Resident Assessment Resident Assessment InstrumentsInstruments

Outcome Measures, MAPLe, Outcome Measures, MAPLe, RUGsRUGs, , QIsQIs

Applications Applications

Assessment

Care Plan

Outcome Measures Quality Indicators

Case-Mix Algorithm

Prevent GamingEvaluateBest Practices

Funding

Report CardsQuality Improvement

Accreditation

Development Time Line for Development Time Line for interinterRAIRAI InstrumentsInstruments

20042004

20052005

20062006

20072007

20032003

20092009

20082008

20022002

20012001

20002000

19991999

19981998

19971997

19961996

19951995

19941994

19931993

19921992

19911991

19901990

interRAI LTCFRAI 2.0RAI 1.0

interRAI MHRAI-MH 2.0RAI-MH 1.0

interRAI AC

interRAI HC

interRAI PAC

interRAI PC

interRAI AL

RAI-HC 2.0

RAI-AC 1.0

RAI-PAC 1.0

RAI-AL 1.0

RAI-PC 1.0

interRAI CMH

interRAI ID

RAI-HC 1.0

interRAI ESP

interRAI CHIP

interRAI CHAinterRAIScreener

Implementation and Testing of Implementation and Testing of interinterRAIRAI InstrumentsInstruments

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

RAI 2.0RAI-HCRAI-MHinterRAI-CMHinterRAI-ESPinterRAI-PCinterRAI-IDinterRAI-ER/ACinterRAI-CHIPinterRAI-CHA

MAPLeMAPLe

MMethod for ethod for AAssigning ssigning PPriority riority LeLevelsvels

Using items in the RAIUsing items in the RAI--HC, seek to identify HC, seek to identify the highest priority home care recipientsthe highest priority home care recipients

Identify those most likely to have Identify those most likely to have caregiver burnout and client caregiver burnout and client institutionalizationinstitutionalization

Derivation of MAPLeDerivation of MAPLe

Dependent variables from RAIDependent variables from RAI--HIP dataHIP data1.1.Actual long term care facility admissionActual long term care facility admission2.2.Caregiver stressCaregiver stress3.3.Better off elsewhereBetter off elsewhere

Independent variables chosen throughIndependent variables chosen throughExpert panel inputExpert panel inputReview of literatureReview of literatureCrosswalk to existing Ontario eligibility Crosswalk to existing Ontario eligibility

Derivation of MAPLe: DataDerivation of MAPLe: DataDerivation sampleDerivation sampleOntario CCAC clientsOntario CCAC clients

Validation samplesValidation samples CanadaCanada

Nova Scotia home care clientsNova Scotia home care clientsManitoba home care clientsManitoba home care clientsBritish Columbia MDSBritish Columbia MDS--HC study sampleHC study sampleNewfoundland FANS study sample Newfoundland FANS study sample Preventive home visits RCTPreventive home visits RCT

US (courtesy interUS (courtesy interRAIRAI))Michigan home care clientsMichigan home care clientsGeorgia home care clientsGeorgia home care clients

International (courtesy interInternational (courtesy interRAIRAI) )

Relationship between MAPLe and Relationship between MAPLe and admission to long term care admission to long term care

facilities in Ontariofacilities in Ontario

02468

101214161820

Low Mild Moderate High Very High

MAPLe Priority Level

% t

o LT

C in

90

days

..

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

Canadian ProvincesCanadian Provinces

0

10

20

30

40

50

60

Low Mild Moderate High Very High

MAPLe Priority Level

% c

areg

iver

str

ess

Ontario British Columbia Nova Scotia Manitoba

Case PresentationCase Presentation

Demonstrate RAIDemonstrate RAI--HC measures and scales HC measures and scales against a backdrop of policy change and against a backdrop of policy change and client characteristics over timeclient characteristics over timePolicy Change: reduction in homemaking Policy Change: reduction in homemaking for home care clients: 2001for home care clients: 2001Waterloo CCAC data: 2000 Waterloo CCAC data: 2000 20052005

MAPLe distribution, Waterloo MAPLe distribution, Waterloo CCAC: 2000 CCAC: 2000 20052005

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

2000

2001

2002

2003

2004

2005

very highhighmediummildlow

Survival Plot: CHESS and death in 8 Survival Plot: CHESS and death in 8 Ontario CCACsOntario CCACs

CHESS = 5

CHESS=0

Depressive Symptoms & Physical Depressive Symptoms & Physical ActivityActivity

(days out of the house in a week)(days out of the house in a week)

0%

2%

4%

6%

8%

10%

12%

14%

16%

% w

ith D

RS 3

+

every day 2-6 days 1 day none

* Ontario year 2004 RAI-HC, 42 CCACs, n=123,647

Case Mix: RUGIII/HCCase Mix: RUGIII/HC

Case Mix ClassificationCase Mix Classification

Wish to model or predict variation in cost for a Wish to model or predict variation in cost for a health servicehealth serviceConstruct rules that allow cases with similar Construct rules that allow cases with similar resource utilization to be grouped togetherresource utilization to be grouped togetherExpected resource intensity can be calculated for Expected resource intensity can be calculated for each groupeach groupThe resulting system is used to estimate the The resulting system is used to estimate the expected resource utilization of a mix of casesexpected resource utilization of a mix of casesUseful in comparing agencies or providers to Useful in comparing agencies or providers to each other or over timeeach other or over time

RUG III (long term care)RUG III (long term care)Hierarchical categorizationHierarchical categorizationAssigned first to one of 7 groups:Assigned first to one of 7 groups:

1.1. Special RehabilitationSpecial Rehabilitation2.2. Extensive ServicesExtensive Services3.3. Special CareSpecial Care4.4. Clinically ComplexClinically Complex5.5. Impaired CognitionImpaired Cognition6.6. Behavioural ProblemsBehavioural Problems7.7. Reduced Physical FunctionReduced Physical Function

Secondary splits primarily based on: Secondary splits primarily based on: services received, depression, and ADL services received, depression, and ADL

RUGRUG--III/HCIII/HC

Designed Designed a prioria priori to be compatible with RUG III for long to be compatible with RUG III for long term careterm careDesigned for Designed for long termlong term home care clientshome care clientsInstrument and performance issues required some Instrument and performance issues required some departures from RUG IIIdepartures from RUG IIIIADL impairment used as additional splitting variableIADL impairment used as additional splitting variable

Reference: Bjorkgren, M., Fries, B. E., & Reference: Bjorkgren, M., Fries, B. E., & ShugarmanShugarman, L. , L. R. (2000). A RUGR. (2000). A RUG--III CaseIII Case--Mix System for Home Care. Mix System for Home Care. Canadian Journal on AgingCanadian Journal on Aging, 19, 106, 19, 106--123 123

(1) Rehabilitation(1) Rehabilitation

Requirement: 120 minutes or more of Requirement: 120 minutes or more of therapy (physical, occupational, or therapy (physical, occupational, or speechspeech--language) in the last 7 dayslanguage) in the last 7 days3 sub3 sub--categories based on ADL and IADLcategories based on ADL and IADL

(2) Extensive Services(2) Extensive Services

Minimum ADL impairment AND at least 1 Minimum ADL impairment AND at least 1 of:of: TracheostomyTracheostomy RespiratorRespirator Other respiratory treatmentOther respiratory treatment

Assignment based on receipt of 1, 2 or 3 Assignment based on receipt of 1, 2 or 3 of the above treatmentsof the above treatments

(3) Special Care(3) Special CareMinimum ADL impairment and one or more Minimum ADL impairment and one or more of the following:of the following:

Stage 3 or 4 Pressure UlcerStage 3 or 4 Pressure Ulcerreceived enteral tube feedingreceived enteral tube feedingdiagnosis of MSdiagnosis of MStreatment for burnstreatment for burnsradiation treatmentradiation treatmentreceiving intravenous treatmentreceiving intravenous treatmenttreatment for fever and one or more of: treatment for fever and one or more of:

dehydrateddehydrateddiagnosis of pneumoniadiagnosis of pneumoniavomitingvomitingunintended weight lossunintended weight loss

(4) Complex Care(4) Complex CareAny of the following:Any of the following:

dehydrated dehydrated any stasis ulcerany stasis ulcerendend--stage diseasestage diseasechemotherapychemotherapyblood transfusionblood transfusionskin problemskin problemdiagnosis of cerebral palsy (ICD code)diagnosis of cerebral palsy (ICD code)diagnosis of urinary tract infectiondiagnosis of urinary tract infectiondiagnosis of diagnosis of hemiplegiahemiplegiadialysis treatmentdialysis treatmentdiagnosis of pneumoniadiagnosis of pneumoniaone or more of the 7 criteria under Special Careone or more of the 7 criteria under Special Careone or more of the 3 criteria under Extensive one or more of the 3 criteria under Extensive

ServicesServicesSplit on ADL, and for lowest ADL splits on IADLSplit on ADL, and for lowest ADL splits on IADL

(5) Cognitively Impaired(5) Cognitively Impaired

Cognitive Performance Scale 3 or moreCognitive Performance Scale 3 or moreSplit on ADL, and for lowest ADL splits on Split on ADL, and for lowest ADL splits on IADL IADL

(6) Behaviour Problem(6) Behaviour Problem

One or more of:One or more of: WanderingWandering Verbally abusiveVerbally abusive Physically abusivePhysically abusive Socially inappropriateSocially inappropriate HallucinationsHallucinations

Split on ADL, and for lowest ADL splits on Split on ADL, and for lowest ADL splits on IADLIADL

(7) Reduced Physical Function (7) Reduced Physical Function

Split on ADL, and for lowest ADL splits on Split on ADL, and for lowest ADL splits on IADLIADL

Michigan & Ontario CMIs: Michigan & Ontario CMIs: Formal & Informal CostFormal & Informal Cost

0

0.5

1

1.5

2

2.5

3

RB RA2 RA1 SE1 SSB SSA CC CB CA2 CA1 IB IA2 IA1 BB BA2 BA1 PD PC PB PA2 PA1

Michigan Ontario

Development of Home Care Development of Home Care Quality Indicators (HCQIs)Quality Indicators (HCQIs)

interinterRAIRAI HCQI CommitteeHCQI Committee Members from Canada, USA and JapanMembers from Canada, USA and Japan

Working groups in Canada and MichiganWorking groups in Canada and MichiganTotal of 22 HCQIs developed (Total of 22 HCQIs developed (19 have risk adjustment19 have risk adjustment))HCQIs all developed from items within RAIHCQIs all developed from items within RAI--Home Care Home Care (RAI(RAI--HC) instrumentHC) instrument

References:References:1.1. Hirdes, Fries, Morris, et al. (2004). Home Care Quality Hirdes, Fries, Morris, et al. (2004). Home Care Quality

Indicators (Indicators (HCQIsHCQIs) Based on the MDS) Based on the MDS--HC. HC. The The GerontologistGerontologist. 44:5 665. 44:5 665--679.679.

2.2. Dalby, Hirdes, Fries. (2005). Risk adjustment methods for Dalby, Hirdes, Fries. (2005). Risk adjustment methods for Home Care Quality Indicators (Home Care Quality Indicators (HCQIsHCQIs) based on the ) based on the minimum data set for home care. minimum data set for home care. BMC Health Services BMC Health Services ResearchResearch. 5:7. . 5:7. http://www.biomedcentral.com/1472http://www.biomedcentral.com/1472--6963/5/76963/5/7

Sample of some HCQIsSample of some HCQIs

Prevalence of inadequate Prevalence of inadequate mealsmealsPrevalence of weight lossPrevalence of weight lossPrevalence of dehydrationPrevalence of dehydrationPrevalence of not Prevalence of not receiving med reviewreceiving med reviewPrevalence of ADL/rehab Prevalence of ADL/rehab potential and no therapiespotential and no therapies

Failure to Failure to improve/incidence of improve/incidence of bladder incontinencebladder incontinenceFailure to Failure to improve/incidence of skin improve/incidence of skin ulcersulcersFailure to Failure to improve/incidence of improve/incidence of decline on ADL long formdecline on ADL long form

Prevalence

(exclude newly on service)

Incidence

(require current and previous assessment)