Background: Approximately 50% of older patients hospitalized for hip fractures are admitted to a geriatric rehabilitation department at a skilled nursing home. Given the wide variation in rehabilitation stay lengths, predicting the length of stay upon hospital discharge would help manage patients’ recovery expectations and create appropriate therapy schedules. Existing literature on length of stay predictors included both acute hospital and in-hospital rehabilitation phases or involved small sample sizes. The present study aims to identify predictors for the length of geriatric rehabilitation stay in skilled nursing homes for older patients after hip fracture surgery upon hospital discharge. Methods: This retrospective cohort study was conducted from 1 October 2017 to 1 July 2023, including 561 patients. Potential predictors of the length of geriatric rehabilitation stay were first tested univariately, with variables showing p < 0.15 entered into a multivariate forward linear regression model. Results: This model identified the following independent predictors of a longer length of geriatric rehabilitation stay: Functional Ambulation Categories (FACs) 0 (B = 29.9, 95% CI 24.1–35.7), 1 (B = 18.0, 95% CI 11.8–24.2), 2 (B = 12.0, 95% CI 7.1–17.0), or 3 (B = 3.6, 95% CI −1.2–9.4) at hospital discharge vs. FAC 4, living independently with home care services (B = 5.9, 95% CI 2.5–9.3) or in a residential home prior to the hip fracture (B = 0.2, 95% CI −7.4–7.8) vs. living independently without home care services, non- or partial weight-bearing mobilization vs. full weight-bearing mobilization (B = 15.4, 95% CI 8.5–22.2), internal fixation vs. hemiarthroplasty (B = 4.7, 95% CI 1.4–7.9), in-hospital delirium (B = 7.0, 95% CI 2.2–11.7), and in-hospital heart failure (B = 7.9, 95% CI 0.5–15.3). The explained variance was 32.0%. Conclusions: This study identified FAC at hospital discharge, premorbid living situation, postoperative weight-bearing protocol, surgery type, in-hospital delirium, and in-hospital heart failure as independent predictors of the length of geriatric rehabilitation stay. Future investigations are needed to identify additional predictors, such as cognitive functioning, to better predict the length of geriatric rehabilitation stay upon hospital discharge.

Objectives: To develop a transmural pathway for healthcare professionals across institutions to monitor the recovery of hip fracture patients. The secondary objectives were to evaluate the pathway's feasibility and initial outcomes. Design: Prospective cohort study. Method: Stakeholders of the hospital and geriatric rehabilitation institutions implemented a transmural monitoring pathway in which different geriatric health domains were monitored during three phases: The in-hospital, inpatient rehabilitation, and outpatient follow-up phase. The outcomes for the first 291 patients and the feasibility of the pathway were evaluated. If the outcomes of the clinimetrics significantly improved over time, progress in functional recovery was assumed. Feasibility was assessed according to the rate of adherence to the clinimetric tests. Results: During the in-hospital phase, patients showed a decline in functional level (the Katz index of independence in Activities of Daily Living (Katz-ADL) pre-fracture vs. discharge: 0 (0–2) vs. 4 (4–5), P < 0.001). Patients, in which 78.6% (n = 140) had cognitive impairment and 41.2% had malnutrition, showed the most progress (Katz-ADL 2 (1–3)) during the inpatient rehabilitation phase. In the outpatient follow-up phase, recovery remained ongoing, but most patients had not returned to their pre-fracture functional levels (Katz-ADL 1 (1–3)). The pathway feasibility during the first phase was excellent (>85%), whereas room for improvement existed during other phases (<85%). Conclusion: The transmural monitoring pathway provides insight into the entire recovery process for all involved healthcare professionals. Patients showed the most progress during the rehabilitation phase. The pathway feasibility was excellent during the in-hospital phase, but improvements could be made during other phases.