This qualitative, descriptive, longitudinal, multiple case study describes the number and type of care transitions and problems experienced by 21 older urban and rural hip fracture patients in the year following hip fracture repair. Three patterns of transitions emerged: home to hospital to inpatient rehabilitation facility (n = 8); home to hospital to skilled nursing facility (SNF, n = 11); and intermediate nursing home to hospital to SNF (n = 2). Hip fracture patients experienced a median of 4 (range = 4 to 8) transitions in the year following repair. Problems common to all patterns were weight loss, delirium, depression, pressure ulcers, falls, and urinary incontinence. Patients newly admitted to SNFs experienced more problems and order discrepancies than those discharged to an inpatient rehabilitation facility. Families often identified problems first. Strategies to improve transitional care to older hip fracture patients should include improved patient and family involvement at the time of transition, irrespective of initial discharge location.
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