InterRAI Home Care Assessments: How to Make the Most of ...€¦ · Capture client outcomes, client complexity and risk factors to support high-quality care. As clients needs change,

Dr. Samir K. Sinha MD, DPhil, FRCPC, AGSFPeter and Shelagh Godsoe Chair in Geriatrics and Director of Geriatrics Sinai Health System and the University Health Network, TorontoProvincial Lead, Ontario Seniors StrategyAssociate Professor of Medicine, University of Toronto and Assistant Professor of Medicine, Johns Hopkins University School of Medicine

Canadian InterRAI Fellow

RGP of Toronto Webinar5 November, 2 @DrSamirSinha

InterRAI Home Care Assessments: How to Make the Most of the Them in Your Clinical Decision Making

Presentation Objectives Understand the Principles of Effective Client Assessment in Providing

Home Care. Understand the role of the InterRAI Contact Assessment (CA) and

InterRAI Home Care Assessment (HC) in the delivery of Home Care in Ontario.

Learn where to Find InterRAI Assessments in the Connecting Ontario Patient Information Portal

Gain some Insights on How to Navigate and Interpret the Information Presented in InterRAI CA and HC Forms in a way that can support the care you provide to your older patients.

Effective and Efficient Client Assessments

Efficiency Quality Safety Customer ServiceReduce burden of data gathering by using a standardized tool to collect information once and use multiple ways:

Supports care planning and resource allocation, including decision-support tools.

Supports risk assessment, including predictive analytics.

Supports reporting, including reporting of outcomes.

Supports analysis based on standardized data.

Capture client outcomes, client complexity and risk factors to support high-quality care.

As clients needs change, reassessments continue to inform care.

Facilitates home care benchmarking, reporting and monitoring of outcomes and quality.

Improve safety and reduces risk of undiagnosed conditions, needs, appropriate servicefor clients.

Facilitates home care benchmarking, reporting and monitoring of safety.

Allow clients to provideinformation, feedback and participate in decision-making about their care.

Can be used to support consistent and transparent decisions about client care so clients know what they can expect.

Improve client care continuity by using a common language, core elements that are understood by all partners.

When standardized assessments are used effectively and efficiently, they serve a variety of purposes in the health system.

Ontario Model for Assessment of Client NeedsLegislation,Regulation and Policy

• Approved agencies who deliver home and community care are required to determine client eligibility, assess client needs and develop a plan of service for the amount and type of services that client will receive.

• Service providers who deliver professional services are required to develop a plan of care for clients to whom they provide professional services such as nursing

• The ministry has supported the deployment of consistent assessments (interRAI) and a common technology platform.

LHIN Assessment Practices

• LHINs have adopted the Client Care Model to assist with the triage, assessment and care management of clients in home and community care.

• Typically assessments are conducted by care coordination staff at the LHIN, usually a nurse.

• LHINs share Client Assessment Results and records through CHRIS/Health Partner Gateway – and now via platforms such as Connecting Ontario

InterRAI assessmenttools

• All 14 LHINs, LTC Homes and many CSS and mental health and addiction agencies, have adopted the use of evidence based interRAI decision support tools to deliver community care.

• The most commonly used tools by LHINs for home care are the interRAIContact Assessment (interRAI CA) and the interRAI Home Care (interRAIHC).

Background on InterRAI Assessments InterRAI is an international collaborative network of researchers in 32 countries. InterRAI has

developed internationally standardized client assessment tools with a focus on older persons, persons with disabilities and those affected by mental illness.

Home care in Ontario has used the InterRAI suite of Assessment tools since 2002 to support evidence informed care in the community.

InterRAI assessment tools provide decision support to health providers including through the use of standard algorithms and client outcome measures e.g. Method of Assessing Priority Levels (MAPLe).

InterRAI based algorithms support the use of analytics, including predictive analytics, in home and community care such as predicting client need for LTC placement and risk of hospital readmission.

InterRAI assessment tools collect standardized information about clients to make evidence informed service allocation decisions for home and community care including:

5

Typically used by LHIN Home Care• interRAI Contact Assessment• interRAI Home Care

Typically used by CSS Agencies• interRAI Preliminary Screener• interRAI Community Health Assessment

Physical Ability

Cognitive Ability

Mental Health

Social Determinants of Health

CaregiverDistress

Medical Complexity

Activities of Daily Living, communication, vision, recent declines

Health condition, nutrition, skin, falls, pain, medication, continence

Cognitive function, mood, behaviour

Health conditions, isolation

Environment, social functional, informal support

Fear, anxiety, other distress by informal caregivers

Facts About InterRAI Assessments InterRAI Assessment Tools – collect the MINIMUM DATA REQUIRED to

help with useful decision making for the users of them while minimizing documentation burden in completing administrative requirements.

The DATA ELEMENTS in each tool are STANDARDIZED and identical to support SHARING across sectors and MINIMIZE DUPLICATION of efforts

Countries across the world have implemented the use of InterRAIInstruments to enable their working processes, standardized data collection and monitoring processes. The instruments are made available FREE of charge.

The Canadian Institutes for Health Information (CIHI) supports the mandated universal adoption of the InterRAI Assessments Across Canada. Currently CIHI stores 12M InterRAI Assessment Records on over 3M Canadians.

Applications of InterRAI’s 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

Courtesy of John Hirdes

We Are Often Used to Using First Generation Assessments….

MMSE

InterRAI Assessment Represent Second Generation Assessment Systems

ObservationsCognition

MoodCommunication

MobilitySelf Care

IADLContinence

FallsPain

Physical EnvironmentSocial Support

Formal Services

Diagnostic Screeners & Risk Assessments

Clinical Assessment Protocols

Quality Indicators

Casemix Tools

Scales & Severity Measures

2016/17 Ontario Home Care InterRAI Assessments

87.4%

12.6%

Linked to initial CA or HC

Newly referred home care clients with an associated Contact or Home Care

assessment

Out of all new clients that were referred to LHIN home care in 2016/17, 87.4% have an associated interRAI assessment. Of these, approximately 22% received an interRAIHome Care assessment – the most comprehensive assessment.

Research indicates that regular re-assessments of long-stay clients are able to identify areas of significant clinical change that may otherwise not be noted.

22.8%

57.2%

7.5%

12.6%

CA+HCCA onlyHC onlyNot linked to initial CA or HC

Assessment groups as a proportion of newly referred home care clients

The majority of clients were assessed with the interRAI CA only, a shorter more streamlined assessment, during the home care episode

Less than one-third of clients are assessed with the more comprehensive interRAI HC assessment.

Source: University of Waterloo, interRAI Canada

In 2016-17 LHIN care coordinators performed ~186,000 interRAI Contact Assessments, accounting for ~2% of their time.

During the same year, LHIN care coordinators performed ~300,000 interRAI Home Care assessments, or ~9% of their time.

Home Care Assessment Trends in Ontario Client Acuity is a strong indicator for whether an assessment is conducted and the decision to use a specific assessment tool. Typically the use of comprehensive assessments (interRAI HC) are reserved for

medically and socially complex clients These clients typically are cognitively impaired, require assistance with activities of

daily living, are clinically unstable and at risk of decline and will likely need care over a long period of time.

The majority of clients who receive the interRAI CA are assessed over the phone Most clients that receive an interRAI CA will receive it over the phone. Where the interRAI CA is used to assess clients with more stable and lower needs.

Generally, clients with a Higher Assessment Urgency are associated with Shorter Median Wait Times to get Assessed (for clients who require an interRAI HC). Clients with complex and high needs typically wait less for assessments to determine

their care needs.

Opportunities exist to improve information sharing and integrate assessment data with provider partners e.g. expanded access to CHRIS and HPG and Connecting Ontario. Improvements need to be made to make assessments conducted by LHINs valuable

for direct care providers e.g. translation and interpretation of assessment information for providers.

Source: University of Waterloo, interRAI Canada

Where to Find InterRAI Home Care Assessments

Unless you have access to the LHIN CHRIS (Client Health Record Information System) or the CSS Led IAR (Integrated Assessment Record) most Specialized Geriatric Services Providers will be able to view InterRAI Contact Assessments (CA) and Home Care (HC) Assessments via Connecting Ontario’s Clinical Viewer The Assessments that can be viewed will appear in the Documents/Notes Section:

Reading an InterRAI Contact Assessment InterRAI Contact Assessments are Standardized 40 Item Assessments Organized in

the Following Sections and based on the Last 24 Hours:

A: Common Demographic InformationB: Intake and Initial HistoryC: Preliminary ScreenerD: Clinical Evaluation E: Summary

InterRAI Contact Assessments Generate 4 Algorithm Scores

1: Self-Reliance Index2: Assessment Urgency Algorithm 3: Service Urgency Algorithm 4: Rehabilitation Algorithm



MoodCommunication

MobilitySelf Care

IADLContinence

FallsPain


Formal Services



Quality Indicators

Casemix Tools


Understanding InterRAI CA Algorithms

1: Self-Reliance IndexA Descriptive Indicator that indicated Impaired Self-Reliance in the Presence of a single ADL or Cognitive Impairment

2: Assessment Urgency Algorithm Is used to Prioritize the Need and urgency for a Comprehensive Follow-Up Assessment (ie InterRAI HC)

3: Service Urgency Algorithm Is used to Identify Persons who may be in urgent needs of services (ie Wound Care, IV Medications)

4: Rehabilitation Algorithm Is used to Identify Persons who may be candidates for rehabilitation services such as physiotherapy or occupational therapy

Assessment Urgency Algorithm

Reading an InterRAI Home Care Assessment InterRAI Home Care Assessments are Standardized and Organized in the Following

Sections:

A: Identification Information O: ResponsibilityB: Intake and Initial History P: Social SupportsC: Cognition Q: Environmental AssessmentD: Communication and Vision R: Discharge Potential and Overall StE: Mood and Behaviour S: DischargeF: Psychosocial Well-Being T: Assessment Information G: Functional StatusH: ContinenceI: Disease DiagnosesJ: Health ConditionsK: Oral and Nutritional StatusL: Skin ConditionM: MedicationsN: Treatments and Procedures



MoodCommunication

MobilitySelf Care

IADLContinence

FallsPain


Formal Services



Quality Indicators

Casemix Tools


Understanding InterRAI Outcome Measures Many InterRAI Outcome Scales have been benchmarked

for validity with industry ‘gold standard’ outcome measures (for example the Cognitive Performance Scale (CPS and CPS2) is validated against the MMSE) and are valid, reliable and responsive.

This allows a single assessment to provide a Clinician with Multiple Outcome Measures without the need to complete multiple separate outcome scales.

Many outcome scales are shared across Different Community Assessments – ie Home Care, Community Health Assessment, Long-Term Care Facilities, Palliative Care.

InterRAI Outcome Scales and Severity Measures InterRAI Home Care Assessments are Standardized and Organized in the Following

Sections:


The higher the score the more severe the outcome scale or measure

Understanding the Cognitive Performance Scale (CPS)




Sections:


Understanding the Depression Rating Scale (DRS)

This Scale identifies a person’s likelihood of a new diagnosis of depression within the next six months based on items E1a to E1g.

For each input item, above. The firs two levels, 0 and 1, are not recoded; level 2 is recoded as 1; and level 3 is recoded to 2.

(Range 0-14. A cut-off score of ≥ 3 has been show to best identify a person at risk of clinical depression)

This scale is validated against the Cornell Scale for Depression in Dementia, Calgary Depression Scale and Hamilton Depression Rating Scale.


Sections:


Understanding the Method for Assigning Priority Levels (MAPLe) Scale (Range 1-5) MAPLe classifies persons based on the risk of adverse outcomes and the

urgency of need to provide support services for these people. Also associated with caregiver distress and risk of nursing home placement. It differentiates people into five priority levels based on their risk of adverse outcomes.

Those in the lowest priority level have no major functional, cognitive, behavioural or environmental problems and are considered self-reliant. The highest priority levels in based on the presence of ADL impairment, cognitive impairment, wandering, behavior problems and the InterRAI Institutional Risk CAP.

MAPLe is a strong predictor of caregiver stress Without intervention, individuals with highest priority level are nearly 9x more

likely to be admitted to a nursing home than are the lowest priority adults

Understanding the Method for Assigning Priority Levels (MAPLe) Scale


Sections:


Understanding the Detection of Indicators and Vulnerabilities for Emergency Room Trips (DIVERT) Scale This Scale identifies a person’s likelihood of future emergency

department use. The higher the score the greater the risk for ED use within 6 months. (Range 1-6)

Understanding the Detection of Indicators and Vulnerabilities for Emergency Room Trips (DIVERT) Scale

InterRAI Outcome Scales and Severity Measures



MoodCommunication

MobilitySelf Care

IADLContinence

FallsPain


Formal Services



Quality Indicators

Casemix Tools


Understanding InterRAI Clinical Assessment Protocols (CAPs)

CAPs use the InterRAI coded items to create reliable, person-centred assessment areas that support comprehensive care and service planning. They can: Highlight possible areas for referral to specialized services Be used to identify people who could benefit from further

assessments of specific problems, because their: risk of decline is higher than expected, or Potential to improve has increased, or Symptoms could be alleviated if the problem were addressed.

4 Broad CAP Areas Functional Performance Cognition/Mental Health Social Life Clinical Issues


CAPs are triggered by research-based algorithms embedded in the assessment. Each one is linked to international best-practice standards.

Some CAPs are triggered based on being present or not, are also triggered to facilitate improvement or prevent decline.

Addressing CAPs Review the Triggered CAPs for the Assessed Person Determine if the triggered CAPs are clinically important for the

person now Prioritize the triggered CAPs as part of developing a targeted

care plan.



Medication List and Section Notes at the End Tend to Be Worth Their Weight in Gold Be Sure to Look at these as they Will Contextualize the

Coded Info in each Section further.

The Assessments always list the LHIN Coordinator and thus can allow one to identify and email them via the ONE-Mail System as well to further dialogue about a patient in common.

Conclusions Standardized Clinical Assessments like the InterRAI Contact

Assessment and Home Care can allow clinicians to speak a common language in the delivery of geriatric care

InterRAI CA and HCs are now readily accessible by all clinicians in Ontario through the Connecting Ontario Patient Information Portal

Taking the time to familiarize and learn how to navigate this way of viewing InterRAI CA and HC Forms can allow you to better appreciate the content within.

InterRAI Assessments that are conducted routinely on intake and for routine re-assessments can help to provide valuable insights in terms of how an individual was previously functioning in the community and further opportunities for improvement.

Thank You

Samir K. Sinha MD, DPhil, FRCPC, AGSFDirector of Geriatrics Sinai Health System and the University Health Network

[email protected]@DrSamirSinha