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Hip Fracture Project

In December 2006, thirty-five organizations from across the GTA, Oshawa to Halton, joined together to efforts to improve care for patients living in the community who experience a hip fracture. The Hip Fracture Project will support the creation of resources to facilitate best practice, enable seamless transition for patients both through the continuum of care, and to ensure each LHIN effectively addresses patient needs for this often marginalized population.

The hip fracture integrated model of care has been designed to assist in coordinating improved access to rehabilitation for patients living in the community who experience a hip fracture. It identifies a system of change and requires acute care, inpatient rehabilitation, and CCAC to provide patients with the appropriate rehabilitation to succeed in managing the return to their pre-fracture living situation.

Surgery, where possible, will occur within 48 hours. The patient’s care will then be guided by a clinical pathway towards ensuring they are medically stable and transferred to inpatient rehabilitation on Day 5 post surgery. The inpatient rehabilitation program will accept patients that are medically stable regardless of weight bearing status, and including those with cognitive issues and unclear discharge plans related to complex social situations. A comprehensive, rapid, 7-10 day assessment and treatment program will determine the patient’s ability to return to their pre-fracture community setting following a 28 day length of stay in inpatient rehabilitation or facilitate transfer to a more appropriate care setting. These other settings may include complex continuing care, a specialized geriatric service, long term care or convalescent care (until able to weight bear). The CCAC will provide support to transition these patients to return to the community following discharge.

Total Joint Network Partner Organizations
The following organizations are partners in the Hip Fracture Project:

Acute Care Hospitals

• University Health Network
• Mount Sinai Hospital
• Sunnybrook Health Sciences Centre
• St. Michael’s Hospital

Rehabilitation Hospitals

• Toronto Rehabilitation Institute
• St. John’s Rehabilitation Hospital
• Bridgepoint Health
• Providence Healthcare
• West Park Healthcare Centre
• Baycrest

Community Hospitals:

Community Care Access Centres:

• Toronto Central CCAC
• Central East CCAC
• Central CCAC
• Central West CCAC
• Mississauga Halton CCAC

Other:

• Provincial Osteoporosis Strategy
• Arthritis Society
• Osteoporosis Society
• Regional Geriatric Program of Toronto
• GTA Rehab Network

Integrated Model of Care
The model of care designed for people living in the community who experience a hip fracture is as outlined below:

Each organizational partner will require a local Steering Committee to implement the necessary changes to facilitate best practice in the care of patients with hip fractures. The Steering Committee needs to include medical, clinical and senior management representation as well as a quality expert where available. The TJN Project Manager will be available for meetings as needed.

Acute Care Hospitals
Although the acute care hospitals are currently providing care for patients with hip fractures, some changes will be required for implementation of the new model of care. These will include:

1. Development of an Acute Care Care Pathway through the TJN partnership that enables;

• Patients to receive surgery in a timely fashion, ideally within 48 hrs
• By Day 2 post surgery- completion of a patient/family assessment to determine pre-functioning level, medical status and co-morbidities, and potential to successfully return home in the community.
• Determination of the patient’s discharge disposition to go home with CCAC services, transfer to inpatient rehabilitation, and for those patients with long term care papers in place, transfer to complex continuing care or long term care
• Access to geriatric services as needed to address patient needs
• Day 5 post surgery-transfer to inpatient rehabilitation.

2. Establishment of repatriation agreements between acute care and inpatient rehabilitation prior to the transfer of patients, ensuring continuous care is maintained for patients, and transfer processes are streamlined and maximize the availability of inpatient rehabilitation services.

Inpatient Rehabilitation
Inpatient rehabilitation is expected to be challenged with a majority of change as the new model of care is implemented. The Toronto Rehabilitation Institute, Fractured Hip Rapid Assessment and Treatment Program (FHRAT) was designed through the GTA Rehab Network as a pilot project to test this new model of care for patient with hip fractures. Several organizational changes have been identified as important to successful implementation:

1. Development of an Inpatient Rehabilitation Care Pathway through the TJN partnership that enables;

• Complete assessment of the patient within 24 hours of admission to inpatient rehabilitation
• By Day 8 – establishment of clear goals with input from the patient and family, and must include determining a target date for discharge
• Use of standardized assessment tools to detect and subsequently treat potential challenges of delirium, cognitive impairment, and affect (depression & anxiety).
• Day 12 to 14 – triage decision made regarding patients need for/ability to continue with inpatient rehabilitation or transfer to another setting including complex continuing care, a specialized geriatric service, long term care or convalescent care (until able to weight bear).
  

2. Implementation of a Clinical Coach with expertise in elder care to provide leadership to the project.

3. Access to geriatric services for consultation. This may include a geriatrician, physiatrist, internist with geriatric expertise or specialty geriatric team.

4. Education/training in dementia care for clinical staff including Project Overview and 1-day education session.

5. Establishment of repatriation agreements between acute care and inpatient rehabilitation prior to the transfer of patients, ensuring continuous care is maintained for patients, and transfer processes are streamlined and maximize the availability of inpatient rehabilitation services.

Community Care Access Centres
The community sector will play an integral role in implementing the model of care as individuals are supported in their return back to their community pre-fracture setting. It is expected fewer individuals who experience a hip fracture will end up in long term care. A Community Care Pathway will be developed through TJN partners to facilitate best practice.

Evaluation:
Three types of performance indicators will be used in the Hip Fracture Project.

1. The implementation status of the organization change indicators will be tracked by TJN to guide system activity:

• Establishment of a Steering Committee
• Availability of access to Geriatric Services
• Implementation of a Clinical Coach role
• Establishment of Relationships between system partners
• Participation in Education – introductory, full day, informal sessions
• Refinement of Care Processes
• Data Collection Processes in place
• Target Implementation Date set

2. Monthly data will be collected from partner organizations and amalgamated by the TJN to track organizational performance and set benchmarks. Indicators for project success will include:

• 80% of patient experiencing a hip fracture will be transferred to inpatient rehabilitation from acute care
• Patient experiencing a hip fracture will have an average 28 day length of stay in inpatient rehabilitation
• 75% of patients experiencing a hip fracture will be discharged home

3. Organizations will internally track operational and clinical change within their own organizations based on their access to resources and their internal processes. This data should be used to by organizational Steering Committees and clinical teams to modify change processes. Indicators may include:

• Patient/Family Satisfaction
• Staff Satisfaction
• Staff Attitudinal Change
• Staff Knowledge about Delirium, Dementia, & Depression
• # of patients with cognitive issues

Results:
The change that occurred through the implementation of the new model of care for hip fracture patients has been successful in improving care for over 2,000 patients across the Greater Toronto Area. To date 24 of 25 hospitals have implemented the new model and 86% of patients are having their surgery within 2 days, 72% of patients that came from home are now having access to rehabilitation despite cognitive impairment and most before 8 days after surgery, and after rehabilitation over 80% are returning home. Patients are receiving the right care in the right place at the right time and having new opportunities to return home.

Canadian Orthopaedic Nurses Association Conference presentation

Final Report: Hip Fracture May 2008
Appendix A - Models of Care
Appendix B - Partner Organizations
Appendix C - Acute Care Clinical Pathway
Appendix D - Osteoporosis Letter for Family Physicians
Appendix E - Repatriation Principles
Appendix F - Patient Family Brochure
Appendix G - 3D's Pt Famiily Brochure
Appendix H - Inpt Rehab Clinical Pathway
Appendix I - Steps to Smooth Hospital Discharges Flow Chart
Appendix J - Steps to Smooth Hosp Discharges
Appendix K - Admission Letter Discharge Planning
Appendix L - Clinical Coach Role Description
Appendix M - TJN Hip Fracture Education Sessions
Appendix N - CCAC Hip Fracture Guidelines
Appendix O - Go Live Requirements
Appendix P - Committee Structure
Appendix Q - Committee Meetings Schedule
Appendix R - Organizational Process Change Indicators. Definitions
Appendix S - Performance Indicator Summary April 08
Appendix T - Hospital Change Indicators Results
Appendix U - Workshop Evaluation
Appendix V - Financial Statement
Appendix W - Hip Fracture Presentations