https://orcid.org/0000-0002-9552-9139
Figures
Abstract
Background
Individuals who experience a hip fracture have numerous care transitions. Improving the transition process is important for ensuring quality care; however, little is known about the priorities of different key interest groups. Our aim was to gather recommendations from these groups regarding care transitions for hip fracture.
Methods
We conducted a concept mapping study, inviting persons with lived experience (PWLE) who had a hip fracture, care partners, healthcare providers, and decision-makers to share their thoughts about ‘what is needed to improve care transitions for hip fracture’. Individuals were subsequently asked to sort the generated statements into conceptual piles, and then rate by importance and priority using a five-point scale. Participants decided on the final map, rearranged statements, and assigned a name to each conceptual cluster.
Results
A total of 35 participants took part in this concept mapping study, with some individuals participating in multiple steps. Participants included 22 healthcare providers, 7 care partners, 4 decision-makers, and 2 PWLE. The final map selected by participants was an 8-cluster map, with the following cluster labels: (1) access to inpatient services and supports across the care continuum (13 statements); (2) informed and collaborative discharge planning (13 statements); (3) access to transitional and outpatient services (3 statements); (4) communication, education and knowledge acquisition (9 statements); (5) support for care partners (2 statements); (6) person-centred care (13 statements); (7) physical, social, and cognitive activities and supports (13 statements); and (8) provider knowledge, skills, roles and behaviours (8 statements).
Conclusions
Our study findings highlight the importance of person-centred care, with active involvement of PWLE and their care partners throughout the care journey. Many participant statements included specific ideas related to continuity of care, and clinical knowledge and skills. This study provides insights for future interventions and quality improvement initiatives for enhancing transitions in care among hip fracture populations.
Citation: Guilcher SJT, Cadel L, Everall AC, Bronskill SE, Wodchis WP, Thavorn K, et al. (2024) Identifying and prioritizing recommendations to optimize transitions across the care journey for hip fractures: Results from a mixed-methods concept mapping study. PLoS ONE 19(8): e0307769. https://doi.org/10.1371/journal.pone.0307769
Editor: Antimo Moretti, University of Campania Luigi Vanvitelli: Universita degli Studi della Campania Luigi Vanvitelli, ITALY
Received: April 1, 2024; Accepted: July 5, 2024; Published: August 26, 2024
Copyright: © 2024 Guilcher et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: All relevant data are within the manuscript and its supporting information files.
Funding: This study was funded by the Canadian Institutes for Health Research (grant #179845). The opinions, results, and conclusions reported in this paper are those of the authors and are independent from the funding sources. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Competing interests: The authors have declared that no competing interests exist.
Introduction
Hip fractures are one of the most common reasons for fall-related hospitalizations in adults over the age of 65 [1, 2]. Older adults with hip fractures often experience functional decline and on-going morbidity after their injury [3–6]. Risk factors for hip fracture may include history of osteoporosis, falls, physical inactivity, medication use (cimetidine, psychotropic anxiolytics/ hypnotics, barbiturates, opioids, antihypertensives, benzodiazepines, anticonvulsants, sedatives, caffeine, and antidepressants), chronic health conditions, older age, and being female [7–9]. Unfortunately, approximately 13.5% of persons die within six months of sustaining a hip fracture injury [10]. Of those that survive, only 40% of persons can perform activities of daily living independently following the first year post-fracture and persons often have a decline in health-related quality of life [11–14].
Smooth care transitions can be challenging for this population, as individuals who experience a hip fracture undergo an average of 3.5 transitions between care settings in the first six months following a hip fracture [15]. These transitions occur within and between many different healthcare providers and diverse settings including hospitals, inpatient rehabilitation units, outpatient clinics, home care, assisted living facilities, and long-term care homes [15–19]. Importantly, some care transitions are a key part of the hip fracture journey and standards of care [20, 21]. For example, rehabilitation post-hip fracture can improve the physical and social aspects of reintegration into the community [21]. Despite the importance and need for some of these transitions, care transitions that result in increased hospital readmissions and emergency department visits, adverse medication events, and overall poor patient and caregiver experience and satisfaction are considered to be suboptimal [22–25]. The one year direct attributable healthcare costs for hip fractures in Canada is $1.1 billion [26] and is estimated to increase to $2.4 billion by 2041 in part due to an aging population [27].
Most research on care transitions in the general population, as well as hip fracture more specifically, has focused on the acute transition from hospital to home rather than across the care continuum [28]. In efforts to address this gap for hip fracture, Stolee and colleagues synthesized multi-site ethnographic qualitative research, which involved perspectives from patients, care partners and clinicians [28]. They proposed a framework that outlines potential areas of intervention. The six broad domains proposed include the following: patient involvement and choice (patients and caregivers are educated on options and able to make decisions), role of family care partners (family caregivers provide information to healthcare team, provide care, and want to be actively involved in care decisions), relationships (relationships between healthcare providers, and between patients and family caregivers), role coordination (understanding of healthcare providers’ roles within and across settings), documentation (written communication about patient’s health and status), and information sharing (use of written and verbal communication to share information formally and informally). These domains align with previous research conducted by this team, which highlighted the need to focus on improved communication and information sharing among patients, their care partners, and health professional team [16–18].
Similarly, our team has conducted several studies exploring experiences with hip fracture along the care continuum in Ontario, Canada [25, 29, 30]. Communication was also identified as an important area of focus, as care partners and healthcare providers often had differing expectations on the roles of care partners, providers, and the health system more broadly [30]. Building on this work, Cadel and colleagues explored service recommendations from the perspectives of patients, care partners, healthcare providers, and decision-makers [29]. Three main categories of recommendations were outlined: (1) hospital-based recommendations; (2) community-based recommendations; and (3) cross-sectoral based recommendations. Hospital-based recommendations focused on improving relationships, communication, and staffing levels. Community-based recommendations included the early identification of at-risk individuals and providing preventative and educational programs. Cross-sectoral based recommendations were grounded in enhanced system navigation through communication and care navigators, particularly within primary and community care settings. While these recommendations from Stolee and Guilcher are informative as an initial step for broad areas of improvement, there is a need for more specific design ideas and priority setting to facilitate actionable implementation strategies for the development of implementable quality improvement initiatives and complex interventions [31, 32].
Further research is warranted with key interest group engagement to understand from their perspectives on specific strategies to assist in care transitions for hip fracture and more importantly, their perspectives on which areas are of a priority. This priority setting step is important to engage in prior to the development and implementation of an intervention to best understand the causal and contextual factors that can be modified [33]. Therefore, in using creative partnership design principles [34], the aim of this study was to create a list of actionable and prioritized recommendations to improve care transitions for individuals with hip fracture from the perspectives of persons with lived experience (PWLE), care partners, healthcare providers, and decision-makers.
Methods
Study design
A mixed methods study was conducted, following the concept mapping methodology outlined by Kane and Trochim [35]. Concept mapping uses a collaborative approach to data collection and analysis that is useful for gathering perspectives from a range of participants for planning and evaluation purposes [36, 37]. Given its action-oriented nature, concept mapping was ideal for the purposes of this project in developing actionable recommendations with creative partnership design principles [35, 38]. This structured methodology is comprised of six sequential steps, including: preparation, brainstorming, sorting and rating, analysis, mapping and interpretation, and utilization [35].
Preparation
The preparation step consisted of two key tasks: identifying the focal prompt (research question) and recruiting participants. The focal prompt developed by the research team to guide all stages of this study was: what do you think is needed to improve care transitions for hip fracture?
Participant inclusion criteria
Participants included persons who had experienced a hip fracture, unpaid care partners (e.g., family or friends), healthcare providers, and decision-makers. PWLE were required to be at least 50 years of age, at the time of the interview, to align with quality standards in Ontario. All other participants were required to be 18 years of age or older. All participants had to be able to speak English. PWLE were required to have received care for any type of hip fracture in Ontario (e.g., osteoporotic, traumatic); care partners were required to have provided care for an individual who experienced a hip fracture; healthcare providers and decision-makers were required to have provided care in a paid capacity for individuals with hip fracture or to influence policy/procedures relating to hip fracture.
Sampling strategy
We used a multipronged purposive sampling strategy [39, 40]. Participants were selected for variation in geographical setting (rural, urban). Healthcare providers and decision-makers were also selected for variation in profession and health sector. To recruit participants, study flyers were posted in healthcare facilities, on partnering professional and healthcare organizations websites, and on social media. Most PWLE and care partners were recruited by healthcare providers in two partnering acute care hospitals (one urban, one rural) using a consent to contact method whereby a healthcare provider identified eligible individuals, gave them a brief description of the study, and obtained verbal or written consent for a member of the research team to contact them. Healthcare providers and decision-makers were identified through the research teams’ contacts in the two partnering hospitals, as well as through health professional organizations and associations. All recruitment occurred between April 2022 and June 2023.
Idea generation: Brainstorming
Brainstorming sessions were guided by the focal prompt: what do you think is needed to improve care transitions for hip fracture? Sessions were held both synchronously and asynchronously, depending on participant availability. Synchronous sessions were conducted as focus groups or interviews and were facilitated by trained members of the research team (ACE, MSc; LC, MSc, PhD candidate). Focus groups were conducted virtually via Zoom and interviews were conducted by Zoom or by telephone between July 2022 and September 2022. The focus groups and interviews followed a semi-structured brainstorming interview guide and allowed for group discussion to generate additional ideas related to the focal prompt. Participants were divided into two groups: a) PWLE and care partners, and b) healthcare providers and decision-makers, to maximize comfort in sharing their thoughts and experiences. Asynchronous sessions were conducted independently by participants using the online concept mapping platform, groupwisdom™, and were only made available to those individuals who were unable to attend a synchronous session. All participants completed a short, online, demographic survey prior to participation.
Statements from all brainstorming sessions, across all participant types, were combined into an Excel spreadsheet for statement synthesis. The original list of brainstorming items needed to be reduced to a manageable number (e.g., less than 100) for the sorting and rating phase [41]. Therefore, two members of the research team (ACE, LC) initially reviewed each of the statements to de-duplicate and remove items that did not answer the focal prompt. The research team then engaged in the final rounds of condensing (combining similar ideas) and rewording the statements for consistency and clarity. The final statement list was added to groupwisdom™ for the subsequent steps of concept mapping.
Sorting and rating
The sorting and rating activities were completed independently by participants on groupwisdom™. Participants created groups of statements based on their perceived conceptual similarity and labelled each group. Participants then rated each statement on two dimensions–importance and priority of the recommendation. For both rating questions, a five-point Likert-type scale was used (importance: 1 = not at all important, 2 = slightly important, 3 = moderately important, 4 = very important, 5 = extremely important; priority: 1 = not at all a priority, 2 = slight priority, 3 = moderate priority, 4 = high priority, 5 = extreme priority).
Concept mapping analysis
All analyses were conducted using groupwisdom™. A point map was created (see S1 Fig), which is a visual representation of all the statements, with the relative distance between the points representing how frequently the statements were sorted together by participants [35]. The goodness of fit is represented by a stress value, with an adequate stress value for concept mapping projects being between 0.205 and 0.365 [35]. Cluster map solutions were created through hierarchical cluster analysis, which groups statements (creates boundaries around statements) based on their relative distance. Cluster map solutions were reviewed by the research team and through group discussion, two cluster solutions were chosen to present to participants. The starting point in reviewing the cluster map solutions was based on the average number of clusters created by participants in the sorting activity. The research team then sequentially reviewed the cluster maps to identify those with conceptually distinct clusters. For each cluster, statement bridging values were averaged to better understand how the statements within each cluster fit together. Bridging values range from 0.00 to 1.00, with a value of 0 indicating that participants sorted statements similarly and 1.00 statements were sorted differently. Clusters with higher bridging values have statements that are likely interconnected with other clusters and interrelated.
Mapping and interpretation session
The synchronous mapping session was held in June 2023 with a subset of participants from the previous phases. It was conducted virtually on Zoom and was led by a trained member of the research team (SJTG, PhD). The research team presented the participants with two cluster map solutions (7-cluster and 8-cluster; see S2 Fig), which had been previously selected as two solutions that best represented the data. Through group discussion guided by the facilitator, participants reached consensus on the final cluster map solution. The statements within each cluster were then reviewed and participants were able to move statements between clusters to ensure conceptual similarity of all statements contained within each cluster. Participants suggested labels for the clusters, which were finalized by the research team following the session.
Using groupwisdom™, the research team created additional visual representations of the data. Cluster rating maps were created for importance and priority to visually display which clusters had a relatively higher average rating. Pattern match diagrams were created to compare average cluster ratings based on different participant demographic variables. Lastly, a go-zone diagram was created to display the mean statement values for importance and priority. The go-zone is the upper right quadrant of the diagram, which displays the statements that were rated higher than average on both dimensions.
Results
Participant demographics
A total of 35 participants took part in this concept mapping study (see Table 1 for participant demographics), with some of those individuals participating in multiple steps; 32 participated in brainstorming, 23 completed sorting and rating, and 11 took part in mapping. Across the three steps of concept mapping (brainstorming, sorting/rating, and mapping), most participants were healthcare providers (n = 21, 66%; n = 15, 65%; n = 6, 55%; respectively) and female, who also identified as women (n = 25, 78%; n = 17, 74%; n = 10, 91%; respectively). Participants were mostly between 18–69 years of age (n = 32, 100%; n = 22, 96%; n = 10, 91%; respectively), with a relatively similar distribution across these age groups. Most participants identified as being white (n = 20; 63%, n = 14; 61%, n = 8; 73%; respectively), with limited representation across other races.
Cluster map
A total of 887 statements were generated by participants in the brainstorming sessions, with the synthesized list containing 74 unique statements. The stress value for the point map was 0.265 indicating a good fit between the multidimensional scaling input and the cluster configurations. The final cluster map selected by participants was the 8-cluster map (see Fig 1), with the following labels: (1) access to inpatient services and supports across the care continuum; (2) informed and collaborative discharge planning; (3) access to transitional and outpatient services; (4) communication, education and knowledge acquisition; (5) support for care partners; (6) person-centred care; (7) physical, social, and cognitive activities and supports; and (8) provider knowledge, skills, roles and behaviours. See Table 2 for cluster names, statements, and average statement ratings.
Each shape represents a cluster containing statements (represented by dots) that were grouped together by participants. Each cluster has a title reflecting the overall concept of the statements assigned.
Cluster 1 –Access to inpatient services and supports across the care continuum
Cluster 1 contained 13 statements that related to access to supports and services both in inpatient acute care and across the care continuum (bridging value = 0.21). Within this cluster, the statement rated highest on importance was 23—increasing staffing so providers can spend more time with patients (mean = 4.48), and the statement rated lowest on importance was 66—prioritizing care of patients who are most likely to decline (mean = 3.65). The statement rated most highly on priority was 26—having established partnerships between hospitals, rehabilitation facilities, and homecare services for consistent transitions (mean = 4.39), and the statement rated lowest on priority was 62—improving access to recreational therapy and group activities (mean = 3.61).
Cluster 2 –Informed and collaborative discharge planning
Cluster 2 contained 13 statements that related to discharge planning (bridging value = 0.45). The statement rated highest on importance was 2 –ensuring support (paid or unpaid) to meet patient needs when returning home (mean = 4.39). The statement rated lowest on importance and priority was 44 –ensuring patients have home visits before discharge (e.g., day/weekend passes) (mean = 2.91, 2.78; respectively). The statement rated highest on priority was 21 –including rehabilitation therapists’ recommendations when considering discharge dates and location (mean = 4.26).
Cluster 3 –Access to transitional and outpatient services
Cluster 3 contained three statements that related to the access of transitional and outpatient services (bridging value = 0.43). The statement rated highest on importance and priority was 64—ensuring timely, consistent, and sufficient homecare services (mean = 4.39, 4.26; respectively), while 18—ensuring physical assistance with transfers between facilities (e.g., ambulance, assistance with getting into/out of car) was rated lowest on both importance and priority (mean = 3.83, 3.70; respectively).
Cluster 4 –Communication, education, and knowledge acquisition
Cluster 4 contained nine statements that related to open and ongoing communication, education, and knowledge acquisition for patients, care partners, and healthcare providers (bridging value = 0.67). The statement rated highest on importance and priority was 33—providing patients and care partners with ongoing communication throughout their care transitions (mean = 4.52, 4.26; respectively). Another statement that was rated most highly on priority was 73—knowing what services exist and how to access them (e.g., homecare, community, social) (mean = 4.26). The statement rated lowest on importance was 36—inquiring about patients’ finances to make appropriate referrals (mean = 3.7), while 3—routinely collecting information on patients’ abilities before hip fracture (mean = 3.39) was rated lowest on priority.
Cluster 5 –Support for care partners
Cluster 5 contained two statements that were specific to supports provided or received by care partners (bridging value = 0.50). The statement rated highest on both importance and priority was 72—having more supports for care partners to address caregiver burden (mean = 4.04, 3.87; respectively). The statement rated lowest on both importance and priority was 16—ensuring care partners can provide in-person support for patients in all care settings (mean = 3.74, 3.70; respectively).
Cluster 6 –Person-centred care
Cluster 6 contained 13 statements that related to providing person-centred care (bridging value = 0.24). The statement rated highest on importance and priority (mean = 4.61, 4.35) was 5—ensuring patients and care partners are included in decisions (e.g., goals, transition processes, and care plans), while 17—bringing pieces of home (e.g., pictures, clothing) across the care transitions was rated lowest on both importance and priority (mean = 2.96, 2.74; respectively).
Cluster 7 –Physical, social, and cognitive activities and supports
Cluster 7 contained 13 statements that related to providing care and supports aligning with individual’s physical, social, and cognitive well-being (bridging value = 0.15). The statement rated highest on both importance and priority was 12—Being compassionate while caring for patients (mean = 4.65, 4.52; respectively). Two statements were rated lowest on importance, with the latter also being rated lowest on priority 19—Using technology to share education materials about exercises and mobilization (mean = 3.04) and 24—Ensuring patients see the same providers at the same time throughout their stay (mean = 3.04, 3.00; respectively).
Cluster 8 –Provider knowledge, skills, roles, and behaviours
Cluster 8 contained eight statements that related to the knowledge, behaviours, skills, and roles of healthcare providers involved in care transitions (bridging value = 0.22). Statement 39—having a care team that works well together was rated most highly on both importance and priority (mean = 4.52, 4.35; respectively). The statement rated lowest on importance was 49—Routinely screening for delirium and cognitive impairment (mean = 4.04), and the statement rated lowest on priority was 32—Conducting frequent patient medication reviews (e.g., adding, changing, removing medications) (mean = 3.78).
Cluster rating maps
Overall, statements were rated relatively high on both importance and priority with all clusters having a mean rating of greater than three (moderate importance/ priority; see Table 2, S3 and S4 Figs). Participants rated Cluster 8—provider knowledge, skills, roles, and behaviours as the most important (mean = 4.32) and highest priority cluster (mean = 4.14). The next most important clusters, as rated by participants, were Cluster 3—access to transitional and outpatient services (mean = 4.19), Cluster 1—access to inpatient services and supports across the care continuum (mean = 4.15), and Cluster 6—person-centred care (mean = 4.15). Similarly, Cluster 3—access to transitional and outpatient services (mean = 4.04) and Cluster 1—access to inpatient services and supports across the care continuum (mean = 3.99) were the clusters rated as the next highest priorities. Participants rated Cluster 2—informed and collaborative discharge planning as the least important (mean = 3.88) and lowest priority cluster (mean = 3.72); however still rated relatively high as both were above neutral.
Go-zone diagram: Identifying the top statements based on importance and priority correlation
A strong correlation between importance and priority was identified in the go-zone diagram (r = 0.94), which can be seen in Fig 2. Statements that were rated highly on importance were typically rated highly on priority as well. Of the 74 statements, over half (n = 41, 55%) were in the go-zone, which represents the statements that were rated above average on both importance and priority. Table 3 outlines all statements contained within the go-zone, organized by cluster, with the statements in descending order based on their overall average rating on importance and priority.
Each dot corresponds to a statement. The colour of the dot corresponds to the cluster it is contained within (see Fig 1). The go-zone is the upper, right quadrant and displays statements that participants rated above average on both importance and priority.
Despite only 41 of the statements being in the go-zone, all statements were rated relatively high on both dimensions. The top statements rated most highly on importance and priority by participants included: 12—being compassionate while caring for patients (mean = 4.65, 4.52; respectively); 5 –ensuring patients and caregivers are included in the decisions (e.g., goals, transition processes and care plans (mean = 4.61, 4.35 respectively), 39 -Having a care team that works well together (mean = 4.52, 4.35, respectively); 26—Having established partnerships between hospitals, rehabilitation facilities, and homecare services for consistent transitions (mean = 4.43, 4.39, respectively); 33—Providing patients and care partners with ongoing communication throughout their care transitions (mean = 4.52, 4.26, respectively); 71 –Having adequate pain management (mean = 4.45, 4.30, respectively); 23 –Increasing staffing so providers can spend more time with patients (mean = 4.48, 4.26, respectively); 37- Ensuring patients’ and care partners’ questions are answered (mean = 4.48, 4.26, respectively); 20—Having access to different healthcare providers (e.g., geriatricians, therapists, social workers) (mean = 4.43, 4.30, respectively); 31- Ensuring providers use the proper transferring techniques (e.g., sit to stand) (mean = 4.43, 4.3, respectively); 53—Using clear and simple language to improve patient and caregiver understanding (mean = 4.45, 4.26, respectively).
Comparison of ratings between participant groups
PWLE and care partners generally rated the same clusters as being of greater importance and priority compared to healthcare providers and administrators; however, relatively small differences were noted in the magnitude of ratings. All clusters, except for support for care partners, were rated more highly on importance by patients and care partners than by healthcare providers and decision-makers. Patients and care partners rated all clusters more highly on priority than healthcare providers and decision-makers (see S5 Fig).
Discussion
In this mixed-methods concept mapping study, we identified 74 statements that were rated on importance and priority to inform improvements in care transitions across the care journey for hip fracture. These statements were organized into eight clusters by participants. The majority of statements mapped onto concepts related to person-centred care and continuity of care. While most statements were rated highly on importance and priority, those specific to clinician knowledge, skills, roles, and behaviours were considered amongst the most important and highest priority statements.
One of the main findings from this study is that many statements mapped onto multiple interrelated aspects (clusters) of person-centred care and most were rated high on importance and priority. This implies an interconnectedness of the constituent requirements for effective care transitions. Well-established in the literature, person-centred care generally relates to the following areas of care: PWLE preferences, emotional support, physical comfort, information and education, continuity and transition, coordination of care, access to care, involvement of care partners [42, 43]. In addition to participants denoting ‘person-centred care’ as its own cluster, many other clusters also related to this approach, including statements relating to compassionate care, shared decision-making, and ongoing communication. By involving PWLE in decision-making, respecting their autonomy, and considering their preferences, person-centered care can promote a sense of empowerment and dignity throughout the transition process [43]; however, there is a need for more research in this area to examine the impact on patient-oriented outcomes [44, 45]. These person-centred principles are particularly important during vulnerable periods of care transitions, and as such, are recommended in quality standards on care transitions in the general population [46, 47].
Not surprisingly, many statements identified in our study also relate to Haggerty and colleagues’ conceptualization of continuity of care (often considered a dimension of person-centred care), which include relational (consistent persons involved in care fostering trust and familiarity), informational (use of information to link care from provider, setting or event), and management (organized care from several providers, adaptability to care needs) [48]. With respect to informational continuity, participants highlighted the importance of ensuring questions are answered, using clear and simple language, and providing ongoing communication throughout care transitions. Previous research on hip fracture care transitions has shown PWLE and care partners experience challenges with lack of information sharing and role confusion [25, 28, 30]. Asif and colleagues, in their scoping review, recommended leveraging written communication, patient navigator/peer support, and digital health technology as potential means to improve information sharing [25]. Similarly, Backman and colleagues’ recent scoping review [49] reviewed different digital health interventions in the literature for post hip fracture care. Most interventions identified focused on digital health technology to improve informational continuity [49], and included telehealth (virtual consultations), care transition/follow-up interventions (mobile and web-based applications with personalized management such as reminders, exercises, medication schedules), online education resources (videos and education modules on hip fractures, treatments, exercises and self-care), and wearable devices/sensor monitoring (e.g., clinicians can monitor remotely vital signs, activity). Overall, Backman and colleagues noted an absence of interventions related to other types of continuity, such as relational, as well as studies examining the acceptability, usability, and feasibility of using digital health technology to improve care continuity for this population. In our study, the use of technology to share educational materials about exercises and mobilization was rated as one of the least important and lowest priority statements. As such, for technology to be implemented and used to its full potential to improve care transitions for hip fracture, more work is needed to understand the unique needs of this population.
Findings in our study also highlighted the importance of management continuity, especially related to the concept of teams working well together and teams/persons working across healthcare sectors. For example, statement 26—Having established partnerships between hospitals, rehabilitation facilities, and homecare services for consistent transitions, was rated high on importance and priority. Our findings support other research that has highlighted the potential benefits to integrated care pathways for hip fracture care [50–52]. In Ontario, bundled hip fracture care is currently recommended to support transitions between acute and rehabilitation hospitals [53]. A recent systematic review and meta-analysis reviewing randomized control trials (n = 12) showed integrated care for hip fractures improved activities of daily living at 6 and 12 months post-fracture [52]. In this review, integrated care was defined as “the cooperation of a multidisciplinary team including an orthopedic surgeon and geriatrician focused on elderly patients with hip fractures” (pg. 65). Notably, in this review, there was substantial variation of what constitutes integrated care (e.g., within hospital or across sectors), which is consistent with challenges reported in the literature [54, 55]. In our study, participants identified the importance of care pathways across sectors to be inclusive of, not only inpatient acute and inpatient rehabilitation, but also across community sectors such as primary care and homecare. Similarly, in efforts to improve integrated care in Ontario for populations with more complex health and social needs, the Ministry of Health has prioritized the formation of Ontario Health Teams to support care continuity across sectors, including primary care and community [56]. Given this focus on integrated care, there is likely a favorable environment to prioritize hip fracture care within these teams. Similarly, while there is a growing focus internationally on integrated care for improving continuity of care, patient outcomes, and experiences post-hip fracture [44, 57, 58], continued work is needed to understand the optimal composition of these teams and across what settings.
Extending beyond continuity, participants identified numerous statements related to clinician knowledge, skills, roles and behaviour, as they relate to hip fracture management (71 –Having adequate pain management, 27—Addressing delirium and cognitive impairment through best practices, and 31 –Ensuring providers use the proper transferring techniques). Sub-optimal acute pain management among those with hip fracture has been associated with increased risk of delirium, delayed mobility, longer hospital stays and poor outcomes (e.g., depression, sleep disturbances, chronic pain) [59]. Optimal hip fracture pain management often requires interdisciplinary collaboration, including medications as well as rehabilitation therapy [60]. The importance placed on clinical knowledge and skills has been supported by a recent scoping review by Djukanovic and colleagues in their examination of the meaning of care continuity among older adults [61]. Interestingly, Djukanovic identified that clinically skilled healthcare professionals were more important among older adults than having the same person involved in clinical care [61].
Moreover, when considering patient complexity, participants in our study emphasized the importance of ensuring adequate clinician knowledge, and skills to provide care for individuals with hip fracture who also experience cognitive impairment and delirium. In a scoping review conducted by Cadel and colleagues, 17 articles examining rehabilitation interventions for adults with hip fracture and cognitive impairment were identified [62]. The interventions were mostly focused on physical rehabilitation initiated in-hospital, with fewer interventions implemented across sectors. Of key importance, none of the studies qualitatively explored patient and care partner experiences with the interventions and specific to those with cognitive impairment and hip fracture, details on how to adapt the interventions to this population were lacking. As such, future research is warranted in exploring the unique barriers and opportunities to improve rehabilitation and care transitions for persons with hip fracture and cognitive impairment.
This study has several limitations to note. We experienced challenges recruiting patients and care partners. Recruitment occurred during the COVID-19 pandemic and our recruitment sites were impacted by capacity and resource restraints. However, there were no new relevant concepts being identified in the statements from the final PWLE and care partner brainstorming sessions. Healthcare providers in our study did not include any physicians, who may have had differing recommendations. Despite the intention to include physicians, we were unable to recruit any. Additionally, despite some diversity among healthcare providers and decision-makers, PWLE and care partners were all women and mostly white, reflecting a gap in our data from perspectives of those identifying as men and those from different ethnicities and language groups. Future research will be needed to capture more diverse perspectives, such as age, gender, race/ethnicity, language, and socio-economic status to inform the design of interventions to address diverse needs. Interestingly, while most of the participants were providers and decision-makers, findings still emphasized the importance of patient and care partners involvement in care and care transitions. This finding is notable, given that our study population consisted predominately of healthcare providers and decision-makers, who may be less likely to identify these necessary improvements than PWLE or care partner participants. Lastly, while this work identified actionable and prioritized statements for improving care transitions for individuals with hip fracture, future work must also assess the feasibility, acceptability, and appropriateness of developed interventions, prior to larger scalability.
Despite these limitations, there are several notable strengths of this study. Concept mapping is a highly participatory approach that puts participants at the centre of the research, giving them a voice in both data collection and analysis [35]. We included PWLE, care partners, healthcare providers, and decision-makers, which allowed us to gain a range of viewpoints, experiences, and perspectives related to recommendations to improve care transitions for adults with hip fracture.
Conclusions
Seventy-four actionable recommendations mapped onto eights clusters to improve care transitions for individuals with hip fracture were identified in this study. Our results highlight the importance of meaningful patient and care partner engagement, with active involvement and a guiding role in all aspects of care including the transition process. Further, many statements included improvements in clinical knowledge and skills related to cognitive impairment, transfers, and pain management, emphasizing important areas for future work. This study provides insights for future interventions and quality improvement initiatives that focus on person-centredness, continuity of care, and clinician knowledge, skills, roles and behaviour to improve transitions in care among hip fracture populations.
Supporting information
S1 Fig. Point map.
Each dot corresponds to a statement generated in the brainstorming sessions. Statement numbers are displayed in Table 2.
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S2 Fig. 7 and 8-cluster maps.
Each shape represents a cluster containing statements (represented by dots). These maps were presented to participants in the mapping session.
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S3 Fig. Importance cluster rating map.
The numbers of layers in a cluster represents its relative importance, with a greater number of layers being rated as more important.
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S4 Fig. Priority cluster rating map.
The numbers of layers in a cluster represents its relative priority, with a greater number of layers being rated as a higher priority.
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S5 Fig. Pattern match diagram.
The pattern match diagram illustrates how patients and care partners rated the clusters of statements on both dimensions (importance and priority) compared to healthcare providers and decision-makers. Abbreviations: PWLE–Persons with lived experience; HCP–healthcare providers; DM–decision-makers.
https://doi.org/10.1371/journal.pone.0307769.s005
(TIF)
Acknowledgments
The authors would like to thank Rasha El-Kotob and Megan Bhalla for administrative support, as well as our patient partner, Lisa Bennett, for her insights provided throughout the process. At the time of this study, SJTG was supported by a CIHR Embedded Clinician Scientist Salary Award on Transitions of Care working with Ontario Health (Quality; formerly Health Quality Ontario). SJTG is currently supported by the University of Toronto Centre for the Study of Pain Scientist Salary Award. KK is the Mathias Gysler Research Chair in Patient and Family Centred Care and WPW is the Research Chair in Implementation and Evaluation Science, both supported through Trillium Health Partners Foundation. The analyses, conclusions, opinions and statements expressed herein are solely those of the authors and do not reflect those of the funding sources; no endorsement is intended or should be inferred.
References
- 1. DeGrauw X, Annest JL, Stevens JA, Xu L, Coronado V. Unintentional injuries treated in hospital emergency departments among persons aged 65 years and older, United States, 2006–2011. Journal of Safety Research. 2016;56:105–9. pmid:26875172
- 2.
Canadian Institute for Health Information. Seniors and Falls. Available online at https://www.cihi.ca/en/seniors_falls_info_en.pdf. 2010.
- 3. Magaziner J, Fredman L, Hawkes W, Hebel JR, Zimmerman S, Orwig DL, et al. Changes in functional status attributable to hip fracture: a comparison of hip fracture patients to community-dwelling aged. American journal of epidemiology. 2003;157(11):1023–31. pmid:12777366
- 4. Borgstrom F, Lekander I, Ivergard M, Strom O, Svedbom A, Alekna V, et al. The International Costs and Utilities Related to Osteoporotic Fractures Study (ICUROS)—quality of life during the first 4 months after fracture. Osteoporosis international: a journal established as result of cooperation between the European Foundation for Osteoporosis and the National Osteoporosis Foundation of the USA. 2013;24(3):811–23. pmid:23306819
- 5. Chong CPW, Savige JA, Lim WK. Medical problems in hip fracture patients. Archives of orthopaedic and trauma surgery. 2010;130(11):1355–61. pmid:20049603
- 6. Hung WW, Egol KA, Zuckerman JD, Siu AL. Hip fracture management: tailoring care for the older patient. JAMA. 2012;307(20):2185–94. pmid:22618926
- 7. Marks R. Hip fracture epidemiological trends, outcomes, and risk factors, 1970–2009. International journal of general medicine. 2010;3:1–17. pmid:20463818.
- 8. Wei TS, Hu CH, Wang SH, Hwang KL. Fall characteristics, functional mobility and bone mineral density as risk factors of hip fracture in the community-dwelling ambulatory elderly. Osteoporosis international: a journal established as result of cooperation between the European Foundation for Osteoporosis and the National Osteoporosis Foundation of the USA. 2001;12(12):1050–5. pmid:11846332
- 9. Harstedt M, Rogmark C, Sutton R, Melander O, Fedorowski A. Polypharmacy and adverse outcomes after hip fracture surgery. Journal of orthopaedic surgery and research. 2016;11(1):151. pmid:27881180
- 10. Mundi S, Pindiprolu B, Simunovic N, Bhandari M. Similar mortality rates in hip fracture patients over the past 31 years. Acta orthopaedica. 2014;85(1):54–9. pmid:24397744
- 11. Vochteloo AJH, Moerman S, Tuinebreijer WE, Maier AB, de Vries MR, Bloem RM, et al. More than half of hip fracture patients do not regain mobility in the first postoperative year. Geriatrics and Gerontology International. 2013;13(2):334–41. pmid:22726959
- 12. Hannan EL, Magaziner J, Wang JJ, Eastwood EA, Silberzweig SB, Gilbert M, et al. Mortality and locomotion 6 months after hospitalization for hip fracture risk factors and risk-adjusted hospital outcomes. Journal of the American Medical Association. 2001;285(21):2736–42. pmid:11386929
- 13. Magaziner J, Simonsick EM, Kashner TM, Hebel JR, Kenzora JE. Predictors of functional recovery one year following hospital discharge for hip fracture: a prospective study. Journal of gerontology. 1990;45(3):M101–7. Epub 1990/05/01. pmid:2335719.
- 14. Gjertsen J-E, Baste V, Fevang JM, Furnes O, Engesaeter LB. Quality of life following hip fractures: results from the Norwegian hip fracture register. BMC musculoskeletal disorders. 2016;17:265. pmid:27387741
- 15. Boockvar KS, Litke A, Penrod JD, Halm EA, Morrison RS, Silberzweig SB, et al. Patient relocation in the 6 months after hip fracture: risk factors for fragmented care. Journal of the American Geriatrics Society. 2004;52(11):1826–31. pmid:15507058
- 16. Toscan J, Manderson B, Santi SM, Stolee P. "Just another fish in the pond": the transitional care experience of a hip fracture patient. International Journal of Integrated Care. 2013;13:e023. pmid:23882170
- 17. Toscan J, Mairs K, Hinton S, Stolee P, InfoRehab Research T. Integrated transitional care: patient, informal caregiver and health care provider perspectives on care transitions for older persons with hip fracture. International journal of integrated care. 2012;12:e13. pmid:22977426
- 18. Elliott J, Forbes D, Chesworth BM, Ceci C, Stolee P. Information sharing with rural family caregivers during care transitions of hip fracture patients. International journal of integrated care. 2014;14:e018. pmid:24959113
- 19. Killington M, Walker R, Crotty M. The chaotic journey: Recovering from hip fracture in a nursing home. Archives of Gerontology & Geriatrics. 2016;67:106–12. 117733145. Language: English. Entry Date: pmid:27483995. Revision Date: 20161014. Publication Type: Article.
- 20. Chudyk AM, Jutai JW, Petrella RJ, Speechley M. Systematic review of hip fracture rehabilitation practices in the elderly. Arch Phys Med Rehabil. 2009;90(2):246–62. Epub 2009/02/25. pmid:19236978.
- 21. Storr B, Peiris CL, Snowdon DA. Community Reintegration After Rehabilitation for Hip Fracture: A Systematic Review and Meta-analysis. Arch Phys Med Rehabil. 2022;103(8):1638–50.e7. Epub 2022/01/03. pmid:34973944.
- 22. Coleman EA, Berenson RA. Lost in transition: challenges and opportunities for improving the quality of transitional care. Annals of internal medicine. 2004;141(7):533–6. Epub 2004/10/07. pmid:15466770.
- 23. Burke RE, Kripalani S, Vasilevskis EE, Schnipper JL. Moving beyond readmission penalties: creating an ideal process to improve transitional care. J Hosp Med. 2013;8(2):102–9. Epub 2012/11/28. pmid:23184714; PubMed Central PMCID: PMC3650641.
- 24. Kripalani S, Jackson AT, Schnipper JL, Coleman EA. Promoting effective transitions of care at hospital discharge: a review of key issues for hospitalists. J Hosp Med. 2007;2(5):314–23. Epub 2007/10/16. pmid:17935242.
- 25. Asif M, Cadel L, Kuluski K, Everall AC, Guilcher SJT. Patient and caregiver experiences on care transitions for adults with a hip fracture: a scoping review. Disability and Rehabilitation. 2020;42(24):3549–58. Epub 2019/05/14. pmid:31081400.
- 26. Nikitovic M, Wodchis WP, Krahn MD, Cadarette SM. Direct health-care costs attributed to hip fractures among seniors: a matched cohort study. Osteoporos Int. 2013;24(2):659–69. Epub 2012/06/28. pmid:22736067; PubMed Central PMCID: PMC3557373.
- 27. Wiktorowicz ME, Goeree R, Papaioannou A, Adachi JD, Papadimitropoulos E. Economic implications of hip fracture: Health service use, institutional care and cost in Canada. Osteoporos Int. 2001;12. pmid:11420776
- 28. Stolee P, Elliott J, Byrne K, Sims-Gould J, Tong C, Chesworth B, et al. A Framework for Supporting Post-acute Care Transitions of Older Patients With Hip Fracture. J Am Med Dir Assoc. 2019;20(4):414–9 e1. Epub 2019/03/11. pmid:30852166.
- 29. Cadel L, Kuluski K, Everall AC, Guilcher SJT. Recommendations made by patients, caregivers, providers, and decision-makers to improve transitions in care for older adults with hip fracture: a qualitative study in Ontario, Canada. BMC geriatrics. 2022;22(1):291. Epub 2022/04/09. pmid:35392830; PubMed Central PMCID: PMC8988316.
- 30. Guilcher SJT, Maunula L, Cadel L, Everall AC, Li J, Kuluski K. Caregiving for older adults with hip fractures: Exploring the perspectives of caregivers, providers and decision-makers in Ontario, Canada. Archives of gerontology and geriatrics. 2021;93:104321. Epub 2020/12/29. pmid:33359957.
- 31. Skivington K, Matthews L, Simpson SA, Craig P, Baird J, Blazeby JM, et al. A new framework for developing and evaluating complex interventions: update of Medical Research Council guidance. BMJ. 2021;374:n2061. pmid:34593508
- 32. O’Cathain A, Croot L, Duncan E, Rousseau N, Sworn K, Turner KM, et al. Guidance on how to develop complex interventions to improve health and healthcare. BMJ Open. 2019;9(8):e029954. Epub 2019/08/20. pmid:31420394; PubMed Central PMCID: PMC6701588.
- 33. Daniel W, Erica W, Ruth J, Lawrence D. Six steps in quality intervention development (6SQuID). Journal of Epidemiology and Community Health. 2016;70(5):520. pmid:26573236
- 34. Rousseau N, Turner KM, Duncan E, O’Cathain A, Croot L, Yardley L, et al. Attending to design when developing complex health interventions: A qualitative interview study with intervention developers and associated stakeholders. PLoS One. 2019;14(10):e0223615. Epub 2019/10/16. pmid:31613913; PubMed Central PMCID: PMC6793869.
- 35.
Kane M, Trochim WMK. Concept Mapping for Planning and Evaluation. Bickman L, Rog DJ, editors. California: Sage Publications 2007.
- 36. Velonis AJ, Molnar A, Lee-Foon N, Rahim A, Boushel M, O’Campo P. “One program that could improve health in this neighbourhood is ____?” using concept mapping to engage communities as part of a health and human services needs assessment. BMC Health Services Research. 2018;18(1). pmid:29490641
- 37. Kiran T, Wells D, Okrainec K, Kennedy C, Devotta K, Mabaya G, et al. Patient and caregiver experience in the transition from hospital to home—brainstorming results from group concept mapping: a patient-oriented study. CMAJ Open. 2020;8(1):E121–E33. pmid:32127383
- 38.
Creswell JW. Research Design: Qualitative, Quantitative, and Mixed Methods Approaches. Fourth ed. ed. California: Thousan oaks; 2014.
- 39. Palinkas LA, Horwitz SM, Green CA, Wisdom JP, Duan N, Hoagwood K. Purposeful Sampling for Qualitative Data Collection and Analysis in Mixed Method Implementation Research. Adm Policy Ment Health. 2015;42(5):533–44. pmid:24193818.
- 40. Collins KMT, Onwuegbuzie AJ, Jiao QG. A Mixed Methods Investigation of Mixed Methods Sampling Designs in Social and Health Science Research. Journal of Mixed Methods Research. 2007;1(3):267–94.
- 41. Burke JG, O’Campo P, Peak GL, Gielen AC, McDonnell KA, Trochim WMK. An Introduction to Concept Mapping as a Participatory Public Health Research Method. Qualitative Health Research. 2005;15(10):1392–410. pmid:16263919
- 42. Kuipers SJ, Cramm JM, Nieboer AP. The importance of patient-centered care and co-creation of care for satisfaction with care and physical and social well-being of patients with multi-morbidity in the primary care setting. BMC Health Serv Res. 2019;19(1):13. Epub 2019/01/10. pmid:30621688; PubMed Central PMCID: PMC6323728.
- 43. Sharma T, Bamford M, Dodman D. Person-centred care: an overview of reviews. Contemporary Nurse. 2015;51(2–3):107–20. pmid:26866531
- 44. Yun D, Choi J. Person-centered rehabilitation care and outcomes: A systematic literature review. International Journal of Nursing Studies. 2019;93:74–83. pmid:30870614
- 45. Backman C, Chartrand J, Crick M, Devey Burry R, Dingwall O, Shea B. Effectiveness of person- and family-centred care transition interventions on patient- oriented outcomes: A systematic review. Nurs Open. 2021;8(2):721–54. Epub 2021/02/12. pmid:33570290; PubMed Central PMCID: PMC7877224.
- 46.
Ontario Health (Quality). Quality Standards: Transitions Between Hospital and Home, Care for People of All Ages. Toronto, Otario: Ontario Health (Quality), 2022.
- 47.
World Health Organization. Transitions of Care: Technical Series on Safer Primary Care. Geneva. CC BY-NC-SA 3.0 IGO: 2016.
- 48. Haggerty JL, Reid RJ, Freeman GK, Starfield BH, Adair CE, McKendry R. Continuity of care: A multidisciplinary review. BMJ. 2003;327:1219–21. pmid:14630762
- 49. Backman C, Papp S, Harley A, Skidmore B, Green M, Shah S, et al. Patient-clinician digital health interventions for the hip fracture population: a scoping review. BMC Health Services Research. 2023;23(1):1052. pmid:37784118
- 50. Flikweert ER, Wendt KW, Diercks RL, Izaks GJ, Stewart R, Stevens M, et al. A comprehensive multidisciplinary care pathway for hip fractures better outcome than usual care? Injury. 2021;52(7):1819–25. pmid:33947587
- 51. Pereira MJ, Molina JAD, Tan BY, Yam MGJ, Ramason R, Chua ITH. Bundled Payments for Hip Fracture Surgery Are Associated With Improved Access, Quality, and Health Care Utilization, but Higher Costs for Complex Cases: An Interrupted Time Series Analysis. Journal of orthopaedic trauma. 2023;37(1):19–26. Epub 2022/07/16. pmid:35839456.
- 52. Hsu Y-F, Chou F-H, Wang H-H, Chu Y-C, Liao K-L. Effectiveness of integrated care for elderly patients with hip fractures: A systematic review and meta-analysis. Geriatric Nursing. 2023;49:65–73. pmid:36446147
- 53.
Health Quality Ontario. Recommendations for Adoption: Hip Fracture. Ontario, Canada: Health Quality ONtario, 2016.
- 54. Armitage GD, Suter E, Oelke ND, Adair CE. Health systems integration: state of the evidence. Int J Integr Care. 2009;9:e82. Epub 2009/07/11. pmid:19590762; PubMed Central PMCID: PMC2707589.
- 55. Goodwin N. Understanding Integrated Care. Int J Integr Care. 2016;16(4):6. Epub 2017/03/21. pmid:28316546; PubMed Central PMCID: PMC5354214.
- 56.
Ministry of Health and Long-Term Care. Ontario Health Teams: Guidance for Health Care Providers and Organizations. Ontario, Canada: Ontario Ministry of Health and Long-Term Care, 2019.
- 57. Heyzer L, Ramason R, De Castro Molina JA, Lim Chan WW, Loong CY, Kee Kwek EB. Integrated hip fracture care pathway (IHFCP): reducing complications and improving outcomes. Singapore Med J. 2022;63(8):439–44. Epub 2021/04/20. pmid:33866715; PubMed Central PMCID: PMC9584078.
- 58. O’Keeffe N, Kelly M, Francis A, Shields J, Keogh P, Kenny P. Bypass: an integrated hip fracture care pathway. Irish Journal of Medical Science (1971 -). 2020;189(4):1159–62. pmid:32072479
- 59. Abou-Setta AM, Beaupre LA, Rashiq S, Dryden DM, Hamm MP, Sadowski CA, et al. Comparative Effectiveness of Pain Management Interventions for Hip Fracture: A Systematic Review. Annals of internal medicine. 2011;155(4):234–45. pmid:21844549
- 60. McDonough CM, Harris-Hayes M, Kristensen MT, Overgaard JA, Herring TB, Kenny AM, et al. Physical Therapy Management of Older Adults With Hip Fracture. Journal of Orthopaedic & Sports Physical Therapy. 2021;51(2):CPG1–CPG81. pmid:33522384
- 61. Djukanovic I, Hellström A, Wolke A, Schildmeijer K. The meaning of continuity of care from the perspective of older people with complex care needs–A scoping review. Geriatric Nursing. 2024;55:354–61. pmid:38171186
- 62. Cadel L, Kuluski K, Wodchis WP, Thavorn K, Guilcher SJT. Rehabilitation interventions for persons with hip fracture and cognitive impairment: A scoping review. PLoS One. 2022;17(8):e0273038. Epub 2022/08/16. pmid:35969624; PubMed Central PMCID: PMC9377630.