A Care Model for Elderly Hip-fractured Persons With Cognitive Impairment and Their Family Caregivers
A Care Model for Elderly Hip-fractured Persons With Cognitive Impairment and Their Family Caregivers
This study aims to develop and examine an innovative family-centered intervention model for
 managing cognitive decline, improving postoperative recovery of hip-fractured patients with
 cognitive impairment, and enhancing family caregivers' competence in dementia care. This care
 model is theoretically underpinned by: (a) the Progressively Lowered Stress Threshold Model,
 a component of Lawton's ecological model of aging, and (b) the concept of partnership with
 family caregivers to strengthen their competence in providing care. Training are provided to
 family caregivers to enhance their competence in caring for hip-fractured patients with
 cognitive impairment. The effectiveness of the care model has been evaluated in a randomized
 controlled trial. The study was approved by the Institutional Review Board of Chang Gung
 Memorial Hospital. A protocol of the family-centered care model was developed, and the
 research nurses were trained to provide the interventions. A checklist, consisting of
 postoperative care, rehabilitation exercises, nutritional health teaching, environmental
 modification suggestions, delirium care, and care issues for elders with cognitive
 impairment, as well as management of behavioral problems, was also developed and are recorded
 by the research nurses. This report is based on data collected from 149 dyads of participants
 who were recruited by September 2018 and randomly assigned to either an experimental group
 (n=73) or a control group (n=76). No significant differences are found between experimental
 and control group in their demographic and clinical variables including age, gender,
 diagnosis, surgery type, the length of hospital stay, the cognitive functioning, marital
 status, and educational level, as well as the age and gender of family caregivers. The
 refusal rate this year is 73.6%. The main reasons for caregivers not participating are not
 needed and too busy or afraid of being interrupted. No significant differences are found in
 demographic variables (ie, age, gender, diagnosis, surgery method, and length of hospital
 stay) between those who participated and those who refused. Causes of the attrition includes
 that participants refused to participate any more (n=25), died (n=12), moved to another
 location (n=6), and loss of contact (n=3). Older persons who quit participating in the study
 are more younger (p=.021) and more are diagnosed with inter-/sub-trochanteric fracture
 (p=.015) as well as more are receiving internal fixation (p=.029). Outcome variables
 including patients' cognitive function, clinical measures, self-care ability, family
 caregivers' competence and preparedness, health service utilization, quality of life, and
 cost of care. In addition to the clinical effectiveness of the family-centered care model
 will be evaluated by hierarchical linear models at the end of this study.
In this proposed clinical trial, the investigators intend to develop and examine an
 innovative family-centered intervention care model for managing cognitive decline, improving
 postoperative recovery of hip-fractured patients with cognitive impairment, and enhancing
 family caregiver's competence in dementia care. This study is innovative in two aspects:
 first, its focus on older persons with comorbid conditions of cognitive impairment and hip
 fracture, and second, the development of a family-centered care model for this population.
 Therefore, the goal of this proposed study is to examine the cost and effects of a
 family-centered care model that includes a family-centered interdisciplinary care component,
 and a training/support component for family caregivers of hip-fractured patients with
 cognitive impairment. The control group receives only usual care and the experimental group
 receives usual care and family-centered care.

 The specific aims are:

 1. To develop a family-centered care model for hip-fractured elders with cognitive
 impairment, consisting of family-centered geriatric assessment, continuous
 rehabilitation, and supported discharge planning, and a family caregiver
 training/support component to manage symptoms and behavioral problems associated with
 cognitive decline and enhance postoperative recovery of hip-fractured patients with
 cognitive impairment and to increase caregiver's competence in dementia care. The
 protocol is pre-tested within the context of a randomized intervention study subject to
 existing constraints of the clinical (i.e., CGMH) and community settings.

 2. To evaluate the effectiveness of usual care and the family-centered care model for
 hip-fractured elders with cognitive impairment in a randomized control trial. Effects of
 the two care models will be evaluated by comparing the trajectories of selected outcome
 variables: patients' clinical outcomes, self-care ability, cognitive function,
 behavioral problems, health-related quality of life (HRQoL), and service utilization,
 and family caregivers' preparedness, competence, and HRQoL. Predictors of recovery
 trajectories for the usual care and family-centered care models will also be compared.

 3. If the effectiveness of the family-center care is established, the costs associated with
 the usual care and family-centered care models will be analyzed. Cost items include: (1)
 costs for personnel time and home care visits, (2) costs of hospitalization, (3) costs
 of emergency or outpatient visits after hospital discharge due to a fall or re-fracture
 in the same location, and due to diagnosis/treatment for post-operative cognitive
 impairment, (4) patients' out-of-pocket costs for equipment such as walkers, crutches,
 nutritional supplements, or other necessities to improve their health conditions or to
 support walking, and (5) transportation expenses for patients and primary caregivers to
 visit hospitals or costs of time away from work.

 Hypotheses

 Based on results from previous studies on the effects of the interdisciplinary care model
 (Shyu et al., 2005, 2008) and of the family caregiver training program for patients with
 dementia (Huang et al., 2013; Kuo et al., 2013), following hypotheses are proposed. During
 the first year after hospital discharge, elderly hip-fractured patients with cognitive
 impairment who receive the family-centered care model will:

 1. Have less cognitive decline, better clinical outcomes, self-care ability, HRQoL, and
 fewer behavioral problems than their counterparts who receive usual care.

 2. Have more outpatient visits and fewer hospital readmissions and emergency room visits
 than their counterparts who receive usual care.

 3. Their family caregivers will have better preparedness and competence in dementia care as
 well as HRQoL than caregivers of elderly hip-fractured patients with cognitive
 impairment who receive usual care.

 4. Have fewer re-admissions and emergency room visits at a lower total costs than the usual
 care and their care givers will have lower productivity losses.

 Background and Significance Dementia and hip fracture are both associated with substantial
 disability and mortality, often coexist, are increasingly common in older adults, and have
 shared risks (Friedman, Menzies, Bukata, Mendelson, & Kates, 2010). Cognitive impairment
 occurs in 31-88% of older persons after surgery for hip fracture (Holmes & House, 2000a,
 2000b). Cognitive impairment is not only a major risk factor for falling and hip fracture,
 but also predicts postoperative complications, delirium, rehabilitation difficulties,
 recurrence of fracture, nursing home placement (Jalbert, Eaton, Miller, & Lapane, 2010; Lee
 et al., 2011; Yiannopoulou, Anastasiou, Ganetsos, Efthimiopoulos, & Papageorgiou, 2012), poor
 functional recovery, increased risk of mortality (Dubljanin-Racpopoć, Matanović, &
 Bumbasirević, 2010; Holmes & House, 2000b), and further cognitive impairment (Shyu et al.,
 2013a).

 Hip fracture in Taiwan, as in many other countries, has become a serious health issue (Liou,
 Tsai, & Lin, 2002). Hip fractures are a significant cause of morbidity and mortality
 worldwide, especially in developed countries among people >50 years old (Johnell & Kanis,
 2006). The number of osteoporotic hip fractures in 2000 was estimated to be 1.6 million
 worldwide (Johnell & Kanis, 2006), and this number was projected to increase by 2050 to 6.26
 to 21 million (Parker & Johansen, 2006). By 2050 half of all hip fractures are estimated to
 occur in Asia (Dhanwal, Dennison, Harvey, & Cooper, 2011). The age-adjusted incidence rates
 (per 100, 000) for hip fracture in Taiwanese adults 50-100 years old from 1996 to 2000 were
 225 in men and 505 in women, and these numbers were 10 to 20 times above the incidence rate
 for the general population (Chie, Yang, Liu, & Tsai, 2004). Excess mortality was reported to
 last 2 to 8 years after hip-fracture surgery (Johnston, Barnsdale, Smith, Duncan, &
 Hutchison, 2010; Robbins, Biggs, & Cauley, 2006). After hip fracture, around half of older
 persons who were independent before hip fracture become partly or completely dependent in
 self-care ability (Shyu, Chen, Liang, Wu, & Su, 2004; Wildner et al., 2002). Hip fracture
 represents a major and growing health care problem in Taiwan. Recovery from and management of
 hip fracture may be significantly complicated by coexisting dementia.

 Few studies have explored the effects of intervention programs on postoperative cognitive
 impairment of older persons with a hip fracture. One study found that 37% of 256 elderly
 hip-fractured patients were cognitively impaired on admission, and 51% of them reached normal
 test scores during hospitalization (Strömberg, Lindgren, Nordin, Ohlén, & Svensson, 1997).
 They also found that cognitive impairment was associated with more postsurgical
 complications. A prior study (Shyu et al., 2013a) found that hip-fractured patients (N = 160)
 who received interdisciplinary care were 75% less likely to be cognitively impaired 6 months
 following discharge than those who received routine care (odds ratio = 0.25, P < 0.001).

 However, it remains unclear whether older hip-fractured persons with dementia benefit from
 similar rehabilitation and geriatric consultation as those without dementia. Some studies
 found that patients with dementia, especially mild and moderate dementia, who suffered a hip
 fracture benefited from multidisciplinary geriatric assessment and rehabilitation by
 returning to the community (Huusko et al., 2000), improving functional recovery (Rolland et
 al., 2004), decreasing postoperative complications, especially delirium and regaining prior
 independence (Moncada et al., 2006; Stenvall et al., 2012). On the other hand, the
 investigators found that cognitively impaired elderly patients (n = 51) benefited from
 interdisciplinary care, consisting of geriatric consultation, continuous rehabilitation, and
 supported discharge planning, by regaining their prior walking ability, but the intervention
 did not prevent these elders' subsequent falls and decrease emergency room visits as it did
 for those without cognitive impairment (n =109) (Shyu et al., 2102). In other words, the
 interdisciplinary intervention effects were greater for those without cognitive impairment.
 Another longitudinal study of 231 older persons with hip fracture found that cognitively
 impaired patients did not retain rehabilitation gains in locomotion, transfers, self-care,
 and sphincter control at 1 year following post-acute rehabilitation discharge (Young, Xiong,
 & Pruzek, 2011). The authors suggested that these cognitively impaired patients would have
 benefited from routine monitoring of cognitive status, a high level of continuity, and a
 reorientation program.

 In conclusion, of the few randomized controlled trials that have examined the effects of
 intervention programs on hip-fractured patients with cognitive impairment, most have analyzed
 the effects on a sub-sample of patients with cognitive impairment. Intervention programs have
 not yet been developed and tested specifically for hip-fractured patients with cognitive
 impairment. In addition, most studies on hip-fractured patients with cognitive impairment
 examined the short-term outcomes of rehabilitation, and few explored intervention effects on
 decreasing cognitive impairment and on recovery trajectories. To fill in these gaps in
 knowledge, this proposed clinical trial will develop and test a family-centered care model
 for hip-fractured patients with cognitive impairment and their family caregivers to
 facilitate postoperative recovery, decrease negative outcomes for patients, and support their
 family caregivers.

 The care model in this study will be delivered using a family-centered approach based on the
 Progressively Lowered Stress Threshold Model (PLST) (Hall & Buckwalter, 1987) and the concept
 of partnership with family caregivers (Harvath et al., 1994) to strengthen family caregivers'
 competence in providing care to hip-fractured patients with cognitive impairment. The PLST
 model proposes that patients with dementia become anxious or agitated by external or
 environmental demands and internal stimuli due to increasing disabilities resulting from
 progressive cerebral pathology and associated cognitive decline. The affected person's
 behavior becomes increasingly dysfunctional and often catastrophic when the stimuli continue
 or increase. Thus, promoting dementia patients' adaptive behavior requires modifying and
 reducing environmental demands and stress. In this study, the PLST model will be tailored to
 the individual needs of hip-fractured patients with cognitive impairment and their family
 caregivers to enhance caregivers' preparedness and competence in dementia care.

 At the same time, the concept of "partnership with family caregivers" emphasizes that
 caregivers possesses important knowledge about the patient under their care of and the care
 that patient receives (Harvath et al., 1994). The most useful and effective approach to
 dealing with caregivers' problems and concerns is to combine the knowledge of caregivers and
 nurses. Based on this notion, our family-centered care model focuses on nurse-caregiver
 collaboration. This collaboration combines the caregiver's and nurse's knowledge to
 facilitate in-home rehabilitation, identify the patient's behavioral problems and their
 causes, and to plan the patient's individual care, thus decreasing behavioral problems and
 improving postoperative cognitive function and recovery. The findings of this study can
 increase knowledge in geriatric medicine about handling comorbidities in older persons,
 especially those with cognitive impairment who are receiving treatment for other medical
 conditions.

 Basic Design The cost and clinical/intervention effectiveness of the family-centered care
 model is evaluated using a randomized experimental design. The proposed project will take
 place over a 5-year period at CGMH.

 The investigators compare a usual care model and a family-centered interdisciplinary care
 model, which consists of a family-centered approach to interdisciplinary care and a family
 caregiving-training component to enhance family caregivers' competence in providing
 post-operative care and handling behavioral problems and neuropsychiatric symptoms of adults
 with cognitive impairment. In this study, the investigators improved the original
 interdisciplinary care model, which included geriatric consultation, continuous
 rehabilitation, and discharge planning, by adding a family-centered approach by involving
 family caregivers in these main intervention components. For this trial, the investigators
 propose comparing one experimental group (usual care plus family-centered care) to a control
 group (usual care).

 After a fall leading to hip fracture, patients are mostly sent directly to the hospital
 emergency room, although some patients may visit outpatient clinics and enter the hospital
 via the clinic. These patients are cared for by orthopedists and receive internal fixation or
 arthroplasty. Consultations for internal medicine care are occasionally made depending on the
 patient's condition. During the first 1-2 days after surgery, nurses teach patients how to
 exercise while still in bed, using caution while changing their position. Pain-relief
 medications and antibiotics are also administered (for 2-3 days). The first day after
 surgery, physical therapy usually starts only for those who received arthroplasty of hip
 replacement. In the first session, physical therapists train patients to use a walker and get
 in/out of bed. Around 3-4 days after surgery, patients are usually discharged from the
 hospital without home assessment. After hospital discharge, no in-home programs are provided
 for rehabilitation or nursing care. Patients usually come back to the clinic around 1-2
 weeks, 1 month, 3 months, 6 months, and 1 year after hospital discharge. However, adherence
 to this follow-up schedule is poor. Telephone follow-ups are seldom used. The current routine
 practice for elderly hip-fractured persons in Taiwan lacks well-organized interdisciplinary
 care protocols, has no continuity of care, and does not provide specific care for
 hip-fractured patients with cognitive impairment.

 Family-Centered Interdisciplinary Care The family-centered interdisciplinary care component.
 The interdisciplinary care model was developed and examined in prior studies, but with
 inconsistent findings (Shyu et al., 2008, 2010, 2013b). Prior analyses showed that the
 difference between usual care and the original interdisciplinary care model has narrowed due
 to improvements in usual care (Shyu et al., 2013b). At the same time, the effects of the
 original interdisciplinary care model were poorer for patients with cognitive impairment than
 without cognitive impairment (Shyu et al., 2012), and the model was not specifically designed
 from a family-centered perspective. Therefore, this study modified the original
 interdisciplinary care to involve family caregivers.

 (A) Family-centered geriatric assessment. The geriatric consultation team has the tasks of
 (1) providing comprehensive geriatric assessment and medical supervision to detect any
 potential medical and functional problems, and (2) decreasing delays before surgery. In
 addition to receiving usual care, patients are contacted within the first day of admission by
 the geriatric nurse who completes the initial assessment and discusses it with the
 geriatrician. Family caregiver will be invited to participate in the assessment and provide
 information. This assessment collects information on medical and fall history, vital signs,
 physical examination, physical and cognitive functions, nutritional status, preoperative
 risks, current medications, and comorbidities. Based on this assessment/consultation,
 suggestions will be made to the primary surgeon regarding time of surgery, utilization of
 infection and thromboembolic prophylaxis, postoperative nutritional management, urinary tract
 management, and delirium management/prevention. The primary surgeon, geriatric nurse, and
 geriatrician will collaboratively develop a postoperative care plan.

 In addition to receiving usual postoperative care, patients will be visited by the geriatric
 nurse on the first day after surgery to assess for signs of delirium, pain, and postoperative
 complications. If a patient presents any signs of delirium, cognitive impairment or any
 psychiatric symptoms, a geriatric psychiatrist will be consulted. If the patient has signs of
 other postoperative complications, the geriatrician will be consulted. Based on this
 geriatric consultation, suggestions are made to the primary surgeon on using infection and
 thromboembolic prophylaxis, postoperative nutritional management, urinary tract management,
 pain management, and delirium management. The health care team reviews the postoperative care
 plan to make any necessary changes.

 In this study, the geriatric assessment will involve family caregivers. At the same time, the
 family members will be informed of the care plan and sign an agreement form.

 (B) Family-centered continuous rehabilitation. The rehabilitation program will include (1)
 providing early postoperative rehabilitation to facilitate mobility, and (2) planning for
 hospital discharge with rehabilitation in the patient's usual environment. Postoperative
 rehabilitation starts on the first day after surgery and continues into the home setting
 after hospital discharge. During hospitalization, the geriatric nurse visits the patient once
 a day starting on the 1st day after surgery. For in-home rehabilitation, the geriatric nurse
 will visit patients to provide in-home rehabilitation training once every week during the
 first month, and once every 2 weeks for the second and third months following discharge. Both
 in-patient and in-home rehabilitation programs contain a hip fracture-oriented intervention
 and a general intervention for deteriorated physical fitness.

 The hip fracture-oriented rehabilitation will focus on pain relief, range of motion, muscle
 strength and endurance, proprioceptive enhancement, and balance challenges. The general
 intervention to rehabilitate deteriorated physical fitness will emphasize exercises to
 increase physical fitness. Physical fitness is defined as "the ability to perform muscular
 work satisfactorily" (Shephard, 1978) and is assessed by five common parameters: aerobic
 capacity, anaerobic capacity, muscle strength and endurance, flexibility, and body
 composition (Skinner, Baldini, & Gardner, 1990). Therefore, as in our prior trial, the
 in-home muscle-strength training program will progress according to the patient's recovery
 condition in six stages: ankle pumping exercises, knee extension, gently bouncing jump with
 knee semiflexed and both feet on the floor, gently bouncing jump with knee semiflexed and
 single foot on the floor (Shyu et al., 2008, 2012), and ball-rolling activities (Shyu et al.,
 2013b). The last exercise uses lower extremities to enhance proprioception. Fast walking will
 be used at later stages to enhance aerobic capacity (Shyu et al., 2013b).

 For the continuous rehabilitation program in this study, family caregivers will be taught the
 rehabilitation protocols as they are responsible for giving or managing patient care.
 Caregivers will be followed at each visit, progress of the rehabilitation will be monitored,
 and family caregivers will be asked to keep a diary to help monitor patients' rehabilitation
 adherence.

 Family caregiver-training component. The family caregiver training will be a two-session
 in-home training program developed in our prior studies (Huang et al., 2013; Kuo et al.,
 2013) and delivered by trained registered research nurses. This training will be implemented
 during the 3rd and 4th home visits (2 and 3 weeks after discharge, respectively) when the
 discharge transition is more settled (Shyu, 2000). During the first caregiver training
 session (3rd home visit), the research nurse will work with the family caregiver on a
 structured guide to assess the condition of the hip-fractured patient with cognitive
 impairment, including habits, daily routines, preferences, behavioral problems and
 environmental safety and stimuli. The strengths, weakness, and resources of the family will
 also be assessed. The research nurse will work with the family caregiver to identify
 behavioral problems and symptoms to target. They will also use the PLST model to explore
 environmental stimuli (antecedents) and consequences of the targeted behavioral problems.
 They will then collaborate on a tentative plan to minimize these stimuli and decrease the
 targeted behavioral problems by modifying the daily schedule and environment.

 During the second caregiver training session (4th home visit), the research nurse will
 confirm the behavioral problems and finalize the plan for handling specific behavioral
 problems. Specific suggestions will be re-emphasized and modified as needed to lower
 environmental stimuli of problem behaviors. The research nurse will also leave contact
 information for family caregivers if any problems arise between visits regarding delivery of
 the interventions.

 Research nurses will make follow-up phone calls to family caregivers once a week for 2 weeks
 to determine if behavioral problems and symptoms are handled, whether the previously made
 suggestions are followed, and if there are any difficulties. Based on these discussions and
 evaluations, research nurses will give further suggestions. In the meantime, family
 caregivers in the control group will receive social contact follow-up phone calls at the same
 time as caregivers in the experimental group.

 The sample size was estimated based on our interest in longitudinal changes in outcome
 variables. For sample estimation, the investigators used "Optimal Design" Software Version
 3.01, free software with a graphical user interface to compute sample size for multi-level
 and longitudinal research (Spybrook, et al., 2011). Since the proposed intervention has never
 been conducted before, the investigators can only estimate the sample size based on prior
 clinical trials of an interdisciplinary care model used with a subsample of hip-fractured
 patients with cognitive impairment (Shyu et al., 2005, 2008) and a training program for
 family caregivers of patients with dementia (Huang et al., 2013; Kuo et al., 2013). To
 estimate patient outcome variables, outcome indicators of overall performance of ADLs and
 IADLs, cognitive function, and physical component summary scores (SF-36) were selected
 because they are the attributes most affected by hip fracture and most likely to change with
 intervention (Shyu et al., 2005, 2008). To estimate family caregiver outcomes, outcome
 indicators of preparedness, competence, and self-efficacy of managing behavioral problems
 were selected because they were the direct outcomes affected by our previous individualized,
 home-based family caregiver-training program (Huang et al., 2013). To estimate the sample
 size for examining the effects of the family-centered care model in this study, the alpha was
 set to 0.05 and sample size per group required for each indicator to achieve a power of 0.80.
 The majority of estimated overall sample sizes for the proposed study ranged from 30 to 116.
 Therefore, the study would require approximately at least 58 subjects for each group. Since
 fewer than 20% to 30% of cases were lost in our previous studies (Huang et al., 2013; Kuo et
 al., 2013), 76 patients in each group would be adequate for the proposed study. Based on our
 recent studies, It is expected to recruit 5 to 6 hip-fractured patients with cognitive
 impairment and at least 60 years old every month. Therefore, data collection will be
 conducted for 26 to 31 months and will follow patient subjects for 1 year after hospital
 discharge.

 Procedure Subjects will be recruited by research assistants who will screen patient lists
 from the emergency room and hospital admissions daily to avoid losing potential cases. For
 patients who meet the study criteria, their primary physicians will be informed, and these
 patients will be invited to participate in this study. Elderly patients and their family
 caregivers who agree to participate will then be randomly assigned to the intervention group
 or the control group by a neutral party. Patients and their family caregivers in the
 experimental group will receive the family-centered care intervention, and those in the
 control group will receive usual care. Patients and families will not be aware of their group
 assignment and will be blinded to the care model they receive. Researchers who gather data
 will be independent of those who will deliver the interventions.

 Patients and caregivers in both groups will be assessed five times longitudinally. The first
 assessment will be in the wards after surgery and before discharge. The second, third, fourth
 and fifth, assessments will be made at 1, 3, 6, and 12 months after discharge, respectively
 (Shyu et al., 2008, 2013b). Family caregivers will keep weekly diaries to record
 rehabilitation and cost information, which will be collected along with interview data. Diary
 recording will be promoted by providing rewards such as giving small gifts and constant
 feedback about patient's progress. Follow-up phone calls will be made for subjects who refuse
 further home visit but agree to give information over telephone calls. Those agree to accept
 telephone follow-ups will be telephoned to collect data on patients' self-care ability,
 service utilization, mortality, and family caregiver's preparedness and competence.

 Training Program for Interveners and Data Collectors Interveners and data collectors will be
 trained based on our extensive experience from prior clinical trials. One registered nurse
 will be trained to deliver family-centered care, including the family-centered rehabilitation
 and discharge planning by the geriatric nurse specialist, Ching-Tzu Yang who is expected to
 graduate from her PhD program this year and become the post-doctoral fellow of this study.
 These nurses will also be trained by our co-PI, Dr. Huei-Ling Huang, who previously trained
 caregivers of patients with dementia (Hung et al., 2013, Kuo et al., 2013), to develop
 collaborative partnerships with family caregivers to identify environmental stimuli of and
 manage behavioral problems/symptoms of patients with cognitive impairment. The protocols of
 the care model will be outlined in a researcher-developed manual. The intervener nurses will
 participate in at least five training sessions: at least one introductory session to explain
 the study purpose, design, theoretical base, and procedures of the intervention program (2
 hours), two sessions of simulated practice to become familiar with the manual (2 hours each),
 and two home visits supervised by the geriatric nurse specialist. After the intervener nurses
 achieve 100% consistency with the geriatric nurse specialist in care delivery, they can
 proceed independently. To ensure the quality of the intervention program, nurse interveners
 will attend regular team meetings with the surgeon, geriatrician, geriatric nurse, physical
 therapist, rehabilitation physician, and psychiatrist to discuss related issues and will be
 constantly supervised by the geriatric nurse specialist.

 Another two registered nurses will collect data. These data collectors will have at least 3
 years research experience and will receive two training sessions. In the first training
 session (2 hours), the PI or Co-PIs will explain the study purpose, design, instruments, and
 the geriatric nurse specialist will demonstrate a simulation interview with the family
 caregiver and patients. In the second training session (2 hours), the data collectors will
 practice collecting data from the patients and family caregivers under the supervision of the
 geriatric specialist. Data collectors will attend monthly research team meetings. Problems
 regarding data collection will be discussed and resolved on a regular, ongoing basis.

 Data Analysis Analyses will be conducted under an intention-to-treat principle. Differences
 in baseline characteristics, including pre-fracture self-care ability, between the
 intervention group and control group will be assessed by one-way ANOVA or chi-square tests,
 with the significance level set to 0.05.

 For Hypothesis 1, hip-fractured patients with cognitive impairment who receive the
 family-centered care model will have better clinical outcomes, self-care ability, cognitive
 function, HRQoL, and fewer behavioral problems than those who receive usual care. For
 Hypothesis 2, intervention participants will have more outpatient visits and fewer hospital
 readmissions and emergency room visits than those who receive usual care. Hypothesis 3,
 intervention participants' family caregivers will have better preparedness, competence, and
 HRQoL than those receiving usual care.

 Changes in outcome variables (patients' cognitive function [MMSE, PRMQ, DRS-R-98], clinical
 outcomes, self-care ability, HRQoL [SF-36], and behavioral problems [CMAI], and family
 caregivers' preparedness, competence, and HRQoL) will be analyzed using hierarchical linear
 models (Raudenbush & Bryk, 2002). A series of multilevel linear models will be estimated
 using usual care (control group) as the reference category.

 For binary outcome variables (dementia risk, delirium, subsequent falls, emergency room
 visit, hospital readmission, mortality, and complete independence in ADL [CBI = 100] and in
 CBI walking ability [walking ability item = 15]), a series of multilevel multinomial logit
 models will be estimated using usual care as the reference category. Doing so will allow us
 to estimate the odds for patient participants receiving family-centered care of being at risk
 for dementia or delirium, of using health services, of being completely independent in ADL
 and walking ability relative to the odds for the usual care group over time. When the
 investigators evaluate the non-linear function of changes with time, centering time will be
 at 3 and 6 months after discharge to minimize the possibility of multicollinearity because
 the most rapid improvement in recovery occurs during the first 6 months (Shyu et al., 2013b;
 Shyu, Chen, Liang, Wu et al., 2004). Finally, attrition will be accounted for with each dummy
 outcome variable, one identifying subjects who die during the 1-year follow-up period, and
 the other identifying those who drop out for other reasons.

 Hypothesis 4, those received family-centered care will have fewer re-admissions and emergency
 room visits at a lower total costs than the usual care and their care givers will have lower
 productivity losses.

 For the cost analysis, an "incremental cost-effectiveness ratio" will be calculated to
 demonstrate the additional costs for each elderly hip-fractured patient with better cognitive
 function outcomes and for clinical outcomes related to hip fracture within the 12-month
 period after hospital discharge. This ratio will then be used to determine whether the
 family-centered care model represents a more cost-effective care model for elderly
 hip-fractured patients. Additionally, a multi-way sensitivity analysis will be employed to
 test the robustness of the study results.

 The study will be completed and all hypotheses will be tested. Moreover, the results will
 provide a reference for planning future care models for elderly hip-fractured persons with
 other comorbidities.
Inclusion Criteria:

 -  Subjects are:

 1. age 60 years or older,

 2. admitted to CGMH due to one-side hip fracture, and being diagnosed as needing
 surgery,

 3. assessed as having cognitive impairment by the Chinese Mini-Mental State
 Examination (CMMSE) (CMMSE score < 21 with < 6 years education, or CMMSE < 25
 with ≥ 6 years education; Yip et al., 1992),

 4. having a primary family caregiver,

 5. living in northern Taiwan (i.e., greater Taipei area, Keelung, Taoyuan, or
 Shin-Ju province).

 -  Family caregivers:

 1. age 20 years or older,

 2. responsible for providing direct care to or supervising care received by the
 patient.

 Exclusion Criteria:

 -  Subjects are

 1. cognitively intact by CMMSE,

 2. without a primary family caregiver,

 3. terminally ill,

 4. severe cognitive impairment such that they are completely unable to follow orders
 (CMMSE < 10; Yip et al., 1992).