Demographics
In total, 210 respondents completed the survey, consisting of 13 managers, 57 acute inpatient physiotherapists, 29 community inpatient physiotherapists, 43 community team physiotherapists, 37 acute inpatient occupational therapists, 18 community inpatient occupational therapists and 13 community team occupational therapists. Of the 70 hospitals contacted in relation to the survey of therapy service managers, 25 agreed to take part, with 13 actually completing the survey, as shown in Appendix 24. It was our aim to recruit therapy service managers from 10% of UK hip fracture centres to which we achieved 7%. Although 24 centres agreed to take part in the survey of managers, the survey links may have been passed on within the centre, resulting in respondents answering a more relevant version of the questionnaire. An example of this is that, although we were unable to recruit any managers from Northern Ireland, we did receive completed surveys from some therapists in Northern Ireland.
Service organisation
Integrated care pathway
In the survey of managers, nine of the 13 centres said that they had a written integrated care pathway for patients with proximal hip fracture including rehabilitation; the remaining four did not. Four centres sent a copy of their integrated care pathway to the research team. The initial assessment of the patient varied between pathways but often included a specific falls assessment to identify patients at risk of further falls. This involved a review of medication and other physical factors, such as visual or auditory impairment, but may also have included an assessment of how the current fall happened, the circumstances that led to it and whether or not the patient had previously fallen. In addition to the falls assessment, the initial assessment often asked about the social history of the patient. This generally focused on the type of accommodation that the patient lived in, who he or she lived with, and where the bed and bathing facilities were located. There was also a pre-fracture mobility assessment that was relatively consistent across the pathways and that assessed the ability of patients to walk indoors and outdoors, and whether they needed a walking aid or assistance. It also addressed specific mobility areas such as transfers, stairs and some ADL. Although this information was consistently recorded across pathways, it may have been located in different sections of the pathways for completion by different staff members, for example in some cases it was included in the nursing assessment section and in others it was contained in a specific occupational therapist assessment section.
A number of the integrated care pathways had clearly defined criteria for the occupational therapy assessment. Those that had specific sections assessed personal and domestic ADL, transfers (chair, toilet and bed), general mobility, standing, walking and stairs. One also assessed home hazards and cognition, whereas, in another, specific assessments were carried out on each day post-operatively. Although there was some variation in how these assessments were carried out or presented in the pathways, the overall rehabilitation aims for the patients were very similar and tended to include a referral to the falls service or other outpatient referrals. These pathways were often written as checklists, with no specific details provided, although one integrated care pathway included a detailed list of inclusion/exclusion criteria for the different services.
Twenty-eight (49%) acute hospital physiotherapist respondents stated that there was an integrated care pathway for patients; however, only eight centres forwarded a copy of the integrated care pathway to the research team. Only three (10%) physiotherapist respondents from community hospitals stated that there was an integrated care pathway for their patients, with 18 (42%) community team physiotherapist respondents stating that there was no integrated care pathway. Seventeen (46%) occupational therapist respondents from acute inpatient hospitals stated that there was a written document describing the integrated care pathway. Only one occupational therapist respondent from a community hospital and three occupational therapist respondents from 10 community teams stated that there was a written document describing the integrated care pathway for patients. It was unclear whether the eight integrated care pathways submitted were sent by occupational therapists, physiotherapists or therapy managers.
Rehabilitation in acute hospitals
For all of the responding centres, the multidisciplinary rehabilitation team in acute hospitals included physiotherapists, occupational therapists and nurses. An orthogeriatrician was involved in 11 of the centres with general geriatricians involved in the others. A social worker and pharmacist were involved in 10 of the centres. A dietitian was routinely involved in five centres and a mental health professional in four. Some respondents also mentioned the pain team.
Type of hospital ward where post-operative rehabilitation was delivered
The wards used for post-operative rehabilitation by the 57 physiotherapist and 37 occupational therapist respondents from acute hospitals are described in ; the majority of respondents worked on orthopaedic trauma wards. Twenty (54%) occupational therapist respondents routinely saw proximal hip fracture patients pre-operatively.
Acute hospital wards used for post-operative rehabilitation by physiotherapists and occupational therapists. GORU, geriatric orthopaedic rehabilitation unit; MARU, mixed assessment and rehabilitation unit.
Occupational therapist care delivered in acute hospitals
Occupational therapists working in acute inpatient routine rehabilitation responded that their care of these patients consisted of:
prescribing specific equipment (n = 37, 100%)
practising various ADL (n = 36, 97%)
providing education about hip precautions (n = 30, 81%)
providing information about falls services (n = 27, 73%)
other activities to encourage independence (n = 23, 62%)
providing information about falls prevention techniques (n = 19, 51%)
anxiety management (n = 16, 43%)
developing self-awareness (n = 9, 24%)
referring patients to a falls prevention service (n = 31, 84%)
referring patients to social services (n = 35, 95%)
referring patients to a discharge team (n = 34, 92%)
home visits with patients prior to discharge (n = 30, 81%)
home environment visits without the patient (n = 32, 86%).
Other duties included assessment and referral for minor adaptations in the home, such as grab rails, furniture height raisers and delivery of equipment, referral to community services for support, and liaising with families and carers to obtain information regarding home circumstances and the level of support available.
When patients were first seen by therapists in acute hospitals
shows the responses given by physiotherapists and occupational therapists when asked when they first saw proximal hip fracture patients, whether or not they saw patients at weekends and when patients were first mobilised post-operatively.
When physiotherapists and occupational therapist respondents saw proximal hip fracture patients
In one pathway the action planning also involved a pre-operative physiotherapy assessment but the rest of the pathways appeared to include physiotherapists and occupational therapists only after surgery, with multidisciplinary teams meeting from the first day post-operatively. There was considerable variation in the specific details of post-operative mobilisation and assessment, but the consensus was for early mobilisation on post-operative day 1 when possible, supported by physiotherapists. There was consensus across the pathways that the minimum expected mobilisation on day 1 was for the patient to transfer from bed to chair (with assistance as needed), with exercise discussions beginning. Increased mobilisation and practice of exercises was planned on subsequent days, with most pathways suggesting that the increase in mobilisation, that is, the number of steps taken, should be recorded and with one pathway specifying that this should include reduced supervision/assistance. Although the general aim of increasing mobilisation was seen across the different pathways, some included more detailed specific aims for daily rehabilitation and there was considerable variation in expectations, with one pathway encouraging bed exercises at day 3 and another expecting that an ADL assessment would be carried out by this point in recovery. There was also variation in who carried out the assessments, with one particular pathway allocating separate goals relating to rehabilitation and mobilisation to nursing staff and the therapy team.
Physiotherapy rehabilitation exercises
Forty-nine (86%) physiotherapist respondents on the acute ward used muscle-strengthening training, 27 of whom used progressive resistance training for at least some of their patients. However, 18 respondents stated that they did not use progressive resistance training. Other exercises used by all included walking, climbing stairs and transferring. Forty-five (79%) physiotherapist respondents used weight-bearing exercises, 37 (65%) gait training and 31 (54%) other exercises, as described in Box 4. Forty-two (74%) physiotherapist respondents from acute hospitals provided patients with exercise sheets.
Other exercises used in strength training
Occupational therapist assessment
All occupational therapist respondents from acute inpatient hospitals performed an individual assessment of patients with regard to functional tasks, which included transfers and personal ADL. Thirty-four (92%) respondents stated that this included domestic ADL, 33 (89%) respondents stated that it included the environment and social support, and 16 (43%) respondents stated that they performed an individual assessment of posture and seating. Other comments concerning functional assessment included:
If needed we will complete access and home visits with patients’ consent.
Level of assessment varies for individual patients.
Mobility.
Equipment needs assessment including Telecare.
Due to time restraints within acute hospital, there is little time to assess patients carrying out domestic tasks. However, we always ask patients if they have support with such tasks at home and discuss with them any concerns that they may have.
Frequency and length of therapy sessions
Sixteen (28%) physiotherapy respondents gave physiotherapy twice a day, 12 (21%) once or twice a day, 27 (47%) once a day, one (2%) every other day and one (2%) only two to three times a week. The length of the sessions is shown in .
Length of physiotherapy and occupational therapy sessions in minutes.
The number of times that occupational therapists in acute inpatient hospitals saw patients was variable. The minimum length of these sessions was 15 minutes and the maximum length was 2 hours (see ), with a mode of 30 minutes.
Assessment of mood and cognition
Routine assessments of cognitive status happened in 11 of the 13 centres responding to the therapy manager survey (one replied ‘no’ and one replied ‘don’t know’). The health-care professionals performing the assessment varied at different sites. Doctors, nurses and therapists all performed these assessments on admission and in pre- and post-operative assessments. Assessments were most often carried out using the Abbreviated Mental Test Score (AMTS)274 and the MMSE.275 Routine assessments of mood occurred in five of the 13 centres (four replied ‘no’ and four replied ‘don’t know’), which were usually completed by the medical staff. The Geriatric Depression Scale (GDS)276,277 was used in one centre to assess mood, with a subjective assessment of mood carried out in four centres. Routine assessments of self-efficacy were carried out in four of the 13 centres (four replied ‘no’ and five replied ‘don’t know’). These assessments were performed by nursing staff, a psychologist or occupational therapists and could occur on admission, as required or prior to discharge.
Routine assessment of fear of falling was carried out in nine of the 13 centres by physiotherapists, occupational therapists, nursing staff or doctors. The tools used varied, from in-house tools to physiotherapy assessments, the Falls Efficacy Scale – International (FES-I),278,279 the Berg Balance Scale,280 the visual analogue scale for fear of falling (VAS-FOF)281 and the Timed Unsupported Steady Stand.282
In terms of routine assessments, 47 (82%) acute hospital physiotherapist respondents reported that cognitive status was measured, 19 (33%) that mood was assessed, eight (14%) that self-efficacy was assessed and 23 (40%) that fear of falling was assessed. Doctors, nurses, physiotherapists and occupational therapists performed these assessments. The majority of physiotherapist respondents, 40 out of 57 (70%), did not use a standard assessment tool but relied on one developed in their locality. In terms of routine assessments, 32 (86%) occupational therapist respondents from acute inpatient hospitals reported that cognitive status was measured, 16 (43%) that mood was assessed, eight (22%) that self-efficacy was assessed and 18 (49%) that fear of falling was assessed. Instruments used to assess cognitive status included the Test Your Memory test283 and the Montreal Cognitive Assessment (MoCA).284 Falls screening was carried out using the Falls Risk Assessment Tool (FRAT).285
Good aspects of the service and areas for improvement
When asked to comment on what they felt were good aspects of the service, more than half of the inpatient acute physiotherapist respondents highlighted the benefits of having a multidisciplinary team available for patient treatment. This was followed by having good access to physiotherapists, in particular on weekends or soon after surgery, to allow for early mobilisation when appropriate. Other positive areas of the service referred to by a smaller number of respondents were the communication with patients/carers and access to specialist team members or ward staff. A similar number of respondents highlighted that they were able to provide a timely response to patient care, with a small number specifically mentioning early or pre-operative assessment within this. A number of respondents also commented on the seamless care provided, with referral to various groups and tailoring of treatment to the specific needs of patients and their families. A few respondents also added that they had access to specialist staff in their multidisciplinary team and that they provided patients with specific goals and educational tools.
When asked to identify where there was room for improvement in their service, more than half of the acute hospital physiotherapist respondents commented that there was a need for more resources for staff, beds in community hospitals and rehabilitation equipment. This was the most common theme emerging from the physiotherapists. A number of respondents also commented on the need for the development and use of existing follow-up programmes, such as referrals to falls groups and the use of workbooks and information sheets. Other aspects of care identified as having the potential for improvement included the treatment of dementia patients, communication with and the involvement of nursing staff, intermediate care and timing of input from physiotherapists. When occupational therapist respondents from acute hospitals were asked what aspects of their service could be improved, the responses were varied. Better communication within the multidisciplinary team, better external services (such as falls groups) and the provision of more staff to enable more time to be spent rehabilitating patients were all mentioned with similar frequency. A few respondents also commented that a more consistent service, the provision of office space and improved patient facilities for assessment would be beneficial.
Discharge planning
With regard to successful discharge planning, managers reported that multidisciplinary team meetings were important, although the frequency of these meetings differed between centres, ranging from daily to weekly. Managers commented that, when it was not already occurring, the input of community staff and social workers would improve outcomes for discharge planning. Managers felt that the close collaborative work of the multidisciplinary team was one of the positive aspects of their service, which contributed to improved discharge times and better patient care, and that having the same team throughout a patient’s care was beneficial. However, a small number of managers commented that liaison between primary services and secondary services could be improved. Other areas highlighted for improvement included better access to rehabilitation beds and therapy/nursing resources, and a ward with a dedicated multidisciplinary team.
Discharge and action planning could also be addressed on admission or within the pre-operative period. This could include an assessment of services that were currently used by patients and whether or not they had any home safety equipment already in place, such as alarm pull cords. Some pathways were quite general and contained only a space to indicate if patients had been given advice leaflets and told about follow-up services. In other pathways this information was more detailed and could include checklists that related to specific areas of recovery, for example patients’ understanding of plans for increasing their mobility post surgery or identifying patients’ needs for planned discharge. Some pathways also included an estimated date of discharge and an indication of which services would be involved in the different areas of discharge. In other pathways, discharge was not specifically mentioned until after surgery.
Routine multidisciplinary team meetings were held to discuss discharge planning in 12 of the 13 centres involved in the therapy manager survey. Comments on the survey about what worked well with regard to these meetings and what could be improved included ‘meeting nursing and occupational therapy staff daily’ and ‘weekly meeting with orthogeriatrician’ as well as ‘more social worker input would be helpful’. In the centre that did not hold multidisciplinary team meetings, the primary nurse was in charge of the discharge plans. Seven of the 13 centres held general multidisciplinary team meetings, whereas five held multidisciplinary team meetings at which only hip fracture patients were discussed. The professionals involved in the multidisciplinary team meetings are shown in . Community nurses attended multidisciplinary team meetings in only one of the 13 centres.
Health professionals routinely involved in multidisciplinary team meetings
In two of the centres patients regularly attended discharge meetings and in three of the centres carers regularly attended discharge meetings. In six centres, specific responsibility for co-ordinating discharges was delegated to the following:
discharge link nurses on each ward whose role it was to expedite discharge
discharge facilitator
integrated discharge bureau to co-ordinate complex discharges or else nurses and the multidisciplinary team organised discharge back to a patient’s home when the social set-up was good, for example younger patients without dementia
hip fracture unit-based occupational therapist or physiotherapist co-ordinated most discharges, with some support from a hip fracture specialist nurse
hip fracture specialist nurse employed by secondary care with responsibility for co-ordinating care and discharge arrangements between professions
community liaison team employed by primary care with responsibility for co-ordinating follow-up in community care
ward nurse
unspecified.
In only two of the centres were there staff members with a specific responsibility for overall co-ordination between secondary care and community care services. These were specified as being rehabilitation nurses and ward nurses.
None of the 13 manager respondents from the community teams attended acute hospital-based multidisciplinary team discharge meetings. Other reasons for not attending meetings included ‘acute hip fracture centre too far away’, ‘not invited’ and ‘we have our own multidisciplinary team’.
Home visits
Forty-seven (83%) acute hospital physiotherapist respondents did not make home visits with patients prior to discharge. Only one respondent (2%) indicated that this happened in all cases, with the remaining nine respondents (16%) indicating that this happened for some patients.
Social support on discharge
We asked therapy service managers whether or not discharge plans included referral to or the provision of patients with information about social support and social activities. In five of the centres therapy service managers reported that patients were routinely referred or signposted to social support or activities on discharge. The following types of referral were mentioned:
home from hospital, Careline Services, befriending, luncheon clubs
referral by social worker for packages of care, which may involve third-sector activity clubs, etc.
an information leaflet given by ward nursing staff
to local exercise groups run by Age UK
routinely signposted to local exercise groups if appropriate after our 6 weeks of input; depending on the needs or wants of patients they may be referred to other groups.
Forty-seven (82%) acute hospital physiotherapist respondents referred or signposted at least some patients to social support or social activities on discharge. Other tasks that physiotherapists mentioned included confidence building, giving advice to patients and carers, referral to community rehabilitation and to falls groups, and attending multidisciplinary team meetings.
Rehabilitation in community hospitals
Occupational therapists from community hospitals reported that their routine rehabilitation consisted of prescribing specific equipment (such as long-handled aids) (n = 18, 100%), practising various ADL (n = 18, 100%), education about hip precautions (n = 15, 83%), providing information about falls services (n = 12, 67%), other activities to encourage independence (n = 12, 67%), falls prevention techniques (n = 15, 83%), anxiety management (n = 6, 33%) and developing self-awareness (n = 3, 17%). Eleven (61%) respondents referred some patients to a falls prevention service, 16 (89%) referred some patients to social services and 12 (67%) referred some patients to a discharge team. Seventeen (94%) respondents carried out home visits with patients prior to discharge and all made a home environment visit without the patient. Other duties included promoting patient empowerment and increased confidence in patients’ ability, teaching relaxation and pain management techniques, and providing advice to carers and patients about good moving and handling practices and joint protection.
When patients were transferred to community hospitals
Nineteen (66%) physiotherapist respondents from community hospitals reported that patients were transferred within the first week post-operatively, nine (31%) reported that patients were transferred in the second post-operative week and three (10%) reported that patients were transferred in the third post-operative week. The other seven respondents gave a variety of time periods, indicating that the timing of transfer varied according to patient and departmental factors. Factors influencing transfer to a community hospital included:
When the GP refers patients – they cannot be directly referred from the acute hospital following discharge.
As soon as medically stable and bed available.
After clinic review, often greater than 6 weeks post-operatively if they are still having difficulties.
When discharge is delayed.
Depends when the consultant or GP refers the patient.
Hard to clarify but some come to us straight from hospital at approximately three weeks post operation. Others go via intermediate care team services so would come to us at between 3–6 weeks post fracture.
Two (11%) occupational therapist respondents from community hospitals noted that their patients were usually transferred in the first post-operative week, eight (44%) that their patients were transferred in the second week and three (17%) that their patients were transferred in the third week, and five (28%) stated that it depended on the patient.
When patients were first seen by therapists in community hospitals
Therapy service managers reported that when the community team members saw their patients varied, with three respondents reporting that they were seen on the day of discharge, one the day after, two within 2 days, one within 7 days and one within 4–6 weeks; for five managers the timing varied according to circumstances. Therapy service managers responded that the services provided by community team physiotherapists were early supported discharge (n = 12), intermediate care (n = 5), neither early supported discharge nor intermediate care (n = 13) and other (n = 13). Most respondents who ticked ‘other type of service’ described it as a combination of early supported discharge and intermediate care.
Thirty-two (74%) physiotherapist respondents from community hospitals stated that the time after surgery at which they first saw patients varied, with most patients being seen within 1 week. Only three respondents saw patients on the day of discharge, with a further five respondents seeing them the day after discharge.
Frequency and length of therapy sessions
For 21 (49%) physiotherapy respondents from community teams the length of contact varied from patient to patient. For one (2%) respondent the contact time was 8 weeks, for 10 (23%) respondents it was 6 weeks, for two (5%) respondents it was 4 weeks and for one (2%) respondent it was only 1 week. Six respondents (21%) saw their patients twice a day, 13 (45%) saw them once a day, one saw them weekly, one saw them three to five times per week, one saw them daily, reducing as discharge planning took place, and one saw them four times a week and in cases of urgency. The minimum length of these sessions was 10 minutes, the maximum 60 minutes, with a mode of 30 minutes.
With regard to the frequency with which occupational therapists saw patients in community hospitals, three (17%) occupational therapists saw them daily, seven (39%) saw them on alternate days, one (6%) saw them every third day, two (11%) saw them twice a week and four (22%) stated that the frequency of sessions depended on the patient. The length of the therapy sessions was variable and depended on the patient; the minimum length of the sessions was 10 minutes and the maximum was 60 minutes, with a mode of 60 minutes.
Assessment of mood and cognition
Community hospital physiotherapists frequently commented on their ability to carry out thorough assessments and provide intensive input to patients, allowing them to tailor rehabilitation to an individual’s needs. A number of respondents also highlighted the good communication and working relationships within the multidisciplinary team, which allowed consistent and seamless care of patients. Some respondents felt that this contributed to safer or quicker discharge of patients. Ten (56%) occupational therapist respondents from community hospitals indicated that they employed a successful client-centred approach. Six (33%) respondents also highlighted the good multidisciplinary team working and six (33%) commented on good patient outcomes, engagement with family members/carers, the provision of intensive rehabilitation and that staff were experienced and of a high calibre.
Ten (34%) physiotherapist respondents from community hospitals used a standardised tool to assess progress: eight used the Elderly Mobility Scale,286 one used the EuroQol-5 Dimensions (EQ-5D)287 and one used the Timed Up and Go test.288 How often progress was assessed varied from daily (n = 14, 48%) to weekly/fortnightly (n = 8, 28%). Sixteen (55%) physiotherapist respondents from community hospitals measured cognitive status, 11 (38%) assessed mood, seven (24%) assessed self-efficacy and 17 (59%) assessed fear of falling. Fourteen (78%) occupational therapist respondents from community hospitals measured cognitive status, 11 (61%) assessed mood, five (28%) assessed self-efficacy and nine (50%) assessed fear of falling.
Physiotherapist rehabilitation exercises
Twenty-five (86%) respondents from community hospitals gave out exercise sheets. In community hospitals, 27 (93%) respondents used strength exercises (quadriceps, hip abductors) in rehabilitation. Of these, four always used progressive resistance training, 10 used it for some patients, seven used it for a small minority of patients, one used it once patients were discharged and five did not use it at all. Twenty-seven (93%) respondents used weight-bearing exercise, 22 (76%) used gait training and one (3%) used treadmill gait training. Other exercises used are listed in Box 4.
In terms of ADL, 28 (97%) physiotherapist respondents from community hospitals encouraged walking and climbing stairs and 27 (93%) encouraged transferring. Other ADL addressed included:
indoor and outdoor mobility when possible
getting in and out of bed
managing clothing
getting on and off the toilet
getting in and out of a car
gait re-education
getting up from the floor
patient-specific goals
balance and falls prevention.
Other interventions that were used included acupuncture for pain relief, the provision of advice about, for example, seating at home, bed height and car seats, hydrotherapy, progression of walking aids and stretches.
Occupational therapist assessment
All occupational therapist respondents from community hospitals performed individual assessments of functional tasks, which included transfers, personal and domestic ADL and the environment, and car transfer practice and stair practice. Seventeen (94%) respondents stated that this also included an assessment of social support and 11 (61%) performed an individual assessment of posture and seating.
Discharge planning including referral to social support
Sixteen (89%) occupational therapist respondents from community hospitals stated that patients were routinely signposted to social support or social activities when discharged, such as day care, community resource teams, Age Concern, local charities, exercise classes and Crossroads.
Referral to social support or activities was reported by 14 (48%) community hospital physiotherapists; this included exercise groups, day centres, lunch clubs, care and repair agencies, falls groups, local charity support groups, Age UK, befriending, Bone Boost and Nordic walking.
Home visits
Sixteen (55%) physiotherapist respondents from community hospitals did not routinely make a home visit. One (3%) respondent always made a routine home visit, whereas 12 (41%) visited according to need.
Good aspects of the service and areas for improvement
Although the time spent with patients was identified as a good aspect of most services, when asked to comment on areas that could be improved, 10 (55%) occupational therapist respondents from community hospitals reported that increased staffing levels would be beneficial. Respondents felt that this would allow for an increased duration and frequency of visits. Five (28%) occupational therapist respondents commented that the provision of facilities and access to referral services could be improved, as well as there being better communication and consistency across the multidisciplinary team. One (6%) occupational therapist respondent also commented that links with the acute hospital could be improved.
Rehabilitation in the community
According to the occupational therapist respondents from community teams routine rehabilitation consisted of prescribing specific equipment (n = 13, 100%), practising various ADL (n = 13, 100%), education about hip precautions (n = 13, 100%), providing information about falls services (n = 12, 92%), other activities to encourage independence (n = 12, 92%), falls prevention techniques (n = 13, 100%), anxiety management (n = 6, 46%) and developing self-awareness (n = 6, 46%). Seven (54%) respondents referred some patients to a falls prevention service, 10 (77%) referred some patients to social services and one (8%) referred some patients to a discharge team. Other duties included checking medication, providing support and advice to family members, partners or carers and referring clients to intermediate care if they had complex needs.
Health professionals involved in community-based rehabilitation
The health professionals involved in community-based rehabilitation, according to the survey of therapy service managers, are shown in . Physiotherapists provided rehabilitation in all of the centres and occupational therapists provided rehabilitation in all but one centre.
Health professionals routinely involved in community-based rehabilitation
Types of community-based rehabilitation service
According to the survey of therapy service managers, the types of community-based rehabilitation service available to proximal hip fracture patients after discharge from the acute hospital were:
community hospital providing hip fracture rehabilitation or other community-run rehabilitation inpatient rehabilitation unit (n = 9)
early supported discharge service providing community-based multidisciplinary rehabilitation for about 4–6 weeks based in the patient’s own home (n = 10)
early supported discharge service providing community-based multidisciplinary rehabilitation for about 4–6 weeks based in the care home/nursing home where a patient has been discharged for the long term (n = 5)
traditional model of community care in which the patient is discharged home (to their own home or to a long-term care setting) under the care of a GP and with individual referral to community health and social care professionals as needed (n = 11).
Three respondents from community teams described their service as an early supported discharge scheme, two as intermediate care and two as neither of these. The remaining six respondents gave their own description of their service:
Intermediate care at home service.
All of the above, early supported discharge has no limit on the rehabilitation time and includes trying to prevent admission to hospital.
Intermediate care team who take rapid response patients for early discharge or prevention of admission.
We see clients for 4–6 weeks. They can be discharged directly from acute hospital or from intermediate care.
Intermediate care team providing community therapy. ‘I provide OT [occupational therapy] services to individuals who come from a variety of sources and who may have multiple conditions’. Work with some of those include individuals who may have been supported home with multidisciplinary team planning from acute or intermediate care beds or they may have suddenly been discharged due to a variety of reasons.
Our team also provides an in-reach therapy service to a 10 bedded rehabilitation unit in a care home. Our team also see people in their own home to deliver therapy interventions following proximal hip fracture.
When patients were discharged home
Community rehabilitation was available to over half of patients after discharge home in 11 centres and to > 75% of patients in five centres. One centre stated that < 10% of patients received community rehabilitation and one centre did not provide any information on this.
When patients were first seen and frequency and length of sessions
Occupational therapists in community teams saw patients in the community according to need. Five (38%) saw patients twice weekly and one (8%) saw patients once a week. The length of time that patients were seen for was variable and depended on the patient. The minimum length of the therapy sessions was 30 minutes and the maximum was 100 minutes, with a mode of 60 minutes.
Assessment of mood and cognition
Eighteen (42%) community team physiotherapist respondents measured cognitive status, 15 (35%) assessed mood, 11 (26%) assessed self-efficacy and 26 (60%) assessed fear of falling. The different assessment tools used by therapists are shown in . As well as using standardised measures, many respondents based their assessments on general observations and discussion with the patient or used local screening tools. Twelve (92%) occupational therapist respondents from community teams measured cognitive status, 12 (92%) assessed mood, seven (54%) assessed self-efficacy and 11 (85%) assessed fear of falling.
Assessment tools used by therapists
Physiotherapy rehabilitation exercises
All physiotherapist respondents from community teams indicated that they used strengthening exercises, with 39 (91%) respondents indicating that they used progressive resistance training with some of their patients. Forty-one (95%) respondents used weight-bearing exercises, whereas only 34 (79%) used gait training. None of the physiotherapists used treadmill gait training. Other exercises used are listed in Box 4. Thirty-nine (91%) physiotherapist respondents from community teams gave their patients exercise sheets. In terms of ADL, 42 (98%) physiotherapist respondents from community teams encouraged walking and climbing stairs and 39 (91%) encouraged transferring. Other ADL addressed included personal care and meal preparation, stair climbing, accessing the community, outdoor walking, car and bus transfers, feeding the cat, walking the dog and caring for a relative. The frequency of physiotherapy sessions varied from patient to patient but was either weekly or fortnightly. The minimum length of therapy sessions was 15 minutes and the maximum was 90 minutes, with a mode of 30 minutes ().
Length of community physiotherapy and occupational therapy sessions.
Occupational therapist assessment
All occupational therapy respondents from community teams carried out individual assessments of functional tasks, which included transfers, personal and domestic ADL, the environment and social support. Five (38%) respondents carried out an individual assessment of posture.
The frequency of occupational therapy sessions varied from patient to patient according to individual need. The minimum length of these sessions was 30 minutes and the maximum 90–100 minutes, with a mode of 1 hour (see ).
Referral to social support
Twenty-six (60%) of the community team physiotherapist respondents referred patients to social support or social activities when discharged. Other tasks performed by physiotherapists that have not already been mentioned included confidence building by performing balance and falls prevention exercises, the provision of home exercise programme/information, the provision of walking aids, orthotics assessment and contacting family members/carers.
Twelve occupational therapist respondents from community teams stated that patients were routinely signposted to social support or social activities when discharged, such as:
befriending services (Age UK/Red Cross)
day care or day centres (social services)
shopping services (Red Cross)
local charities and lunch clubs
Age UK and local voluntary good neighbouring and support services
Women’s Royal Voluntary Service to aid with transport and shopping
enablement services
long-term care services
sensory impairment services
art classes
exercise classes.
Good aspects of the service and areas for improvement
When commenting on good aspects of their service, the majority of community team physiotherapists mentioned the relationship with the patients and their ability to be responsive and flexible to tailor treatment to individual patients’ needs. Some respondents also highlighted strong links and communication within the multidisciplinary team as positive aspects of their service. More than half of the respondents from community teams felt that the amount of time that they were able to spend with patients, particularly in their own home, was a positive aspect of their service. A number of participants also commented on good multidisciplinary team working and a few individuals highlighted the inclusive nature of their service and how they were able to work to the goals of patients and their family.
When asked to comment on areas that needed improvement, a common response was that community teams would benefit from increased staffing levels and better links to hospitals. Smaller numbers of respondents also commented that improvements could be made by increasing the number of available rehabilitation beds, improving access to specific referral groups (e.g. falls, balance and exercise groups) and using standardised assessments for treatment. Only one community physiotherapist respondent routinely attended multidisciplinary team discharge meetings. The reasons for not attending included insufficient staffing levels and good links with inpatient staff, with the discharge of complex patients discussed on the telephone. A few respondents from community teams felt that communication with other services could be improved and that therapists had an overload of patients, which decreased the time that they were able to spend with each individual patient. One respondent felt that there should be less focus on outcome measurement sheets as they were a waste of time, whereas another respondent commented that the regular use of standardised outcome measures would be useful.
