RecommendationPatients admitted from care or nursing homes should not be excluded from rehabilitation programmes in the community or hospital, or as part of an early supported discharge programme.
Relative values of different outcomesThe GDG considered the most important outcomes to be functional status, readmission to hospital and return to pre-fracture residence.

Early assessment and MDR offered as part of a hip fracture programme with continued rehabilitation for patients admitted from care/nursing homes is likely to improve/maintain the patient's functional ability with regard to mobility, transfers from bed to chair and activities of daily living. This is in the interests of both patients and care/nursing home staff. In addition patient status as a care home resident as opposed to a nursing home resident may be maintained and equality for patients in care/nursing homes is maintained with regard to access to rehabilitation.
Trade off between clinical benefits and harmsThere is no evidence of harm accruing to care/nursing home residents from the provision of appropriately individualised rehabilitation programmes.

For some patients admitted from care/nursing homes there may be advantages (and no particular risks) in completing their rehabilitation after hospital MDR within that home (subject to the recommended criteria above), recognising that their rehabilitation goals may be more complex and must be shared by the HFP team on a continuing basis with the care/nursing home staff.

The potential benefits of ESD for patients admitted from care/nursing homes include the possibility of functional recovery within the patient's familiar environment, shared communication, goal setting and collaboration between care/nursing home staff and HFP team resulting in improved functional outcome, and the possibility of reduced hospital stay and inappropriate hospital readmission.

This subgroup is considered at particular risk of premature discharge because of ease of access to the care/nursing home environment and the corresponding perception that functional recovery matters less. Failure to undertake adequate rehabilitation carries the subsequent risk of inappropriate functional decline and/or levels of dependency, reduced quality of life, unnecessary hospital readmission, and premature mortality.

Provision of part of a patient's continuing rehabilitation programme in the care or nursing home of origin is correctly categorised as either early supported discharge or intermediate care, and the continued involvement of the Hip Fracture Programme team in liaison with the community-based component is therefore correspondingly a requirement.
Economic considerationsThere was no cost-effectiveness evidence. The GDG believe that any increase in the cost of hospital bed days from the avoidance of premature discharge should be at least partially offset by the avoidance of inappropriate readmissions and reduction in subsequent care costs resulting from optimised functional status.
Quality of evidenceNo RCTs were identified regarding patients admitted from care or nursing homes undergoing community ESD, as this patient subgroup has typically been excluded from clinical trials. The recommendation is based on GDG opinion and consensus that this group of patients would benefit from ESD.
Other considerationsThere is a high prevalence of cognitive impairment in this population, therefore realistic rehabilitation goals need to be defined, but not at the expense of excluding rehabilitation.

From: 12, Multidisciplinary management

Cover of The Management of Hip Fracture in Adults
The Management of Hip Fracture in Adults [Internet].
NICE Clinical Guidelines, No. 124.
National Clinical Guideline Centre (UK).
Copyright © 2011, National Clinical Guideline Centre.

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