2.1 Facility-based rehabilitation

Facility-based rehabilitation is common, effective and typically resource intensive. Most healthcare systems attempt to balance costs and benefits, so it is essential to assess the functional ability of the patient to determine if clinically appropriate care can be delivered in a lower intensity setting. The most common facility settings for rehabilitation are described below:

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  When patients receive rehabilitation in inpatient geriatric wards, ie, in the same facility where the acute care was provided, placement in a geriatric care-based unit for the entire hospitalization appears to be superior to a 2-step model of postoperative transfer from an orthopedic surgical ward to a geriatric rehabilitation ward. This ward model can be more expensive but minimizes the risk of institutional transitions of care [5, 6]. Inpatient ward based rehabilitation is more common in European healthcare systems.

  
  
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  Inpatient rehabilitation facilities can be located within a hospital or exist as standalone facilities. Patients that are managed in these facilities can typically tolerate intensive rehabilitation, ie, more than 3 hours per day, while still receiving access to comprehensive nursing care. These settings are appropriate if the intensity, frequency, and duration of therapeutic activities make it impractical to obtain the services in a less intensive setting. While younger and more robust patients may get superior outcomes from IRF-based rehabilitation, many fragility fracture patients (FFPs) cannot tolerate this intensity of services.

  
  
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  A skilled nursing facility or postacute care setting is a setting of care where staff manages, observes and evaluates care including routine medication administration, postsurgical care, and rehabilitation. This is the most common FFP rehabilitation setting in North American healthcare systems, with multidisciplinary staff including nurses, physical and occupational therapists, social service workers, nutritionists and recreational therapists. Medical providers are not onsite at all times, and acute onsite medical evaluation is not always possible.

As suggested above, patients admitted to geriatric wards and IRFs should be generally able to participate in, and be likely to benefit from, at least 3 hours of rehabilitation activities per day, five times per week. In many of these settings a physician specialized in rehabilitation sees the patient at least three times per week.

Patients admitted to IRFs usually have shorter lengths of stay than those admitted to SNFs. In addition, IRF patients typically receive more physical and occupational therapy than patients admitted to SNFs. Some reports suggest that this comes at a higher cost without a significant change in functional outcomes [2, 7].

Patients can be transitioned to a less resource-intensive level of care from IRFs when all functional rehabilitation goals have been achieved or when therapy services are no longer required to meet rehabilitation goals. Patients should also be considered for transfer if further progress toward rehabilitation goals is not expected or can be achieved at a less resource-intensive level of care [8].

Most organized healthcare systems offer a predetermined number of covered rehabilitation days per eligibility period for patients to use when needed. Hip fracture patients admitted to SNFs can typically receive rehabilitation services at least five times per week. As the literature suggests, hip fracture patients admitted to SNFs have similar levels of recovery as those admitted to inpatient rehabilitation hospitals and at a lower cost.

The main difference between an acute rehabilitation hospital and an SNF is the level of staffing, the frequency of physician evaluation, and the intensity of the rehabilitation services. In the US, most insurers authorize payment for rehabilitation of FFPs in SNFs due to their lower operational cost.

2.2 Home and outpatient-based rehabilitation programs

Among patients who have completed standard rehabilitation after hip fracture, the use of a home-based functionally focused exercise program can provide some added improvement to mobility. Using home-based services as the only mode of rehabilitation after a hip fracture should be reserved for those with very high functional status in the immediate postfracture period or those that have a support system that allows them to receive adequate services in this setting [9, 10].

3.1 Multidisciplinary rehabilitation team

Once a comprehensive evaluation of the patient′s needs has been completed, an individualized plan of care should be designed for each patient with the input of a multidisciplinary team. Team members often include physical and occupational therapists, medical providers, nurses, nutritionists and social workers. As mobility is the best overall predictor of a successful outcome, physical therapists play a central role in the rehabilitation process. Occupational therapists assist in specific ADL achievement, overall functioning, and reducing fall risk. If cognitive impairment is affecting communication or swallowing, a speech therapist can be helpful. The optimal degree of direct involvement of certified therapists has yet to be determined. When local resources permit, physicians with experience in geriatrics and rehabilitation typically manage the ongoing medical comorbidities and rehabilitation program.

Nursing care typically focuses on symptom assessment, pain control, managing medications and preventing pressure ulcers. Nurses involved in the care of FFPs should be familiar with common geriatric syndromes (eg, delirium, dementia, falls, and incontinence).

Nutritional enhancement in those who are malnourished or undernourished can improve outcomes [13]. Nutritionists are best suited to evaluate and recommend dietary regimens.

Social workers play an essential role in assisting with social or financial issues affecting long-term care needs. Moreover, the spouse, family, or caregivers play a significant role in providing psychological support and motivation to the patient. The medical and orthopedic providers are responsible for supervising the medical plan of care, monitoring clinical progress, and striving to avoid medical complications [14].