The purpose of this project was to test the effectiveness of a systematic approach to continuous care delivery with a Gerontologic Advanced Practice Nurse (GAPN) as care coordinator in order to improve recovery outcomes following hip fracture in elderly clients. Client recovery outcomes included health status plus mood, client living situation (living at home as before the fracture), level of functional independence, and satisfaction with care. The design was a randomized two-group clinical trial. Outcomes were assessed at five points in time (baseline, 6, 12, 26 and 52 weeks post fracture) using the Functional Status Index, the Geriatric Depression Scale, and several tracking forms for discharge location. In addition, the GAPN kept a journal of encounters with clients and recorded time spent per type of intervention activity. Statistical analyses included descriptive statistics, non-parametric analysis of variance and of correlations. Care was provided in various care settings: acute care, nursing home, transitional care, rehabilitation facilities, and home. The study was conducted from 1997-2000. The sample was drawn from two acute care facilities in St. Paul, Minnesota. Of 100 eligible elders over 65 admitted for repair of a hip fracture, 43 agreed to hear about the study; 33 enrolled--17 were randomized to the treatment group, and 16 to the control. In order to be included in the study, clients were to have fractured the hip at home (except if home=nursing home or skilled nursing facility); "home" did include assisted living facilities, and they must have been ambulatory prior to the fracture. The intervention involved planning and implementation of care according to an evidence-based care management protocol, the Extended Care Pathway(ECP), in one health care delivery system by a GAPN care coordinator who worked with the client for six months following the fracture. The ECP was designed to encompass the entire hip fracture episode, serving as a systematic approach to providing continuous care to clients. It was developed by a multi-disciplinary team. The GAPN was a master's prepared nurse with special knowledge in gerontology. She functioned as care coordinator for all clients with hip fracture in the treatment group, guiding care across settings according to the ECP. The GAPN coordinated therapeutic services to clients on the pathway, and served as link between caregivers, agencies and the client and (family) caregivers. She served as consultant and teacher for all caregivers to assure continuity of the client's care across care settings, and evaluated care effectiveness, making necessary adjustments to the plan of care, working with the elder's physician and surgeon. Comparison of client recovery outcomes between the treatment and control groups confirmed the effectiveness of the GAPN in improving function in elders following hip fracture. In the treatment group there was an observed improvement in the elder's ability to perform all the activities related to Activities of Daily Living (ADL) and to Instrumenta lADLs. At three months post surgery, the treatment group experienced significantly less difficulty with these activities than the control group. Upon analyses of the GAPN's activities in response to clients, we found several strong and significant correlations between time the GAPN spent in counseling, discussing, advising and planning with the client and improvement in client function. These relationships were not significant at six months, but were at 12 months. Mood trajectories were similar in both groups; both improved, but the control group's change was significant. Mortality rates (22% in both groups) were comparable to national rates (10-40%). The summary of discharge location at twelve months indicated that only 13% of our sample resided in nursing homes rather than returning home after one year as compared to 25% cited in other studies. Limitations include the small sample size, the inability to control for discharge location, and the lack of formal authority of the GAPN. Further research needs to be done to identify which factors are key to building interventions that work for better outcomes after hip fracture, who should deliver those interventions, how they should be delivered and for how long. Based on this and other studies of elders in the post-acute period of care, there is a need for further testing of the GAPN Care Model for elders with hip fracture.
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