Coordination of in-hospital and postsurgical care have been accomplished through a series of both formal and informal interdisciplinary programs. Written clinical pathways designed by both orthopaedic, nursing, rehab and social service professionals. The pathways specifically describe what actions should be taken for each patient entering the hospital with a hip fracture on each day of his or her hospitalization. All members of the hospital staff, including physicians, nurses, therapists, social workers have a clear understanding of who is responsible for which aspect of care and when and how the process should proceed. These pathways have avoided significant duplication of services and misunderstanding between professionals regarding responsibility for care.
Patients receive educational brochures, which are explained by the nursing staff upon admission.
The educational information includes the type of fracture, and various aspects of treatment, including postoperative care, rehab and home care. A strong case management system. A case manager, usually a registered nurse, is assigned to each patient immediately upon hospital admission. The case manager can not only facilitate the various aspects of care, but also is familiar with the insurer's contracted providers so patients are not assigned to home health care agencies that are not covered by their insurance, or durable medical equipment delivery is not delayed because of a lack of coverage. In essence, the case manager serves to coordinate the various professional disciplines and aspects of care during the patient's hospitalization.