Following a consultation and review process, the interRAI suite of assessment tools was chosen as the most suitable instrument for assessment of the care needs of older people in Ireland. We used previously validated questionnaires to examine the usability, practicality and acceptability of these tools to professionals, carers and clients in rural and urban acute, long-term care and community settings. Of the 45 professionals, 42-44 (93-98%) agreed or strongly agreed with 14 of 15 positive statements regarding the acceptability, clinical value and ease of use of the interRAI tools; 39 (87%) felt the terminology was consistent and familiar, although 35 (78%) felt some areas would require further explanation. Responses from carers (n=15) and clients (n=68) were similarly overwhelmingly positive regarding the experience of being assessed using these tools. These results support the clinical utility and practicality of using this approach to assess older people in Irish clinical practice.
In 2010 the Health Service Executive (HSE) set up a multi-agency and multi-disciplinary National Single Assessment Tool Working Group (SAT WG) with the task of selecting, piloting and recommending a Single Assessment Tool (SAT) for use with older people nationally. The initiative aimed to address Irish health and social care policy requirements for a nationalstandardised needs assessment, to better support integrated service delivery and best practice in older persons care.1-3 A number of processes were used to select a suitable SAT. These included: a ‘Values and Principles’ exercise, a Literature Review, a Market Sounding exercise and a detailed OptionsAppraisal. Following extensive stakeholder consultation and review, it was agreed that a computerised assessment tool would be preferable and three assessment tools were shortlisted. Selection criteria were agreed and a decision-matrix approach using a quantitative technique was employed, to rank each tool against the multi-dimensional options of the set of criteria. This resulted in the interRAI™suite of assessment tools being chosen as the most suitable instrument.4
The first interRAI instrument, commonly known as the Resident Assessment Instrument (RAI), was developed in the United States to assess nursing home residents. Subsequently, a network of international clinicians and researchers set up interRAI™, as a not for profitcollaborative organisation to apply the RAI to nursing home residents in other countries and to develop other structured, multi-disciplinary assessment tools to assess the wide-range of health and social care needs of older people. Currently, the suite comprises 14 instruments available for use across a range of settings. By using a common language of assessment, the interRAI system facilitates information sharing in a consistent and transferable way betweenhealth and social service agencies. Aggregated data can be used to support outcome measurement, resource allocation, service planning, quality measurement, research and policy decision-making (Figure 1). Internationally, these tools are used in over 30 countries and have been extensively tested with proven reliability, validity and sensitivity.5
The primary aim of this pilot was to explore the suitability of the interRAI system in the Irish healthcare context by examining the views of Irish assessors’ (health professionals), clients’ (older people) and carers’ (older peoples’ representatives) views on the interRAI system’s usability, practicality and acceptability. The study further sought to explore the system’s technical aspects in order to inform service development. The interRAI™ tools (Version 9.1) selected forpiloting were the Long Term Care Facility assessment (interRAI LTCF) and the Home Care assessment(interRAI HC) for use in community (district nursing) and acute services.
A mixed methodology involving, multi-site surveys, interRAI data analysis and focus groups were employed. This paper reports on the survey strand. Stratified sampling methods were used to select settings, sites and study participants. Ten sites (five urban and five rural) were selected comprising of six long-term care facilities (three private, two public and one voluntary); two community care areas (ten community health units); and two acute hospitals. As no voluntary long-term care unit was available in the rural setting, an additional private nursing home was selected.
Clients aged over 65 years, their carers and health professionals who participated in a formal needs assessment in long-term care settings or who were undergoing assessment in community or acute services regarding the need for long-term care admission or home care packages were eligible for inclusion in the interRAI data analysis strand. For survey and focus group inclusion, clients had to be deemed by assessors to have sufficient mental capacity to participate. The Standardised Mini Mental Status Exam (SMMSE) was used to support professional judgement: SMMSE scores of 0-20 (severe to moderate cognitive impairment [C.I]) and less than 25 were used as a guide to insufficient capacity for the survey and focus groups, respectively.6 Those who did not participate in the specified needs assessments within the study sites were excluded from the study. Informed consent was gained for all participants with ‘Process Consent’ methods employed to ensure valid consent for those with C.I.7-9 Ethical approval was gained from three Research Ethics Committees.
Six assessor participants per site (n=60) were to be recruited using the study’s inclusion/ exclusion criteria. However, one acute hospital employed a single health professional in this role. This resulted in 55 assessors being recruited. Each assessor was asked to recruit 5 clients and their carers, where possible. During the study 8 assessors withdrew due to retirement (2) or illness (6). Clients, carers and assessor surveys were completed using pre-piloted and modified versions of the questionnaires used by McCormack and colleagues.10 In these questionnaires, participants’ views are self-rated using a four point Likert Scale ranging from ‘Strongly Agree’ to ‘Strongly Disagree’. Two open-ended questions captured additional information. Education supported by written instruction was provided to all participants. Quantitative data were analysed using SPSS, while qualitative data were analysed using cognitive mapping to extract the main themes
Figure 1 The interRAI Model
Health Professionals Survey
A 96% survey response rate (n=45/47) was achieved. Nurses accounted for 93% (n=42) and doctors 7% (n=3) of the study population. Of the responders, 62% worked in long-term care, 22% in the community and 16% in acute hospitals. The majority of assessors (68%, n=28) completed interRAI assessments in less than 1.5 hours. Completion times ranged from less than 1 hour (17%, n=7) to over 4 hours (7%, n= 3). In comparison to assessors’ usual work place assessments, 42% of participants (n=19) reported the interRAI took less time (11%, n=5) or that completions times were comparable (31%, n=14). However, 58% of participants (n=26) reported that interRAI assessments took longer.
Overall, the responses to 16 survey questions were strongly positive. More than 95% of respondents agreed or strongly agreed that the interRAI tool promotes the person’s perspective throughout the assessment process, captures the needs of the individual and the individual’s wishes and preferences on their goals for care, triggers further assessment where appropriate, provides evidence for multidisciplinary team recommendations based on the individual’s care needs and promotes professional judgement. 93% reported that they felt competent in completing a computer-based interRAI assessment, although 78% reported areas which would require further explanation.
In the open-ended questions assessors recorded their views on what worked well / did not work so well. The majority of positive comments (n=31) centred on the benefits of the interRAI’s comprehensiveness in identifying clients’ health and social care needs, particularly with regard to previously unidentified needs. Other positive areas included the systems’ in-built supports for care planning and the system’s user friendliness. Negative comments (n=37) mainly focused on assessors’ difficulty/ frustration in entering clients’ medications and disease diagnoses into the system. The fact that medications were loaded into the software system using trade as opposed to generic names caused frustration as several trade names exist for each medication. Similarly, the fact that the entire International Classification of Diseases (ICD) was loaded into the software system caused delays in accessing appropriate codes for clients’ diagnoses. Other areas included: the time taken to complete assessments; terminology coding difficulties when using the interRAI HC tool in acute care; variances in the interRAI standards from Irish practice standards; and internet connectivity difficulties; and laptops were seen by some as a barrier to person centred care.
Survey response rates were 100% for clients (n=68/68) and 83% for carers (n=15/18). Again survey reposes were overwhelmingly positive (Table 1). Clients and carers found the language easy to understand and stated they were ‘happy’ or ‘satisfied’ with the assessment process. Negative comments (n=4) were concerned with the length of time to complete the assessment (n=2 clients) and the use of a computer during assessment which was found to impact negatively on person-centred assessment processes (1 client and 1 carer).
The surveys demonstrate the largely positive views of participants in using the interRAI assessment system in Irish health care. Professionals found that these tools provided useful and accurate data that could inform good practice and be responsive to clients’ needs and preferences. Clients and carers were satisfied with the assessment process. For assessors the main areas of frustration related to the medications and disease diagnosis sections. These problems can be rectified by uploading medications onto the system by their generic names and by using established ‘stripped’ ICD lists. Other areas of concern can be targeted through future health professional education and development training sessions. Overall, the three surveys demonstrate a high level of acceptability of the interRAI system as an assessment tool for older people in both rural and urban Irish settings.
Correspondence: L McDermott-Scales
HSE Services for Older People, 3rd Floor, Stewarts Hospital, Palmerstown, Dublin 20
The work of the SAT Working Group and the many health professionals, older people and their families who gave willing of their time to participate in this project.
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