This document summarizes a study investigating how hospital and municipal rehabilitation teams in Denmark plan and perform post-discharge rehabilitation for older adults after hip fractures. The study found that the hospital team took a biomedical approach while the municipal team took a biopsychosocial approach, with no formal assessment of patients' mental functions and lack of communication between the teams. The study aims to understand how rehabilitation can be improved through a structured process using a common framework, joint assessments, and information sharing between teams.

1. Monica Milter Ehlers
PhD candidate, MSc in Nursing, RN
DEFACTUM, Central Denmark Region and Department of
Public Health, Aarhus University, Denmark
Planning and performance of post-
discharge rehabilitation of older
adults after hip fracture
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2. Monica Milter Ehlers | monehl@stab.rm.dk
The theoretical framework of the study
The international definition of rehabilitation
The Danish definition of rehabilitation
The International Classification of Functioning, Disability and Health
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3. Monica Milter Ehlers | monehl@stab.rm.dk
The present knowledge of post-discharge hip fracture rehabilitation
Reduced functional performance (60 %)
Problems managing daily activities
Affected physical and mental functions, self-care
and social participation
Inability to return home (> 10 %)
Need of long-term follow-up (25 %)
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4. Monica Milter Ehlers | monehl@stab.rm.dk
Aim of the study
”To investigate and discuss how an outgoing, multidisciplinary
hospital-based team and a municipal rehabilitation team plan and perform
post-discharge rehabilitation of community-dwelling
older adults after hip fracture”
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5. Monica Milter Ehlers | monehl@stab.rm.dk
Methodology and Methods
Focus group interviews with
13 health professionals
Semi-structured interview guides (the theoretical framework)
Philosophical hermeneutics (Hans-Georg Gadamer)
Deductive content analysis
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6. Monica Milter Ehlers | monehl@stab.rm.dk
Findings
Different core services (different aspects of post-discharge rehabilitation)
The hospital-based team biomedical approach to rehabilitation
The municipal team biopsychosocial approach to rehabilitation
No assessment of mental functions
The contribution of relatives was not mentioned
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7. Monica Milter Ehlers | monehl@stab.rm.dk
Findings
A goal-oriented rehabilitation process
No information sharing on goals, treatment and rehabilitation
Misunderstandings between teams
Fragmented and overlapping treatment, training and
rehabilitation
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8. Monica Milter Ehlers | monehl@stab.rm.dk
Implications for practice
Core services
Mental functions
Communication and information sharing
Relational coordination
Rehabilitation structure based on ICF, joint
assessments, difficult areas, goals, target strategies
and rehabilitation outcome evaluations
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9. Monica Milter Ehlers | monehl@stab.rm.dk
Future research
Mental functions
The relatives´ roles
A joint rehabilitation structure
Conventional rehabilitation structure versus a joint rehabilitation structure
Communication and cooperation between teams
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10. Monica Milter Ehlers | monehl@stab.rm.dk
Thank you for your attention
And a warm thanks to:
The health professionals from the outgoing, multidisciplinary team at
Aarhus University Hospital, Central Denmark Region, Denmark and the
health professionals from the outgoing, rehabilitation team at the
municipality of Aarhus, Denmark.
Public Health in the Middle,
Central Denmark Region, Denmark
Health Research Fund of Central Denmark Region, Denmark, for providing
Denmark
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