Communication within pathways of care in hip fracture physiotherapy rehabilitation in England and Wales

Purpose

Hip fracture is a leading cause of morbidity in people over 60 years old. People experiencing hip fracture require rehabilitation, often from a number of teams, throughout their recovery period. Communication between these different teams poses a challenge to the continuity of care. Communication between professionals delivering care is essential to ensure safe and effective care, continuity of treatment and rehabilitation planning. We used data from the national 'Hip Sprint' audit to understand the flow of information across the hip fracture pathway.

Half of hip fracture patients
return directly to their own home after hip fracture.
A predicted 1000 more patients could return straight home every year
if they received at least 20 minutes of rehab every day in the first 7 days after hip fracture

Approach

A 'facilities audit' was created to capture information about the information flow within and between different parts of the hip fracture rehabilitation pathways used. We used the existing network of NHFD Leads within each hospital to identify physiotherapists working in hip fracture rehabilitation. We asked these physiotherapists to identify other physiotherapists in other parts of the pathway. Data collected between May-August 2017.

Outcomes

580 physiotherapists recruited from across acute, next steps and community settings in England and Wales. Datasets on 7000 (78.6%) people receiving care following a hip fracture were collected. In 37% of acute hospitals physiotherapists did not attend multi-disciplinary hip fracture governance meeting or no such meetings existed.

Variety of models and pathways identified

Care pathways are either a two-stage process including hospital and home, or a three-stage process including hospital, intermediate care and home. Organisational boundaries between stages of the care pathway can lead to delay in receiving optimal care, or not receiving care at all.

Pathways are simple in compact geographical areas with limited ‘catchment’ areas of people with hip fracture, and where the acute centre provides and/or co-ordinates all care before discharge home.

Pathways are more complicated where the acute hospital serves a large geographical area, and links with a series of community and intermediate services that provide sandwich care between acute care and home care.

Mapping an individual’s person route through the whole rehabilitation pathway is variable according to geography, service configuration and a person’s individual needs and circumstances.

Care Models are dependent on local service configuration and innovation.

Care Models are clinically focussed around the nature of the injury, or population focussed around a descriptor of the person, or patient-centered around the needs of person with hip fracture as a whole, or capacity-based around the resource of the acute unit. Four main models identified.

  • Traditional orthopaedic care
  • Older peoples services care
  • Orthogeriatric care
  • Outlier non-specified care

Nearly 10% of acute services provide either no handover of patients, or only a telephone transfer of information, to the next part of the pathway. Nearly all intermediate care services provide a hand-over to community services (99%). 10% of community services say they receive no handover at all. Email is the commonest method of transferring physiotherapy information, used by one-third of acute and next steps services. Transfer of integrated multidisciplinary notes occurs in 14% of acute service transfers, and 12% of intermediate care transfers.

Cost and savings

The project was run by the Royal College of Physicians with a £30K grant from the CSP Charitable Trust. The Hip Sprint 1 project ran from Feb 17 – Feb 18.

Implications

A small but significant number of patients do not receive continuity of hip fracture rehabilitation due to poor communication within the care pathway.

Physiotherapists are not involved in local decision making about hip fracture rehabilitation in a significant number of services

Communications methods used may not be efficient or effective between physiotherapists between stages in the pathway as it appears that some referrals are lost in the pathway.

Physiotherapists need to improve communication channels and pathways to ensure that every patient receives continuity of care throughout each stage of the recovery process.

Patient experience of hip fracture rehabilitation can be enhanced by improving the communication across the whole pathway.

Physiotherapists need to embed with local hip fracture governance teams to optimise rehabilitation from Day 1.

Local referral structures between sectors in the pathway should be reviewed to ensure that these are suitable for efficient handover of appropriate information.

Only half of hip fracture patients return directly to their own home after hip fracture. If every patient received at least 20 minutes of rehab every day in the first 7 days after hip fracture it is predicted that 1000 more patients could return straight home every year.

Top three learning points

  • Hip fracture care is heavily focussed on acute hospital interventions, with little detail around onward rehabilitation.
  • At a service level, hip fracture care still takes an organisation-centered approach rather than a patient centred approach.
  • Services have been able to redesign the care they offer to improve outcomes in response to previously poorer outcomes for patients
  • Integration and good communication is essential for seamless patient-centred care.

Fund acknowledgements

The Hip Sprint project was funded by The Chartered Society of Physiotherapy.

Additional notes

This work was presented at Physiotherapy UK 2018.