interrai suite as a tool for management of health services

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interRAI Suite as a Tool for Management of Health Services for the Elderly:

An Integrated Screening and Assessment System

John P. Hirdes, Ph.D.Ontario Home Care Research and Knowledge Exchange Chair

Professor, Department of Health Studies and Gerontology University of Waterloo &

Scientific Director, Homewood Research Institute

Hirdes Firenze 2010

www.interrai.org

Agenda

• interRAI instruments in Canada• Literature on screening and assessment

• A conceptual framework for use the interRAI Instruments

• interRAI Contact Assessment• Emergency Department Screener

• Method for Assigning Priority Levels (MAPLe)

Hirdes Firenze 2010

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The interRAI Family of Instruments• Home Care

+ Contact Assessment

• Nursing Homes

• Acute Care + ED Screener

• Mental Health• Inpatient• Community• Emergency Screener• Forensic Supplement• Prisons• Brief Mental Health Screener

• Intellectual Disability

• Palliative Care

• Post-Acute Care-Rehabilitation

• Community Health Assessment• AL supplement• Functional supplement• MH supplement• Deafblind supplement

• Subjective Quality of Life• Long term care• Home and community care• Mental Health

Hirdes Firenze 2010

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Applications of interRAI’s Assessment Instruments:One assessment … multiple applications

Assessment

Care Plan

Outcome Measures Quality Indicators

Resource Allocation

Prevent GamingEvaluateBest Practices

Case-mixSingle Point Entry

Patient SafetyQuality ImprovementPublic Accountability

Accreditation

www.interrai.org

Implementation & Testing of interRAI Instruments

Solid symbols – mandated or recommended by govt; Hollow symbols – research/evaluation underway

RAI 2.0 (NH)RAI-HCRAI-MHinterRAI CMHinterRAI ESPinterRAI PCinterRAI IDinterRAI ED/ACinterRAI CAinterRAI CHAinterRAI ALinterRAI SQoLDB

Hirdes Firenze 2010


interRAI Tools for Screening and Assessment


What does the literature say about assessment and screening?



• Comprehensive assessment• Can identify unmet needs• Can reduce

• Hospitalization, Institutionalization, Mortality, Morbidity




• Hospitalization, Institutionalization, Mortality, Morbidity• Preventive Home Visits

• Some evidence that can reduce costs• BUT, not cost effective if used with persons not at risk of major health

decline, hospitalization, etc




• Hospitalization, Institutionalization, Mortality, Morbidity• Preventive Home Visits

• Some evidence that can reduce costs• BUT, not cost effective if used with persons not at risk of major health

decline, hospitalization, etc• Screening

• Used to target persons most likely to benefit from intervention• Some evidence that fairly simple screens can help to differentiate

subpopulations • e.g., self-rated health is a strong predictor of mortality in general elderly

population

www.interrai.org

Some basic questions for service provisionQuestion interRAI SolutionIn the general population of older persons, who needs a comprehensive geriatric assessment?

interRAI CA & Assessment Urgency Algorithm

Among the people who are assessed, how should we prioritize access to services?

interRAI HC & MAPLe

Who is at greater risk of adverse outcomes?

Who is most likely to benefit from intervention?

What will it cost to provide them care?

CAPs

CAPs

RUG-III/HC

Hirdes Firenze 2010


Integrated Screening Methodologies(Compatible assessment, consistency in referral logic)

Single Point EntryContact Assessment HC

Acute Care




ED Screener AC

Acute Care




ED Screener AC

NursePractitioners

CHA

Acute Care




ED Screener AC

NursePractitioners

CHA

CommunitySupportAgencies

CHA

Acute Care




ED Screener AC

NursePractitioners

CHA

CommunitySupportAgencies

CHA

Family PhysiciansSelf-report Screener

Acute Care


Design Parameters for Contact Assessment


Design Parameters for Contact Assessment• Aim to identify

• Clients needing comprehensive assessment (i.e., interRAI-HC)• Clients needing services urgently• Type of clients (e.g., rehab)• Expected length of stay• Needs of short stay clients who will not received further assessment




• Used with all intakes• Hospital and community• Telephone and in-person





• Compatible interRAI HC• NOT a replacement for interRAI HC• Contains a standardized set of interRAI items






• Consistent with MAPLe






• Consistent with MAPLe• Decision support vs automated decision making

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Self reliance indicator

Long Stay/Clinically Complex

Family overwhelmed

Self-rated health excellent or

good

ImpairedSelf-reliant

Dyspnea or unstable condition

or flareup

Unstable condition or

flareup

Self-rated mood: sad, depressed,

hopeless

Personal hygiene ADL

No Yes No

No

238%

463%

350%

120%

685%

579%

353%

686%

Yes

YesNo NoYes Yes

NoYes

Assessment Urgency Algorithm

Hirdes Firenze 2010


Percentage of clients rated as requiring interRAI HC by Assessment Urgency algorithm, study

sample (n=408) and provincial data (n=22,410)

0

20

40

60

80

100

1 2 3 4 5 6

Assessment Urgency Score

%

Derivation Sample Provincial Data


Actual length of stay of home care clients by Assessment Urgency score at intake, n=408

Algorithm level D/C within 14 days

D/C within 60 days

Case open over 60 days

5,6 (likely long stay) 3% 33% 64%3,4 9% 42% 49%1,2 (likely short stay) 19% 43% 37%

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interRAI Emergency Department Screener

Hirdes Firenze 2010


Functions of interRAI ED Screener


Functions of interRAI ED Screener• Screener for elderly patients in acute care based on CA



• Identify complex patients requiring specialized geriatric assessment and interventions

• May already have a problem (e.g., delirium, ADL imp)o Needs are often under-detected

• May develop problems during acute hospital stay





• May develop problems during acute hospital stay • Improve management of frail elderly in acute care to reduce risk of:

• Bad patient outcomes (e.g., falls, delirium, functional decline)• Bad administrative outcomes (long hospital stay, NH placement,

readmissions)





• May develop problems during acute hospital stay • Improve management of frail elderly in acute care to reduce risk of:

• Bad patient outcomes (e.g., falls, delirium, functional decline)• Bad administrative outcomes (long hospital stay, NH placement,

readmissions)• Screener used to trigger

• interRAI Acute Care assessment for admissions to hospital• Referral to home care and interRAI HC assessment if not

admitted

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Comprehensive Assessment

Required

Admitted to Acute Care from

Emergency Room

Long Stay/ALC Patient, if Admitted

to Acute CareOdds Ratio

(95% CL)c Stat Odds Ratio

(95% CL)c Stat Odds Ratio

(95% CL)c Stat

interRAI ED Screener1

High RiskMedium Risk

6.84 (4.80‐9.74)3.12 (2.12‐4.59) .71

3.18 (2.29‐4.40)1.30 (0.90‐1.88) .63

4.90 (1.58‐15.20)4.08 (1.23‐13.52) .63

ISAR2+ 4.22 (3.12‐5.71) .66 2.55 (1.91‐3.39) .61 Not Significant ‐

TRST2+ 4.82 (3.34‐6.97) .64 1.40 (1.02‐1.91) .53 Not Significant ‐

[1] interRAI ED Screener results based on the interRAI Assessment Urgency algorithm.

Hirdes Firenze 2010

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Distribution of Canadian Triage Assessment Scale (CTAS) and Assessment Urgency Scores Among ED Patients Aged

75+

Hirdes Firenze 2010

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Method for Assigning Priority Levels (MAPLe)

Hirdes Firenze 2010

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Development of MAPLe

• Decision support tool for interRAI HC to establish priority for access to community and nursing home services

• Developed to predict three key outcomes• Caregiver distress• Nursing home placement• Person considered “better off elsewhere”

• MAPLe can also be derived from interRAI AC, CHA & CMH

Hirdes Firenze 2010

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Variables used in MAPLe Algorithm• ADL Hierarchy Scale• Cognitive Performance Scale• Behaviour Disturbances:

• Wandering• Verbal abuse• Physical abuse• Socially inappropriate• Resists care

• Worsening of decision-making• Medication management• Pressure or stasis ulcers

• Environment:• Bathroom• Kitchen• heating/cooling• Personal safety• Access to home

• Falls• Few meals• Meal preparation• Swallowing• Geriatric Screener• NH Risk CAP

Hirdes Firenze 2010

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Rate of Nursing Home Admissions Within 90 Days of Assessment by MAPLe Level, Ontario, Derivation Sample

02468

1012141618

Low Mild Moderate High Very High

MAPLe Level

%

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Relationship between MAPLe and signs of caregiver stress in selected Canadian Provinces

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Distribution of MAPLe Scores, by Diagnosis, Ontario Home Care Clients

Hirdes Firenze 2010

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Rates of Any Indicator of Caregiver Distress by MAPLe Score and Diagnosis, Ontario CCAC

Clients

Hirdes Firenze 2010

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International Differences in Access to Home Care:Distribution of MAPLe Levels by Country

0

10

20

30

40

50

60

low mild moderate high very high

MAPLe Level

%

Sweden Denmark Iceland Netherlands NorwayFinland Winnipeg Ontario UK GermanyCzech Rep France Italy


Rate of Caregiver Distress by Percentage of Clients with MAPLe Level 4 or 5, by Country

Pearson’s r=0.82

CZ

DK

FI

FR

GE

IS

PAPHR

NLNO

SW

UK

NS

WRHAON

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MAPLe

Low

Mild

Moderate

High

Very High

Expected Service Type

I & R

Home Care

LTC Facility

Using MAPLe for Matching Services to Needs

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MAPLe

Low

Mild

Moderate

High

Very High


I & R

Home Care

LTC Facility

Case ManagerReview

•Self-rated health•Poor stamina•Prior hospitalizations•Emergency visits•Caregiver needs•Hrs of informal care•Hrs of formal care•Family Preferences•Client Preferences•CHESS Score•24 hr supervision


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MAPLe

Low

Mild

Moderate

High

Very High


I & R

Home Care

LTC Facility

Case ManagerReview

•Self-rated health•Poor stamina•Prior hospitalizations•Emergency visits•Caregiver needs•Hrs of informal care•Hrs of formal care•Family Preferences•Client Preferences•24 hr supervision

Actual Service Type

I & R

Homemaking

Personal Care

Home Care

LTC Facility

CCC Facility

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Nursing Home Placement Among Home Care Clients by MAPLe Level, Ontario & Winnipeg Regional Health Authority

Ontario

Hirdes Firenze 2010

Winnipeg

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Concluding remarks

• interRAI family of instruments provide evidence based approach to screening, assessment and prioritization of clinical services

• Can be used at individual level to match needs to services

• … but also at the population level to benchmark quality of care and evaluate performance of services for the elderly

Hirdes Firenze 2010

www.interrai.org

Thank you!

Hirdes Firenze 2010

interrai suite as a tool for management of health services

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