interRAI Suite as a Tool for Management of Health Services ...
Transcript of 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
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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
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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
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interRAI Tools for Screening and Assessment
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What does the literature say about assessment and screening?
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What does the literature say about assessment and screening?
• Comprehensive assessment• Can identify unmet needs• Can reduce
• Hospitalization, Institutionalization, Mortality, Morbidity
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What does the literature say about assessment and screening?
• Comprehensive assessment• Can identify unmet needs• Can reduce
• 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
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What does the literature say about assessment and screening?
• Comprehensive assessment• Can identify unmet needs• Can reduce
• 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
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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
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Integrated Screening Methodologies(Compatible assessment, consistency in referral logic)
Single Point EntryContact Assessment HC
Acute Care
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Integrated Screening Methodologies(Compatible assessment, consistency in referral logic)
Single Point EntryContact Assessment HC
ED Screener AC
Acute Care
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Integrated Screening Methodologies(Compatible assessment, consistency in referral logic)
Single Point EntryContact Assessment HC
ED Screener AC
NursePractitioners
CHA
Acute Care
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Integrated Screening Methodologies(Compatible assessment, consistency in referral logic)
Single Point EntryContact Assessment HC
ED Screener AC
NursePractitioners
CHA
CommunitySupportAgencies
CHA
Acute Care
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Integrated Screening Methodologies(Compatible assessment, consistency in referral logic)
Single Point EntryContact Assessment HC
ED Screener AC
NursePractitioners
CHA
CommunitySupportAgencies
CHA
Family PhysiciansSelf-report Screener
Acute Care
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Design Parameters for Contact Assessment
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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
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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
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www.interrai.orgHirdes Firenze 2010
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
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www.interrai.orgHirdes Firenze 2010
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
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www.interrai.orgHirdes Firenze 2010
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• 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
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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
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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
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Functions of interRAI ED Screener
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Functions of interRAI ED Screener• Screener for elderly patients in acute care based on CA
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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
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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 • 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)
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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 • 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
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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
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
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
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
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
Expected Service Type
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
Using MAPLe for Matching Services to Needs
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Using MAPLe for Matching Services to Needs
MAPLe
Low
Mild
Moderate
High
Very High
Expected Service Type
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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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
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Thank you!
Hirdes Firenze 2010