Educational draft · awaiting clinical reviewThe full textbook explains uncertainty but does not replace live national or local guidance, specialist advice, or current prescribing information.
Multidisciplinary rehabilitation and discharge planning
Musculoskeletal medicine and orthopaedics · UK scope · Sources checked 27 Aug 2026 · Clinical review pending
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Functional decline may be clinical deterioration
A sudden new inability to transfer or mobilise can reflect PE, infection, anaemia, delirium, stroke, wound failure, dislocation or fracture rather than a routine therapy setback.
Action: Pause discharge progression, use ABCDE and focused limb and neurological assessment, obtain urgent senior review and update the rehabilitation prescription only after the cause is defined.
Purpose and principles
Coordinate medical recovery, mobility, daily function, medicines, equipment and community support around patient-defined goals so discharge is timely, safe and continues rehabilitation rather than ending it.
Rehabilitation restores participation rather than only joint movement. At admission, establish pre-injury walking distance and aid, transfers, stairs, activities of daily living, cognition, communication, work, caring roles and home layout. Ask the patient which outcome matters most and what level of risk they accept. Distinguish temporary postoperative impairment from longstanding disability and identify carers' actual capacity rather than assuming availability. This baseline allows the team to measure recovery and select home, supported discharge, inpatient rehabilitation or care placement rationally.
Create one shared plan. The orthopaedic surgeon documents diagnosis, procedure, wound and structural precautions, exact limb-specific loading and review. Orthogeriatric or medical clinicians optimise physiology, delirium, falls and bone health. Physiotherapy addresses transfers, gait, strength, balance and stairs; occupational therapy assesses washing, dressing, toileting, cognition, equipment and home tasks. Nursing records function across the day and reinforces self-care. Pharmacy reconciles analgesia, anticoagulation and chronic treatment. Dietetics, pain, mental health, social work and community services contribute according to identified need.
Indications, selection and cautions
Rehabilitation potential
The patient can engage, learn and improve meaningful function even if they have not returned to their pre-injury baseline.
Medical barrier
Pain, delirium, anaemia, hypotension, hypoxia or infection may explain poor therapy performance and require parallel treatment.
Task-specific independence
Safe bed-to-chair transfer does not establish toilet, stair, cooking or nighttime independence in the home environment.
Carer capacity mismatch
A willing relative may lack physical ability, time, training or consent to provide the proposed level of care.
Unsafe medicines transition
Duplicate prescriptions, unclear anticoagulant duration and new opioid exposure are common high-consequence discharge hazards.
Loss of recovery trajectory
A plateau or sudden decline should trigger reassessment of diagnosis, complications and rehabilitation dose before destination is fixed.
Red flags requiring action
New chest pain, hypoxia, syncope, tachycardia or unilateral leg swelling during rehabilitation requires urgent cardiopulmonary and VTE assessment.
Fever, wound drainage, spreading erythema, escalating joint pain or sudden inability to bear weight suggests infection, dislocation or fixation failure.
Assessment before treatment
01First-line multidisciplinary functional assessmentFirst stepFirst line
Why
Measure transfers, walking, stairs, balance, cognition and daily activities against the destination's actual demands.
Interpretation and limitations
Record assistance, aid, distance and quality; one isolated success under ideal supervision may not generalise to home.
02Medical stability and reversible-barrier review
Why
Identify pain, hypoxia, infection, anaemia, delirium, hypotension, nutrition and bowel or bladder problems limiting progress.
Interpretation and limitations
Stability means needs can be safely managed at the destination, not that every test or symptom is normal.
03Occupational home and equipment assessment
Why
Match toileting, washing, dressing, kitchen, stairs and access needs to aids, adaptations and available carers.
Interpretation and limitations
Trial equipment where possible and confirm delivery before discharge; assumptions from a generic home description are unreliable.
04Medicines reconciliation and administration assessment
Why
Compare pre-admission, inpatient and discharge medicines and determine whether the patient or carer can use them safely.
Interpretation and limitations
Resolve intentional changes, duplications, anticoagulant stop dates, opioid supply and monitoring before transfer.
Treatment approach
01AdmissionDefine baseline and destination demandsFirst stepAn orthopaedic patient enters acute care with likely rehabilitation needs.+
1Record pre-event residence, mobility, cognition, self-care, carers, environment and personally important goals.
2Identify anticipated structural restrictions, medical risks and likely equipment or community-service needs.
3Set shared measurable goals and begin referrals early rather than after the discharge date is chosen.
4Nominate a coordinator and update the patient and carers in an accessible format.
02Daily rehabilitationTreat barriers while practising functionSurgery or fracture treatment is complete enough for recovery activity.+
1Mobilise at the guideline-supported time within exact loading and surgical constraints.
2
Complications, monitoring and follow-up
Track daily transfer level, walking aid, distance, stairs and activities of daily living against agreed goals and baseline.
Review pain, sedation, bowel function, nutrition, wound, oxygenation, haemoglobin, cognition and postural symptoms that alter participation.
Reconcile weight-bearing and brace instructions across surgical, therapy, nursing and discharge records whenever one changes.
Confirm equipment delivery, carer training and community-service acceptance before the patient leaves the ward.
After discharge, monitor falls, readmission warning symptoms, medicine use, wound healing, therapy attendance and ability to manage at home.
Revisit goals and destination if progress changes, ensuring decisions include the patient's current priorities and capacity.
Special situations
Discharge starts on admission
Early baseline and home information reveals barriers while there is still time to arrange equipment, care and rehabilitation.
Medically stable is contextual
A controlled problem can be managed in one destination but remain unsafe where monitoring or treatment is unavailable.
Therapy is not a destination
The patient needs the right intensity and disciplines wherever they live, rather than an inpatient bed simply labelled rehabilitation.
Carers need consent and capacity
Family availability should be discussed directly and never presumed from proximity or goodwill.
Teach-back exposes gaps
Asking the patient to demonstrate aids and explain medicines or warning signs reveals misunderstandings before harm occurs.
Sudden plateau needs diagnosis
An abrupt loss of function is a clinical signal, whereas a gradual plateau may reflect rehabilitation dose or goal mismatch.
Common pitfalls
01
Choosing a destination before assessing baseline, current function and the home's actual tasks.
02
Calling a patient independent after one supervised corridor walk while ignoring toileting and stairs.
03
Treating delirium or pain-related non-participation as absence of rehabilitation potential.
04
Assuming relatives can provide lifting, injections or overnight supervision without discussion and training.
05
Sending several conflicting loading instructions to community services.
06
Discharging with a referral pending but no confirmation, contingency or responsible clinician.
Practice
Two practice questions
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Musculoskeletal medicine and orthopaedicsOriginal SBA
Early supported discharge criteria
An older adult after hip-fracture surgery is medically stable, can engage with rehabilitation, transfers safely and walks a short distance with a frame but has not reached full potential. What is the best option if the specialist team can continue care at home?
Sources and review status5 sources · checked 27 Aug 2026 · clinical review pending+
Sources
Sources and review status
National guidance is shown before implementation-dependent detail. Apply principles in context and verify current guidance when a decision affects care. Source check completed 27 Aug 2026; clinical approval remains outstanding.
Mobilise early when safe. After hip-fracture surgery, NICE recommends physiotherapy assessment and mobilisation the next day unless medically or surgically contraindicated, followed by at least daily mobilisation. Treat pain, nausea, constipation, anaemia, hypotension, hypoxia and delirium that block participation, but do not wait for complete absence of symptoms. Test the exact weight-bearing prescription with appropriate aids and measure assistance, distance and task quality. Progress through meaningful activities and prevent prolonged sedentary time.
Choose destination by current ability, trajectory, environment and available support. Early supported discharge after hip fracture requires medical stability, mental ability to participate, transfer and short-distance mobility and remaining rehabilitation potential, while the programme team stays involved. A patient need not regain baseline before leaving acute care, but unresolved needs must be deliverable at the destination. Avoid delaying solely for a service that can safely begin in the community, and avoid premature transfer when essential equipment, care or clinical monitoring is not available.
Make handover operational. Reconcile medicines and give exact doses, changes, anticoagulant duration, opioid taper and bowel support. State wound care, dressing, clip or suture plan, weight-bearing status, exercises, equipment, driving and work restrictions and follow-up appointments. Include VTE, infection, dislocation, neurovascular, delirium and wound warning symptoms with contact routes. Send the plan before or at transfer to the patient, carer, GP, community nursing, therapy and care provider, and confirm high-risk referrals were accepted.
Review outcomes after discharge. Monitor mobility, daily activities, falls, pain, wound, nutrition, cognition, mood and participation, not only range of movement. Reconcile any conflicting instruction and escalate new deterioration clinically. Progress aids and loading through responsible review, and continue falls and fracture prevention. If goals are not being met, ask whether the barrier is untreated disease, an unrealistic plan, inaccessible environment, insufficient therapy or changing priorities. Update the plan with the patient rather than labelling them as lacking motivation.
Key points
Begin discharge planning at admission by recording baseline residence, mobility, cognition, self-care, carers, stairs, equipment and what outcome matters to the patient.
Set specific goals across medical stability, transfers, walking, stairs, washing, dressing, toileting, nutrition, cognition, pain, wound and self-management.
The team needs shared information: surgeon defines structural and weight-bearing limits; physician manages physiology; therapists test function and environment; nursing observes twenty-four-hour performance; pharmacy reconciles medicines; social care and community services deliver support.
After hip fracture, offer physiotherapy assessment and mobilisation on the day after surgery unless contraindicated, then mobilisation at least daily with regular review.
Early supported discharge after hip fracture is appropriate only when medically stable, mentally able to participate, able to transfer and mobilise short distances and still able to benefit, with the Hip Fracture Programme team remaining involved.
First-line discharge decision tests real tasks with the prescribed aid and weight-bearing status; bed exercises or one corridor walk cannot prove home safety.
Complete medicines reconciliation, VTE course, analgesia and bowel plan, wound and suture care, equipment, transport, contact numbers and booked follow-up before transfer.
Acute fluctuating attention, withdrawal or agitation requires delirium assessment and cause treatment before judging rehabilitation potential.
New focal weakness, speech change, severe headache or loss of coordination requires an acute neurological pathway.
An unsafe home, absent essential care, coercion, neglect or inability to access food and medicines creates a safeguarding and discharge barrier.
Discharge without a reconciled high-risk medicine, anticoagulant stop date or opioid plan can cause preventable bleeding, withdrawal, toxicity or readmission.
05Destination-specific risk and support confirmation
Why
Verify community therapy, nursing, social care, transport, food and follow-up can meet current needs.
Interpretation and limitations
A referral sent is not a service delivered; confirm acceptance, start timing and contingency arrangements.
06Targeted investigation for unexpected functional decline
Why
Detect PE, infection, dislocation, fracture, stroke, anaemia or metabolic disease when recovery deviates suddenly.
Interpretation and limitations
Choose tests from the new phenotype and pause routine discharge rather than attributing decline to poor motivation.
Practise transfers, walking, stairs and daily tasks while nursing reinforces activity outside formal therapy.
3Treat pain, delirium, hypotension, anaemia, constipation, hypoxia and nutrition problems in parallel.
4Review progress, complications and goals at multidisciplinary meetings with patient involvement.
03Destination decisionMatch current need to deliverable supportThe patient no longer needs all acute hospital resources but has not necessarily regained baseline.+
1Test actual destination tasks and determine equipment, supervision, care and therapy frequency required.
2Consider early supported discharge only when its clinical and functional criteria are met and programme involvement continues.
3Confirm carers agree and can provide the proposed help and address safeguarding or capacity issues.
4Select home, supported community, rehabilitation or care setting based on needs and goals, documenting trade-offs.
04Transfer and follow-upSend one executable planA discharge date and destination are agreed.+
1Reconcile medicines, wound, VTE, analgesia, bowel, nutrition, loading, aids and follow-up instructions.
2Provide equipment and training and use teach-back for warning signs and contact routes.
3Send the plan to the patient, carer, GP, nursing, therapy and receiving service and confirm high-risk handovers.
4EscalationReview function and symptoms after transfer and escalate unexpected decline or unmet support promptly.
Use teach-back and an accessible written plan that states restrictions, warning symptoms, who to contact and which team owns each next action.