Resident Assessment Instrument - Minimum Data Set (RAI-MDS) 2.0

Presentation to Family Councils’ DurhamWednesday, October 22, 2008

Soo Ching Kikuta, RN, MScN, Business Lead, LTCH CAP

Jennifer Ratcliff, Communications Lead, LTCH CAP

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Presentation Overview

• Part A:Resident Assessment Instrument - Minimum Data Set 2.0 (RAI-MDS 2.0)

• Part B:Long-Term Care Homes Common Assessment Project (LTCH CAP)

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Part A:Resident Assessment Instrument- Minimum Data Set (RAI-MDS) 2.0

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Alberta Resident Classification System(ARCS)

External Classifier

Assess Nursing and Personal Care Needs of Resident

Based on 8 indicators: eating, toileting, transferring, dressing, potential for injury, ineffective coping, urinary continence bowel continence

Output - FUNDING

Home Case Mix Measure (CMM)

Home Case Mix Index (CMI)

Sum of care levels of all A to G residents in the home

Relative number used for fundingSnapshot - annually

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ARCS and RAI-MDS 2.0 (Examples)

ARCS RAI-MDS 2.0Funding tool

Focuses and rewards disability - no incentive with financial penalty to do rehabilitation, and preventative care

Participates by selected registered staff members in the process - no interdisciplinary team involvement

Funding output: CMI and CMM by home and provincial

No linkage to resident care, care planning or quality improvement

A clinical tool that enhances the assessment, develops an effective care plan, and improves resident care

Values restorative, enablement, rehabilitation, health promotion and prevention

Requires involvement of the resident, family/significant others and care team members

Builds-in monitoring system and can generate multiple output reports for tracking and monitoring of resident care progress and improvement quarterly

Multiple applications: care plan development, quality improvement, accreditation, benchmarking, data quality, funding, resource allocation, strategic planning, performance evaluation

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Ontario RAI-MDS 2.0 Implementation inLong-Term Care Homes

• 625 Homes (77,228 beds)

• 35% of homes in Ontario are using RAI-MDS 2.0 (representing 217 homes across all LHINs)

• 100% of home participation has been voluntary

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North AmericaCanada, USA

Nordic CountriesIceland, Norway, Sweden,

Denmark, Finland

EuropeNetherlands, Germany, Switzerland, France,

UK, Italy, Spain,Czech Republic, Poland, Estonia

Pacific RimJapan, China, Taiwan, Hong Kong,

South Korea, Australia, New Zealand

Middle EastIsrael

interRAI Countries

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RAI-MDS 2.0 Instrument Adoption in Canada

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RAI-MDS 2.0 Model

Assessment

Minimum Data Set

Resident Assessment

Protocols (RAPs)

Triggers

Plan of Care

Case Mix/Resource

Utilization Groups

OutcomeMeasurement

Scales

QualityIndicators

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The MDS Assessment

The MDS assessment tool has 19 sections with over 450 assessment items in the categories of:

A. Identification Information

B. Cognitive Patterns

C. Communication/Hearing Patterns

D. Vision Patterns

E. Mood and Behaviour Patterns

F. Psychosocial Well-Being

G. Physical Functioning and Structural Problems

H. Continence

I. Disease Diagnoses

J. Health Conditions

K. Oral/Nutritional Status

L. Oral/Dental Status

M. Skin Condition

N. Activity Pursuit Patterns

O. Medications

P. Special Treatments and Procedures

Q. Discharge Potential and Overall Status

R. Assessment Information

U. Medication List

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Resident Assessment Protocols (RAPs)

RAPs are potential or actual problems that may require further assessment. There are 18 RAPs triggered by specific resident responses from one or a combination of MDS elements:

• Delirium

• Cognitive loss/dementia

• Visual function

• Communication

• ADL function/rehabilitation

• Urinary incontinence and indwelling catheter

• Psychosocial well-being

• Mood state

• Behavioral symptoms

• Activities

• Falls

• Nutritional status

• Feeding tubes

• Dehydration/fluid maintenance

• Dental care

• Pressure ulcers

• Psychotropic drug use

• Physical restraints

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From Home Software:

Reports

• Outcome Scales

• Quality Indicators

• Resource Utilization Groups (RUGs)

RAI-MDS 2.0

outputs

RAI-MDS 2.0 assessment data is to be submitted electronically to Canadian Institute for Health Information (CIHI) quarterly.

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Outcome Scales

• Derived from MDS data (no extra work - it is calculated by the software, real time data!)

• Aggregates information on resident needs and outcomes

• Can be used to evaluate the resident’s clinical status at present and change over time

• Comparative reports (by unit, resident, program and Home)

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Scale Measures

Cognitive Performance Scale (CPS) Level of cognition

Depression Rating Scale (DRS) Level of depression

Activity of Daily Living (ADL Short Form,

ADL Long Form, ADL Hierarchy)

ADL performance

Changes in Health, End-Stage Disease

and Signs and Symptoms Scale

(CHESS)

Predictor of mortality

Index of Social Engagement (ISE) Degree of social engagement

Pain Scale Prevalence of pain

Outcome Scales

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Quality Indicators (QIs)

• Flagging or identifying exemplary care and potential care concerns

• Not direct measuring of quality

• Monitoring resident’s risk or condition change and progress over time

• Identifying residents for review

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Quality Indicators (QIs)

There are 24 QIs for long-term care homes

• New fractures

• Falls

• Behavioural symptoms affecting others

• Symptoms of depression

• Depression with no antidepressant

• therapy

• Use of nine or more medications

• Cognitive impairment

• Bladder or bowel incontinence

• Occasional or frequent bladder or bowel incontinence without a toileting plan

• Indwelling catheters

• Fecal impaction

• Urinary tract infections

• Weight loss

• Tube feeding

• Dehydration

• Bedfast residents

• Decline in late-loss ADLs

• Decline in ROM

• Anti-psychotic use in the absence of psychotic or related conditions

• Anti-anxiety / hypnotic use

• Hypnotic use more than two times in last week

• Daily physical restraints

• Little or no activity

• Stage 1 - 4 pressure ulcers

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Resource Utilization Groups (RUGs)

• Upon completion of the MDS, the software automatically classifies residents into groups

• There are 7 major groups, further divided into 44 distinct subcategories

• These groups classify residents according to their clinical and diagnostic characteristics and resource utilization

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Resource Utilization Groups (RUGs III)

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Multiple Uses for Data Collected at Point of Care

e.g. Do Ontarians' have equitable access to

quality health services and how do we

compare with other provinces?

e.g. Are we getting the best outcomes for our health care dollars?

How effective are our services? What are the

priorities for quality improvement?

e.g. What are the outcomes of care? Do our residents achieve

their health goals? What resources were

used?

RAI-MDS 2.0 Assessment

Operational & Strategic

Management

Public Accountability

Clinical Decision-making

Clinical & Utilization Research

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Benefits: Residents and Family Members

• Encourages resident and family involvement

• Respects the value of helping residents achieving their highest level of functioning and quality of life

• Offers a holistic interdisciplinary assessment of resident care needs and the development of a focused, individualized care plan

• Flags actual and potential resident care needs in a timely fashion

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What Families have said:

“We were very impressed with the Home. We have noticed Mum is much happier, especially in bed, and is not complaining of pain as much. She is not on as many medications. The Home explained everything they were doing. They treat her like family”.

“My brother felt like someone was finally paying attention to him. I noticed small improvements - he could walk on the carpet or out on the deck and he was able to dress himself. I was told what was being done and when I knew about his depression, I could watch out for signs of it and tell the staff”.

“The variability in the care delivery worried me. RAI-MDS makes a big difference. It helps the staff give the same level of care, regardless of which PSW is on shift. When someone is new, they can quickly be better informed”.

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Benefits: Care Providers

• Provides a common resident care approach in assessment and care planning

• Increases awareness regarding residents’ strengths, symptoms, needs and preferences

• Provides access to real time clinical information of residents; pinpoints underlying conditions unseen or yet to emerge

• Helps to improve clinical practice by:

- Tracking resident-specific outcomes and

- Monitoring resident change over time

• Improves resident teaching - related to ‘readiness for discharge’

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What Care Providers have said:

“I must emphasize how important the family involvement is,

they are truly a part of the care team and we need their

information to help us form the best possible care plan…

they provide a wealth of information and are key in the care

plan development process.”

- RAI Coordinator

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Benefits - Administration or Executives

• Enables informed decisions to be made regarding staffing, resource allocation, risk management, program planning, strategic planning and utilization by connecting RAI-MDS information with other management information

• Contains clinical data to benchmark with other homes, has ability to identify and learn from industry leaders and sharing of best practices

• Provides timely access to performance information to evaluate the home and track record of evidence

• Improves staff training related to evidence of clinical performance

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What Management has said:

“(MDS) has enabled the resident and family to have greater

input into the plan of care. The plan of care becomes more

personalized. The front line staff feel that they have a greater

say about the resident.”

- Nursing Home Manager

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Benefits - Health Care System

• Informs public reporting on health system performance- empowers the consumer

• Enhances the availability of consistent, comprehensive and quality data in an open and transparent approach

• Improves confidence of the long-term care sector

• Enhances information, aids benchmarking, policy development and sector planning

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Lessons Learned - Benefits

• “The implementation of RAI MDS increases team communication”

• “Residents appreciate their added involvement in the assessment”

• “With the implementation of RAI MDS 2.0 processes, we improve the co-ordination of resident assessment and interdisciplinary team meetings because MDS provides a common language”

• “Our PSWs are feeling more engaged and valued by their increased participation in assessment”

• “The MDS has uncovered underlying clinical conditions resulting in proactive treatment for residents”

• “All discipline documentation is centralized…reduces discrepancies in documentation…and a more holistic view of the resident”

• “Better care plan and more individualized”

• “Given the high turnover of staff…the MDS assessment…helps safeguard and protect our residents….newly hired employees…may miss important assessment, however the MDS [is] foolproof”

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Part B:

Long-Term Care Homes Common Assessment Project (LTCH CAP)

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Architecture & Integration Standards Security, Privacy & Risk Management

CommonAssessments

Program Footprint

Business Systems

Program Streams

Continuing Care e-Health

LTCHCMH & ACSSCCAC

CMH CAP(CMHCA)

LTCH CAP(RAI MDS)

Local Health Integration Networks

CMH&A MIS LTCH

MISFSMS

CSS MIS

CSS HRISCMH&A

HRIS

Project LegendCAP = Common Assessment Project CCM = Common Case Management CIAT = Common Intake Assessment Tool CMH&A = Community Mental Health & Addictions CSS = Community Support Services HC = Home CareFSMS= Financial & Statistical Mgmt Systems HRIS = Human Resources Information System LSAS = Long Stay Assessment Software LTCH = Long-Term Care HomeMIS = Management Information Systems RAI-MDS = Resident Assessment Tool Min. Data Set

Project Rolling Out

Project in pilot

Completed project

HC CAP(CIAT)

HC CAP(LSAS)

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Implementation Timelines

Phase 6

Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec

09/10

Phase 7 Phase 8

Project Implementation Model

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Education ModulesModule Description Requested Participants Training

Day

1a Home Preparation * Administrator, DOC,

RAI Coordinator & Backup

1

1b RAI Coordinator Forum

(RAI Coordinator & Backup)

RAI Coordinator and Backup 1

2 Assessment (Coding) DOC, RAI-C and Backup 2

3 Data Submission DOC, RAI-C and Backup 4 hrs.

Web-X

4 RAI Outputs/Reports* Administrator, DOC, RAI-C and

Backup

1

5 Data Quality Management DOC, RAI-C and Backup 2 hrs.

Web-X

6 RAPs and Care Planning DOC, RAI-C and Backup 1

Total Training Days = 6 days; 6 hours Web-X

Timeline = 9-12 Months

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Regional Training and Support Teams

4 Hubs

Toronto London Ottawa North

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Implementation Support

Implementatio

n

Toolkit

AIS

Mentorship Program

DART

Site Visit

Regional Teleconference Support

Phone Support

Designated RAI Educator

CIHI User’s Manual

RAI-MDS Nutritional Care Resource Guide

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Implementation Support

Implementation Toolkit: training, presentations, tools, checklists

60 Minutes audio presentations

Continuous training schedule

Project e-Newsletter

Frequently Asked Questions for Coding and Data Submission

Discussion Boards for Homes

On-Line Web Portal

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Implementation Support

Support Centre

In-person help desk

416-314-7365 or 866-909-5600

Operating 8:30 a.m. – 4:30 p.m. Monday to Friday

www.ltchcap.ca (with password)

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Contact information

Long-Term Care Homes Common Assessment Project

ltchproject.moh@ontario.ca

416-314-7365 or 1-866-909-5600

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Questions?