Short summary

Kom Trygt Hjem is an expanded collaboration between somatic hospitals, municipal acute care nurses, and municipal care personnel. The target group is patients discharged Department of Orthopedics, OUH with a hip fracture, who are transferred to nursing homes and 24-hour rehabilitation in the municipalities of Funen.

Rationale

The initiative originates from a project between Sygehus Lillebælt, Fredericia, and Kolding municipalities, which took place in 2018-2020. The results from this project show a significant increase in survival and a significant reduction in readmissions within 30 days. Additionally, patients experienced better quality of life, and employees reported improved collaboration between hospitals and municipalities.

In the implementation of the program on Funen, we will focus on expanding the cross-sectoral collaboration between hospitals and the primary sector. This includes focus on common systematic approaches, methodologies, and, importantly, closer collaboration during the sector transition.

The aim of the study is to: - Prevent complications such as infections, falls, and constipation - Improve functional level - Increase health-related quality of life - Reduce the number of readmissions within 30 days - Increase survival within 30 days

Description of the cohort

Patients over the age of 65 with a hip fracture discharged from Department of Orthopedics OUH (Odense and Svendborg) to nursing home and 24-hour rehabilitation.

Data and biological material

Admission time, comorbidity, complications, re-admission, survival, mobility, EQ5D, CAS, data from municipalities.