interRAI Assessment Research Articles

Implementing and Evaluating a Model of Care Coordination in Primary Care for Older Adults using a Co-Design Approach

Background : Older Canadians with chronic diseases are the biggest users of the health care system. Primary health care (PHC) could play a central, coordinating role in assessing and managing older adults, but at present lacks specific strategies to fulfil this role. Priorities for enhanced care coordination in PHC include: 1) consistent processes to identify and assess older persons and create individual care plans aligned with risk levels; 2) improved care coordination and system navigation; 3) improved access to appropriate services; and 4) improved patient and caregiver engagement (Heckman et al., 2013; World Health Organization, 2008; Wagner, 2000; Goodwin et al., 2013). Aims : This study aims to understand how a model of risk-stratified care coordination for older adults can be developed and implemented in primary care. Information gathered will provide an in-depth understanding of: (1) the local context a region in Ontario, Canada (2) what referral pathways can link older patients to services appropriate for their level of risk, and (3) providers, patients and caregivers experiences to understand how the model could be modified and what factors are important for implementation in future primary care sites. Methods: This study used mixed methods, within a developmental evaluation approach (Patton, 2011). Ongoing focus group (n=6) and key informant interviews were conducted with patients (n=15), families (n=4), and primary care and community care providers (n=15) in three locations (rural and urban) in Ontario, Canada. Data were coded using a line by line, emergent approach. Risk-screening data (n=600) and service utilization were also collected and analyzed at the study sites. Results : A model of care coordination was developed through engagement of patients, families, and health care providers. Components of the model include: a) consistent screening (interRAI Assessment Urgency Algorithm) and referral processes; b) coordination of care through individualized care plans; and c) patient and caregiver engagement in decision-making. Implementation resulted in patient and provider awareness of resources for self-management, stronger linkages between PHC teams and community resources; improved patient and caregiver experiences and engagement in decision-making. Conclusions : A model of care coordination was developed and implemented in primary care through an ongoing, iterative process with older adults, caregivers, and health care providers. This process resulted in key principles necessary for improving care coordination in primary care for older adults and their caregivers. Limitations : This project was conducted in one Ontario region. Strategies may need to be tailored to the specific needs and resources of other communities. Suggestions for Future Research : The next phases of our work will involve implementing and evaluating this model in primary care sites that are not team-based settings.

The Health and Well-Being of Older Adults with Dual Sensory Impairment (DSI) in Four Countries.

ObjectivesDual sensory impairment (DSI) is a combination of vision and hearing impairments that represents a unique disability affecting all aspects of a person’s life. The rates of DSI are expected to increase due to population aging, yet little is known about DSI among older adults (65+). The prevalence of DSI and client characteristics were examined among two groups, namely, older adults receiving home care services or those residing in a long-term care (LTC) facility in four countries (Canada, US, Finland, Belgium).MethodsExisting data, using an interRAI assessment, were analyzed to compare older adults with DSI to all others across demographic characteristics, functional and psychosocial outcomes.ResultsIn home care, the prevalence of DSI across the four countries ranged from 13.4% to 24.6%; in LTC facilities, it ranged from 9.7% to 33.9%. Clients with DSI were more likely to be 85+, have moderate/severe cognitive impairment, impairments in activities of daily living, and have communication difficulties. Among residents of LTC facilities, individuals with DSI were more likely to be 85+ and more likely have a diagnosis of Alzheimer’s disease. Having DSI increased the likelihood of depression in both care settings, but after adjusting for other factors, it remained significant only in the home care sample.ConclusionsWhile the prevalence of DSI cross nationally is similar to that of other illnesses such as diabetes, depression, and Alzheimer’s disease, we have a limited understanding of its affects among older adults. Raising awareness of this unique disability is imperative to insure that individuals receive the necessary rehabilitation and supportive services to improve their level of independence and quality of life.

Entry into Residential Care After Discharge from Hospital

Background: Planning services for elderly is imperative with the increasing elderly population and high utility of residential care facilities. Methods: Descriptive study of patients living at home discharged from hospital to residential care from 1st January 2012 to 30th June 2012. To assess aspects of hospital management particularly Vitamin D prescription and medications. InterRAI assessments and electronic clinical records were retrospectively reviewed. Results: 67 patients median age 86. Half lived alone, but most had carers. They had limited independence. 64 % were confused during admission. Almost half were discharged to the highest level residential care. One year mortality was 43 %. Diagnosis of confusion, polypharmacy management and considering Vitamin D supplementation could be improved. Conclusion: Patients are highly dependent for activities of daily living and require planned support for their health care needs. They suffer from polypharmacy, are susceptible to confusion which is often undiagnosed, and have a high mortality rate post discharge.

Identifying mental health symptoms in children and youth in residential and in-patient care settings.

This study demonstrates the use of the interRAI assessment instruments to examine mental health symptoms in children and adults within residential and in-patient care settings. Regardless of service setting, children exhibited more harm to self and others than adults. Children in adult in-patient beds were more likely to exhibit suicide and self-harm and less likely to exhibit harm to others compared to children in child-specific service settings. Implications related to service system improvements are discussed.

Polypharmacy among inpatients aged 70 years or older in Australia.

To investigate medication changes for older patients admitted to hospital and to explore associations between patient characteristics and polypharmacy. Prospective cohort study. Patients aged 70 years or older admitted to general medical units of 11 acute care hospitals in two Australian states between July 2005 and May 2010. All patients were assessed using the interRAI assessment system for acute care. Measures of physical, cognitive and psychosocial functioning; and number of regular prescribed medications categorised into three groups: non-polypharmacy (0-4 drugs), polypharmacy (5-9 drugs) and hyperpolypharmacy (≥10 drugs). Of 1220 patients who were recruited for the study, medication records at admission were available for 1216. Mean age was 81.3 years (SD, 6.8 years), and 659 patients (54.2%) were women. For the 1187 patients with complete medication records on admission and discharge, there was a small but statistically significant increase in mean number of regular medications per day between admission and discharge (7.1 v 7.6), while the prevalence of medications such as statins (459 [38.7%] v 457 [38.5%] patients), opioid analgesics (155 [13.1%] v 166 [14.0%] patients), antipsychotics (59 [5.0%] v 65 [5.5%] patients) and benzodiazepines (122 [10.3%] v 135 [11.4%] patients) did not change significantly. Being in a higher polypharmacy category was significantly associated with increase in comorbidities (odds ratio [OR], 1.27; 95% CI, 1.20-1.34), presence of pain (OR, 1.31; 1.05-1.64), dyspnoea (OR, 1.64; 1.30-2.07) and dependence in terms of instrumental activities of daily living (OR, 1.70; 1.20-2.41). Hyperpolypharmacy was observed in 290/1216 patients (23.8%) at admission and 336/1187 patients (28.3%) on discharge, and the proportion of preventive medication in the hyperpolypharmacy category at both points in time remained high (1209/3371 [35.9%] at admission v 1508/4117 [36.6%] at discharge). Polypharmacy is common among older people admitted to general medical units of Australian hospitals, with no clinically meaningful change to the number or classification (symptom control, prevention or both) of drugs made by treating physicians.

Derivation of a frailty index from the interRAI acute care instrument.

BackgroundA better understanding of the health status of older inpatients could underpin the delivery of more individualised, appropriate health care.Methods1418 patients aged ≥ 70 years admitted to 11 hospitals in Australia were evaluated at admission using the interRAI assessment system for Acute Care. This instrument surveys a large number of domains, including cognition, communication, mood and behaviour, activities of daily living, continence, nutrition, skin condition, falls, and medical diagnosis.ResultsVariables across multiple domains were selected as health deficits. Dichotomous data were coded as symptom absent (0 deficit) or present (1 deficit). Ordinal scales were recoded as 0, 0.5 or 1 deficit based on face validity and the distribution of data.Individual deficit scores were summed and divided by the total number considered (56) to yield a Frailty index (FI-AC) with theoretical range 0–1. The index was normally distributed, with a mean score of 0.32 (±0.14), interquartile range 0.22 to 0.41. The 99% limit to deficit accumulation was 0.69, below the theoretical maximum of 1.0.In logistic regression analysis including age, gender and FI-AC as covariates, each 0.1 increase in the FI-AC increased the likelihood of inpatient mortality twofold (OR: 2.05 [95% CI 1.70 – 2.48]).ConclusionsQuantification of frailty status at hospital admission can be incorporated into an existing assessment system, which serves other clinical and administrative purposes. This could optimise clinical utility and minimise costs.The variables used to derive the FI-AC are common to all interRAI instruments, and could be used to precisely measure frailty across the spectrum of health care.

Use of the interRAI CHESS Scale to Predict Mortality among Persons with Neurological Conditions in Three Care Settings

BackgroundPersons with certain neurological conditions have higher mortality rates than the population without neurological conditions, but the risk factors for increased mortality within diagnostic groups are less well understood. The interRAI CHESS scale has been shown to be a strong predictor of mortality in the overall population of persons receiving health care in community and institutional settings. This study examines the performance of CHESS as a predictor of mortality among persons with 11 different neurological conditions.MethodsSurvival analyses were done with interRAI assessments linked to mortality data among persons in home care (n = 359,940), complex continuing care hospitals/units (n = 88,721), and nursing homes (n = 185,309) in seven Canadian provinces/territories.ResultsCHESS was a significant predictor of mortality in all 3 care settings for the 11 neurological diagnostic groups considered after adjusting for age and sex. The distribution of CHESS scores varied between diagnostic groups and within diagnostic groups in different care settings.ConclusionsCHESS is a valid predictor of mortality in neurological populations in community and institutional care. It may prove useful for several clinical, administrative, policy-development, evaluation and research purposes. Because it is routinely gathered as part of normal clinical practice in jurisdictions (like Canada) that have implemented interRAI assessment instruments, CHESS can be derived without additional need for data collection.

Prevalence and risk factors of depressive symptoms in a Canadian palliative home care population: a cross-sectional study

BackgroundDepression in palliative care patients is important because of its intrinsic burden and association with elevated physical symptoms, reduced immunity and increased mortality risk. Identifying risk factors associated with depression can enable clinicians to more readily diagnose it, which is important since depression is treatable. The purpose of this cross-sectional study was to determine the prevalence of depressive symptoms and risk factors associated with them in a large sample of palliative home care patients.MethodsThe data come from interRAI Palliative Care assessments completed between 2006 and 2012. The sample (n = 5144) consists of adults residing in Ontario (Canada), receiving home care services, classified as palliative, and not experiencing significant cognitive impairment. Logistic regression identified the risk factors associated with depressive symptoms. The dependent variable was the Depression Rating Scale (DRS) and the independent variables were functional indicators from the interRAI assessment and other variables identified in the literature. We examined the results of the complete case and multiple imputation analyses, and found them to be similar.ResultsThe prevalence of depressive symptoms was 9.8%. The risk factors associated with depressive symptoms were (pooled estimates, multiple imputation): low life satisfaction (OR = 3.01 [CI = 2.37-3.82]), severe and moderate sleep disorders (2.56 [2.05-3.19] and 1.56 [1.18-2.06]), health instability (2.12 [1.42-3.18]), caregiver distress 2.01 [1.62-2.51]), daily pain (1.73 [1.35-2.22]), cognitive impairment (1.45 [1.13-1.87]), being female (1.37 [1.11-1.68]), and gastrointestinal symptoms (1.27 [1.03-1.55]). Life satisfaction mediated the effect of prognostic awareness on depressive symptoms.ConclusionsThe prevalence of depressive symptoms in our study was close to the median of 10-20% reported in the palliative care literature, suggesting they are present but by no means inevitable in palliative patients. Most of the factors associated with depressive symptoms in our study are amenable to clinical intervention and often targeted in palliative care programs. Designing interventions to address them can be challenging, however, requiring careful attention to patient preferences, the spectrum of comorbid conditions they face, and their social supports. Life satisfaction was one of the strongest factors associated with depressive symptoms in our study, and is likely to be among the most challenging to address.

Prevalence of neurological conditions across the continuum of care based on interRAI assessments

BackgroundAlthough multiple studies have estimated the prevalence of neurological conditions in the general Canadian population, limited research exists regarding the proportion affected with these conditions in non-acute health care settings in Canada. Data from standardized clinical assessments based on the interRAI suite of instruments were used to estimate the prevalence of eight neurological conditions across the continuum of care including Alzheimer’s disease, Parkinson’s disease, epilepsy, traumatic brain injury, multiple sclerosis, cerebral palsy, Huntington’s disease, and amyotrophic lateral sclerosis.MethodsCohorts of individuals receiving care in nursing homes (N=103,820), home care (N=91,021), complex continuing care (N=10,581), and psychiatric hospitals (N=23,119) in Canada were drawn based on their most recent interRAI assessment within each sector for a six-month period in 2010. These data were linked to the Discharge Database and National Ambulatory Care Reporting System data sets to develop five different case definition scenarios for estimating prevalence.ResultsThe conditions with the highest estimated prevalences in these care settings in Canada were Alzheimer’s disease and related dementias, Parkinson’s disease, epilepsy, and traumatic brain injury. However, there were notable cross-sector differences in the prevalence of each condition, and regional variations. Prevalence estimates based on acute hospital administrative data alone were substantially lower for all conditions evaluated.ConclusionsThe proportion of persons with neurological conditions in non-acute health care settings in Canada is substantially higher than is generally reported for the general population. It is essential for these care settings to have the expertise and resources to respond effectively to the strengths, preferences, and needs of the growing population of persons with neurological conditions. The use of hospital or emergency department records alone is likely to substantially underestimate the true prevalence of neurological conditions across the continuum of care. However, interRAI assessment records provide a helpful source of information for obtaining these estimates in nursing home, home care, and mental health settings.

Eldra fólk á bráðamóttöku: Íslenskar niðurstöður úr fjölþjóðarannsókn InterRAI

Old people attend emergency departments (ED´s) in increasing numbers. Old people have age related changes in all organ systems and tend to have multiple chronic diseases, be on multiple medications and often have physical and cognitive functional impairments. Hence, they have complex health and social service needs. The purpose of this study was to describe function and geriatric syndromes of old people who present at Landspitali Emergency Department, Iceland, with comparison to ED´s in six other countries.A prospective descriptive study of people (>75 year´s) attending ED´s in seven countries, including Iceland. The InterRAI assessment tool for ED´s was used by nurses to assess participants.At Landspitali ED, 202 individuals were assessed, of whom 55% were women. Of the 202 individuals, 34% attended the ED within 90 days and of those 48% lived alone. On admission to the ED, 59% had physical or cognitive functional impairment; 13% had only cognitive impairment and 36% were unable to walk without assistance. Caregiver distress was identified in 28% and 11% felt overwhelming burden. From the ED, 46% were admitted to the hospital. Compared with foreign results greater number of Icelandic participants lived alone and caregiver's distress was slightly higher (28% vs. 18%). Fewer individuals in Iceland were admitted to a hospital and Iceland had higher admission rate to rehabilitation compared with the overall group.Geriatric syndromes and functional impairment afflicted majority of old people who attended the Landspitali ED. These observations should be taken into account in ED design and care planning for old people to maximize efficiency, safety and quality.

Scaling functional status within the interRAI suite of assessment instruments

BackgroundAs one ages, physical, cognitive, and clinical problems accumulate and the pattern of loss follows a distinct progression. The first areas requiring outside support are the Instrumental Activities of Daily Living and over time there is a need for support in performing the Activities of Daily Living. Two new functional hierarchies are presented, an IADL hierarchical capacity scale and a combination scale integrating both IADL and ADL hierarchies.MethodsA secondary analyses of data from a cross-national sample of community residing persons was conducted using 762,023 interRAI assessments. The development of the new IADL Hierarchy and a new IADL-ADL combined scale proceeded through a series of interrelated steps first examining individual IADL and ADL item scores among persons receiving home care and those living independently without services. A factor analysis demonstrated the overall continuity across the IADL-ADL continuum. Evidence of the validity of the scales was explored with associative analyses of factors such as a cross-country distributional analysis for persons in home care programs, a count of functional problems across the categories of the hierarchy, an assessment of the hours of informal and formal care received each week by persons in the different categories of the hierarchy, and finally, evaluation of the relationship between cognitive status and the hierarchical IADL-ADL assignments.ResultsUsing items from interRAI’s suite of assessment instruments, two new functional scales were developed, the interRAI IADL Hierarchy Scale and the interRAI IADL-ADL Functional Hierarchy Scale. The IADL Hierarchy Scale consisted of 5 items, meal preparation, housework, shopping, finances and medications. The interRAI IADL-ADL Functional Hierarchy Scale was created through an amalgamation of the ADL Hierarchy (developed previously) and IADL Hierarchy Scales. These scales cover the spectrum of IADL and ADL challenges faced by persons in the community.ConclusionsAn integrated IADL and ADL functional assessment tool is valuable. The loss in these areas follows a general hierarchical pattern and with the interRAI IADL-ADL Functional Hierarchy Scale, this progression can be reliably and validly assessed. Used across settings within the health continuum, it allows for monitoring of individuals from relative independence through episodes of care.

Diagnostic data for neurological conditions in interRAI assessments in home care, nursing home and mental health care settings: a validity study

BackgroundThe interRAI suite of assessment instruments can provide valuable information to support person-specific care planning across the continuum of care. Comprehensive clinical information is collected with these instruments, including disease diagnoses. In Canada, interRAI data holdings represent some of the largest repositories of clinical information in the country for persons with neurological conditions. This study examined the accuracy of the diagnostic information captured by interRAI instruments designed for use in the home care, long-term care and mental health care settings as compared with national administrative databases.MethodsThe interRAI assessments were matched with an inpatient hospital record and emergency department (ED) visit record in the preceding 90 days. Diagnoses captured on the interRAI instruments were compared to those recorded in either administrative record for each individual. Diagnostic validity was examined through sensitivity, specificity and positive predictive value analysis for the following conditions: multiple sclerosis, epilepsy, Alzheimer’s disease and other dementias, Parkinson’s disease, traumatic brain injury, stroke, diabetes mellitus, heart failure and reactive airway disease.ResultsIn the three large study samples (home care: n = 128,448; long-term care: n = 26,644; mental health: n = 13,812), interRAI diagnoses demonstrated high specificity when compared to administrative records, for both neurological conditions (range 0.80 – 1.00) and comparative chronic diseases (range 0.83 – 1.00). Sensitivity and positive predictive values (PPV) were more varied by specific diagnosis, with sensitivities and PPV for neurological conditions ranging from 0.23 to 0.94 and 0.14 to 0.77, respectively. The interRAI assessments routinely captured more cases of the diagnoses of interest than the administrative records.ConclusionsThe interRAI assessment collected accurate information about disease diagnoses when compared to administrative records within three months. Such information is likely relevant to day-to-day care in these three environments and can be used to inform care planning and resource allocation decisions.

The involvement of the general practitioner in an interRAI assessment for the care of elderly in Flemish nursing homes and home care: an explorative study

Introduction: Since complexity of the care for the elderly increases and since a frail older person often moves across different care settings, interprofessional collaboration matters. Therefore, the BelRAI web tool with the interRAI instruments was developed in Belgium. The interRAI instruments are internationally validated, comprehensive geriatric assessments, used to collect data of clients in a structured and standardized way by different professionals and across settings. In a pilot study, financed by the Belgian Federal Government, other professionals such as nurses and social workers complained about the lack of collaboration of general practitioners (GPs). Not only this pilot study, but also scientific literature underlines that physicians are reluctant to engage when a new electronic tool is implemented. However, the studies also show that their involvement is crucial. This paper tries to explain how other professionals evaluate the collaboration with the GP and how the involvement of the GP can be improved. Methods: Data was gathered via semi-structured telephone interviews with 39 GPs. Other professionals shared their views on the role of the GP in focus groups and 123 other professionals by filling out a survey. Results: The questionnaire shows a higher GP involvement in nursing homes than in home care. The interviews reveal that the more the GPs are involved with BelRAI, the more positive their views. GPs state their involvement would increase under the following conditions: limited time investment per client (n=11), BelRAI output usable in GP practice (n=10), a more user-friendly application (n=9) and financial compensation (n=8). Conclusions and Discussion: There is room for improving GPs involvement in BelRAI and thus to increase interprofessional collaboration in care for older people in Flanders (Belgium). The findings from this study can be of help to improve the involvement of the GP and to optimize the use of the interRAI instruments via a web based tool. 13 th international Conference on Integrated Care, Berlin, Germany, April 11-12, 2013 2 International Journal of Integrated Care – Volume 13, 23 October – URN:NBN:NL:UI:10-1-114684– http://www.ijic.org/

An evaluation of data quality in Canada’s Continuing Care Reporting System (CCRS): secondary analyses of Ontario data submitted between 1996 and 2011

BackgroundEvidence informed decision making in health policy development and clinical practice depends on the availability of valid and reliable data. The introduction of interRAI assessment systems in many countries has provided valuable new information that can be used to support case mix based payment systems, quality monitoring, outcome measurement and care planning. The Continuing Care Reporting System (CCRS) managed by the Canadian Institute for Health Information has served as a data repository supporting national implementation of the Resident Assessment Instrument (RAI 2.0) in Canada for more than 15 years. The present paper aims to evaluate data quality for the CCRS using an approach that may be generalizable to comparable data holdings internationally.MethodsData from the RAI 2.0 implementation in Complex Continuing Care (CCC) hospitals/units and Long Term Care (LTC) homes in Ontario were analyzed using various statistical techniques that provide evidence for trends in validity, reliability, and population attributes. Time series comparisons included evaluations of scale reliability, patterns of associations between items and scales that provide evidence about convergent validity, and measures of changes in population characteristics over time.ResultsData quality with respect to reliability, validity, completeness and freedom from logical coding errors was consistently high for the CCRS in both CCC and LTC settings. The addition of logic checks further improved data quality in both settings. The only notable change of concern was a substantial inflation in the percentage of long term care home residents qualifying for the Special Rehabilitation level of the Resource Utilization Groups (RUG-III) case mix system after the adoption of that system as part of the payment system for LTC.ConclusionsThe CCRS provides a robust, high quality data source that may be used to inform policy, clinical practice and service delivery in Ontario. Only one area of concern was noted, and the statistical techniques employed here may be readily used to target organizations with data quality problems in that (or any other) area. There was also evidence that data quality was good in both CCC and LTC settings from the outset of implementation, meaning data may be used from the entire time series. The methods employed here may continue to be used to monitor data quality in this province over time and they provide a benchmark for comparisons with other jurisdictions implementing the RAI 2.0 in similar populations.

Good News and Bad News: Depressive Symptoms Decline and Undertreatment Increases With Age in Home Care and Institutional Settings

Examination of prevalence of depressive symptoms among older persons in home care (HC) and complex continuing care (CCC) hospitals/units, factors associated with depressive symptoms in those settings, and rate of antidepressant use among older persons with depressive symptoms. Observational study using data from interRAI assessments used in normal clinical practice. Logistic regression models were used to identify factors associated with depressive symptoms in the frail elderly and treatment approaches were described. Fourteen HC agencies and 134 CCC hospitals/units in Ontario, Canada. Older persons (N = 191,9871) aged 65 years and older, including 114,497 persons from HC and 77,490 persons from CCC. Data were collected using Resident Assessment Instrument 2.0 (RAI 2.0) (1996-2004) in CCC and Resident Assessment Instrument for Home Care (RAI-HC) (2003-2004) in HC. Prevalence of depressive symptoms among older HC enrollees was lower (12.0%) than in CCC (23.6%). It decreased significantly with age in HC (to about 6% in those older than 95 years) but there were not substantial age differences in CCC. Common factors associated with depressive symptoms in both types of care were cognitive impairment, instability of health, daily pain, disability in activities of daily living; however, advanced age lost its protective effect in CCC. Less than half of the persons in HC and CCC with depressive symptoms were treated with antidepressants and their use decreased with age. Undertreatment of depressive symptoms among older persons remains a serious problem. Learning more about factors associated with depressive symptoms among the oldest old might improve detection and treatment of depression.

InterRAI assessment instruments: Basics, applications and research

InterRAI assessment instruments: Basics, applications and research

Development of quality indicators for monitoring outcomes of frail elderly hospitalised in acute care health settings: study protocol.

BackgroundFrail older people admitted to acute care hospitals are at risk of a range of adverse outcomes, including geriatric syndromes, although targeted care strategies can improve health outcomes for these patients. It is therefore important to assess inter-hospital variation in performance in order to plan and resource improvement programs.Clinical quality outcome indicators provide a mechanism for identifying variation in performance over time and between hospitals, however to date there has been no routine use of such indicators in acute care settings.A barrier to using quality indicators is lack of access to routinely collected clinical data. The interRAI Acute Care (AC) assessment system supports comprehensive geriatric assessment of older people within routine daily practice in hospital and includes process and outcome data pertaining to geriatric syndromes.This paper reports the study protocol for the development of aged care quality indicators for acute care hospitals.Methods/DesignThe study will be conducted in three phases:1. Development of a preliminary inclusive set of quality indicators set based on a literature review and expert panel consultation,2. A prospective field study including recruitment of 480 patients aged 70 years or older across 9 Australian hospitals. Each patient will be assessed on admission and discharge using the interRAI AC, and will undergo daily monitoring to observe outcomes. Medical records will be independently audited, and3. Analysis and compilation of a definitive quality indicator set, including two anonymous voting rounds for quality indicator inclusion by the expert panel.DiscussionThe approach to quality indicators proposed in this protocol has four distinct advantages over previous efforts: the quality indicators focus on outcomes; they can be collected as part of a routinely applied clinical information and decision support system; the clinical data will be robust and will contribute to better understanding variations in hospital care of older patients; The quality indicators will have international relevance as they will be built on the interRAI assessment instrument, an internationally recognised clinical system.

Beyond the ‘Iron Lungs of Gerontology’: Using Evidence to Shape the Future of Nursing Homes in Canada

Institutionalization of the Elderly in Canada suggested that efforts to address the underlying causes of age-related declines in health might negate the need for nursing homes. However, the prevalence of chronic disease has increased, and conditions like dementia mean that nursing homes are likely to remain important features of the Canadian health care system. A fundamental problem limiting the ability to understand how nursing homes may change to better meet the needs of an aging population was the lack of person-level clinical information. The introduction of interRAI assessment instruments to most Canadian provinces/territories and the establishment of the national Continuing Care Reporting System represent important steps in our capacity to understand nursing home care in Canada. Evidence from eight provinces and territories shows that the needs of persons in long-term care are highly complex, resource allocations do not always correspond to needs, and quality varies substantially between and within provinces.

A Care Planning Strategy for Traumatic Life Events in Community Mental Health and Inpatient Psychiatry Based on the InterRAI Assessment Instruments

Clinical triggers from the Traumatic Life Events Clinical Assessment Protocol (CAP) identify individuals who might benefit from formal services or additional supports targeted towards trauma treatment. The Traumatic Life Events CAP identifies two groups who have experienced one or more potentially traumatic life events: (1) those who are in immediate danger due to current abuse/criminal victimization; (2) those who have experienced one or more traumatic events that evoked an intense sense of horror or fear. Descriptive analysis was conducted across psychiatric hospital and community-based mental health service settings to compare the two triggered groups to those without traumatic experiences (the not-triggered group). The Traumatic Life Events CAP identified subpopulations with unrecognized and untreated traumatic-stress-related symptoms, which are of great concern for those in community-based mental health services who are in immediate danger due to current abuse.

Cost of prescribed and delivered health services resulting from a comprehensive geriatric assessment tool in New Zealand

The objective of this study was to estimate the health service use and costs resulting from the introduction of the interRAI Minimum Data Set-Home Care (MDS-HC) assessment compared with usual assessment.A randomised controlled trial of elderly people in New Zealand measured the use and cost of prescribed and delivered (4 months post-assessment) health services of 153 participants assessed using the standard [Needs Assessment and Service Co-ordination (NASC)] tool,and 158 participants assessed using the MDS-HC. The results suggest that the MDS-HC resulted in more prescribed personal health and community services, and less disability support services than with NASC. The cost of prescribed services was significantly greater for the MDS-HC (NZ$1840) than the NASC (NZ$1522, P < 0.001). The cost of delivered services was significantly greater for the MDS-HC (NZ$4809)than the NASC (NZ$2727, P < 0.001), including higher costs of hospitalizations (NZ$2523 vs. NZ$1112, P= 0.257). There were pronounced differences among 'low-need' compared with 'high-need'elderly people. These results suggest that the interRai assessment tool resulted in greater cost of prescribed preventive services and less prescribed disability services than the NASC. However, differences in delivered services were driven primarily by differences in hospitalizations. The results highlight the importance of integrating the assessment procedure with the delivery of health services, but suggest that further study is warranted. The results have implications for purchasers of health services for elderly people.