Recommendations made by patients, caregivers, providers, and decision-makers to improve transitions in care for older adults with hip fracture: a qualitative study in Ontario, Canada
Open accessAbstract
Background: Older adults frequently experience fall-related injuries, including hip fractures. Following a hip fracture, patients receive care across a number of settings and from multiple different providers. Transitions between providers and across settings have been noted as a vulnerable time, with potentially negative impacts. Currently, there is limited research on how to improve experiences with transitions in care following a hip fracture for older adults from the perspectives of those with lived experienced. The purpose of this study was to explore service recommendations made by patients, caregivers, healthcare providers, and decision-makers for improving transitions in care for older adults with hip fracture. Methods: This descriptive qualitative study was part of a larger longitudinal qualitative multiple case study. Participants included older adults with hip fracture, caregivers supporting an individual with hip fracture, healthcare providers, and decision-makers. In-depth, semi-structured interviews were conducted with all participants, with patients and caregivers having the opportunity to participate in follow-up interviews as they transitioned out of hospital. All interviews were audio-recorded, transcribed verbatim, and analyzed thematically. Results: A total of 47 participants took part in 65 interviews. We identified three main categories of recommendations: (1) hospital-based recommendations; (2) community-based recommendations; and (3) cross-sectoral based recommendations. Hospital-based recommendations focused on treating patients and families with respect, improving the consistency, frequency, and comprehensiveness of communication between hospital providers and between providers and families, and increasing staffing levels. Community-based recommendations included the early identification of at-risk individuals and providing preventative and educational programs. Cross-sectoral based recommendations were grounded in enhanced system navigation through communication and care navigators, particularly within primary and community care settings. Conclusions: Our findings highlighted the central role primary care can play in providing targeted, integrated services for older adults with hip fracture. The recommendations outlined have the potential to improve experiences with care transitions for older adults with hip fracture, and thus, addressing and acting on them should be a priority.
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Family caregivers support system navigation.
“caregivers provide the majority of care in homes and communities, support system navigation, and maintain continuity of care, often bridging the gaps left by fragmented service delivery models [2,3,4].”
From Home care comparison (2026) · cites this paper as [4]
The Results (Cross-sectoral based recommendations; page unavailable) indicate that caregivers are involved in navigating the healthcare system and arranging supports for older adults after hip fracture. However, the paper emphasizes caregivers’ difficulty doing so and their need for a care navigator, rather than establishing a general role in which family caregivers provide navigation support. (LLM, conf=0.78)
Experimental — accuracy not yet measuredFamily caregivers provide the majority of care in homes and communities.
“caregivers provide the majority of care in homes and communities, support system navigation, and maintain continuity of care, often bridging the gaps left by fragmented service delivery models [2,3,4].”
From Home care comparison (2026) · cites this paper as [4]
The Results (Community-based recommendations; page unavailable) describe caregivers planning support for aging family members and seeking information about community services. The paper does not establish that family caregivers provide the majority of care in homes and communities. (LLM, conf=0.77)
Experimental — accuracy not yet measuredFamily caregivers maintain continuity of care, often bridging gaps left by fragmented service delivery models.
“caregivers provide the majority of care in homes and communities, support system navigation, and maintain continuity of care, often bridging the gaps left by fragmented service delivery models [2,3,4].”
From Home care comparison (2026) · cites this paper as [4]
The Results (Cross-sectoral based recommendations; page unavailable) describe caregivers navigating a complex system and trying to arrange supports after hip fracture. They also identify communication gaps between services, but do not establish that family caregivers maintain continuity of care or routinely bridge those gaps; participants instead recommend dedicated care navigators. (LLM, conf=0.77)
Experimental — accuracy not yet measuredCaregivers in Alberta, like those across Canada and in most countries, remain the de facto system navigators, often acting as case managers without training or support.
“Caregivers in Alberta, like those across Canada and in most countries, remain the de facto system navigators [4,29,30].”
From Home care comparison (2026) · cites this paper as [4]
The Results (Cross-sectoral based recommendations; page unavailable) describe an Ontario hip-fracture care system that patients and caregivers found difficult to navigate and a need for someone to coordinate services. They do not establish that caregivers are routinely the de facto navigators in Alberta, across Canada, or in most countries. The added characterization that they act as case managers without training or support is also not established for caregivers by these passages. (LLM, conf=0.84)
Experimental — accuracy not yet measured
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- Authors
- Cadel, L., Kuluski, K., Everall, A. C., & Guilcher, S. J. T.
- Affiliations
- University of Toronto (CA)
- Corresponding author
- Guilcher, Sara J. T.
- Venue
- BMC Geriatrics
- Published
- 2022-04-07
- Volume
- 22
- Issue
- 1
- Pages
- 291-291
- ISSN
- 1471-2318 (ISSN-L)
- PMC
- PMC8988316
- OpenAlex
- W4223644610
- Cited by
- 23
- References
- 62
- Citations by year
- 2026: 6 · 2025: 5 · 2024: 8 · 2023: 4
- FWCI
- 4.06
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Locations
- BMC Geriatrics (publishedVersion, cc-by)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion)
- Funders
- Canadian Institutes of Health Research
- Topics
- Health Sciences › Medicine › Surgery › Hip and Femur Fractures
- Health Sciences › Medicine › Emergency Medicine › Hospital Admissions and Outcomes
- Health Sciences › Health Professions › Speech and Hearing › Adolescent and Pediatric Healthcare
- Keywords
- hip fracture, older adults, care transitions, patient and caregiver perspectives, provider recommendation, care navigation, primary care, hospital-community care coordination, fall prevention, staffing levels, lived experience
- MeSH terms
- Aged, Decision Making, Hip Fractures, Humans, Ontario, Caregivers, Qualitative Research
About these checks
Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
Statistics and arithmetic are recomputed, not judged.
Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.
What counts as a claim ›How we measure confidence ›How we check this ›
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