1. Gardner, Kristin O'Mara


The current bundled payment reimbursement from the Centers for Medicare & Medicaid Services will not cover the additional cost of hospital readmission for the same diagnosis, and patients with hip fractures have one of the highest cost-saving opportunities when compared with other admission reasons. Common reasons for readmission to the hospital after hip fracture include pneumonia, dehydration, and mobility issues. The learning modalities including visual, aural, read/write, and kinesthetic were used to make recommendations on how the education can be incorporated into the instruction of patients with hip fractures and their families. These learning techniques can be used to develop education to decrease possibility of 30-day readmission after hip fracture. Nurses must focus their education to meet the needs of each individual patient, adapting to different types of adult learners to increase the health literacy of patients with hip fractures and their families.


Article Content

Hip fractures account for roughly 258,000 hospitalizations annually and are associated with high mortality and morbidity rates (Centers for Disease Control and Prevention, 2013). In 2010, it was estimated that 84% of all patients who sustained a hip fracture were 65 years of age and older (Centers for Disease Control and Prevention, 2012). Patients with hip fractures have a 20%-25% mortality rate in the first year after injury (American Orthopaedic Association: Own the Bone, 2011; Marks, 2010). Early hospital readmission in patients with hip fractures nearly doubles their 1 year mortality risk (French, Bass, Bradham, Campbell, & Rubenstein, 2008; Khan, Hossain, Dashti, & Muthukumar, 2012). Kates et al. (2010) found that the average financial burden of an inpatient stay for a hip fracture is $33,000. In the first year after injury, an estimated additional $40,000 will be spent for the care of the patient with a hip fracture and $5,000 will be spent in each subsequent year of life (Brauer, Coca-Perraillon, Cutler, & Rosen, 2009). Using these numbers, the cost incurred during the first year following a hip fracture is estimated to be $73,000; if the patient lives for an additional 10 years, it could cost up to $123,000 over the life span of a patient who has sustained a hip fracture. By the year 2030, 20% of the U.S. population will be older than 65 years, and by 2040, it is estimated that there will be 500,000 hip fractures a year (Kates et al., 2010; Centers for Disease Control and Prevention, 2013).


In an effort to obtain greater safety and quality of medical care, the Centers for Medicare & Medicaid Services (CMS) has altered its reimbursement to hospitals for the care and management of their patients by utilizing a single payment for each episode of care in the hospital (Sood, Huckfeldt, Grabowski, & Newhouse, 2011). This type of payment is referred to as a bundled payment in which there will not be any additional reimbursement for a readmission within 30 days of discharge from the hospital for the same diagnosis. According to CMS guidelines, an episode of care begins 3 days prior to an acute care admission and ends 30 days after discharge from the acute care setting. Jencks, Williams, and Coleman (2009) found that almost 18% of Medicare pay-for-service patients who underwent hip or femur surgical intervention were readmitted within 30 days of discharge. When utilizing the bundled payment reimbursement from the CMS, patients with hip fractures have one of the highest cost-saving opportunities when compared with other reasons for admission (Sood et al., 2011). Newmann et al. (2013) found that hospital readmissions can be prevented with increased patient and physician education, solid discharge planning, and optimizing perioperative care by utilizing focused programs, or patient pathways. Peter et al. (2015) conducted a study on congestive heart failure (CHF) education, noting that patients who were taught by nurses utilizing the teach-back process had a 12% lower readmission rate than patients who had not been taught utilizing this method.


Research Question

What information do geriatric patients with a hip fix and their families need to know prior to discharge in order to decrease 30-day readmissions?


Problem Statement

The problem identified was the lack of knowledge regarding what information should be included in patient and family hip fracture education to reduce inpatient readmission rates.


Significance to Nursing

Effective communication in the healthcare environment greatly increases quality and safety. Patient-centered care focuses on communication between patients, families, and healthcare providers to educate and individualize the care of hospitalized patients (Boykins, 2014). Nurses provide patient-centered care when they assess and evaluate a patient's communication preference and tailor their education to meet the individual needs of their patients and families (Boykins, 2014). The ability for patients and their families to retain and process health information is defined as health literacy. Patients and their families with poor health literacy have a reduced understanding of healthcare concepts, lower incidences of taking medications as prescribed, and a decreased frequency of participating in medical decisions (Boykins, 2014). Poor health literacy can also lead to higher rates of emergency department, hospitalization, and medical costs (Boykins, 2014). Nurses and other healthcare providers must develop communication skills, including the use of the teach-back process or technique, to increase the health literacy of the patients they are caring for (National Network of Libraries of Medicine, 2014).


Using a patient-centered approach, nurses and other healthcare professionals can increase the health literacy of patients with hip fractures. Nurses must be able to deliver health and safety information that is accurate and incorporate evidence-based standards to create learning materials that can be used and understood by patients and families (U.S. Department of Health and Human Services, 2010). By taking a patient-centered approach, the development of this educational approach to be used for patients with hip fractures and their families will increase the quality and safety of patients and improve health literacy.


Theoretical Framework

Malcolm S. Knowles's theory of adult learning was used as the theoretical framework for this project. Knowles's 1973 theory has six assumptions of adult learning: (a) Adults need to know why they need to learn something; (b) the learner is self-directed; (c) they learn on the basis of experiences; (d) the learner must be eager to learn; (e) learning is approached similarly to problem solving; and (f) adults will learn best when the topic is personally important (Knowles, Holton, & Swanson, 2011). Knowles's theory has implied that adults are self-directed learners who must be able to see how information is relevant and important in their lives. This theory has highlighted that adults need to learn at their own pace (Knowles, Holton, & Swanson, 2011). Knowles's theory was chosen because it asserts that patients need to understand why the information they are learning is important to them and they need to be able to learn at their own pace. Patients who have sustained a hip fracture need to understand why preventing pneumonia, dehydration, and increasing their mobility is important to them. They should be given educational materials that allow them to learn at their own pace and be taught using interventions that complement the varying learning styles of each individual adult learner.


Literature Review

There has been limited research evaluating 30-day readmission reasons, or diagnosis, in patients recently discharged after sustaining a hip fracture. However, there were many studies that address predictors and causes of readmissions specifically during the inpatient stay. These predictors and causes included a longer length of hospital stay, increased length of time to surgery, increased age, discharge to a skilled nursing facility, development of inpatient complications and comorbidities including diabetes mellitus, obstructive pulmonary disease, renal failure, cardiac disease, and cancer, or weight loss and poor nutritional intake (French et al., 2008; Kates et al., 2010; Khan et al., 2012; Teixeira et al., 2009). Many of these predictors could not be altered with patient and family education. Because the goal of this project was to focus on the education of patients and their families to decrease readmission rates, this article has concentrated on specific patient education that could be developed to decrease hospital readmission rates by increasing health literacy. After a search through the literature, there was limited research specific to causes of 30-day readmissions; however, it was noted and is described later.


Khan et al. (2012) found that the most common reason for 30-day readmission in patients with hip fractures were (a) pneumonia (27.3%), (b) renal dysfunction due to dehydration (18.2%), (c) decreased mobility (18.2%), (d) and noninfective bowel and urinary disorders (11%), which were most commonly presented as constipation and urinary retention. French et al. (2008) noted that 30-day readmissions after a hip fracture included (a) respiratory (20.9%), (b) muscular skeletal (16.1%), (c) circulatory problems (14.8%), (d) digestive system (8.1%), (e) health status influences (7.3%), (f) infectious and parasitic (6.6%), and (g) kidney and urinary tract problems (6.3%). Kates et al. (2010) found that 8.5% of readmissions were due to medical complications including pneumonia, gastrointestinal problems, CHF, and renal failure. On the basis of this literature review, the development of education to decrease 30-day readmissions for patients with hip fractures and their families was focused on the prevention of pneumonia, dehydration, and immobility.



Kates et al. (2010) found that only 1.8% of hospital readmissions were due to surgical complications and roughly 8.5% resulted from the development of other medical problems, including pneumonia. Khan et al. (2012) noted that most of the readmissions after a hip fracture were due to nonsurgical complications, with the leading cause being pneumonia. French et al. (2008) found that respiratory issues accounted for nearly 21% of readmissions after a hip fracture, and Jencks et al. (2009) noted that 9.7% of their study readmissions were due to pneumonia. None of these studies indicated if the respiratory complications, including pneumonia, were bacterial or viral in nature.


The physiological and age-related changes that occur in geriatric patients put them at an increased risk for developing a respiratory tract infection (Buckley & Schub, 2014). Other risk factors for developing pneumonia include alcoholism, obstructive pulmonary disease, malnutrition, and multiple comorbidities (Buckley & Schub, 2014). The 30-day mortality rate for geriatric patients who develop pneumonia ranges from 14% to 26% (Buckley & Schub, 2014). With the geriatric patient already at an increased risk for acquiring pneumonia, a geriatric patient with a hip fracture has an even greater chance of developing pneumonia due to decreased mobility, inadequate nutrition, and poor hydration. Prevention of pneumonia is one way to reduce the possibility of readmission. It is recommended that adults beginning at the age of 65 years receive the influenza vaccine each year in addition to the pneumococcal vaccine, which requires a repeated dose every 10 years (Buckley & Schub, 2014).



Several studies found that renal dysfunction and renal failure secondary to dehydration were another reason for readmission after patients sustained a hip fracture (French et al., 2008; Kates et al., 2010; Khan et al., 2012). Khan et al. (2012) found that renal dysfunction was caused by dehydration and reflected poor nutrition and inadequate fluid intake after discharge from the hospital. Constipation was noted to be the most common reason of noninfected bowel readmissions in patients with hip fractures (Khan et al., 2012).


Because of physiological changes, the geriatric patient has an increased difficulty maintaining homeostasis, which affects water balance (Schols, DeGroot, Van Der Cammen, & Olde Rikkert, 2009). Some of these physiological changes have included (a) decreased water storage, (b) decreased sense of thirst and inability to identify dry mucous membranes, and (c) decreased kidney function, which alters sodium and water retention (Schols et al., 2009). Dehydration in older adults increases their chances of developing urinary tract and pulmonary infections, kidney stones, constipation, blood clotting issues, hyperthermia, and orthostatic hypotension (Schols et al., 2009).



Khan et al. (2012) found that 18.2% of patients with hip fractures were readmitted with mobility-related issues, and French et al. (2008) noted that 16.1% of their readmissions were due to connective tissue and musculoskeletal issues. Decreased mobility after a hip fracture lasts well past the healing of the hip fracture (Kline Mangione, Lopopolo, Neff, Craik, & Palombaro, 2008). Roughly only half of patients who sustain a hip fracture are able to return to prefracture mobility (Gorman et al., 2013). Murphy et al. (2011) found that providing patients with a hip fracture educational booklet increased their mobility, leading to decreased length of hospital stay, fewer inpatient complications, and increased patient satisfaction. Patients who are able to see that they are improving every day, are able to make exercise part of their daily routine, and are more determined to return to prefracture mobility levels, such as being able to walk to church or walking without a walker, are more likely to have more positive mobility outcomes (Gorman et al., 2013).



A literature search was completed using MEDLINE and CINAHL search engines. The key words used were hip fracture, readmission, patient education, discharge education, and patient readmission. Articles were limited to the last 10 years, humans, and English language. Key points were gleaned from the literature review of preventing pneumonia, dehydration, and mobility problems and were evaluated by fellow graduate students, an orthopaedic clinical nurse specialist, an orthopaedic trauma physician, and the MSN capstone advisor. Changes were made to the proposed education topics on the basis of feedback (see Table 1).

Table 1 - Click to enlarge in new windowTable 1. Methodology Table

Ethical Considerations

Whenever research is completed, investigators must keep in mind certain ethical considerations and standards. All researchers must uphold the characteristics of beneficence, justice, and autonomy when completing research projects (Bonnel & Smith, 2014). One ethical consideration addressed for this project was making sure that the research studies referenced throughout this article were conducted so properly and appropriately (Bonnel & Smith, 2014). Institutional review board approval was unnecessary for this project, as it posed no risk to participants because this research will be used as a guide for the development of education for patients and their families.



The analysis, or evaluation, of this educational project was done by field experts. An orthopaedic trauma physician, a physician assistant, a clinical nurse specialist, and a physical therapist who work at a tertiary, nonacademic, Level I trauma center acted as content specialists and reviewed the hip fracture readmission prevention education proposal for accuracy. An advisor to the MSN program was asked to review the objectives and educational approach developed, as she has expertise in clinical/acute care education recommendations and evaluation with increased knowledge and awareness of health literacy issues and consequences. Once all of the feedback was received, changes were made to the proposed educational program to reflect recommendations.


Review of Evidence and Recommendations

After the initial literature review to identify some more frequent post-hip fracture 30-day readmission reasons, a second literature review was done to investigate what education or tools were currently available for pneumonia, dehydration, and mobility. The review included both orthopaedic and nonorthopaedic related research.


In today's nursing environment, although hospitals have been trying to decrease length of stay due to smaller reimbursement, it has been even more imperative that nurses are able to adequately teach their patients in a shorter amount of time. Nurses must learn to evaluate how their patients learn and adapt their teaching styles to meet the needs of each patient individually, using a patient-centered care concept. Older, or elderly adults, learn differently than younger adults do. Older adults tend to learn better when (a) their learning is active, (b) they can relate to the situation and use their experiential knowledge to assist in retention, (c) they are allotted more time in a calm environment, and (d) it is of interest to them and they do not feel pressure to retain the knowledge (Osorio, 2008). It is important for older adults to actively participate in their learning, with educators providing them with adequate informational materials and allotting them appropriate time for their tasks and activities, giving them ample opportunities to contemplate what they are learning in a relaxing environment (Osorio, 2008). The decline in auditory and visual capacity in older adults decreases their ability to receive information and their ability to process information is reduced (Beagley, 2011). Patients who may be experiencing pain, anxiety, or fear can have a harder time retaining new information (Beagley, 2011). An unplanned admission to the hospital to undergo surgery to repair a hip fracture can be a very painful and stressful time in an older adult's life. With this in mind, it may be beneficial to empower and educate the patient's family and/or caregivers to continue to reinforce education after discharge from the acute care setting. Statistically, 71% of adults older than 60 years have a difficult time with printed material, 80% have a hard time understanding charts and forms, and 68% have a challenging time interpreting numbers and completing calculations National Network of Libraries of Medicine, 2014).


There are four basic learning styles, or preferences, that are used by individuals. These preferences can be summarized by using the acronym VARK: visual (V), aural (A), read/write (R), and kinesthetic (K) (Leite, Svinicki, & Shi, 2010). Visual learners acquire information best by seeing what they are learning and enjoy having things such as charts and graphs to help them understand concepts (Beagley, 2011; Leite et al., 2010). Aural, or auditory, learners like to hear what they are learning, which can be accomplished by reading information aloud or having a conversation or discussion (Beagley, 2011; Leite et al., 2010). Learners who learn by reading/writing prefer to do so through written materials and handouts (Leite et al., 2010). A kinesthetic learner prefers to learn by actively completing a skill or task (Beagley, 2011; Leite et al., 2010). In an effort to prepare educational and learning opportunities to suit many different types of learners, it is recommended that the pneumonia, dehydration, and mobility education utilize different learning styles. The preferred learning modality in adults 55 years and older are (a) visual (20.7%), (b) aural (24.2%), (c) read/write (28.4%), and (d) kinesthetic (26.7%) ("VARK: A Guide to Learning Styles," 2015). The VARK learning styles were used for this project because of the use of the acronym and the ease of understanding for the bedside nurse. Leite et al. (2010) noted that when looking at the validity of VARK scores, there is preliminary support for the utilization of the VARK learning inventory with potential issues with the wording of the questions. They found that many of the study's participants had a combination of learning preferences. The hip fracture education should be adapted to each individual patient and it is also important to note that each patient may be able to learn by utilizing more than one learning style. With this in mind, the patient and family learning objectives should reflect the type of learning utilized as the teaching method (see Table 2).

Table 2 - Click to enlarge in new windowTable 2. Patient/Family Learning Objectives


The education developed for patients with hip fractures could utilize the I COUGH acronym that was originally developed by Cassidy, Rosenkranz, McCabe, Rosen, and McAneny (2013). This acronym is easy to use and understand by staff, patients, and families. On the basis of postimplementation of the I COUGH program, Cassidy et al. (2013) found that incidents of postoperative respiratory complications, including pneumonia, decreased. The I COUGH acronym is used to describe incentive spirometer (I), cough and deep breathing (C), oral care (O), understanding (U), getting out of bed (G), and head of bed elevation (H) (Cassidy et al., 2013). The patient must be instructed on how to use his or her incentive spirometer (IS), performing the activity at least 10 times every hour (Cassidy et al., 2013). If a patient or family member is watching TV, one tip in helping them to remember to use their IS is to use it once every commercial break; which will attain their goal of using the IS 10 times every hour. Evidence shows that lung expansion exercises, such as deep breathing, decreases patient's chances of developing pneumonia (Cassidy et al., 2013). Deep breathing may cause coughing, which should be encouraged by the nursing staff. Coughing assists in the expulsion of mucous and helps open lung alveoli. Oral care, including brushing teeth at least twice a day and using mouthwash, helps rid the mouth of bacteria that can lead to the development of pneumonia (Cassidy et al., 2013). It is important for the nursing staff to ensure that patients understand their plan of care and the interventions that have been put in place to decrease the development of complications (Cassidy et al., 2013). Another element of the I COUGH acronym is that patients should get out of bed at least three times a day (Cassidy et al., 2013). The last recommendation to reduce the possibility of developing respiratory complications is to maintain at least a 30[degrees] elevation of the head of the bed at all times (Cassidy et al., 2013).


After reviewing a patients preferred learning style, and it is discovered that the patient is an auditory learner, the nurse needs to adapt his or her teaching style to meet the needs of his or her patient. When educating a patient who is an auditory learner, the elements of I COUGH should be taught in a way that would allow the auditory learner to hear the education and instructions as they are given. Auditory learners benefit from hearing the education and instructions that are given (Beagley, 2011; Leite et al., 2010). These types of learners do not prefer to read about the information but instead would benefit from having a discussion with their nurse educator. Auditory learners would also benefit from the teach-back method in which they are asked to repeat back what they learned ("VARK: A Guide to Learning Styles," 2015). In a study conducted by Peter et al. (2015), they utilized the teach-back method to reduce hospital admissions and had the nurses ask basic introductory questions such as "So that I know I did a good job showing you how to draw up your insulin, can you show me how you are going to do this when you get home?" (p. 36). It is helpful for the nurse to make sure he or she is using varying verbal tones, speed, and volume to meet the needs of the auditory learner (Beagley, 2011). In addition, the patient and his or her family should be in a quiet environment with minimal distractions to promote retention of the education (Schols et al., 2009). Nurses should encourage auditory learners to take notes and write down key components while promoting them to still listen to the message that is being delivered (Beagley, 2011). Older adults learn best when they are in an active learning environment; therefore, adult auditory learners would benefit from participating in a discussion in which they can ask questions and receive feedback (Beagley, 2011; Osorio, 2008).


Key evidence of pneumonia prevention when taught to an auditory learner.


* IS use at least 10 times every hour.


* Coughing and deep breathing should be taught.


* Oral care, preferably with mouthwash, should be completed twice a day.


* Patients should be able to verbalize understanding and effectively demonstrate their plan of care.


* Patients need to get out of bed at least three times a day.


* Keep the patient's head of bed elevated at least 30[degrees] at all times.


* Auditory learners would learn best by hearing their instructions and having a discussion allowing them to actively participate in their learning, and benefit from the teach-back technique.


* Educators should ensure a quiet environment and vary their verbal tones, speed, and volume to meet the needs of the auditory learner.



Water is important for proper hydration and essential for many bodily functions. Water transports nutrients and minerals, controls body temperature, preserves the structural integrity of tissue, and assists in many cell functions, including brain function (Schols et al., 2009). Risk factors for developing dehydration in the older adult hospitalized patient include pain, fever, wounds, blood loss, anxiety, delirium, dementia, mobility impairments and decreased exercise tolerance, incontinence, malnourishment, seclusion and loneliness, poor access to fluids, and lack of trained personnel (Schols et al., 2009). Symptoms of dehydration in older adults can be sometimes hard to assess, making diagnosing dehydration difficult. Some clinical signs of dehydration include low blood pressure or orthostatic hypotension, decreased level of concentration, confusion, dizziness, falls, dry mucous membranes or tongue (with a lengthwise grove), decreased skin turgor, increased feeling of thirst, oliguria, and fever with no known cause (Schols et al., 2009). Monitoring patient's intake and output of fluids should be done to ensure that more fluid is being consumed than excreted (Schols et al., 2009). Significant weight loss, of about 3% of the patient's body weight, is one of the more valuable indications of dehydration and monitoring a daily weight could be an effective way to monitor for dehydration (Schols et al., 2009). A decrease in urine output and thirst would be a late signs of dehydration (Schols et al., 2009). One way to prevent dehydration is for caregivers to offer fluids often to patients and ensuring that they are within reach (Schols et al., 2009). Elderly patients should be reminded to drink roughly 1.5-2 L of fluid daily, preferably in small amounts throughout the day, unless contraindicated because of medical conditions such as CHF (Schols et al., 2009). In addition to water, other recommended sources of fluids include fruit juice, tomato juice, sports drinks, milk, and mineral drinks, including clear soups or bouillon (Schols et al., 2009).


After assessment of a patient's learning style, it has been discovered that a patient prefers to learn by reading and writing. The nurse needs to adapt his or her teaching style and keep in mind that people who learn by reading and writing benefit when given printed instructions, which include things such as lists, definitions, handouts, and taking notes verbatim ("VARK: A Guide to Learning Styles," 2015). Educational materials should be well organized and easy to read in a font that is not too small and needs to be written at an appropriate grade level, allowing for it to be understood by most patients and their families (Beagley, 2011). It is recommended that the material is written at no higher than the fifth-grade level and should be on matte paper, with contrasting colors making it easier to read (Beagley, 2011).


Key evidence of dehydration prevention developed for a reading/writing learner.


* Intake and output should be monitored to ensure intake is greater than output.


* Weight loss of 3% would be an effective measure for dehydration, with decrease in urine production being a late sign of dehydration; therefore, daily weights would be recommended.


* Caregivers should ensure that fluids are easily in reach to prevent dehydration.


* Elderly patients need to drink 1.5-2 L of fluid a day, unless medically contraindicated.


* Use concisely written and well-organized information at an appropriate grade level, in easy to read font.



Early mobilization decreases the development of complications and helps the body return to a normal functional status. Mobilization prevents complications such as pneumonia, venous stasis and deep vein thrombosis, pulmonary embolism, gastrointestinal problems such as constipation, urinary retention, and orthostatic hypotension, loss of muscle tone, and bone demineralization (Morris, Benetti, Marro, & Rosenthal, 2010). Loss of muscle mass has been noted to begin after 2 days of bed rest, resulting in a 20% loss of muscle mass in 1 week of bed rest and a risk of balance problems and falls (King, 2012). Because of a lack of mobility and weight-bearing exercises, bone demineralization could lead to additional fractures (King, 2012).


After 2-3 days of bed rest, the sensitivity of baroreceptors in the aorta and carotid arteries decreases, which makes it harder for the body to regulate blood pressure, resulting in higher incidence of orthostatic hypotension (King, 2012). Initiation of mobility should begin the day of surgery and the patient should dangle his or her legs at the bedside (Morris et al., 2010). Mobility and activity levels should be increased on Postoperative Day 1 as tolerated and increase as ordered by the physician, to getting out of bed at least three times a day (Cassidy et al., 2013).


After reviewing a patients preferred learning style, and it is discovered that the patient is a kinesthetic learner, the nurse needs to adapt his or her teaching style to meet the individual needs of this patient. Demonstration and return demonstration would benefit kinesthetic learners because these learners like to have hands-on activities (Beagley, 2011). Nurse educators can instruct their patients by helping them get out of bed and teaching them how to do so safely. While doing this activity, they can ask their patients questions and take time to educate them on why it is important to get out of bed and ambulate after surgery to prevent surgical complications and decrease the chance of readmission to the hospital. Kinesthetic learners would benefit from the act of ambulating and getting out of bed, so if a discussion or the use of handouts in needed, nurse educators should encourage patients and their families to take notes (Beagley, 2011). Kinesthetic learners also benefit from frequent breaks, allowing them to move freely, so a resting period may be necessary to help them learn (Beagley, 2011).


Key evidence for immobility prevention when taught to a kinesthetic learner.


* Ambulation should occur as soon as medically possible after surgery.


* Patient should dangle/sit at the side of the bed on the day of surgery.


* Mobility needs to be increased daily, based on physicians' orders and patient toleration, getting out of bed at least three times a day.


* Demonstration and return demonstration are beneficial to kinesthetic learner; taking notes is also helpful.


* Frequent breaks in the educational process and encouraging the patient to move about the room would assist a kinesthetic learner in retaining information.



The CMS reimbursement for the care and management of its patients using a bundled payment model will leave 30-day hospital readmissions for the same condition to forgo additional payment, or reimbursement, to cover the patient's readmission hospital stay. These unpaid readmissions will leave hospitals and healthcare systems to absorb the cost of each readmission. It has been noted in the literature that hip fracture admissions have one of the highest cost-saving opportunities when compared with other reasons for admission. In addition to the financial impact for institutions, it is even more important to keep in mind that readmissions have a negative impact on a patient's recovery, well-being, and quality of life.


Review of the literature found there was no research targeting what specific information would be helpful to reduce the incidence of 30-day readmission after a hip fracture. There was, however, evidence regarding the causes for 30-day readmission after a hip fracture. After review of the causes for readmission, it was noted that education for patients and families to decrease the probability of hospital readmission should focus on pneumonia, dehydration, and mobility. Sound evidence aimed at the prevention of developing pneumonia, dehydration, and mobility complications was found in the literature and should be incorporated into the educational materials created for patients with hip fractures and their families. Many of the interventions that were found in the evidence to reduce the prevalence of pneumonia, dehydration, and mobility complications are interrelated and complement each other. On the basis of the evidence on how adults learn, it is recommended that the pneumonia, dehydration, and mobility education be taught in a manner that will suit many different types of learners and use the different learning styles of visual, aural, reading and writing, and kinesthetic. Utilizing different teaching styles for the various learning preferences would help facilitate comprehension of the education to meet the individual needs each patient and increase the health literacy of patients with hip fractures and their families.


The aforementioned proposed education can be adapted to meet the unique educational needs of each patient. The nurse may then apply the most effective of these learning modalities to future educational opportunities, as these are not necessarily limited to just educating patients on the prevention of pneumonia, dehydration, and mobility complications. Nurses need to continue to focus their education to meet the needs of individual patients because nurses play the most vital role in the education of their patients. They must learn to provide patient-centered care and education in order to develop the communication skills needed to increase the health literacy of their patients. Nurses have a huge opportunity to decrease their patients' prevalence of readmission after a hip fracture; they create a great cost-saving opportunity and can positively impact their patients' recovery when they educate their patients and families using evidence-based literature.




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Morris B. A., Benetti M., Marro H., Rosenthal C. K. (2010, September-October). Clinical practice guidelines for early mobilization hours after surgery. Orthopaedic Nursing, 29(5), 290-316. 0b013e318ef7a5d [Context Link]


Murphy S., Conway C., McGrath N. B., O'Leary B., O'Sullivan M. P., O'Sullivan D. (2011). An intervention study exploring the effects of providing older adult hip fracture patients with an information booklet in the early postoperative period. Journal of Clinical Nursing, 20, 3404-3413.[Context Link]


National Network of Libraries of Medicine. (2014). Health literacy. Retrieved from[Context Link]


Newmann D. N., Quinn M., Sivanesan S., Farooq U., Hendrickse C. W., Bowley D. M. (2013). Preventing readmissions: Are we doing enough? British Journal of Healthcare Management, 19(7), 348-353. [Context Link]


Osorio A. R. (2008). The learning of the elderly and the profile of the adult educator. Convergence, 41(2-3), 155-172. [Context Link]


Peter D., Robinson P., Jordan M., Lawrence S., Casey K., Salas-Lopez D. (2015, January). Reducing readmission using teach-back. The Journal of Nursing Administration, 45(1), 35-42. doi:10.1097/NNA.0000000000000155 [Context Link]


Schols J. M., DeGroot C. P., Van Der Cammen T. J., Olde Rikkert M. G. (2009, November 2). Preventing and treating dehydration in the elderly during periods of illness and warm weather. The Journal of Nutrition, Health& Aging, 13(2), 150-157. [Context Link]


Sood N., Huckfeldt P. J., Grabowski D. C., Newhouse J. P. (2011, September). Medicare's bundled payment pilot for acute and postacute care: Analysis and recommendations on where to begin. Health Affairs, 30(9), 1708-1717. [Context Link]


Teixeira A., Trinquart L., Raphael M., Bastianic T., Chatellier G., Holstein J. (2009). Outcomes in older patients after surgical treatment for hip fracture: A new approach to characterize the link between readmissions and the surgical stay. Age and Ageing, 38, 584-589. [Context Link]


U.S. Department of Health and Human Services. (2010). National action plan to improve health literacy [Issue summary]. Retrieved from U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion, website:[Context Link]


VARK: A guide to learning styles. (2015). Retrieved from[Context Link]


For 100 additional continuing nursing education activities on orthopaedic topics, go to