Improving healthcare efficiency with coordination between levels of care: orthogeriatrics/Mejora de la eficiencia asistencial con la coordinación interniveles: ortogeriatría

HF patients often require long stays on trauma wards due to their age [1], other characteristics (multiple pathologies and medications, as well high rates of cognitive impairment and acute complications) and the difficulty of them returning home given their functional deterioration. Further, therapies for functional recovery, indicated in these patients to help them return to their previous level of independence, tend to be applied late, and fail to reach all patients who could potentially make a good recovery; this means social and healthcare costs associated with a level of dependency that could have been avoided.


Introduction
Hip fracture (HF) is a serious health problem, the prevalence of which is increasing with population ageing [1,2]. It commonly causes dependency and has high social and healthcare costs [3].
HF patients often require long stays on trauma wards due to their age [1], other characteristics (multiple pathologies and medications, as well high rates of cognitive impairment and acute complications) and the difficulty of them returning home given their functional deterioration. Further, therapies for functional recovery, indicated in these patients to help them return to their previous level of independence, tend to be applied late, and fail to reach all patients who could potentially make a good recovery; this means social and healthcare costs associated with a level of dependency that could have been avoided.

Theory and methods
The objectives were to: Enable the return to the greatest possible level of • • independence among all patients with potential to make a good recovery Provide care that meets the specific needs of elderly (OGU), during the first 24 hours in the unit therapies for relearning to walk and recovering independence in activities of daily living are initiated and measures taken to stabilise concomitant processes and to prevent common geriatric problems (falls, pressure ulcers, delirium, and iatrogenic complications) following a geriatric model of comprehensive and interdisciplinary assessment and care [4,5]. There is planning for discharge from the moment • • of admission, adapting care provided to the clinical, functional and cognitive status of each patient in coordination with social services. If the patient is considered a candidate for outpatient rehabilitation, access to the gym should be arranged for them before they are discharged to ensure that their physiotherapy is not interrupted.

Results
In the first year, 390 patients were included in the project, 297 (76%) women and 93 (24%) men. Of these, 238 (61%) were transferred to the OGU, the mean age of this subset being 82.1 years. The mean length of stay of these HF patients in the acute tertiary care hospital fell from 19.7 days in 2009 to 10.6 days in 2010 after the launch of the project.
The functional improvement measured in the OGU was 37.8 points on the BI, the mean BI score on discharge being 72. The mean length of stay in this unit was 21.4 days vs. 34.3 days for HF patients cared for the previous year, with an efficiency score of 1.7 and a Montebello Rehabilitation Factor score of 0.69.
On discharge, 7.3% of patients were institutionalised while for 54 patients (23.1%) their general practitioner was contacted for joint management of their case. Candidates for rehabilitation as outpatients continued their therapy without any interruption on discharge.

Discussion
This project with the establishment of a new protocol has enabled the early transfer to an Orthogeriatric Unit of all patients who it was judged could potentially benefit from the type of care it offers. This group included individuals with mild-to-moderate cognitive impairment, in whom it has previously been shown that satisfactory recovery of walking ability can be achieved with tailored rehabilitation [6,7], thereby minimising avoidable dependence.
The use of the different levels of care has improved, with a notable reduction in the length of stay in the acute hospital and also a decrease in the time spent in sub-acute care. This can be attributed to patients being transferred earlier to a care environment focused on the prevention of geriatric problems and recovery of independence, leading to a fall in the number of complications and a lower level of care being required on discharge [8].
This represents considerable cost savings on hospitalisation, as has previously been demonstrated in relation to Orthogeriatric Units of other acute care hospitals [9]. The functional improvements were also good, as has been achieved in other units with similar characteristics [8,10]: the OGU is efficient in achieving its objective of reducing dependency, managing to enable patients return to a functional status similar to prior to their fall as indicated by the rehabilitation factor score obtained. Further, the coordination between levels of hospital and outpatient care has been strengthened, both in terms of the management of complex cases and of the continuation of physiotherapy on discharge. Importantly, the good functional recovery meant that the rate of institutionalisation on discharge was low [11,12] and a corresponding saving in the costs of social care services related to hip fractures.

Conclusions
We found that: A comprehensive assessment of all geriatric patients 1.
with hip fracture allowed those individuals who could potentially make a good recovery to be identified. Coordination between levels of care following a pro-2.
tocol enabled a rapid transfer of patients to appro-priate types of care avoiding unnecessary delays and hospital stays.
The application of a model of geriatric care suited 3.
to the needs of these patients led to good functional recovery and a low rate of institutionalisation.
The tailoring of the length of stay and type of care 4.
provided to such patients had a positive impact on both the direct costs of hospitalisation and those due to the need for care on discharge associated with dependency.