Construction of Value: Providers’ Perspectives on Best Practices for Hip Fracture Rehabilitation

PURPOSE: Identify rehabilitation providers’ perspectives on best practices for hip fracture rehabilitation.

BACKGROUND: The majority of older adults who experience a hip fracture are discharged from the hospital to a skilled nursing facility (SNF) for postacute care (PAC) rehabilitation. As part of PAC, interdisciplinary team occupational and physical therapy practitioners provide care aimed to maximize independence and facilitate a safe community transition. Yet, despite this treatment objective and high PAC rehabilitation utilization, outcomes are poor (e.g., failed community transitions and long-term institutionalization), which has resulted in concerns over care quality. Currently, no guidelines exist that define best practices for hip fracture rehabilitation, leaving rehabilitation practitioners ill equipped to systematically improve patient outcomes. Capturing PAC providers’ perspectives of best practices is a fundamental step to informing the development of evidence-based patient-centered rehabilitation guidelines and quality improvement initiatives.

DESIGN: Qualitative study

PARTICIPANTS: A diverse sample (N = 99) of rehabilitation staff, including occupational and physical therapists and assistants employed across 13 SNFs throughout Los Angeles County.

METHOD: Thirteen focus groups were conducted in SNFs. Purposive sampling of facilities was conducted to capture SNFs that vary by key characteristics known to affect care delivery for individuals with a hip fracture (e.g., location, resources, organizational structure, staffing, and patient case mix). The focus groups aimed to elicit providers’ perspectives on the best practices for hip fracture rehabilitation. Each session was audiorecorded and transcribed.

ANALYSIS: An interdisciplinary research team systematically analyzed the transcripts utilizing a grounded theory approach to identify major themes and subthemes. The software program Atlas.ti was used to facilitate data analysis.

RESULTS: Seven major themes highlighting best practices for hip fracture rehabilitation were identified: (1) assessing and treating fear of falling and fall risk; (2) collaborating on patient–clinician goal setting and status updates; (3) collaborating with nursing and the patient on pain management; (4) engaging in early mobilization; (5) addressing habits, roles, and routines within the context of functional abilities; (6) assessing the home environment before discharge; and (7) preparing the patient and caregiver for transition back to the community.

DISCUSSION: High-quality care must be delivered for PAC rehabilitation to achieve optimal outcomes, such as a safe transition back to the community. Clinical guidelines are critical tools to facilitate clinical decision making and engage in quality improvement. The findings of this study highlight the clinician perspective on what constitutes best practices for hip fracture rehabilitation across a diverse sample of SNFs. This work provides critical information to advance the development of rehabilitation clinical guidelines and quality measures. Future research is needed to verify these best practices from the perspective of other stakeholders (e.g., patients), ensure their alignment with current evidence, and develop measures for evaluating their implementation and relationship to desired outcomes.

IMPACT: For occupational therapy to demonstrate its contribution to PAC interdisciplinary teams, it is necessary not only to identify the interventions that constitute best practices during an episode of care but also to ensure their implementation in practice, documentation, and relationship to desired outcomes. This study lays a foundation for future research quantifying the role of occupational therapy in PAC hip fracture rehabilitation.