Hip fractures present a significant healthcare problem in older adults. Epidemiological data vary between countries, but globally, it is estimated that hip fractures affect approximately 18% of women and 6% of men. By 2025, 2.6 million people per year will suffer from a hip fracture worldwide. This number is expected to increase to 6.3 million by 2050, based on the increasing life expectancy of the world population. This thesis aims to optimize the care of frail older adults with hip fractures across institutional boundaries: from hospital admission to geriatric rehabilitation and follow-up at an outpatient clinic. To achieve this aim, the first part (Part I) of this thesis focuses on identifying older adults with a hip fracture at high risk of a complicated course. Early identification enables proactive tailoring of orthogeriatric treatment, hopefully preventing complications or at least reducing the severity of the complication. In the second part (Part II) of this thesis, we evaluated the existing intramural orthogeriatric care pathway and extended this into a digital transmural monitoring pathway involving geriatric rehabilitation in nursing home facilities and follow-up at the outpatient clinic.