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Table 1 Overview of perioperative and post-discharge protocol for all patients in the study

From: Reducing mortality in hip fracture patients using a perioperative approach and “Patient- Centered Medical Home” model: a prospective cohort study

Perioperative management (All patients) Post-discharge management (All patients) Medical home management (Patient-Centered Medical Home patients only)
1. Perioperative risk assessment and management 1. Follow-up with High-Risk Osteoporosis Clinic (if needed) 1. Nurse Case Manager (CM) makes initial call to patient within 24–48 hours of hospital discharge.
2. Timing of surgical intervention 2. Continuation of aggressive physical therapy
3. Prophylactic antibiotics
4. Thromboembolic prophylaxis 3. Deep venous thrombosis (DVT) Prophylaxis 2. CM reviews medication list with patient.
5. Prevention and management of delirium
4. Wound check, functional evaluation, and radiographic examination at 6 weeks 3. CM ensures that follow-up visit is scheduled with primary care provider within 7 days.
6. Prevention of decubitus ulcers
7. Prevention of Constipation
8. Physical therapy intervention 5. Periodic assessment (no less than every 3 months) until a baseline functional state or death occurs 4. CM ensures that a patient-specific action plan is in case if patients have any trouble.
9. Assessment for underlying osteoporosis
10. Appropriate discharge placement 5. Patients receive weekly calls (2–3 minutes) for 4 weeks, to ask about complications or areas that need follow-up from CM.