What is the appropriate discharge plan for a 68-year-old Aboriginal woman with a history of hypertension, type 2 diabetes, recent transient ischemic attacks (TIAs), and vascular dementia, who was admitted to hospital after a hypoglycemic event resulting in a fractured right hip?

From the Guidelines

Lorna requires a comprehensive discharge plan that addresses her complex medical and social needs, prioritizing her safety, well-being, and positive aging. Lorna is a 68-year-old Aboriginal woman with a recent hospitalization for a right hip fracture following a hypoglycemic event, and newly diagnosed vascular dementia. Her medical history includes hypertension and type 2 diabetes, diagnosed two years ago, coinciding with her retirement after a 30-year career as a clerical assistant. Socially, she lives with her daughter's family on a rural property, having moved there five years ago to help raise her grandchildren, and experiences significant stress due to family conflict between her daughter and son.

Diversities and Challenges

Lorna's complex health needs require a tailored approach, considering her:

• Medical history: hypertension, type 2 diabetes, vascular dementia, and recent hip fracture
• Social situation: rural location, family conflict, and stress
• Cultural background: Aboriginal, requiring culturally appropriate care
• Reported excessive daytime sleepiness, warranting sleep assessment to rule out sleep apnea or medication side effects

Planning, Prioritization, Implementation, and Evaluation

For discharge planning, we must address several priorities, including:

• Medication management for diabetes, hypertension, and potential anticoagulation therapy for TIA prevention, with medication reconciliation to ensure no chronic medications are stopped and to ensure the safety of new and old prescriptions 1
• Physical rehabilitation for her hip fracture, requiring in-home physiotherapy services and mobility aids
• Cognitive assessment and support for vascular dementia, including memory strategies, environmental modifications, and regular cognitive monitoring
• Family education about her conditions, particularly recognizing signs of hypoglycemia and TIAs
• Social support services to address family conflict, possibly through counseling, and provide respite care options for her daughter
• Engagement of Aboriginal health liaison services to ensure culturally appropriate care
• Regular follow-up with a multidisciplinary team, including geriatric, endocrine, and neurological specialists, to support Lorna's complex care needs and promote positive aging

Discharge Planning and Follow-up

A structured discharge plan, as recommended by the standards of medical care in diabetes-2022 1, should be tailored to Lorna's individual needs, considering her diabetes type and severity, effects of her illness on blood glucose levels, and her capacities and preferences. This plan should include:

• Identification of the healthcare provider who will provide diabetes care after discharge
• Level of understanding related to the diabetes diagnosis, self-monitoring of blood glucose, home blood glucose goals, and when to call the provider
• Definition, recognition, treatment, and prevention of hyperglycemia and hypoglycemia
• Information on making healthy food choices at home and referral to an outpatient registered dietitian nutritionist to guide individualization of the meal plan, if needed
• Scheduling follow-up appointments prior to discharge to increase the likelihood that Lorna will attend, and arranging transportation services for follow-up appointments, considering telehealth options due to her rural location.

From the Research

Diversities and Challenges

• Lorna is a 68-year-old local Aboriginal woman with a complex medical history, including hypertension, type 2 diabetes, and recent diagnosis of vascular dementia 2.
• She has experienced multiple Transient Ischaemic Attacks (TIAs) and recently had a fall during a hypoglycaemic event, resulting in a fractured right hip and admission to hospital for repair and rehabilitation.
• Lorna's social history includes living with her daughter and family on a farm, 35 minutes drive from town, and experiencing stress due to conflict between her daughter and brother.
• Her previous work as a clerical assistant at the local council and her enjoyment of organising social events may be relevant to her current situation and potential rehabilitation plans.

Planning, Prioritisation, Implementation, and Evaluation of Nursing Practices

• Considering Lorna's dementia diagnosis, it is essential to provide early analgesia and timely surgical fixation of the fracture, as well as early and intensive inpatient rehabilitation to improve postoperative outcomes 3.
• A coordinated care approach, including an "orthogeriatric" team, can decrease mortality and improve long-term outcomes for hip fracture patients with dementia 3.
• Discharge planning should be tailored to Lorna's individual needs, taking into account her medical and social history, to reduce hospital length of stay and readmission rates 4, 5.
• Assistance and support, both formal and informal, may be required post-discharge, including follow-up services for health-related and social needs, as well as family support to manage her chronic illnesses and dementia care considerations.
• Further investigations may be necessary to assess Lorna's cognitive and functional status, as well as her risk of future falls and hospitalizations.

Respect for Identity and Dignity

• It is crucial to respect Lorna's identity and dignity throughout the management plan, taking into account her cultural background and individual preferences.
• Involving Lorna and her family in the decision-making process and providing person-centred care can help to promote her autonomy and dignity.
• The management plan should also consider Lorna's previous work and social activities, as well as her current living situation, to provide a comprehensive and holistic approach to her care.
• Studies have shown that patients with diabetes, like Lorna, can have similar post-hip fracture rehabilitation potential compared to non-diabetics, despite more co-morbidities, highlighting the importance of resource allocation for post-hip fracture rehabilitation among patients with diabetes 6.