A New Integrated Model of Care for Central East: 
Helping Patients Following a Hip Fracture Return Home

A hip fracture is a significant threat to older persons’ independence and ability to live in the community.  Health care services for patients experiencing a hip fracture were identified as fragmented and limited, especially for those with cognitive and weight bearing issues. 

The Total Joint Network (TJN) is a partnership of 35 healthcare organizations in Greater Toronto from Oshawa to Halton that has designed a new integrated model of care to ensure patients who live in the community and experience a hip fracture receive the right care in the right place at the right time by increasing their access to health care and reducing wait times both to surgery and rehabilitation.  This model of care has been implemented across many of the Central East LHINs hospitals and Central East Community Care Access Centre.  

Hip fracture patients have traditionally remained in acute care for 9 to 15 days depending on their discharge destination. Rehabilitation stays were 35 to 45 days and often were not considered as an option when patients presented with cognitive impairment or other complications.  For many patients, they were streamed directly into long term care despite their previous success in living in the community.

The new model of care provides all patients the opportunity for rehabilitation and focuses on achieving a transfer to rehabilitation 5 days after their surgery or once the patient is medically stable. This is achieved by improved care throughout the patient’s hospitalization from the Emergency Department and through the acute care and the rehabilitation stays. On discharge, the majority of patients receive support through the CCAC.  The model also focuses on providing education for patients and families about the care process and such complications as delirium, dementia and depression that may be issues following a hip fracture.

The new model of care was launched at The Scarborough Hospital, Rouge Valley Health System, and Lakeridge Health Corporation through the spring and fall of 2007. It is being planned for Peterborough Regional Health Centre and Ross Memorial Hospital in 2008.  Results show over 70% of patients are now accessing rehabilitation earlier, have rehabilitation stays of 22 days, and for most patients (80%) the chance to return home.  The TJN Hip Fracture Project is demonstrating benefits for patients and their families, as well as for the healthcare system.  Older persons are being offered new opportunities for rehabilitation and most patients are going home sooner. 

For more information, please visit the Total Joint Network website at www.totaljointnetwork.org. 

Submitted by:

Janet McMullan, Total Joint Network, Project Manager
Nizar Mahomed, University Health Network, Director MSK & Arthritis Program
John Flannery, Toronto Rehabilitation Institute, Medical Director MSK Program
Rhona McGlasson, Total Joint Network, Quality Improvement Lead
Heather Brien, Toronto Central CCAC, Manager
Aileen Davis, University Health Network, Researcher
Judy Moir, GTA Rehab Network, Executive Director
Maryanne Brown, Total Joint Network, Advanced Practice Nurse