|Rehabilitation for life||Usual rehabilitation and care|
Continuous and progressive rehabilitation as well as early detection of critical illness and complication during and after hospitalisation will improve the older adults’ physical performance and decrease mortality.|
Knowledge empowers older adults and facilitates a change in mindset among health professionals.
Activity-based rehabilitation restore and maintain the activities of daily living.|
Older adults’ need to regain functions creates motivation.
25 rehabilitation sessions with a physiotherapist over 12 weeks of these 5 within 2 weeks from discharge are planned.|
A virtual meeting between physiotherapist in the primary and secondary sectors and older adults is conducted in the 2 rehabilitation sessions after discharge.
The suitcase contains knowledge and equipment the older adults need to take responsibility and perform daily exercises.
Health professionals participate in a workshop.
Early detection of critical illness and complications performed day 3 after discharge.
Older adults’ general amount of rehabilitation is approximately 1–2 rehabilitation sessions a week for 6–8 weeks.|
Care has to be prescribed.
|Who provide||Physiotherapists, nurses, and social- and health assistants.||Physiotherapists, nurses, and social- and health assistants.|
|How||Face to face, virtual meetings, and app||Face to face.|
|Where||Ortho-geriatric ward, the patients’ home, and in the rehabilitation centres.||Ortho-geriatric ward, the patients’ home, and in the rehabilitation centres.|
|When and how much||
Weeks 1–2 after discharge:|
- Five training sessions with a physiotherapist, duration up to 60 min.
-One virtual meeting duration 30 min.
-Vial measurements, duration up to 45 min. If necessary, one follow-up meeting with the municipal emergency nurse assessment, duration up to 45 min.
Week 3 to week 12 after discharge:
2 weekly rehabilitation session with a duration up to 45 min is planned.
During admission: rehabilitation in the ortho-geriatric consist of a daily session with a physiotherapist duration of 30 min.|
Week 1 after discharge:
-1 rehabilitation session duration up to 45 min.
Weeks 2–8 after discharge:
-1 or 2 weekly sessions of rehabilitation duration 45 min.
|Tailoring||Patients with a CAS score ≥ 4 receive rehabilitation at a rehabilitation centre. Progression follows the national guidelines .||The patients rehabilitate at home or at a rehabilitation centre, pending on an individual assessment.|