older community-residing adults who participated in a rehabilitation program following HF surgery. The health care professionals on the rehabilitation unit in this feasibility study had never cared for such patients who were so frail, with multiple co-morbidities including cognitive impairment (CI). After an innovative model of care was developed and the staff trained in the novel approach to care, the unit opened for all patients living within the community who had fractured their hip, regardless of their CI. Of the 31 elderly patients consecutively admitted post-HF in this retrospective study, 18 were found to have CI postoperatively as determined by a Mini-Mental State Examination (MMSE) score ≤23. There were no differences in length of stay (LOS), rehabilitation efficiency, and motor FIM gain scores between the two groups of patients. This feasibility retrospective study suggests that staff can learn how to care for patients with CI in rehabilitation settings, and that such clients can achieve outcomes comparable to those without CI in a setting dedicated to caring for patients with a HF.

Introduction

A HF is often a catastrophic event that is a significant threat to an individual's independence and ability to live in the community (Naglie et al., 2002). Population trends indicate that an increasing number of individuals are likely to survive to ages at which HF is common (Jaglal et al., 1996). Despite good surgical outcomes, studies have found that functional outcomes after HF surgery are variable, with as few as one-third of people able to regain their pre-fracture level of physical functioning (Koot et al., 2000, Gruber-Baldini et al., 2003, Lieberman et al., 2006). A recent review of the Canadian Institute for Health Information data found that 26% of HF patients (many of who were living in the community pre-fracture) were discharged to long-term care (LTC) facilities and never received appropriate rehabilitation (GTA Rehab. Network, 2006). Furthermore, the outcomes for patients with a HF are often complicated by the presence of CI. About 17% of community dwellers who experience a HF have a diagnosis of CI, and this percentage is expected to rise (Wiktorowicz et al., 2001). Of these patients, it is not clear what percentage have delirium, dementia or both, nor the extent of their dementia, mild, moderate or severe.

Current health care services for people with HF, and those with CI in particular, are fragmented and limited (Wiktorowicz et al., 2001, GTA Rehab. Network, 2006). The several inpatient rehabilitation options after HF surgery include rehabilitation beds in acute-care hospitals or free-standing rehabilitation hospitals, specialized geriatric units, higher level sub-acute long-stay beds, and convalescent care beds. In the United States for example, HF patients with CI are admitted to geriatric sub-acute units located in nursing homes and receive rehabilitation care (Barnes et al., 2004). All of these care settings, however, have their own admission and discharge criteria that are not consistent or complementary. For example, a recent study of eight Geriatric Rehab. Units (GRUs) in Ontario found that acceptance of patients with CI varied across the units (Wells et al., 2008), despite evidence that patients with CI can benefit from rehabilitation programs (Goldstein et al., 1997, Heruti et al., 1999, Naglie et al., 2002, Barnes et al., 2004, Rolland et al., 2004).

At present, there is no standardized, integrated continuum of care for HF patients, especially for those with CI in Ontario (Davis et al., 2006). Therefore, these patients are frequently unable to access appropriate rehabilitation in a timely fashion, if at all, which contributes to poor functional and quality care outcomes (Wells et al., 2004). Earlier work has shown that access to beds in GRUs is limited and often excludes patients with CI because of their cognitive and behavioral symptoms (Wells et al., 2008), and there is no reason to believe this is different in any other country. Not rehabilitating these patients leads to further physical and mental deconditioning, thereby, compromising patients’ long-term outcomes. In a recent report, Davis et al. (2006) recommended that new models of care be established, including all sectors of the health care continuum, to optimize the function of HF patients with CI.

In response to this need, members of our team developed an integrated practice-based model of care, referred to as the Assessment, Patient-Centered Goals, Treatment, Evaluation, and Discharge (ACTED) model of care. This model aims to provide an optimal rehabilitation setting at the appropriate time for the geriatric patient with CI. The innovative aspects of the ACTED model include the following: (1) early admission to rehabilitation (i.e., on or before Day 5 post-op); (2) individualized assessments and interventions focused on the patients’ remaining abilities; (3) assessments for dementia, delirium, and depression within the first 3 days of admission to rehabilitation; (4) patient-centered goals that involve input from patients and their families; (5) individualized rehabilitation care at the bedside if necessary; (6) a focus on care strategies that minimize behavioral and cognitive symptoms related to CI; and (7) education and support to health care providers (HCPs) and facilities to implement the model of care. As part of the ACTED program, a physiatrist, geriatrician, and family physician were available to provide medical guidance on the care of the patients. An advanced practice nurse (APN) in gerontology provided guidance to staff to individualize care. The overall objective of this feasibility study was to evaluate patient and system outcomes for the older adults who participated in the ACTED program of care following HF surgery.

A growing body of research has focused on the rehabilitation of persons with CI following a HF. These patients with CI are more prone than other HF patients to delirium (Inouye and Charpentier, 1996), longer lengths of acute hospital stays (Wells et al., 2004), and mortality (Koot et al., 2000). A literature review of 21 studies from eight countries reported that HF patients with CI can benefit from participating in rehabilitation targeted at improving self-care and motor function (Magaziner et al., 1990, Cummings et al., 1996, Patrick et al., 1996, Goldstein et al., 1997, Heruti et al., 1999, Adunsky et al., 2002, Hoenig et al., 2002, Naglie et al., 2002, Gruber-Baldini et al., 2003, Barnes et al., 2004, Lenze et al., 2004, Rolland et al., 2004, Arinzon et al., 2005, Haentjens et al., 2005, Shyu et al., 2005, Bitsch et al., 2006, GTA Rehab. Network, 2006, Lieberman et al., 2006, Moncada et al., 2006, Yu et al., 2006).

The primary goal of HCPs in working with persons following a HF is to maximize their functioning (Shabat et al., 2005). Outcomes related to patients’ functioning include improvement in patients’ mobility level during inpatient rehabilitation (Patrick et al., 1996, Heruti et al., 1999) and a return to pre-fracture functional status (Wells et al., 2004, Shabat et al., 2005). HCPs’ secondary goal is to discharge patients back to their previous environment (Wells et al., 2004).

A patient-centered rehabilitation model of care (Fig. 1), a modification of Donabedian's (1966) framework, was selected to guide this research study as it provided a useful framework for understanding how contextual factors (i.e., patient and system characteristics) and processes of care affect the outcomes of people with a HF. Patient characteristics include personal resources needed to participate in the rehabilitation intervention as well as personal and health-related characteristics, such as cognitive level. System characteristics include the physical and social aspects of the environment, such as policies on the unit, and time interval from surgery to admission to the rehabilitation program. Processes of care consist of the components of the intervention conceptualized as being critical for achieving the anticipated outcomes (Lipsey, 1993), such as effective team processes. Concepts of focus for this feasibility study are highlighted in bold (Fig. 1).

Several studies of the determinants of HF rehabilitation outcomes have shown that patient characteristics are the primary indicators of functional gain. These include the following: age (Arinzon et al., 2005); sex (Rolland et al., 2004); pre-fracture cognitive function (Gruber-Baldini et al., 2003); pre-fracture functional status (Cummings et al., 1996, Naglie et al., 2002, Moncada et al., 2006); medical co-morbidities (Patrick et al., 1996, Patrick et al., 2002); pre-fracture frailty (Arinzon et al., 2005); sensory (hearing and vision) impairment (Rolland et al., 2004); nutritional status (Lieberman et al., 2006); social support (Beaupre et al., 2005); depression (Goldstein et al., 1997, Lenze et al., 2004, Shyu et al., 2005); and delirium or incident CI (Adunsky et al., 2002, Gruber-Baldini et al., 2003, Bitsch et al., 2006).

Researchers have found that the type of HF (Haentjens et al., 2005), depression (Fredman et al., 2006), delirium (Bitsch et al., 2006), and level of CI (Moncada et al., 2006) influence the LOS on inpatient rehabilitation units and the cognitive improvement that patients make. MMSE scores at discharge (Lenze et al., 2004), depression (Lenze et al., 2004), living situation (i.e., alone vs. with others, Cummings et al., 1996), and the presence of social support (Beaupre et al., 2005) have been shown to influence the discharge disposition of these patients.

System characteristics that may have an impact on rehabilitation outcomes include the following: length of time from the injury to surgery (Adunsky et al., 2002, Hoenig et al., 2002) and the time interval from surgery to admission to inpatient rehabilitation (Adunsky et al., 2002, Yu et al., 2006).

The overall objective of this feasibility study was to evaluate patient and system outcomes for the older adults who participated in the ACTED program of care following HF surgery. The specific objectives were to identify the contextual and system factors associated with the four outcome measures, namely, functional gain, cognitive gain, rehabilitation efficiency, and discharge location. The specific research questions were: (1) Are there differences in outcomes (functional gain, cognitive gain, rehabilitation efficiency, and discharge location) between two groups of older adults, those with CI and those with intact cognition? (2) What additional patient characteristics are related to outcomes? and (3) What system characteristics influence outcomes?