Individual research recommendation details

Recommendation ID

CG124/05

Question

Early supported discharge in care home patients: What is the clinical and cost effectiveness of early supported discharge on mortality, quality of life and functional status in people with hip fracture who are admitted from a care home?

Any explanatory notes
(if applicable)

Why this is important?
Residents of care and nursing homes account for about 30% of all people with hip fracture admitted to hospital. Two-thirds of these come from care homes and the remainder from nursing homes. These people are frailer, more functionally dependent and have a higher prevalence of cognitive impairment than people admitted from their own homes. One-third of those admitted from a care home are discharged to a nursing home and one-fifth are readmitted to hospital within 3 months. There are no clinical trials to define the optimal rehabilitation pathway following hip fracture for these people and therefore represent a discrete cohort where the existing meta-analyses do not apply. As a consequence, many people are denied structured rehabilitation and are discharged back to their care home or nursing home with very little or no rehabilitation input.

Given the patient frailty and comorbidities, rehabilitation may have no effect on clinical outcomes for this group. However, the fact that they already live in a home where they are supported by trained care staff clearly provides an opportunity for a systematic approach to rehabilitation. Early multidisciplinary rehabilitation based in care homes or nursing homes would take advantage of the day-to-day care arrangements already in place and provide additional NHS support to deliver naturalistic rehabilitation, where problems are tackled in the person's residential setting.

Early supported multidisciplinary rehabilitation could reduce hospital stay, improve early return to function, and affect both readmission rates and the level of NHS‑funded nursing care required.

The research would follow a 2‑stage design: (1) an initial feasibility study to refine the selection criteria and process for reliable identification and characterisation of those considered most likely to benefit, together with the intervention package and measures for collaboration between the Hip Fracture Programme team, care-home staff and other community-based professionals and (2) a cluster randomised controlled comparison (for example, with 2 or more intervention units and matched control units) set against agreed outcome criteria. The latter should include those specified above, together with measures of the impact on care-home staff activity and cost, as well as qualitative data from patients on relevant quality-of-life variables.

Source guidance details

Comes from guidance

Hip fracture: management

Number

CG124

Date issued

June 2011

Other details