16.1 Introduction

Fragility fracture is the result of a combination of bone fragility and a fall. Hip fracture and other significant 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 influence 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 significant fragility fractures for discharge. 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.

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 and Carer Involvement in Discharge from Hospital

Communication is a significant 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 post-hospital 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 satisfied, accepting of their caregiving role and experience less anxiety. For patients 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 firm plans for discharge may be uncertain. Although a discharge date will not be definite, 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 fixed 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 fit 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 4 years 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 finding this process difficult as she says she seems to have lost her confidence and she is struggling to get her appetite back.

On admission, the plan for discharge was that Mrs. da Silva would be discharged approximately 10 days 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?

16.4 Preparing for Discharge

Discharge from hospital of an older person after hip fracture or other significant 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 discharge, 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 modified 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].

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 define 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 identifies 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.

Table 16.1 Elements of Comprehensive Geriatric Assessment (CGA) to be considered in discharge planning

16.5 Discharge Readiness

The length of stay in hospital following hip fracture, other significant 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.

Higher acuity and pressure on hospital beds have led to shorter lengths of stay in many localities. The impact of this is less time for the interdisciplinary team to assess and prepare patients, families, and caregivers for discharge. Assessment of length of hospital stay must be considered individually and identifying when the patient is ready for discharge will vary. Being medically ready for discharge may not mean the patient is ready in other aspects such as physical, psychological, and social readiness. The focus on shorter hospital stays has meant that some guidelines recommend that the medical well-being and functional capacity of the patient should be assessed before the patient can be considered ready for discharge as identified in the discharge checklist in Box 16.2 [14].

Box 16.2 Medical Discharge Readiness Checklist [14]

Hemodynamically stable?

No fever?

Is haemoglobin level stable and not decreasing?

Is kidney and cardiovascular function acceptable, with no major electrolyte disturbances?

Is there a normal level of consciousness (Glasgow Coma Scale)?

Is pain management adequate?

Are delirium and other complications under control?

Is there an acceptable fluid and nutritional intake?

Medical conditions and symptoms under control?

Is mobility adequate for discharge location and support available?

Although clinicians may clear the patient medically for discharge, the patient may not feel ready for discharge physically nor psychologically. Box 16.3 provides a case example of the impact of this. Preparing them for discharge, giving an estimate of length of stay on admission, and actively involving the patient and family/caregivers in decisions can be instrumental in the formulation and execution of a transitional care plan in which the patient is fully engaged. Preparing patients and their caregivers for what to expect after discharge involves giving them the opportunity to provide input into the plan of care regarding their values and preferences.

An important component of this preparation is to ensure that the person and their caregivers are given clear advice on how to manage their conditions, how to recognise warning signs that something has worsened needs attention (e.g. delayed wound problems, infections) and who to contact [15].

Studies have demonstrated the effectiveness of case management in hip fracture patients. Through patient assessment, effective communication, coordination, and careful allocation of resources, integrated and personalised social and health services can improve the quality of patient care [6]. Case management accompanies patients from admission to discharge, from the ward to home, and provides them with assistance and help in every detail. This approach can ensure that patients receive high-quality personalised nursing and other services, but also provide psychological support, which facilitates patients’ rapid return to society after their injury/surgery [7, 8]. Evidence has shown that a case manager for patients with hip fractures can also increase the rates of appropriate treatment of osteoporosis with a subsequent reduction in future fractures, an increase in life expectancy, and a substantial reduction in costs [9, 10].

Box 16.3 Case Study: Discharge Readiness

Ms. Hansen, an 84-year-old with dementia and paroxysmal atrial fibrillation, has been living in a nursing home for the last year. She was admitted to the orthopaedic unit after a fall but had to wait 48 h for the operation because she is anticoagulated with direct oral anticoagulants (DOAC) She had a hemiarthroplasty for her sub-capital hip fracture 2 days after she was admitted to hospital. She was very confused, anxious, and agitated preoperatively. Post-operatively, she has been mobilised, but she seems lethargic and very reluctant to move. Her haemoglobin dropped from 10.1 to 7.5 mg/dL, and she was transfused with 2 units of blood the same day she was discharged.

It is the usual routine for nursing homes to be informed on admission that the patient will be discharged a day or two after surgery. Ms. Hansen was discharged back to the nursing home 2 days after the operation, the nursing home staff were given notice the same day.

Three days later, she was readmitted with deterioration in her general condition, low haemoglobin, and fever.

Consider:

  1. 1.

    What can we learn from this patient’s story?

  2. 2.

    What do you suggest might be the reasons for readmission?

  3. 3.

    Could the readmission have been prevented, and how?

16.6 Case Management Models: A Resource in the Discharge Process

In some countries, case management is a model of care that supports individuals and families facing numerous health and well-being challenges, including fragility fractures. As case management practices have evolved, the definition of the term has become increasingly complex, with different organisations offering a myriad of case management interventions. Case managers come from diverse professional backgrounds in health and social care services, including nursing, medicine, social work, rehabilitation counselling, workers’ compensation schemes, and psychological and social healthcare providers. The main role of case managers is to support clients and support systems in managing complex care needs [16].

The term ‘case management models’ encompasses a range of approaches and services that have evolved over the years. Case management was originally conceived as a service for persons with severe and persistent mental illness [17, 18] but has expanded to include other groups such as older people being discharged from hospital.

There are several case management models; the four most critical ones that can be modified and adapted to ensure effective results in a variety of case management contexts, including discharge planning, are [19]:

  • The Brokerage Model Case Management

  • The Clinical Case Management Model

  • The Strengths-Based Clinical Case Management Model

  • The Intensive Case Management (ICM) Model

16.6.1 The Brokerage Case Management Model

This model focuses on needs assessment, referral to services, and synchronisation and supervision of ongoing treatment. The services are mainly office-based, and the case manager coordinates the services offered by a range of agencies and professionals. The model aspires to the individual being given responsibility for deciding the approach and timing for using the resources available to them once they have been informed about the options. In this model, case managers are not as involved with the client as in other models, and most of their time is spent organising patient care and ensuring a smooth flow of services. Like all case management models, the Brokerage Model has its merits and disadvantages. While the model offers clients higher levels of freedom, it also allows case managers to serve more clients, as there is less interaction. The model is not considered ideal for some complex cases where case managers need to spend more time with clients. Since they cannot have a closer relationship with case managers, many clients do not opt for this model [20].

16.6.2 The Clinical Case Management Model

This model grew out of the need for case managers to provide therapeutic services. Although the clinical model is similar to the brokerage model (in the prominence of commitment assessment, assessment and planning, and community liaison), it has the added component of therapeutic interventions, including psychotherapy, psychoeducation, and crisis intervention. Considering hospital discharge as an event that can cause despondency, anxiety, and worry, the therapeutic interventions offered by this model is useful for both patients and their families.

Studies [19, 20] show that this case management model can be very effective when performed by nurses. Because the nurse case manager is aware of the person’s needs, their level of understanding enhances their ability to identify needed services and connect the person with formal resources in the form of community service providers. Clinical care providers can also encourage the patient and their family to connect with family, friends, and peers, helping them to address social, emotional, and psychological barriers to services. This association can increase the client’s willingness and ability to engage with services.

Being clinicians, case managers in the Clinical Case Management (CCM) model have more responsibility than in the Brokerage model, as they provide a wider variety of services. They focus more on executing the entire care plan for the patient, rather than simply referring them to other professionals as in the Brokerage model. As they are more involved with clients/patients, they can assess gaps and identify areas for improvement in their care plans. Clients feel more motivated and supported, which makes care more efficient.

The CCM model is built around the client’s personal strengths, goals and needs, valuable information that is carefully incorporated into each step of the rehabilitation process, helping the patient to feel more enthusiastic, increasing its effectiveness.

16.6.3 The Strengths-Based Clinical Case Management Model

As the name suggests, the model is based on a person’s strengths. The case manager in the strengths-based model has the responsibility and skills to identify and analyse a client’s particular strengths. The analysis of these strengths then forms the basis of a tailored care plan for the client [16, 18].

The reason why strength-based clinical case management models are successful is that they are built around the person’s goals and personal needs, valuable information that is carefully incorporated into every step of the recovery/rehabilitation process. Through such personalised care, the model dispels the notion of ‘one size fits all’ and instead creates care plans that are perfectly tailored to each client’s needs.

This model of case management recognises that the critical goal of a case manager goes beyond simply accessing services, while caseworkers focus on empowering clients and their families. This approach is highly effective, for example, with hip fracture patients and their careers, where empowerment is the basis of all education and support interventions. This topic is discussed in more detail in Chap. 15.

This model also recognises the value of community services and working with families; it encourages the client to develop and maintain informal support networks as well as recognising and accessing formal community services and established resources.

16.6.4 The Intensive Case Management (ICM) Model

The objective of the ICM model is to provide high-quality services in a short period of time. One of the ways in which the model differs from the brokerage model is that patients receive much more individual attention from case managers, as the goal is to do more in less time. The case manager can meet regularly with the patient and follow their progress, determine the duration of rehabilitation or discharge date according to their individual needs, and share information with other clinicians and case managers to ensure comprehensive individual care.

With a greater degree of involvement, recovery/rehabilitation/discharge is achieved earlier than with other case management models. Moreover, the relationship between the client and the case manager is stronger than any other model, promising better and faster results. The downside is that some clients may find the ICM care plan intense, potentially causing stress about their progress in the rehabilitation process [20].

16.7 The Transition to Post-hospital Care

Although some re-hospitalisations are appropriate and unavoidable, it is estimated that between 13 and 20% of those experienced by chronically ill older adults are preventable [19,20,21]. Patients with hip fracture are often older adults with multiple chronic conditions complicated by other risk factors, such as deficits in activities of daily living or social barriers. They experience multiple challenges in managing their healthcare needs, especially during episodes of acute illness. Identifying effective strategies to improve transitions and outcomes of care is essential. One rigorously tested model that has consistently demonstrated effectiveness in addressing these complex needs while reducing healthcare costs is the Transitional Care Model (TCM). The TCM is a nurse-led intervention targeting older adults at risk for poor outcomes as they move across healthcare settings and between clinicians.

The TCM focuses on improving care, improving patient and family caregiver outcomes, and reducing costs among vulnerable and chronically ill older adults identified in health systems and community-based settings such as patient-centred care/nursing homes. The model emphasises the identification of patient health goals, the design and implementation of a streamlined care plan, and continuity of care across settings and across providers during and following acute illness episodes (e.g. from hospital to home) [22,23,24]. Care is delivered and coordinated by the same advanced practice registered nurse, in collaboration with patients, their families, physicians, and other members of the multidisciplinary healthcare team [24].

We can illustrate this pathway as if it were the guarded passage of a precious stone (the patient) between the hands of the different hospital actors (such as the nurse case managers) until it arrives in the hands of the territorial actors of post-hospital care (such as the family nurse, a figure present in European and South American healthcare settings) [25].

The rigorous evaluation of TCM-based interventions and review of detailed case summaries developed by the participating expert nurses led to the development and continuous refinement of the nine core components of the model. Each of the core elements of TCM are identified and defined in Table 16.2 [26, 27]. Although each element is defined separately, it is important to note that all are interconnected and part of a holistic care process.

Table 16.2 Transitional Care Model (TCM) components and definitions

Following hip fracture and other significant fragility fractures, patients require care from a wide range of providers in different settings, including hospitals, inpatient rehabilitation units, outpatient clinics, home care, assisted living facilities, and long-term care homes [28, 29]. It is estimated that they undergo an average of 3.5 moves or relocations within 6 months of the injury [30]. Care transitions are a vulnerable time for patients, as poorly managed transitions can lead to medication errors, hospital readmissions, negative patient outcomes, and compromised patient satisfaction.

As discussed in Chap. 15, during and after the discharge process of fragility fracture patients, it is crucial to give attention to their caregivers. During care transitions, caregivers are often the only constant factor in the patient’s life [30]. Caregivers and patients can provide insight into the quality-of-care transitions and their involvement in care planning can improve patient outcomes [8]. A randomised controlled trial found that older patients had lower hospital readmission rates when caregivers and patients received tools to communicate with providers, were encouraged to take an active role in care planning and received guidance from a transition coach. Unfortunately, despite the importance of caregivers in care planning, caregiver involvement during care transitions is often lacking [30]. Jeffs et al. [31] found that caregivers of orthopaedic patients were not actively involved during care planning and did not receive adequate support from the care team after discharge.

16.8 Post-hospital Care

Leaving the hospital setting, often perceived as a protected environment, and returning home can be traumatic for patients and their families. Following hip fracture and other significant fragility fractures, patients are at risk of functional decline, multi-morbidity, and institutionalisation [32]. Approximately 13.5% of patients die within 6 months after hip fracture and, of those who survive, only 50% regain their pre-fracture mobility [33]. This generates worry, anxiety, and stress within the family unit [34].

In a reality where the World Health Organization identifies the home as the ideal place of care, health systems are called upon to make this type of care feasible and to support the family unit by providing adequate territorial social and health services [35]. The care pathway of older adults following significantly fragility fractures such as hip fracture has been the subject of several studies [28, 29, 36] in which patients, their relatives, and caregivers were interviewed at each point of transition in order to understand their experiences during the entire care pathway, including the return home [36]. In transitions to and from formal care settings, patients and caregivers were particularly troubled by confusion about the roles of the multiple providers involved in their care, and often described difficulty in distinguishing between different types of staff or providers in acute care and hospital rehabilitation settings.

In all transitions, information about the patient’s condition, care and transition trajectory was not readily available or provided to patients or caregivers. This lack of information was particularly relevant for patients and caregivers transitioning from acute care to home, or from hospital rehabilitation to home. Caregivers who experienced the transition from acute care explained that they often did not receive any information. The patient, however, was often overloaded with information while sedated, tired, or anxious. Sometimes, patients were given brochures or information sheets containing general information about the hip fracture and the surgery but were left free to interpret this information independently. In some cases, the written information was even passed on to them by patients who had received other operations, such as hip replacements. Many of the patients’ questions, however, concerned their care needs and recovery process so the standard written information provided by the brochures was not helpful in answering their questions or preparing them for their return home.

The difficulty patients and caregivers experienced in obtaining information from providers contributed to the feeling of being instructed during care, rather than being actively involved in their care decisions. Patients and caregivers in transitions from acute care or hospital rehabilitation to home did not feel involved in decisions made about their care.

Toscan and colleagues [28] explained that, in the transition to home, the greatest challenge is isolation and self-doubt, suggesting that this uncertainty can be a significant obstacle for patients and caregivers transitioning to a home environment. The transition home was particularly stressful for family caregivers, who were suddenly responsible for most of the patient’s care. Caregivers were expected to manage the transition, which involved a several care tasks [37]. These expectations often came without any flexibility or consideration of the caregiver’s availability and without direct instructions on how best to provide the patient with the care they needed at home. This dependence on family caregivers causes discomfort and stress, especially because most caregivers lack the skills and knowledge to adequately care for the patient at home. In the transition to home care, patients and caregivers felt very unprepared and uncertain about patient care in the future. This feeling of unpreparedness was particularly hard on caregivers, who felt very unsure of how to care for the patient at home. Brooks and colleagues [38] concluded that, in the transition to home care, caregiver stress is associated with a lack of information. Supporting caregivers is considered in more detail in Chap. 15.

Staying in the home setting is not always possible. Worsening health status, the patient’s level of dependency, changes in family structure and economic conditions are among the reasons why the demand for residential care facilities (RCF) has increased rapidly. The transition to an RCF is a critical period for older adults as a significant life event that requires them to adapt to a new environment, facing substantial challenges. Studies have reported that individuals experienced substantial emotional responses, limited communication opportunities, isolation, and changes in social support and living patterns. Newly admitted residents to care homes experienced loss of autonomy, stress, and uncertainty at the beginning of the move. Older people are more vulnerable to stress and anxiety in these new locations because they usually depend heavily on familiar people and their usual environment to maintain their independence. Maladaptation to the new situation can damage the quality of life and health status of older people [37].

The process of moving to an RCF requires residents to make complex and important decisions [38]. The decision-making process is the first phase of the transition when the degree of preparedness for the transfer is very important because it determines the outcome of the overall transition. Adaptation was poor for residents whose admission to a nursing home was unplanned. Some older people who felt excluded from the process reported a decrease in psychological well-being [30]. The decision-making process consisted mainly of two elements: the reasons for the move and the behaviour of the placement decision-maker. Similar results were found in a study that revealed four phases: initiation of the placement decision (mainly the reasons), evaluation and weighting of the decision, finalisation of the decision, and evaluation of the decision [39].

Culture is also an important factor influencing how older people respond to care home life [39]. The RCF is often a place of residence for older people of different socio-economic statuses, education levels, and career and cultural backgrounds. Older people from different countries and cultures respond differently to relocation.

Despite common levels of stress and burden, most caregivers reported wanting to care for their chronically ill family members at home and consider RCFs as a last resort [37].

Nurses play a central role in educating, advocating, and supporting the transition of residents into RCFs. However, they need to understand that the adaptation process is dynamic and that tailor-made interventions should be considered to meet the needs of residents in their own time. There are four key points to promote adaptation [39]:

  • Encouraging residents to express their feelings

  • Establishing trust and conveying respect towards residents

  • Interacting with residents as much as possible

  • Increasing family involvement

Patients, carers, and caregivers experience transitions between care settings differently, generating the need for personalised approaches and systems integration to improve care transitions. Older adults with complex conditions, including hip fractures and other significant fragility fractures, receive care from multiple providers and experience multiple care transitions. Future research should further explore ways in which other transition contexts can impact the patient, caregiver, and healthcare provider experience, and quality of care for a range of complex health conditions. Such evidence would provide important directions for practice change, including improving discharge planning practices, enhancing information sharing between healthcare organisations, clarifying roles between healthcare providers and providing appropriate education and involvement of patients and their caregivers.

Summary and Main Points for Learning

  • Older people often feel anxiety, stress, and uncertainty about the future after a hospital stay and involving the patient in discussions and decision-making about the plan for post-hospital care can decrease stress and increase their satisfaction.

  • Family caregivers who feel involved in hospital-to-home transitions are likely to be more satisfied, accepting of their caregiving role and experience less anxiety, take a more active role during care transitions.

  • The aim of discharge planning is to secure a safe transition from the hospital to the next level of care. 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 is vital to allow exchange of vital information and clarify any elements of uncertainty.

  • Being medically ready for discharge may not mean the patient is ready in other aspects such as physical, psychological, and social readiness.

  • Case management is a model of care that supports individuals and families facing numerous health and well-being challenges, including fragility fractures, managing complex care needs and discharge planning.

  • Leaving the hospital setting and returning home or moving to a residential care facility can be traumatic for patients and their families.

16.9 Suggested Further Study

Asif M, Cadel L, Kuluski K, Everall AC, Guilcher SJT (2020) Patient and caregiver experiences on care transitions for adults with a hip fracture: a scoping review, Disabil Rehabil 42(24):3549–3558. https://doi.org/10.1080/09638288.2019.1595181.

Hestevik CH, Molin M, Debesay J, Bergland A, Bye A (2019) Older persons’ experiences of adapting to daily life at home after hospital discharge: a qualitative metasummary. BMC Health Serv Res 19(1):224. https://doi.org/10.1186/s12913-019-4035-z.

Lilleheie I, Debesay J, Bye A, et al (2019) Experiences of elderly patients regarding participation in their hospital discharge: a qualitative metasummary. BMJ Open 9:e025789. https://doi.org/10.1136/bmjopen-2018-025789.

World Health Organization (2016) Transitions in Care. https://apps.who.int/iris/bitstream/handle/10665/252272/9789241511599-eng.pdf

Woodward J, Rice E (2015) Case management. Nurs Clin North Am 50(1):109–121. https://doi.org/10.1016/j.cnur.2014.10.009.