ABSTRACT BOOK...Prior to joining CIHI in 2014, Mr. O’Toole spent more than 20 years in the Ontario public sector, including as deputy minister of Natural Resources, deputy minister

ABSTRACT BOOK

2

Contents Keynote speakers ............................................................................................................................................... 4

Keynote 1 - Nigel Millar .................................................................................................................................... 4

Keynote 2 - Len Gray ......................................................................................................................................... 5

Keynote 3 - David O'Toole ................................................................................................................................ 6

Keynote 4 - Lynn Martin and Chantal Van Audenhove ..................................................................................... 7

Keynote 5 - John P. Hirdes ................................................................................................................................. 9

Meet the Experts .............................................................................................................................................. 10

Expert 1 – Brant Fries ...................................................................................................................................... 10

Expert 2 – Ulla Harriet Finne-Soveri ............................................................................................................... 11

Expert 3 – Shannon Stewart ............................................................................................................................. 12

Oral presentations ........................................................................................................................................... 13

Session 1: Frailty .............................................................................................................................................. 13

Session 2: interRAI Check-Up ......................................................................................................................... 16

Session 3: Quality of Care ................................................................................................................................ 19

Session 4: Palliative Care 1 .............................................................................................................................. 22

Session 5: Nursing home care 1 ....................................................................................................................... 24

Session 6: Training ........................................................................................................................................... 27

Session 7: Implementation 1 ............................................................................................................................ 30

Session 8: Mental Health .................................................................................................................................. 33

Session 9: Cognition ........................................................................................................................................ 36

Session 10: Community Care ........................................................................................................................... 39

Session 11: Transitions in care ......................................................................................................................... 42

Session 12: LTC ............................................................................................................................................... 45

Session 13: Home Care 1 ................................................................................................................................. 48

Session 14: Emergency Departments ............................................................................................................... 51

Session 15: Implementation 2 .......................................................................................................................... 54

Session 16: Palliative Care 2 ............................................................................................................................ 57

Session 17: Acute and Post- Acute Care .......................................................................................................... 61

Session 18: Policy 1 ......................................................................................................................................... 64

Session 19: Mental Health 2 ............................................................................................................................. 67

Session 20: Family Carers ................................................................................................................................ 70

Session 21: Medication .................................................................................................................................... 73

Session 22: Complexity of Care ....................................................................................................................... 76

Session 23: Quality of life ................................................................................................................................ 79

Session 24: Hospital and Community Care ...................................................................................................... 81

Session 25: Nursing homes 2 .......................................................................................................................... 83

Session 26: Implementation and Policy ........................................................................................................... 86

3

Session 27: End-of-life ..................................................................................................................................... 89

Session 28: Home Care 2 ................................................................................................................................. 92

Session 29: Care Planning ................................................................................................................................ 95

Session 30: Children's instruments ................................................................................................................... 98

Session 31: Home Care 3 ............................................................................................................................... 102

Session 32: Long term Care 2 ........................................................................................................................ 105

Session 33: Policy 2 ....................................................................................................................................... 108

Session 34: Transitions................................................................................................................................... 111

Session 35: Case-mix ..................................................................................................................................... 114

Symposia .......................................................................................................................................................... 116

Symposium 1: Using interRAI 'big data' to promote person-centered approaches, practices and systems .... 116

Symposium 2: Cross National Research with interRAI Mental Health Instruments: Current and Future

Initiatives ........................................................................................................................................................ 118

Symposium 3: Development and validation of an Optimized Photograph-supported interRAI Oral Health-

related Section ................................................................................................................................................ 121

Symposium 4: The interRAI Check-up Self Report version: A New Assessment System for Primary Care 125

Symposium 5: BelRAI 2.0: the implementation of the interRAI instruments in Belgium ............................. 127

Symposium 6: What can we learn from the implementation of the interRAI Suite in seven countries? Case

study research on process characteristics and lessons learned ....................................................................... 129

Symposium 7: National perspectives on Acute Care Utilization ................................................................... 135

Symposium 8: BelRAI as part of the Flemish Social Protection policy: How to get from policy to

implementation ............................................................................................................................................... 139

Symposium 9: InterRAI Education Pick ‘n’ Mix: a sample of educational approaches and training methods

for interRAI from around the world ............................................................................................................... 142

Symposium 10: interRAI roll-out in residential care: practical experiences in Belgium and The Netherlands

........................................................................................................................................................................ 146

Symposium 11: Can we Identify best practice organisations caring for vulnerable older care recipients?

Findings from The IBenC study ..................................................................................................................... 148

Symposium 12: interRAI in Finland: 20 years and going stronger -impact on legislation, leadership &

management, Quality of Care ......................................................................................................................... 151

Symposium 13: The interRAI Acute Care: development, validation, implementation, evaluation, and

integration into practice .................................................................................................................................. 154

Symposium 14: Using interRAI to support care planning in mental health care ........................................... 158

Symposium 15: The interRAI Mental Health and Addictions Suite of Instrument: From Research to “Real

World” Use..................................................................................................................................................... 161

Symposium 16: Using BelRAI in Flanders: experiences from home care ..................................................... 163

Poster presentations ...................................................................................................................................... 165

Poster Session 1 .............................................................................................................................................. 165

Poster Session 2 .............................................................................................................................................. 186

4

Keynote speakers KEYNOTE 1 - NIGEL MILLAR

InterRAI assessment in New Zealand – why we did and how it is going

Nigel Millar

Southern District Health Board, New Zealand

Short Bio: Nigel joined the Southern District Health Board (DHB) in New Zealand in March 2016 as Chief

Medical Officer and physician. Nigel is an InterRAI Fellow for New Zealand and continues clinical practice

Geriatric Medicine whilst working as a clinical leader in health transformation in the Southern-most part of New

Zealand.

Being a small and isolated country on the edge of the planet makes it an imperative to engage actively

with world leading health systems. A population of 4 million is a small base to create the intellectual

capability to develop every health technology. In summary we needed partners to build strength in our

health care systems for older people.

New Zealand has taken a long term strategic approach to implementing and utilising InterRAI

assessment systems for older people. This began in 2001 with a chance encounter at the World Congress

of Gerontology 2001 in Vancouver. Following this the InterRAI community internationally was most

supportive in helping the idea grow in New Zealand.

A vision for assessment of older people using InterRAI as an exemplar was developed locally and

promoted across the health sector. This was included in the 2002 Health of Older People Strategy “The

Ministry, in collaboration with DHBs, will develop an implementation plan and guidelines for

comprehensive integrated assessment for older people and their carers.” Having a clear national policy

statement was the starting point of success. A guideline for assessment was developed and then an

independent academic review of available assessments. These pointed toward the InterRAI programme

as being the best available option.

All the elements of the vision have made progress and now assessments for Long Term Care (LTCF),

and Home Care (HC) are nationally mandate. Palliative Care (PC), Contact Assessment (CA) and

Community Health Assessment (CHA) are also actively used. This is all done on one national

assessment IT system with an associated national training and accreditation programme for assessors.

Taking a national implementation approach has resulted in a single nationally coordinated programme

of high quality and, of course, a large consolidated data set for research.

The InterRAI assessment programme is firmly embedded in the New Zealand Health System and has

long term plan. It provides a framework to support international cooperation that greatly benefits the

people of New Zealand and hopefully other countries. We are indebted to the founding work of the

InterRAI group.

5

KEYNOTE 2 - LEN GRAY

Integrating functional assessment into the acute hospital setting: the interRAI Acute Care

Hospital Systems

Len Gray

The University of Queensland, Australia

Short Bio: Professor Len Gray is the Director of the Centre for Health Services Research and Professor in

Geriatric Medicine at the University of Queensland, Brisbane, Australia. Within interRAI, he coordinates

development of hospital systems. Beyond interRAI, his research interests involve telehealth, decision support, re-

engineering health care delivery and policy development.

Functional and psychosocial issues are common among hospital patients. They influence the care

required, the care outcomes and the cost of care. Documentation of these issues appropriately falls to

nursing staff, as they are best placed to observe and respond to these issues. However, these problems

should influence the care delivered by all other contributing professionals.

Current hospital systems that capture this information are highly inconsistent, with lack of

standardisation. Different approaches are used in the various hospital settings. This results in poor

compliance, very limited secondary use of the information for care planning, clinical decision support,

service planning or outcome assessment, and lack of data sharing across the hospital continuum and

beyond. The interRAI hospital systems were designed to overcome these deficiencies.

In this presentation, the key design features will be illustrated, together with a commentary on the

particular challenges associated with introducing such systems into the hospital context.

6

KEYNOTE 3 - DAVID O'TOOLE

Canada and the InterRAI: Experiences in Data, Care, Outcomes and Strategy

David O'Toole

Canadian Institute for Health Information (CIHI), Canada

Short Bio: David O’Toole is President and CEO of the Canadian Institute for Health Information (CIHI), and the

Chair of the Board of Directors of the Kingston Health Sciences Centre. Prior to joining CIHI in 2014, Mr.

O’Toole spent more than 20 years in the Ontario public sector, including as deputy minister of Natural Resources,

deputy minister of Northern Development, Mines and Forestry, and assistant deputy minister in the Cabinet

Office.

David O’Toole, President and CEO of the Canadian Institute for Health Information (CIHI), will

describe Canada’s experience in implementing the InterRAI suite of instruments including key factors

for success, lessons learned, and some of the resulting impacts on health policy, and clinical and

population health outcomes. This discussion will contemplate the InterRAI suite in the broader context

of emerging data ecosystems, where these longitudinal data sets can be optimized as strategic data assets

at local, national and international levels. Finally, he will discuss some of the foundational building

blocks that will pave the way for the future including a strong data infrastructure, good data governance,

appropriate public engagement, and space to encourage innovation between research communities and

the public & private sectors.

7

KEYNOTE 4 - LYNN MARTIN AND CHANTAL VAN AUDENHOVE

Using interRAI "big data" to create responsive, person-directed practices, policies, and systems

Lynn Martin

Lakehead University, Canada

Short Bio: Dr. Lynn Martin is a Professor and Chair of the Department of Health Sciences at Lakehead University

in Thunder Bay, Ontario, Canada. She is a Fellow of interRAI and member of its Instrument, Systems, and

Development (ISD) Committee, and leads work related to the interRAI Intellectual Disability assessment system.

The interRAI suite of assessment systems consist of items, measures, algorithms, and planning

protocols that provide information on the strengths, preferences, and needs of individuals. This means

that person-centeredness is also the foundation on which interRAI assessment systems are built. So why

is it that the first question every interRAI fellow gets is: “Is interRAI person-centered?”

The session will focus on the ways in which person-centred approaches to data collection, interpretation

and use are the foundation on which interRAI and the "big data" produced by its assessment systems

relies, and on which responsive, person-directed systems are built.

8

interRAI and person-centered care

Chantal Van Audenhove

LUCAS - KU Leuven, Belgium

Short Bio: Chantal Van Audenhove is clinical psychologist and full professor at the KU Leuven Department of

Public Health and Primary Care. As director of LUCAS, the Centre for Care Research and Consultancy of KU

Leuven her focus is on practice- and policy oriented research in care and social welfare. As promotor-coordinator

of the Policy Research Centre for Welfare, Public Health and Family (SWVG) she is responsible for the

management of a network of researchers all over Flanders. Her research mainly focuses on mental health and care

for persons with dementia. Within mental health care, her main research topics are: Community mental health

care and mental health reform, prevention of depression and suicide, stigma and discrimination, shared decision

making and vocational rehabilitation. More info: www.kuleuven.be/LUCAS

The session will focus on the use of interRAI in the context of important innovations and transitions in

mental health care. What are important contributions and challenges of interRAI use at the system level,

the organizational level and in the clinical context? What challenges do we have to tackle to guarantee

high quality person-centered care?

9

KEYNOTE 5 - JOHN P. HIRDES

Mental health over the life course: Use of interRAI systems to support recovery across the

continuum of care

John P Hirdes

University of Waterloo, Canada

Short Bio: Dr. Hirdes is Professor in the School of Public Health and Health Systems, University of Waterloo.

He is Chair of the University’s Committee on Student Mental Health. He is the Senior Canadian Fellow and Board

Member of interRAI. He chairs interRAI's Network for Mental Health and the interRAI Network of Canada.

This presentation will examine the use of interRAI’s mental health assessment and screening systems

to support the strengths, preferences, and needs of persons living with mental illness over the life course.

It will include an overview of how these instruments utilize shared decision-making to support recovery

from both clinical and subjective, personal perspectives.

10

Meet the Experts EXPERT 1 - BRANT FRIES

interRAI case-mix systems, including Resource Utilizations Groups

Brant Fries

interRAI, United States of America

Dr. Brant E. Fries is a founder and President of interRAI, and an Emeritus Professor of Health

Management and Policy and Research Professor of Internal Medicine at the Division of Geriatrics and

Palliative Medicine at the University of Michigan.

He is a principal author of the Resource Utilization Groups (RUG-IV) system for classifying nursing

home residents, used nationwide to pay over $33million per year to United States nursing homes under

the federal Medicare system, and co-authored the National Nursing Home Resident Assessment

Instrument (RAI) used in every US nursing home.

Within interRAI, he is has co-authored assessment systems for aging persons, prisoners in correctional

facilities, and caregivers. His research has worked with US states and international governments to

develop better decision-making, from the clinical to policy level.

He has authored 38 books and over 150 peer-reviewed articles on long-term care and quantitative

modeling of health care systems.

11

EXPERT 2 - ULLA HARRIET FINNE-SOVERI

interRAI Quality Indicators

Ulla Harriet Finne-Soveri

Institute for Health and Welfare, Finland

Harriet Finne-Soveri, M.D. Ph.D is vice president of interRAI and leader for the interRAI committee

for strategic planning and operations. She acts as a guest visiting professor at the Institute for Health

and Welfare, right under the Ministry of Social Welfare and Health. She has acted as chief medical

officer for the elderly care services, in Helsinki city, Finland, covering a clientele of approximately 9

000 home care clients and 6500 long-term care residents. She has acted as principal investigator for

Finland in several European Commission funded research programs, Such as Ad-HOC (Quality of

home-care, in Europe), SHELTER (Quality of long-term care facilities, in Europe), IBENC (Quality

and cost efficiency of home-care, in Europe), And PACE (Quality of dying in long-term care facilities,

in Europe).

Her research areas cover clinical fields such as nutrition, pain, rehabilitation, and appropriate use of

medications in the old age. The areas also cover elderly care services, particularly issues such as quality

of care, work-load and skill-mix of the staff, payment systems, job satisfaction, and different fields of

leadership and management. Her main occupation and research interests have, since 2005, focused on

how to organize elderly care services with highest possible quality and cost efficiency, and on the impact

of different policies on those issues. She is member of EAMA (European Academy for Medicine of

Ageing).

12

EXPERT 3 - SHANNON STEWART

interRAI Children and Youth instruments

Shannon Stewart

Western University, Canada

Dr. Stewart is a Registered Psychologist and joined the Faculty of Education at Western University in

the area of Applied Psychology in July of 2014. In addition to being an Associate Professor within the

Faculty of Education, she is also the Clinical Training Director in the School Psychology and Applied

Child Program. Additionally, she is an Adjunct Assistant Professor within the Department of

Psychiatry, Child and Adolescent Division at Schulich School of Medicine at Western University. She

is also an Associate Scientist at the Children’s Health Research Institute (CHRI) as well as an interRAI

Research Fellow. As an interRAI Research Fellow, she is leading the international development efforts

of the interRAI Child and Youth mental health suite of instruments.

She holds several grants at the National and International levels concentrating on improving services

for vulnerable children and youth exhibiting mental health struggles.

Her overarching program of research focuses on:

1. Improving early identification of child and youth mental health and substance use

2. Enhancing access to mental health care services

3. Contributing to increased evidence-informed care planning to improve the functionality of

mental health services across multiple service sectors

13

Oral presentations SESSION 1: FRAILTY

Chair(s): Nancye M. Peel

Assessing frailty among home service recipients using a frailty index derived from the interRAI-

HC: Findings from the “fraXity” study

Catherine Ludwig1, Catherine Busnel2

1Geneva School of Health Sciences, HES-SO, Switzerland; 2Geneva institution for homecare and

assistance (imad), Switzerland

Abstract summary: The “fraxity” study uses a frailty index (FI) derived from the interRAI-HC to assess frailty

among older adults receiving either home care or assistance and individuals free of formal home services. Result

demonstrate reliable FI differences across groups and support the usefulness of frailty screening in populations

with different needs.

Keywords: homecare, frailty, screening

Background: Frailty is multidimensional nonspecific state of vulnerability that increases risks of

dependence and adverse health outcomes. In a context of population aging, scholars and clinicians

recommend its early screening. Current evidence demonstrates that data collected with interRAI

instruments can serve to derive a frailty index (FI), hence tooling up health professionals for frailty

screening. The “fraXity” study described elsewhere [1] applies this approach to community dwelling

adults aged 65 or older living in Geneva, Switzerland, with an aim of comparing frailty in individuals

receiving home care or assistance, to individuals free of formal home services.

Methods: Participants were recruited in the community using a convenient sampling method. All

participants received an interRAI-HC assessment completed by questionnaires documenting

sociodemographic outcomes. Four trained nurses collected the data at the participants’ home. An

algorithm initially proposed for the Swiss RAI-HC served to derive the FI. Data were analyzed using

descriptive and inferential statistics. Regression modelling served to assess group differences.

Results: The sample consisted in 231 participants (77.5% women, aged 79.4 ± 8.1 years); 67 recipients

of home care, 73 of home assistance and 91 were free of formal home services. To the exception of age,

groups did not significantly differ on sociodemographic characteristics. All three groups differed

significantly on the FI with the Controls group showing the lowest value (FI=0.14, 95%CI=[0.12.-

0.15]) followed by the Assistance group (FI=0.20, 95%CI=[0.18.-0.22]) and by the Care group

(FI=0.27, 95%CI=[0.25.-0.29]). Group differences remained significant after the effect of age was

partialled out. Discussion: Findings support the potential usefulness of a FI derived from interRAI-HC

to distinguish different types of home service recipients. They also support the relevance of frailty

screening not only for home care recipients, but also for individuals receiving home assistance. A

detailed analysis of the deficit patterns across groups should allow identifying specific targets for

implementing adapted preventive strategies.

References:

[1] BMC Geriatr. 2019;19(1):207. doi:10.1186/s12877-019-1230-z

14

Frailty: is it just about older people?

Nancye M. Peel, Natasha Reid, Ruth E. Hubbard


Abstract summary: Frailty is prevalent across the age range of patients in acute care indicating that universal

screening and assessment is needed to identify issues contributing to patient complexity and risk of harm.

Keywords: frialty, assessment, acute care

Background: Frailty is largely considered a geriatric syndrome, since it increases with age and is

associated with adverse outcomes. However, the presence of frailty is rarely investigated in younger

and middle aged adults. This study aimed to measure frailty in a sample of hospitalised adults across

age groups and investigate if variables that contribute to frailty differ among younger, middle-aged and

older adults.

Methods: A prospective cohort study was conducted in four hospitals in Australia during September

2015 to June 2016, recruiting patients aged 18 and over. Research nurses assessed patients at admission

using the interRAI Acute Care instrument. A frailty index (FI) was derived from the instrument, based

on accumulated deficits over multi-domains including cognitive function; communication; mood and

behaviour; physical function; continence; number of comorbidities; health conditions; nutritional status;

skin integrity and number of medications. Comparison of mean FIs (ANOVA) was conducted across

three age groups- younger adults (18-49 years), middle-aged (50-69 years), and older adults (≥70 years).

The distribution of domains contributing to the FI was also examined by age group.

Results: The median age of participants (n = 910) was 66 years (range 18-99) and 48% were female.

Mean frailty index increased significantly across the age categories, such that younger adults (n=214)

were least frail with a mean (SD) frailty index of 0.19 (0.10), increasing to 0.23 (0.11) for middle-aged

adults (n=303) and 0.32 (0.14) for older adults (n=393). Approximately 27% (n=57) of younger adults

and 40% (n=122) of middle-aged adults were found to be frail (FI > 0.25), compared with 66% (n=261)

of older adults (p<0.001). In those who were frail in each age category, the proportion of patients

exhibiting deficits in communication, continence, health conditions, polypharmacy (≥ 5 regular

medications), and comorbidities (≥3) was significantly higher in older adults. Proportions with deficits

in categories including cognition, mood and behaviour, physical function (activities of daily living) and

nutrition did not differ significantly by age group.

Conclusions: The high prevalence of frailty in adult in-patients indicates that universal screening and

assessment is needed to identify issues contributing to patient complexity and risk of harm.

15

A “genetic algorithm-based approach” to optimize the construction of a frailty index in the

interRAI suite

Davide Liborio Vetrano1,2, Alberto Zucchelli3, Graziano Onder2, Angelo Carfì2, Emanuele Rocco

Villani2, Roberto Bernabei2

1Aging Research Center, Karolinska Institutet, Stockholm, Sweden; 2Catholic University of Rome,

Italy; 3Department of Clinical and Experimental Sciences, University of Brescia, Italy

Abstract summary: Using a “genetic algorithm”, we built a frailty index (FI) to predict 1-year mortality in NH

residents assessed with the InterRAI LTCF participating in the SHELTER study. The best generated FI presented

an AUC of 0.701. The genetic algorithm is a feasible method to build highly performant FI.

Keywords: frailty, nursing home, genetic algorithm

Background. The frailty index (FI) is a reliable prognostic indicator based on an individual’s clinical

and functional deficits, which is strongly associated with poor outcomes. We hypothesize that an

optimization algorithm may help to select the best candidate deficits to generate a highly-predictive FI.

Aim. We aimed to optimize the predictive accuracy (area under the curve; AUC) of a FI employing a

“genetic algorithm”, an iterative meta-heuristic that selects and recombines the most accurate FIs among

randomly-generated ones. We used data from 4156 nursing home residents participating in the Services

and Health for Elderly in Long TERm care (SHELTER) project, assessed with the InterRAI LTCF tool.

To avoid overfitting, the algorithm was run on a randomly-chosen subsample (70%) of 10 imputed

datasets. One-year mortality was chosen as an outcome.

Results. About 825,000 FIs were built, evaluated, and recombined. The best FI included 31 deficits and

showed in the test subsample (30% of the population) an AUC of 0.701. In the same subsample, the

predictive accuracy of other commonly used measures was lower: NH frailty scale AUC=0.677;

Hierarchical Activities of Daily Living (hADL) scale AUC=0.652. Changes in Health, End-Stage

Disease, Signs, and Symptoms (CHESS) Scale AUC=0.607. Subgroups analyses (based on sex and age)

will be presented.

Conclusions. The genetic algorithm is a feasible method to optimize the construction of a highly

performant FI that might be used to assess health comprehensively both in clinical and research settings.

16

SESSION 2: INTERRAI CHECK-UP

Chair(s): Nathalie Isabelle Helena Wellens

Early decline in independent community dwellers using the interRAI Check Up

Nathalie Isabelle Helena Wellens

Head Strategic Program interRAI Implementation Canton Vaud, Department of Public Health

Services and Social Affairs, Lausanne, Switzerland

Abstract summary: The interRAI Check Up was found appropriate to detect early decline in independent

community dwelling home care clients. A two-step approach was introduced to distinguish assessment for

complex versus independent situations. Clinical results and experiences by nurses and health workers in home,

day and short term care will be shared.

Keywords: implementation, interRAI Check Up, home care

Background: Home care services serve a wide variety of persons. In fairly independent persons,

professionals often notice health and social issues beyond the initial service demand. However,

comprehensive geriatric assessment was experienced as inadequate. To ensure timely detection of early

deterioration and unreported needs, a tailored approach is needed.

Methods: A participative public health programme combined implementation research and policy in

collaboration with scientists, project leaders, health workers, international interRAI experts and

software providers. First, current assessment procedures were examined. To find a suitable instrument,

the interRAI Suite was browsed for following criteria: light care profiles, social domains, early decline

detection, a minimum of scales and CAPs, compatibility with interRAI Home Care, use without

extensive expertise, appropriate length. The Check Up -at that time in pre-publication version- was

tested. To distinguish between comprehensive assessment for complex versus independent situations,

the Assessment Urgency Algorithm served as stratification tool. Trained nurses used interRAI tools in

routine practice in a multi-center exploratory study in 5 home care facilities, with emphasis on care

planning and preventive actions. A research team evaluated acceptability, feasibility and cut-offs based

on mixed methods. Two groups were included: nursing care versus services.

Main findings: The two-step approach including stratification to determine differentiated assessment is

shown feasible, acceptable, and efficient. Findings indicate several necessary changes for adoption. The

content was tweaked to the local context. In addition to pilot results, policy decisions reinforced

necessary changes in processes for optimal use, e.g. stratification by reference professionals instead of

the first-point-of-contact; routine visits replacing specialist assessors. The greatest change, both clinical

and financial, is the expansion of systematic assessments by non-nurses.

Throughout the care trajectory of community dwelling independent older persons, the interRAI Check

Up seems a facilitator in situations of co-management between care structures. Therefore it has sparked

interest for testing in short term and day care.

Conclusion: The interRAI Check Up was found appropriate and efficient, resulting in a policy decision

fostering adoption by 1500 health workers in home care services. Pilots in other community structures

are launched and nationwide use is being considered.

17

Assessment of health needs, pain intensity and psychosocial factors among older adults in Cape

Town, South Africa using the InterRai Checkup SR

Simone Steyn, Gabrielle Kelly, Leon Neville Geffen

Samson Institute for Ageing Research, South Africa

Abstract summary: This study describes the health and wellbeing of older adults from four communities in Cape

Town, South Africa and highlights the particular relationship between pain intensity and psychosocial issues.

Keywords: pain intensity, psychosocial factors, older adults

Background: The growing population of older adults in lower and middle-income countries (LMICs)

poses significant challenges to resource-constrained health systems. Focusing on South Africa, this

study contributes to building knowledge on the health, well-being, functional status and needs of older

persons in low-resource settings.

Methods: Using the InterRai Checkup Self-report instrument, multidomain assessments of older people

(n=1830) were conducted in primary care and home settings in four communities in and around Cape

Town, South Africa. The instrument was adapted from the InterRAI Checkup, translated into local

languages, validated for use by non-healthcare workers and administered to older persons (n=1830) by

trained assessors. Statistical analysis was conducted using the R package (v3.3.3) to compute

descriptive statistics and multivariate logistic regression was conducted to test relationships between

pain intensity and other psychosocial covariates.

Results: The total sample comprised mainly females (66%) and the median age was 70 years (range 61-

97). While low levels of functional and cognitive impairment were present, there were high levels of

unmanaged pain, anxiety and depression. 39% of the population reported experiencing moderate or

higher pain intensity, 28% experienced moderate or greater anxiety, and 25% experienced moderate to

high levels of depression. 44% of people reported having recently experienced a major life stressor and

social anhedonia was present in 36% of the population. 51% of the population, and 60% of those in

low-income communities, reported making trade-offs because of financial constraints. 32% of the

population reported loss of 5-10% body weight in the last six months. 28% reported eating one or less

meals in two of the last three days. Having moderate or higher levels of anxiety resulted in 1.92 greater

odds of experiencing pain of moderate or higher levels after adjusting for covariates (OR= 19.2 CI:

0.92, 1.33). Furthermore, 58% reported that their reported that their memory is a problem at least

sometimes and there was relatively high prevalence of urinary incontinence (22%).

Conclusion: Results indicate important gaps regarding the well-being in this population and shows the

need for introducing simplified multi-domain screening assessments that will allow healthcare

professionals and health planners better insights into the needs of older persons.

18

Upskilling of community health workers to gather information using the interRAI Check Up

Self Report tool

Robyn Black, Leon Geffen


Abstract summary: Through appropriate training and support, SIFAR has shown that it is possible to effectively

upskill community health workers, with little to no previous assessor experience, to effectively administer the

interRAI Check Up Self Report as an information gathering tool.

Keywords: Upskilling, Community Health Workers, interRAI Check Up Self Report

We have been piloting the use of the newly developed interRAI Check Up Self Report tool in primary

care settings in urban and rural areas of the Western Cape, South Africa. South Africa is a middle-

income country, and the areas where the project has been rolled out are in lower socio-economic areas.

These areas include; Khayelitsha (urban), Bishop Lavis (urban), Woodstock (urban) and Mamre (rural).

The scope of the pilot project immediately identified the need to recruit and train assessors who could

reliably administer the interRAI Check Up Self Report tool, with little to no guidance post completion

of training. The most efficient and effective way to administer the assessment was to employ and upskill

members of the identified communities as assessors/data gatherers. This paper presents our experiences

in training assessors and provides useful insights into effective teaching techniques implemented to

train people with little assessment experience, to effectively administer an interRAI assessment.

To date (September 2019), we have successfully upskilled 12 community health workers to reliably

administer the interRAI Check Up SR tool. These assessors work independently or in pairs,

administering the assessment and inputting the data into the software system. The assessors range in

age from 22 years old to 73 years old, with three assessors in their 70s. Two assessors have post-

graduate University degrees, 9 assessors have a grade 12 education (with or without some post graduate

courses), and one assessor has only completed grade 10.

Guidance and support has been required throughout implementation of the pilot projects, however there

has been no need for micromanagement. The older data-gatherers have struggled with confidence with

using the software system but continue to persevere.

Our experience with training and upskilling these community health workers has identified that with

appropriate and well-structured initial training, most people with aptitude and drive to learn, can be

trained in the reliable implementation of the interRAI Check Up SR regardless of their level of

education or previous experience.

The use of upskilled community health workers to conduct multi-domain assessments could make it

more feasible to gather valuable information on older persons in low-income settings.

19

SESSION 3: QUALITY OF CARE

Chair(s): Veronique Boscart

Public Reporting of Long-Term Care Quality Indicators: Monitoring, managing and bettering

the health of Canadians

Norma Hall

Canadian Institute for Health Information, Canada

Abstract summary: The Canadian Institute for Health Information in partnership with interRAI, embarked on a

recent initiative to publically report on Quality Indicators. This presentation provides details on the methodology

developed to enable fair comparisons between facilities/jurisdictions, as well as our approach to risk adjustment,

using examples from multiple care sectors.

Keywords: quality, reporting, methodology

The Canadian Institute for Health Information (CIHI) has a unique relationship with interRAI including

a recent initiative to publically report on interRAI Quality Indicators.

Your Health System (yourhealthsystem.ca) was developed at CIHI to provide the public, decision-

makers and facilities with comprehensive information on key health indicators to monitor, help manage

and better understand the Canadian health care system and health of Canadians. It presents comparative

indicators that facilitate sharing of best practices and guide quality improvement strategies. Indicators

were selected to meet the evolving performance information needs of multiple stakeholders, including

9 Quality Indicator (QIs) from the Long-Term Care sector.

When comparing QI rates between facilities, it is important to consider the factors that may affect

residents’ outcomes that are beyond a facility’s control, such as residents’ age or chronic conditions

that existed prior to admission to a facility. To enable more appropriate and fair comparison of the true

quality of care, these population differences are accounted for through a statistical adjustment known

as risk adjustment.

QIs support both clinical and organizational decision-making and are used to monitor care, for

accountability and public reporting; therefore, it is critical that differences in performance between

facilities reflect true performance differences and not statistical anomalies. Building on risk adjustment,

CIHI developed a methodology to help address this challenge based on the concept of random error and

confidence intervals.

This presentation will provide details on the approach CIHI took to developing a methodology to enable

fair comparisons between facilities/jurisdictions in the context of our experience with public reporting

of Quality Indicators. We will share lessons learned as our work continues to grow to meet the evolving

needs of our stakeholders.

20

Improving care through measurement and understanding of interRAI Quality Indicators in a

collaborate long-term care community of practice.

Julie Dawn Weir1, Christina Cormier2

1New Brunswick Association of Nursing Homes, Canada; 2Shannex Inc., Canada

Abstract summary: New Brunswick implemented of the LTCF and Quality of Life surveys provincially in 2017.

Our long-term care leaders are informed and engaged in quality improvement. This community of practice model

of collaboration has demonstrated great success in expanding our reach and influence, crossing our provincial

borders.

Keywords: quality improvement, long-term care, evidence-informed

Being a small Canadian Province with 68 community-based Nursing Homes has many advantages. Our

focus on the social model of care, volunteerism and innovative care delivery methods has enabled us to

work collaboratively with a number of different stakeholders to evaluate and improve care. So, it made

logical sense to implement the interRAI LTCF (Long Term Care Facility) assessment and Quality of

Life surveys provincially, for the purpose of gathering data to drive care improvements.

To this end, we have engaged seven of our leading Francophone nursing homes in New Brunswick,

along with two other Francophone long-term care organizations in Canada. With the objective of using

their LTCF and Quality of Life data to compare the quality of these homes across the network, against

themselves historically and against the larger comparator of homes across Canada using interRAI

systems. The bulk of our work is focused on driving changes in quality as it relates to the frail elders

that we are all caring for. These efforts are being supported by grant funding from the Canadian Frailty

Network.

Amongst our newly formed Francophone group, the group has identified an opportunity to focus on the

more tangible quality indicators of restraint use and falls reduction, all the while considering the impact

on Quality of Life for their residents. We are meeting as a group quarterly to review and discuss

strategies undertaken by the homes to improve their quality indicators in a collaborative and supportive

community of practice environment. We hold monthly conference calls between our face to face

meetings to provide that ongoing and regular support.

In the end, we in New Brunswick strive to provide quality of care and quality of life for our residents

that is based on evidence informed best practice. Our member homes work very collaboratively together

and are very informed and engaged in this process of quality improvement. This community of practice

model of collaboration has demonstrated great success in expanding our ability to reach outside of our

own Provincial demographic borders.

21

Nursing Home Administrators’ Perceptions of interRAI Documentation and Reporting to

Provide Quality Care: A Canadian Perspective

Veronique Boscart1, Samantha Yang2, Linda Sheiban Taucar1, Keia Johnson1, Katherine McGilton3

1Conestoga College, Canada; 2University of Toronto, Canada; 3Toronto Rehabilitation Institute,

Canada

Abstract summary: This study explored nursing home administrators’ perceptions of the interRAI Minimum

Data Set (MDS) to promote high quality care for residents. A qualitative analysis of interviews (n=14) revealed

dynamics between MDS perceptions and role, specific skills are needed to collect and interpret data, and

limitations to optimal data use exist.

Keywords: Nursing homes, clinical practice, quality care

This study focused on exploring nursing home (NH) administrators’ perceptions of the interRAI

Minimum Data Set’s (MDS) value to promote high quality care for residents. It is part of a larger

programme examining facilitators, barriers and opportunities to/for regulated nurses’ optimal utilization

of MDS in NH settings and their impact on care quality and organizational outcomes. A qualitative

thematic analysis of individual interviews with six administrators, six directors of care, and two assistant

directors of care (n=14 participants) across seven NHs were conducted. Interviews explored

participants’ perceptions of the MDS and its potential to provide high quality care for NH residents.

Three themes emerged: (1) optimal use of MDS to promote quality care; (2) limitations to utilizing

mandatory MDS documentation to promote quality care; (3) situating NH regulations in promoting

quality of care; and (4) the essential value of communication within care teams. Participants discussed

intriguing dynamics between administrators’ perception of regulator aspects and the role that MDS

could actually play in optimizing care quality. Furthermore, participants identified that a specific skillset

was needed to collect and interpret MDS data in order to improve care quality; a skillset that was not

always present. Perceptions of the use of MDS from an administrator standpoint are revealing in that

they uncover some clear limitations to the optimal use of MDS to improve quality care, however, this

study only covers one part of the story. Further qualitative research is necessary to gain a nursing

perception of MDS use, as is a quantitative exploration of the MDS data.

22

SESSION 4: PALLIATIVE CARE 1

Chair(s): Kirsten Hermans

The interRAI Palliative Care instrument: Better informed palliative care in nursing homes?

Kirsten Hermans1, Nele Spruytte1, Joachim Cohen2, Chantal Van Audenhove1, Anja Declercq1

1KU Leuven, Belgium; 2VUB, Belgium

Abstract summary: This PhD shows that the interRAI PC has many advantages which plead for its use in nursing

homes. However, policy makers, software providers, researchers and clinicians should collaborate to tackle

critical remarks of caregivers in nursing homes as to increase the usefulness, feasibility, face validity and

effectiveness of the instrument.

Keywords: interRAI Palliative Care, nursing homes, older adults

Background: Nursing homes are important locations for palliative care. The use of comprehensive

assessments in nursing homes can support the evaluation of residents’ palliative care needs. The

interRAI Palliative Care instrument (interRAI PC) is a comprehensive assessment that evaluates diverse

palliative care needs of adults in all healthcare settings.

Aims: This PhD aimed to evaluate the comprehensiveness, usefulness, feasibility and face validity of

the interRAI PC in nursing homes. Additionally, it aimed to examine the effect of using the interRAI

PC on the quality of palliative care in nursing homes.

Methods: Phases 0, I and II of the Medical Research Council (MRC) framework were covered. In phase

0, a systematic review was conducted. In phase I, the interRAI PC was adapted for use in Belgium and

implemented on the BelRAI-website, and a practical training was developed. In phase II, the interRAI

PC was tested in 15 nursing homes. Qualitative data regarding the usefulness and face validity of the

instrument were collected through focus groups and interviews. Using a pretest-posttest design with

quasi-random assignment to the intervention or control group, the effect of the interRAI PC on the

quality of palliative care was evaluated with the Palliative care Outcome Scale (POS).

Results: The interRAI PC was evaluated as a useful instrument. However, it was not always feasible to

complete the instrument due to organizational impediments and the complex architecture of the

software. Furthermore, the face validity of the instrument could be improved since certain items were

perceived as lacking, redundant or complex. One year after introducing the interRAI PC, residents’

needs and symptoms were not reduced in the intervention nursing homes. We did find a positive effect

in the subgroup of intervention nursing homes that did not have prior experience with the interRAI

instruments.

Conclusion: The interRAI PC showed many advantages which argue for its use in nursing homes.

However, policy makers, software providers, researchers and clinicians should collaborate in order to

tackle the critical remarks of care professionals to optimize the interRAI PC for use in nursing homes.

23

Use of the InterRAI-PC instrument: experiences of Palliative Care Nurses

Emmanuel Bagaragaza, Frédéric Guirmand, Danièle Leboul

Maison Médicale Jeanne Garnier, France

Abstract summary: The assessment of patients’ needs is a critical step in achieving the goals of palliative care

approach: preventing, relieving, treating physical, psychosocial, and spiritual symptoms. Using InterRAI-PC, as

a comprehensive needs assessment tool, should improving patients' needs identification, nurses' clinical

competencies, and patients-nurses relationship.

Keywords: needs assessment, interRAI-PC, nurses experiences

Context: During research on the validation of interRAI-PC carried out in different PC settings (home,

hospital and PC unity), 80 nurses were involved in the whole process of this research. At the end of the

research, a qualitative study was carried out to gain nurses’ experiences of undertaking research.

Objective: To study the impact and contribution of using a comprehensive needs assessment tool

(InterRAI-PC) to the professional lived experience of PC nurses.

Methods: A qualitative design was used; we held four focus groups comprised thirty nurses from PC

25 settings across France, all were involved in the process of using InterRAI-PC. Qualitative content

analysis, supported by QDA Miner, was conducted by 2 researchers who agreed on a final thematic

tree. Guba’s model was used to support our attention to ensure the trustworthiness of the study.

Results: For the nurses, the interRAI-PC played the role of mediation at four levels. First, its use allowed

to release the free speech and to open the relationship space between caregivers, patients, and relatives;

second, it helped to frame the evaluation and encouraged the nurses to take a specific assessment time

which is appreciated and rewarding for the patients; third, it has provided an effective mechanism for

supporting the nurses’ reflexivity on their clinical practice; finally, the data collected by this instrument

objectified the assessment carried out by nurses and contributed to the positive reinforcement of

professional identity all the while questioning their clinical and evaluative skills. Furthermore, the deep

comprehensive assessment could be a source of tension and guilt for the nurses unable to address

effectively the patient’s needs.

Conclusions: The use of patients’ needs assessment tools in PC can have several effects on clinical

practice other than to identify patients’ needs, it also has an impact on the professionals’ and patients’

experience. Future studies should be interested, not only with the validity and the reliability of the

assessment tools, but also with the impact of their use as perceived by stakeholders.

24

SESSION 5: NURSING HOME CARE 1

Chair(s): Silva Katariina Siponkoski

Utilisation of RAI-LTC information to support older people’s cultural rights and well being in

cooperation between municipalities, at a national level

Silva Katariina Siponkoski

AILI, the national network for art and culture with senior citizens and older people

Abstract summary: RAI-LTC information supports the using of art-based methods in LTC. Utilisation of the

RAI system in the promotion of older people’s cultural rights and well being is possible in cooperation at a national

level.

Keywords: cultural rights, art-based methods, RAI-LTC

In the recent years, the discourse on art’s effects on health and well-being has boomed in Finland. Art

is seen and experienced increasingly in elderly care institutions. Cultural activities and art-based

methods as well as the evaluation of their impact should be integrated as part of rehabilitation and as

part of daily living in long term care. (I.a. Huhtinen-Hilden 2013, 8–16; Huhtinen-Hilden, Puustelli-

Pitkänen, Strandman, Ala-Nikkola 2017, 15; Rosenlöf 2014.)

The focus of Siponkoski’s (2017) study was to research if there is useful information in RAI-LTC-

system that could support the realization of older peoples cultural rights and the planning process of

art-based elderly care . Siponkoski’s (2017) study states that the questionnaires for RAI-LTC include

questions applicable to collect information about clients preferences, goals and cultural background.

Data was collected from RAI-LTC system on the basis on theories of coordinates of agency and

acknowledgement of persona. (Jyrkämä 2008, 190–203, and Pirhonen & Pietilä, 2015, 95–103). For

example, RAI-LTC information gives an opportunity to recognize peer groups and individual

backgrounds sorted by professions, cohorts and education. This kind of information is something, which

professionals should study regardless of resident’s ethnic background. The information should be

examined on both an individuals and the actual housing communities level.

In year 2018 AILI, the national network for art and culture with senior citizens and older people, started

national development project based on Siponkoski’s study. The use of RAI information in the

development of art and culture related work with older people is widely supported in social and health

care and culture services.

Conclusion: RAI-LTC information supports the using of art-based methods in elderly care. It is also

useful tool for knowledge based leading in collaboration between the cultural and health fields.

Utilisation of the RAI system in the promotion of older people’s cultural rights is also possible in

cooperation between municipalities, at a national level. However, RAI-LTC information cannot be the

only source on which the planning is based on.

25

Using Belrai in Long term care facilities in the Flemish part of Belgium, experience from the

field

Bernadette Van den Heuvel, Margot Cloet

Zorgnet-Icuro, Belgium

Abstract summary: Our presentation would focus on the experience of our members in the current use of

BELRAI. We would focus on the pro’s and the con’s expressed by a variety of care providers. We will end our

presentation with positive feedback to the policy makers.

Keywords: long term care, BELRAI, financing

The sixth state reform in Belgium, 1th July 2014, introduced a big division between the regional level

(Flanders, Wallonia, Brussels, German-speaking Community) and the national level. Ignoring the flaws

in this sixth state reform, we could in general state that the organisation and financing of long term care

(and partially the post acute and rehabilitation care) is a regional power and all acute care competencies

remained national. The Flemish region decided to use the BELRAI assessment instruments as common

language between (long term) care providers and has the ground breaking ambition to use BELRAI as

an algorithm in the financing of these care facilities. BELRAI is not yet ready for such use. Many layers

have to be added to the algorithm and tested in real life care situations in the Flemish region. We want

to share our views on the further development of BELRAI.

Zorgnet-Icuro is a federation of more than 750 care institute providers, ranging from hospitals, to mental

health services, to elderly homes and assisted living facilities. Our presentation would focus on the

experience of our members in the current use of BELRAI. We would focus on the pro’s and the con’s

expressed by a variety of care providers (elderly homes, mental health facilities, rehabilitation hospitals)

and the possible use of the different RAI-instruments for people with complex care needs. We will end

our presentation with positive feedback to the policy makers concerning the BELRAI development

process in Belgium/Flanders.

26

Clinical characteristics and drug use of frail nursing home residents in Europe: results from the

SHELTER study

Emanuele Rocco Villani1, Graziano Onder1, Davide Liborio Vetrano1,2, Roberto Bernabei1

1Centro di Medicina dell'Invecchiamento, Department of Geriatrics, Università Cattolica del Sacro

Cuore di Roma and IRCCS Fondazione Policlinico "A. Gemelli", Rome, Italy.; 2Aging Research

Center, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet and Stockholm

University, Stockholm, Sweden

Abstract summary: To evaluate clinical characterics and drug use profile according to frailty status in a sample

of European NH(from the SHELTER study), frailty was defined according to the Frailty-NH score. 1938(46.6%)

participants were frail(mean age 84.6±9.2 years, 76.4% female), with greater prevalence of geriatric syndromes

and different profile in drug therapy.

Keywords: nursing home, frailty, drug use

Background: In Europe, up to 8% of the population aged≥65 years lives in nursing home(NH). NH

population has a greater prevalence of frailty than general population.

Aim: To evaluate prevalence of frailty, related clinical characterics and drug prescription according to

frailty status in a sample of European NH.

Materials and Methods: Multicentre cohort study based on the SHELTER study(Services and Health

for Elderly in Long TERm care) conducted in 7 European countries between 2009 and 2011.

Participants were assessed through the interRAI-Long Term Care Facilities(LTCF). Frailty was defined

according to the Frailty-NH score, based on seven variables: fatigue; reduced mobility; incontinence;

shrinking, difficulties in feeding, transfers and dressing. Cognitive function was evaluate according to

the Cognitive Performance Scale(CPS). Drugs were categorized by ATC codes. Polypharmacy was

defined as concomitant use of≥5 drugs. All the residents whose data were available were included in

this study(4121 participants).

Results: 1938(46.6%) participants were frail(mean age 84.6±9.2 years, 76.4% female). Compared to

non-frail participants, frail ones had a higher rate of moderate-severe cognitive impairment(70.9% vs.

52.7%, p<.001) and impairment in ADLs(89.8% vs. 43.1%, p<.001). Geriatric syndromes such as

polypharmacy(76.4% vs. 71.6%, p<0.001), falls(22.2% vs 14.9%, p <.001), delirium(24.5% vs 15.7%,

p <.001) were more prevalent in frail participants. Neurological comorbidities were more prevalent

among frail participants(Parkinson, 8.7% vs. 5.6%, p <.001; stroke, 28.9% vs. 15.9%, p <.001;

dementia, 22% vs 16.9%, p <.001). Among frail participants there was lower prescription of

NSAIDs(2.5% vs. 5.9%, p<.001), statins(10.8% vs. 17.6%, p<.001), ACE inhibitors(17.2% vs. 26.9%,

p<.001), AR2B(2.9% vs. 8.4%, p<.001), diuretics(28.3% vs. 39.9%, p<.001), beta-blockers(17.8% vs.

25.6%, p<.001), benzodiazepines(32.1% vs. 37.2%, p<.001) and antidementia drugs(7.8% vs. 12.5%,

p<.001). There was greater prescription of opioids(14.8% vs. 12%, p=.007), paracetamol(23.7% vs.

20.6%, p=0.014), antibiotics(6.6% vs. 3.8%, p<.001) and laxatives(48.9% vs. 32.8%, p <.001). There

was no difference for antipsychotics(26.1% vs 25.4%, p=.62) and antidepressants(34% vs. 34.8%,

p=.56)

Conclusions: Frailty is prevalent in European NHs and shows peculiar clinical characteristics, with

greater prevalence of geriatric syndromes and different profile of drug therapy. In prospective studies,

associations between these characteristics and outcomes such as death and hospitalization should be

evaluated.

27

SESSION 6: TRAINING

Chair(s): Brigette Meehan

The Geneva RAI-HC training model: implementation for 650 imad nurses

Christina Gueninchault, Catherine Busnel

Institution genevoise de maintien à domicile, Switzerland

Abstract summary: A specific training process has been created for the 650 nurses at the Geneva home care

institution routinely which use the Resident Assessment Instrument Home Care to assess the overall health status

of patients and set individualized goals. Since 2005, imad has trained nearly 2000 nurses in this evaluation process.

Keywords: training, promotion, pedagocical approaches

The 650 nurses at the Geneva home care institution routinely use the Resident Assessment Instrument

Home Care (RAI-HC) adapted for Switzerland, to assess the overall health status of patients and set

individualized goals. To this end, a specific training process has been created. It is based on the principle

that each nurse providing care also ensures the referral and evaluation of certain situations. In imad,

each nurse manages a portfolio of about 20 patients evaluated at least 2 to 4 times a year. To promote

this clinical role, the training consists of several steps: 1) a collective classroom time, 2) a period of

individual application, 3) local support and 4) validation by a clinical nurse specialist. Educational and

computer-based materials allow nurses to deepen the various stages of clinical analysis from the

collection of clinical data using RAI-HC to the development of the intervention plan. The validation of

the training takes into account the use of RAI-HC, from clinical analysis to the development of the

intervention plan using the problem-solving method. This monthly training course of more than 36

hours is intended for all new nurses. In addition, each year, a session is given to all nurses from the 40

home care teams to ensure that the changes in the RAI HC, data quality and clinical perspectives are

updated. Since 2005, imad has trained nearly 2000 nurses in this evaluation process. Thanks to this

training model, imad has about 15,000 RAIs available annually. The use of the Swiss RAI-HC as an

instrument for standardised assessment of care situations represents a considerable added value, both

for patient care, for the promotion of nursing skills and for the institution in its development and training

strategies. This integration module offers a complete, regular and individualized training program that

promotes the acquisition and updating of nursing skills at home. Within a few months with the

replacement of the Swiss RAI-HC by the interRAI-HC, imad is preparing to adjust its training and

develop new pedagogical approaches.

28

Using interRAI assessment information to inform care: efficiency and cost effectiveness of an

online training programme

Brigette Meehan

TAS, New Zealand

Abstract summary: New Zealand interRAI Services has begun offering online training for health professionals

who wish to read and understand their clients’ interRAI assessments but will not complete the primary assessment.

This is covering an increasing demand from health professionals more widely involved in a person’s care to use

assessment information.

Keywords: training, users, wider care

interRAI assessments can be used as a single point of information collection which can then be

considered when making care planning decisions for the individual.

Our model of interRAI assessment involves a primary assessor having a structured conversation with

the person and relevant others (including clinical notes) and then using their clinical judgement to input

this information into software. In this model the assessor uses the decision support properties in the

assessment to plan a person’s care, sharing the plans as required with the immediate care team. This is

the model of assessment we implemented in New Zealand for community and long-term care facilities

(LTCF) assessments. It worked well.

Increasingly, the value of the assessment findings has been recognised by health professionals more

widely involved in the person’s care, such as rehabilitation therapists, community agencies or general

medical practice.

This created a new demand for training – for health professionals who would like to read and understand

their clients’ interRAI assessments but will not complete the primary assessment.

In this presentation, we will talk about how we developed and use our online “end user” training

launched on 1 August 2019.

The training outcomes include an introduction to interRAI assessment; the ability to navigate the

software (used in New Zealand) to find a specific client’s last assessment or assessment history and

how to interpret the outcome measures derived from the assessment.

The introduction of online end user training increases efficiency – we are able to reach more people and

they can learn when it suits them. It is more cost effective as it removes the demand for face to face

training, and, now that infrastructure is established, it opens the opportunity for providing other courses

that may be suitable for online learning.

Overall this initiative has strengthened interRAI assessment in New Zealand as more value is derived

from that single assessment episode between the assessor and person.

29

iCARE: Building a network of interRAI clinical champions

Veronique Boscart1, George Heckman2, Margaret Saari2, Melissa Northwood3, Caitlin McArthur4,

Leslie Eckel2, Connie Schumacher5, Michelle Heyer1, Meaghan Davey1, Linda Sheiban Taucar1, Erin

Patterson1, Amanda Aguilar Nova2, Geri St-Louis6, Stella Arthur2, Ashley Garner2, John Hirdes2

1Conestoga College, Canada; 2University of Waterloo, Canada; 3McMaster University, Canada; 4Hamilton Health Sciences, Canada; 5Local Health Integration Networks, Canada; 6Canadian

Institute for Health Information, Canada

Abstract summary: The interRAI Clinical Application of Research Evidence (iCARE) group aims to forward

the clinical perspective of interRAI tools and advocate for their clinical utility. This oral presentation will discuss

the network’s development, describe its strategic plan, identify resources used, discuss stakeholder activities

undertaken, and highlight resulting knowledge products.

Keywords: interdisciplinary, knowledge dissemination, clinical practice

The interRAI suite of instruments include metrics across the continuum of care and have clinical,

administrative and research applications so is widely used across long-term care, home care,

rehabilitation and mental health care settings. Suboptimal completion of their assessments and

utilization of their data for decision making, however, has prompted a group of health care professionals

to create the interRAI Clinical Application of Research Evidence (iCARE) group. The aim of this group

is to promote and advance the clinical perspective of interRAI tools and lead knowledge dissemination

of their clinical utility. In part to achieve this goal, this oral presentation will discuss the mechanisms

used to develop and lead a network of interRAI clinical champions; describe the iCARE group’s

strategic plan (including its objectives, accountability structure and stakeholder engagement); identify

resources used to inform meetings and support knowledge products; discuss activities taken to engage

stakeholders (e.g., visiting a hospital using the mental health assessment tools to guide care planning)

and highlight knowledge products that iCARE has developed (including scholarly manuscripts,

conference presentations and news articles). Future steps will focus on expanding the network across

Canada and creating additional structures that allow for focused subgroups. iCARE is determined to

facilitate the clinical application of interRAI’s research evidence.

30

SESSION 7: IMPLEMENTATION 1

Chair(s): Jennifer Berger

Stories of success across sectors – What happens after implementation?

Geri St.Louis, Jennifer Berger


Abstract summary: The Canadian Institute for Health Information (CIHI) launched an interRAI Implementation

Toolkit at the 2016 World interRAI conference. After supporting thousands of implementations, CIHI will present

stories from the perspective of implementing organizations and CIHI to provide insight into lessons learned, best

practices and key success factors for sustaining an implementation.

Keywords: implementation, best practices, stories

Canadian Institute for Health Information (CIHI) is an independent, not-for-profit organization that

provides essential information on Canada’s health systems and the health of Canadians. The CIHI and

interRAI partnership is founded in a commitment to establishing clinical standards that support clinical

care while also providing information for use in policy decisions and management of the health system

including quality improvement.

In the 2016 World interRAI conference, CIHI launched a digital interRAI Implementation Toolkit that

includes practical resources for use by organizations through the implementation of an interRAI

instrument. With an emphasis on everyone having a role in data quality, the toolkit incorporated

elements change management as well as considerations for the technical aspects of incorporating new

processes into practice.

Now with thousands of interRAI implementations in Canada across sectors (home care, long term care

and mental health), CIHI is taking a moment to reflect on how well the many implementations are being

sustained. Along with the traditional process of using the data to evaluate outcomes, there are many

success stories and implementation challenges we can learn from. This presentation will tell those

stories from both the perspective of the implementation organizations and CIHI that provide insight into

the lessons learned, best practices for sustaining an implementation and key factors for success.

31

Putting interRAI into practice – Lessons learned from the introduction of interRAI in New

Zealand aged residential care

Michele McCreadie

TAS, New Zealand

Abstract summary: After interRAI was introduced into New Zealand aged residential care, an independent

review returned recommendations covering areas like training, implementation, communications and efficiencies.

This presentation gives an insight into the practical considerations when introducing interRAI into a long-term

residential context, at a national scale, and how to mitigate these issues.

Keywords: implementation, LTCF, training

interRAI was first introduced to aged residential care in New Zealand through a project between 2011

and 2015. It was made mandatory for aged residential care facilities in 2015.

The project faced challenges such as how to introduce a software supported assessment programme in

a sector which was until then largely paper based and had a low level of technology capability, and how

to educate and support an assessor workforce who had little or no experience with the use of a computer.

Other challenges included access to training, and how to get a significant part of the health sector to

change their assessment practices.

Following the project and on behalf of the interRAI New Zealand Governance Board, interRAI Services

commissioned an independent review of the project.

The review was thorough and returned ten recommendations, covering areas like training,

implementation, communications and efficiencies.

Since publication, a major focus of interRAI Services’ work has been to implement the ten

recommendations. Eighteen months later, the interRAI Services team published their final response

with all issues addressed and recommendations closed.

This presentation gives an insight into the practical considerations when introducing interRAI as an

assessment system into a long term residential context, at a national scale, and what can be done to

mitigate these issues.

32

Coordination of the nationwide update towards the interRAI Suite in Swiss Home Care

organisations

Esther Bättig, Cornelis Kooijman

Spitex Switzerland

Abstract summary: In a first step towards New Suite, interRAI CMH was digitally introduced in 2019 and

interRAI HC will be introduced from 2020. The experience gained with the nationwide update of interRAI

instruments and the application in clinical practice of the homecare-setting will be demonstrated using the example

of Switzerland.

Keywords: home care, assessment, implementation

Background: In Switzerland, it is a legal regulation to evaluate the needs of every person who receives

care or services at home. The approximately 500 Nonprofit Home Care organisations (Spitex-

organisations) will use interRAI instruments.

About 15 years ago, Spitex started introducing RAI-HC as a uniform, structured assessment instrument

throughout Switzerland. A few years later, interRAI Mental Health was applied in paper form. In a first

step towards the New Suite, interRAI CMHSwitzerland was digitally introduced in 2019, in 2020

interRAI HCSwitzerland will follow.

Objectives of the presentation: The experiences with the nationwide introduction of interRAI

instruments and its application in clinical practice of the home care setting will be demonstrated with

the example of Switzerland.

Challenges and results: In the preparation phase, both interRAI instruments were tested with nursing

professionals with focus on applicability in home care practice in Switzerland and conditions in the

Swiss healthcare system. It was important for the specialists that only data of relevance to the care

planning should be collected and used in the assessment instrument. In the process of instrument

adaptation, there are legal regulations relating to data protection, competences and financing to be taken

into consideration. Further challenges are the trilingualism of Switzerland and 12 software providers

who have to integrate and certify the interRAI tools as part of the standard nursing documentation. Last

but not least, the switch from the previous generation assessments to the interRAI Suite assessment

tools also affects processes within the organisations. Here, too, it was necessary to define exactly which

aspects can be standardised and which should be entrusted to the organisations.

The two instruments and the corresponding technical specifications for the digital implementation are

made available to the software providers in German, French and Italian. The manuals are published in

three languages. To guarantee smooth transition from the older generation instruments to the interRAI

Suite, an update module will be offered in the existing train-the-trainer system. An eLearning tool is

being developed for the care professionals.

33

SESSION 8: MENTAL HEALTH

Chair(s): John P Hirdes

Rates and determinants of emergency and non-emergency control interventions use in older

psychiatric inpatients in Ontario, Canada

Gary Cheung1, Yoram Barak2, John Hirdes3

1University of Auckland, New Zealand; 2University of Otago, New Zealand; 3University of Waterloo,

Canada

Abstract summary: This study used routinely collected interRAI Mental Health assessments to examine the use

of control interventions (CIs) in older psychiatric inpatients. We found the rates of CIs use increased with age. In

non-emergency situations CIs were more likely to be used in people with functional impairment, aggressive

behaviour and delirium.

Keywords: control interventions, older adults, psychiatry

Objectives: The use of control interventions (CIs) (e.g. acute control medications, physical/mechanical

restraint) is associated with negative physical and psychological outcomes, particularly in older adults

who are physically vulnerable. The aims of this study were to (i) compare the rates of CIs use in older

(age 65+) psychiatric inpatients with younger age groups, and (ii) examine the determinants of CIs use

in older psychiatric inpatients.

Methods: Routinely collected interRAI Mental Health assessments from 2005-2017 in Ontario, Canada,

were analysed to determine the rates of CIs use. Two logistic regression analyses were performed to

examine the sociodemographic and clinical determinants of CIs use in non-emergency situations and

any (emergency and non-emergency) situations.

Results: There were 226,119 (female: 48.9%; mean age=44.6, SD=18.2) interRAI assessments. The

rates of CIs use in the four age groups were: (i) non-emergency situations: 18-44=9.4%, 45-64=8.3%,

65-84=9.9%, 85+=13.2%; (ii) any situations: 18-44 =17.8%, 45-64=14.3%, 65-84=21.1%, 85+=28.3%.

In non-emergency situations, the three most significant determinants of CIs use were impaired activities

of daily living (ADL Short Form score 8-16: OR=3.26, 95% CI=2.67-3.97; score 5-7: OR=1.28, 95%

CI=1.01-1.63), mild to moderately severe aggression (Aggressive Behaviour Scale score 1-3: OR=1.61;

95% CI=1.38-1.88; score 4-6: OR=1.80, 95% CI=1.48-2.18), and a diagnosis of delirium (OR=1.60,

95% CI=1.39-1.85). For any situations, the three most significant determinants of CIs use were

aggression (Aggressive Behaviour Scale score 10-12: OR=8.57, 95% CI=7.17-10.24; score 7-9:

OR=5.48, 95% CI=4.87-6.17; score 4-6: OR=3.39, 95% CI=3.09-3.71; score 1-3: OR=1.67, 95%

CI=1.54-1.81), severely impaired activities of daily living (ADL Short Form score 8-16: OR=2.45, 95%

CI=2.23-2.70) and higher score on the Positive Symptoms Scale (score 9-24: OR=2.03 95% CI=1.83-

2.26). Females were less likely to have CIs in non-emergency (OR=0.84, 95% CI=0.73-0.95) and in

any situations (OR=0.80, 95% CI=0.75-0.85).

Conclusion: The higher rates of CIs use in older psychiatric inpatients is concerning, particularly in

non-emergency situations where CIs are more likely to be used in people with functional impairment,

aggressive behaviour and delirium. Alternative non-pharmacological and person-centred management

strategies should be considered to manage these presentations.

34

The mental health of the Dutch homeless service users: results of cross-sectional research with

the InterRAI Community Mental Health questionnaire

Coline van Everdingen1, Prof. Dr. Philippe Delespaul2

1Maastricht University, VEZC, the Netherlands; 2Maastricht University, Mondriaan, the Netherlands

Abstract summary: In the Netherlands, the CMH has been employed for an integrated health and needs

assessment of the adult homeless services users (N=436). In this presentation, the researcher will share the major

mental health outcomes and reflect on the way they were used in the regional and national debates on

homelessness.

Keywords: serious mental illness, marginalization, recovery

Aims and objectives: Cross-sectional research is used to give insight into the pathways into

homelessness, health, resources, and needs for recovery of the current Dutch homeless service (HS)

users.

Methods: A snowball-sampling method was used to engage the adult HS users in 7 cities from 2015 to

2017. The data, mainly consisting of biographical information and the interRAI Community Mental

Health questionnaire, was collected in semi-structured interviews by the same researcher (CvE). This

yielded a broad assessment of mental, physical and social conditions covering all dimensions of positive

health.

Results: All of the 436 participants had experienced homelessness. 8% slept rough, 67% in a night

shelter, and 23% were houseless. The majority were male, single, persistently unemployed, had a low

education and a migration background. Preliminary data point out that comorbid conditions were high.

In the majority mental illness, substance related disorders and one or more chronic physical conditions

were present. Intellectual disability was found in a substantial part. Traumas were common: in one third

past life events still invoked a sense of horror. HS users were socially isolated: half of the participants

had only one or no informal helper at all. The majority had been previously homeless. Many participants

had history of psychiatric admissions or ambulant mental care, but did not receive mental care at

present. Considering this complex pattern of severe needs, most HS users were best served in

comprehensive long-term integrated care for serious mental illness.

Conclusions: Serious mental illness is a common problem in the mainly chronic or episodic HS users

in the Netherlands. In addition to housing, other care needs should be met to promote sustainable

recovery. The CMH,taking into account both the participants’ and professional points of view, is helpful

to study their interaction and the marginalization process.The CMH CAPs and scales support quick

translation of the collected data into the current needs. The CMH is applicable both at the level of

individuals and populations to address (unmet) care needs and promote health and recovery in

vulnerable populations with complex needs.

35

Profile of Residents with Mental Disorders in Long-Term Care Facilities

Vahe Kehyayan1, Jonathan Chen2, John P Hirdes3

1University of Calgary in Qatar, Qatar; 2University of Waterloo, Waterloo, Ontario, Canada; 3University of Waterloo, Waterloo, Ontario, Canada

Abstract summary: Residents in long-term care facilities, diagnosed with mental disorders or Alzheimer’s

Disease and Related Dementias, present unique characteristics making them highly vulnerable because of their

double burden of mental and physical comorbidities. They are more likely to be cognitively impaired, manifest

aggressive behavior, receive psychotropic drugs, and be physically restrained.

Keywords: long term care facilities, interRAI, mental disorders and ADRD

Objectives: The purpose of this study was to develop an understanding of the characteristics and care

requirements of LTC facility residents with mental disorders (MD) and Alzheimer’s Disease and

Related Dementias (ADRD) and to identify their implications for practice, research and policy.

Method: A cross-sectional study compared the profile of residents with MD and ADRD with residents

without such conditions (the comparison group).

Results: 76% of residents had MD (40%) and ADRD (36%). Residents with MD and ADRD were more

likely to be cognitively impaired, manifested aggressive behavior, receive psychotropic drugs, and be

physically restrained, and less likely to be socially engaged.

Discussion: Residents with MD and ADRD, compared to those without either one of these conditions,

are highly vulnerable because of their double burden of mental and physical comorbidities. Such rich

data will inform the development of policies and programs for quality and safe healthcare for LTC

facility residents.

36

SESSION 9: COGNITION

Chair(s): Terry Lum

Clients participation in RAI-assessment: Does cognition matter?

Maarit Lind, Anja Noro, Satu Havulinna, Matti Mäkelä

Finnish Institute for Health and Welfare (THL), Finland

Abstract summary: RAI-assessment is based on observing and asking the clients abilities and needs. We

explored whether client RAI-assessment participation is associated with client cognition. The results indicate that

almost half of the clients did not participate and even clients with intact or borderline cognitive impairment did

not always participate.

Keywords: older people, services, RAI-assessment

Background and aim: Client participation is included in legistlation and quality recommendations of

older people care and services in Finland. RAI-assessment is based on observing and asking the clients

abilities and needs. This study aim was to explore whether client RAI-assessment participation is

associated with client cognition.

Materials and methods: We used data of 53 089 RAI-LTC and RAI-HC assessments done in 2018.

Among them 49 % were clients in home care, 41 % clients in residental care, 6 % clients in nursing

homes, 3 % clients in sheltered housing and 1 % clients in long-term hospital care. Majority (69 %)

were female and average age was 83 year. The average length of care was three years. The data was

analysed with frequencies and percentages. Algorithm for the quality indicator was “Client participation

= no”.

Results: The results indicate that almost half (40 %) of the clients did not participate in the RAI

assessment. The CPS (Cognitive Performance Scale, CPS 0-6) distribution of all the clients: 50 % the

clients had CPS 2-3, 30 % had CPS 0-1 and 20 % had CPS 4-6. The CPS distribution was similar in

home care and sheltered housing. Clients in home care participated the most (71 %). Clients in the long-

term hospital care participated the least (36 %). Clients with CPS 0-2 participated the most, whereas,

clients with CPS 5-6 the least. Clients with CPS 0-2 did not automatically participate, while, some of

the clients with CPS 5-6 did. This was evident in all of theservice types, but mostly in residental care.

Conclusions: Despite the recommendations, even clients with intact or borderline cognitive impairment

did not always participate to RAI-assessment. Individual care plan should be based on assessment of

individual’s needs, and therefore, client participation, regardless of his or her cognitive abilities, is

crucial. Further effort is needed to ensure that every client will be able to take part to planning and

carrying out their own care, especially in long-term care – that should matter.

37

The service profiles of older people living at home with memory disorders in Finland

Rauha Heikkilä, Matti Mäkelä and Anja Noro

Finnish Institute for Health and Welfare, Finland

Abstract summary: In Finland the population is aging fast and the prevalence of older people with memory

disorders is increasing. Memory disorders increase need for social and health services. Older people with memory

disorders can cope at home with help of informal care even though there is an increasing need for service.

Keywords: memory disorders, services, home care

Background and aim: In Finland the population is aging fast and the prevalence of older people with

memory disorders is increasing. Memory disorders increase need for social and health services. The

aim of this study is to investigate the service profiles of older people with memory disorders living at

home.

Materials and methods: Data from the RAI database of the Finnish Institute for Health and Welfare

were drawn from the time period 1.7.2015 – 30.6.2016 and based on RAI-Home Care and RAI-Long

Term Care assessments. The sample included older people with impaired cognition (Cognitive

Performance Scale, CPS = 1, 2 or 3) and diagnosed with memory disease (Alzheimer's disease or other

dementia) comprised of new service seekers (n=1 431) and those in regular home care (n=1 742).

Service needs were classified with Method for Assigning Priority Levels, MAPLe segments. The

sampled RAI data were merged with the Social and Health Care Register that gave information of older

people with memory disorders in various services after one month of the baseline assessments.

Frequency distributions, cross-tabulation and Fisher's exact test and its Monte Carlo simulation (10,000

iterations) were used in the analyses

Results: The service profile of the service seeking group indicated that almost every other person with

memory disorders had very high service needs. They were in the segment the cognition deficit and high

ADL need for help. Among those receiving regular home care about every third client with memory

disorders had large service needs. They were classified in the segment having the limited cognitive

deficits. Their main service for them was home care and very little use of other services.

Conclusions: Older people with memory disorders can cope at home with help of informal care even

though there is an increasing need for service. Segmentation by MAPLe algorithm could be a helpful

tool for service planning of older people with memory disorders.

38

Cognitive Impairment and Physical Frailty Interact to Predict 6-Month Adverse Health

Outcomes and Service Utilisation in Residential Care Setting

Jennifer Tang, Gloria Wong, Hao Luo, Terry Lum

The University of Hong Kong, Hong Kong S.A.R., (China)

Abstract summary: Cognitive impairment and physical frailty are independent predictors of adverse health

outcomes and drivers for increased care costs. Using data from 986 older persons living in residential care homes,

we found an interaction between cognitive impairment and physical frailty in predicting care needs and care

service utilization in 6 months.

Keywords: cognitive impairment, physical frailty, interaction

Background: Cognitive impairment and physical frailty are independent predictors of adverse health

outcomes and drivers for increased care costs. Although they are common comorbidity, especially in

residential care settings, their short-term interaction effects are less well understood. These effects can

affect care planning at an individual level and resources allocation at an organization level.

Methods: interRAITM data from 986 older persons living in residential care homes were analysed.

Cognitive impairment at baseline was measured using Cognitive Performance Scale (CPS). Physical

frailty at baseline was measured using Frail-NH. Changes in activities of daily living (ADL) and service

utilization at 6 months were assessed. We controlled for age, gender, baseline ADL, other common

comorbidities in our models.

Results: CPS and physical frailty were positively associated with ADL changes. There was a significant

CPS x physical frailty interaction, with ADL deterioration more prominent in residents with higher CPS

and lower level of frailty. For service utilisation, there was a significant CPS x physical frailty

interaction, suggesting that when frailty is high, the increase in total care cost/social care cost associated

with cognitive impairment decreased. There is also a quadratic relationship between CPS and social

care cost, with an increase in CPS predicts higher social cost, but the rate of change is smaller when

cognitive impairment is more severe.

Discussion: Mental health and physical health are intertwined in old age, with complicated implications

on care needs and care costs. Using service data over 6 months, we have been able to demonstrate that

the increase in care needs and related care service utilisation among frail older persons is non-linear and

complex, with interaction between the severity of cognitive impairment and physical frailty. Our

findings suggested directions for future service design and resources allocation.

39

SESSION 10: COMMUNITY CARE

Chair(s): Luke Turcotte

The Community Rehabilitation Assessment: Results from A Proof of Concept Pilot Study in

Canadian Outpatient Clinics

Luke Turcotte1, Caitlin McArthur2, Katherine Berg3

1University of Waterloo, Canada; 2McMaster University; 3University of Toronto

Abstract summary: The interRAI Community Rehabilitation Assessment (CRA) is designed to collect essential

information to develop a comprehensive care plan and measure outcomes in outpatient rehabilitation. This

presentation describes results from a proof of concept pilot study to evaluate this new assessment with a sample

of 700+ Canadian patients across 25 clinics.

Keywords: rehabilitation, community, PROMs

The interRAI Community Rehabilitation Assessment (CRA) is a standardized health assessment that is

designed to collect essential information to develop a comprehensive care plan for outpatient

rehabilitation. Recognizing the importance of a patient-centred approach to rehabilitative care, the CRA

serves as a patient-reported outcome measure of functional change and attainment of goals of care. It

can also be used by health system administrators as a minimum data set to describe patient

characteristics at both system and organizational levels. This presentation describes results from a proof

of concept pilot study to evaluate the feasibility of using the CRA as a means of describing clinical need

and measuring outcomes in outpatient rehabilitation clinics in Ontario, Canada.

Over one year period, a total of 709 patients were assessed with the CRA across 25 outpatient clinics.

Participants in the sample received rehabilitation for a variety of conditions, the most common being

total joint replacement (30%), other orthopedic conditions (14%), and stroke (12%). Patient and

clinician-based measures of function, gait speed, cognition, communication, pain, and mood were

compared between admission and discharge to illustrate how the CRA can be used to measure

rehabilitation outcomes. Additionally, using a cohort of Canadians receiving home-based rehabilitation

that were assessed with the interRAI RAI-HC assessment, this presentation compares the clinical

characteristics of recipients of outpatient versus home-based rehabilitation.

Through this proof of concept pilot study, the CRA has demonstrated utility as an instrument that is

capable of assessing clinical need across numerous domains of health and wellbeing. Given that the

CRA is based on validated interRAI items that are used in hospital, community, and long-term care

settings, the CRA may be used to guide patient care planning and measure change in health status as

patients transition along the continuum of care. Finally, the CRA provides program stakeholders and

funders with the necessary information to evaluate the effectiveness of outpatient rehabilitative care

programs.

40

Developing a decision-support tool for referral to specialized geriatric services in Ontario,

Canada

Sophie Hogeveen

McMaster University, Canada

Abstract summary: Very few older home care clients in Ontario, Canada, benefit from the care of a geriatrician.

This study explored current practice patterns using RAI-HC data linked to administrative services use data and

proposed an embedded decision-support tool to identify clients who would benefit most from limited specialized

geriatric services.

Keywords: geriatric medicine, home care clients, health services utilization

Background: Community-based specialized geriatric services (SGS) have an important role to play in

caring for complex older adults with frailty and multimorbidity in Ontario, Canada, but their availability

is limited. Provincial stakeholders partnered to create a standardized decision support tool to identify

older home care (HC) clients who would benefit most from SGS care. However, little is known about

the practice patterns of geriatric medicine and the determinants of contact with this specialist discipline

by community-dwelling older adults. The objective was to describe patterns of service use,

characteristics associated with SGS contact, and to propose a decision support tool for referral.

Methods: This was a population-based retrospective cohort study of older adults who received publicly-

funded HC in Ontario, Canada, from 2012 to 2015 (N=196,444). For each unique client, their Resident

Assessment Instrument – Home Care (RAI-HC) admission assessment was linked to administrative

services use data.

Results: 49.6% of older HC clients had ≥4 contacts with physicians following assessment but only 5.2%

had any contact with geriatric medicine. In the final multivariable generalized estimating equation

model, adjusted for regional effects, female sex, difficulties accessing the home, impaired locomotion

outside of the home, good prospects of recovery, diagnosis of hemiplegia/hemiparesis, and cancer were

associated with lower odds of geriatric medicine contact. Age, worsening of decision-making, dementia,

hallucinations, Parkinsonism, osteoporosis, and risk of caregiver distress and institutionalization

(MAPLe score) were associated with higher odds of geriatric contact. The factors associated with

geriatric medicine contact were conditions typically associated with functional and cognitive loss in old

age, but older home care clients with other complex medical needs did not appear to access their care.

Implications: Based on these findings, a decision support tool was proposed which identifies HC clients

at risk for caregiver distress and institutionalization (based on current practice patterns), with medical

instability and complexity (based on provincial expertise), and needs within multiple domains of the

SGS scope of practice for consideration for referral to SGS. A tool that is compatible with standardized

assessments within HC and other care sectors will allow for allocation of resources more rationally and

equitably.

41

Shared Care Arrangement of Older Adults with Stroke

Vivian Lou1,2, C. W. Kwan 1,3, Iris Chi1,4

1Sau Po Centre on Ageing, The University of Hong Kong; 2Department of Social Work & Social

Administration, The University of Hong Kong; 3Department of Statistics & Actuarial Science, The

University of Hong Kong; 4Suzanne Dworak-Peck School of Social Work, University of Southern

California

Abstract summary: The present study examined care arrangement of older adults with stroke and its association

with distress of primary caregivers using a sub-sample of assessment data using MDS-HC in Hong Kong. Shared

care among primary, secondary caregivers, and community care were observed, which had three clinical

implications.

Keywords: MDS-HC, stroke caregiver, shared care

Objective: Stroke is one of the key factors that contributes to disability which put on heavy burden for

health and social care worldwide. From 2015 to 2017, the number of stroke survivors living in the

community has increased by 11% in Hong Kong (Census and Statistics Department, 2015; 2017). The

objective of the present study was to examine care arrangement of older adults with stroke and its

association with distress of primary caregivers.

Methodology: A sub-sample of assessment data using MDS-HC from a large cohort of community-

dwelling older adults applying for public long-term care services in Hong Kong from 2015 and 2016

calendar year was selected. The inclusion criteria were 1) 65 years or older; 2) stroke; 3) had a spouse

or off-spring as a primary caregiver; 4) first assessment; and 5) living at home. A total of 3,315

applicants contributed to the active dataset for the present study.

Findings: Around fifty percent of older adults with stroke were taken cared by both primary and

secondary caregivers; while about twenty percent were taken cared either by primary caregivers only,

or by a combination of a primary caregiver, a secondary caregiver, and community services. After

controlling covariates, for both spousal caregivers and offspring caregivers, when there were secondary

caregivers or share care by using community services, the primary caregivers were more likely (OR =

2.234, 2.212) to be distressed. For the spousal caregivers, if the care recipients had more severe

depression issues, the caregivers were more likely (OR = 1.183) to be distressed. For the offspring

caregivers, if the elderly had more severe cognition issues (OR = 1.148) or received longer informal

help during the weekdays (OR = 1.025), the caregivers were more likely to be distressed.

Implications: Three clinical implications could be generated: 1) set families adopting shared care

arrangements as a prioritized target group; 2) for spouse primary caregivers, care recipients showing

depressive symptoms were recommended for prioritized interventions; and 3) for offspring primary

caregivers, care recipients showing cognitive impairment symptoms were recommended for prioritized

interventions.

42

SESSION 11: TRANSITIONS IN CARE

Chair(s): Margaret Saari

Where to live: Independently in the community or a retirement village?

Robyn Johnston, Ray Kirk, Kate Reid

University of Canterbury, New Zealand

Abstract summary: Increasing numbers of older people in New Zealand, choose to live independently in

retirement villages. Little research has been conducted to discover if this is a positive ‘ageing in place’ option.

Using the CHA and the Enlightenment Scale we sort to discover how wellness impacts on wellbeing for this

group.

Keywords: CHA, wellbeing, retirement village

New Zealand residents aged 75 years and older are increasingly choosing to live independently in a

retirement village. In 2012, a little more than nine percent of this group had purchased occupational

right agreements to ‘buy’ a townhouse, villa or apartment within one of these complexes. However, by

2018, this figure had risen to over 13 percent with the upward trend predicted to continue into the

foreseeable future. Within the next few years, the first of the baby boomers will enter the 75 years plus

age group. It is anticipated that as the baby boomers progressively reach this stage of life, they will add

to the demand for housing in retirement villages. The village owners promote their facilities as ‘lifestyle

resorts’, offering such things as swimming pools, manicured gardens, sporting and recreational

activities. At the same time, health professionals encourage older people to ‘age in place’ in their own

home, within their community, for as long as possible. There is scant information available to indicate

that moving to a retirement village is beneficial to a resident’s health and wellbeing.

We sort to clarify the level of wellness of those living independently in a large retirement village through

a prospective cohort study. Using the interRAI Community Health Assessment (CHA), a group of self-

selected residents (n=120) with a median age of 80 years (68-92 years) was assessed at the beginning

and end of the year-long study period and changes were noted. Alongside the CHA we conducted the

Enlightenment Scale, a wellbeing measure, to investigate how changes in health altered our

participants’ perception of their wellbeing. This was administered alongside the CHA for all

participants. Two thirds of the study recruits completed the Enlightenment Scale at four regular intervals

during the study period.

Our results show that, for more than half of the study participants, their overall wellness stayed the same

or improved over the study period. We also discovered that across this group, their wellbeing increased

with age.

43

Mental health needs in older adults with medical complexity: Why a holistic approach to care in

transitional care settings is necessary

Margaret Saari1,2, Heather McNeil2, Courtney Genge2, Diane Mitchell2, Paul Holyoke2

1University of Waterloo, Canada; 2SE Research Centre, SE Health, Canada

Abstract summary: Routine underestimation and lack of understanding of patients’ mental health issues affects

care across settings. Results from analysis of admission assessments of patients in a community-based transitional

care program reveal a need to support holistic care planning that includes a focus on mental health and social care.

Keywords: transitional care, mental health, medical complexity

Background: Delayed discharge is a major issue for healthcare systems globally. In Ontario, Canada

approximately 15% of hospital beds are occupied by individuals who no longer require acute care but

are unable to return home. Transitional care programs, developed to address this issue, have

traditionally focused on physical deficits resulting from prolonged hospitalization. However, mental

health and social issues have been recognized as barriers to patients’ return to community.

Objectives: To examine and describe the mental health and social care needs of older adults who

experienced delayed discharge from an acute care or rehabilitation hospital and provide

recommendations to promote needs-based, client-centered design of transitional care programs.

Design: This study is part of a larger prospective cohort study undertaken to generate a comprehensive

picture of a community-based transitional care program. Cross-sectional data collected during

admission assessments were examined for this presentation.

Setting and Participants: All clients admitted to a 75-bed transitional care program in Toronto, Ontario

between Jun 1st, 2018 and May 31st, 2019 with available data were included. Admissions to the

program focus on three population streams: medically complex, dementia and mental health.

Measures: Demographic, clinical and treatment variables were extracted from the interRAI Community

Health Assessment and reported using descriptive statistics.

Results: While demographic differences existed between clients with a documented mental health

diagnosis and those without, there were few differences in clinical complexity, mental health status

indicators or indicators of social isolation noted. Clients with documented mental health diagnoses were

more likely to be male, younger and have no identified caregiver. Several mental health concerns

including indicators of depression, loneliness and social isolation were prevalent in this population

regardless of population stream.

Conclusion and implications: The population served by transitional care programs is both clinically and

socially complex. Mental health needs were not restricted to those with mental health diagnoses. Given

the traditional focus on functional needs for this care setting, these findings have important implications

for assessment, individualized care planning, and group programming as well as skill-mix and training

considerations.

44

Health State Transitions and Adverse Events Following Rehabilitation in Ontario Complex

Continuing Care Hospitals

Luke Turcotte1, Brant Fries2, Jeff Poss1, Katherine Berg3, John Hirdes1

1University of Waterloo, Canada; 2University of Michigan, USA; 3Univeristy of Toronto, Canada

Abstract summary: Post-acute rehabilitative care aims to provide patients with the necessary resources to

effectively self-manage their health following hospital discharge. Using linked interRAI hospital and community

care assessments, this presentation describes patient characteristics and facility practice patterns that are associated

with health state transitions after discharge to the community.

Keywords: post-acute care, home care, rehabilitation

Complex Continuing Care (CCC) facilities in Ontario, Canada provide hospital-based nursing and

rehabilitation services to individuals that are recovering from acute illness and who have complex

clinical needs. Recognizing that CCC facilities are a transition point along the rehabilitative continuum

of care, a priority goal of care in this care setting is to provide patients with the necessary resources to

effectively self-manage their health in the community, and prevent unplanned hospital readmission and

need for long-term care after discharge. Leveraging interRAI hospital and community care assessments

linked to Ontario administrative health databases, this presentation will describe patient factors and

rehabilitation practice patterns that are associated with health state transitions following discharge from

a CCC facility.

A Markov chain multistate transition model was fit for a sample of CCC patients that were discharged

to community care between January 1st, 2010 and January 1st, 2014 and assessed with a RAI-HC

assessment within 105 days of CCC discharge (transitions = 12,824). Patients were classified into two

initial states using functional measures from the RAI-HC assessment. Possible transition states of

interest included functional improvement and decline, hospital admission, residential long-term care

facility admission, death, and discontinuation of home care services. Within one year of CCC discharge,

13% of state transitions resulted in rehospitalization, 5% resulted in residential long-term care

admission, and 6% resulted in death. Among non-absorbing state transitions, 7% resulted in functional

improvement and 6% resulted in functional decline. After adjusting for patient characteristics, physical

and occupational therapy intensity in CCC was not associated with greater odds of experiencing most

health state transitions after discharge.

Using linked assessments from numerous health service settings along the continuum of care, this study

describes patient and process factors that are associated with positive and negative health state

transitions following rehabilitation in CCC hospitals. Results form this study suggest that the provision

of rehabilitative care in post-acute care hospitals has a time-limited effect that may not persist after

community discharge. Ongoing access to therapy in the community may be required to sustain benefits

over time.

45

SESSION 12: LTC

Chair(s): Hao Luo

Survey on Demand Feature of Elderly People Living alone in Long-term Care Services in

Shanghai, China

Lingshan Wan, Yifan Cao, Jia Xue, Hansheng Ding (Corresponding Author)

Shanghai Health Development Research Center (Shanghai Medical Information Center), People's

Republic of China

Abstract summary: The team studied the demand features of long-term care services among elderly people living

alone by conducting 300 questionnaire surveys in Shanghai, China. There were significant differences in the needs

of home-based basic life support nursing services among elderly people living alone in different gender, age and

family income level.

Keywords: long-term care service, care for elderly people living alone, home care.

Objective: To study the demand features of long-term care services among elderly people living alone

in Shanghai, China.

Methods: We conducted questionnaire surveys on the needs of long-term care service of 300 elderly

people living along in Shanghai, who were selected via stratified random sampling. We designed the

questionnaire by learning from the interRAI Home Care Assessment System (HC) and the interRAI

Long-Term Care Facilities Assessment System (interRAI LTCF). Logistic regression analysis was used

to explore the factors that related to the demand of long-term care service. We compared four

dimensions of the demand features among elderly which are: home-based basic life support nursing

services; home-based basic medical services; nursing home services and community care services.

Results: The home-based basic medical services was one of the most needed services among elderly

people living alone, especially among male elderly. The demand of nursing home services was much

less than the demand of other three types of services. Moreover, we found that there were significant

differences in the needs of home-based basic life support nursing services among elderly people living

alone in different gender, age and family income level.

Conclusion: The demand feature of long-term care services is closely related to the personal information

and the personal physical condition among elderly people living alone in Shanghai. The survey can also

show the imbalance between supply and demand of care services. Improving the supply of long-term

care service especially for elderly people living alone is the next consideration.

46

Factors associated with self-harm among people in long-term care in Canada

Yi Chai1, Hao Luo1, Paul S.F. Yip1, Terry Y.S. Lum1, John Hirdes2

1The University of Hong Kong, Hong Kong S.A.R. (China); 2University of Waterloo, Canada

Abstract summary: Long-term care data collected using interRAI-LTCF and interRAI-HC were linked to

Ontario hospital records to examine factors associated with self-harm. In LTCF, significant factors identified

included younger age, marital status, psychiatric disorders, brain injury, polypharmacy, and pain. Additional

factors, including male, substance abuse, and loneliness, were found in HC settings.

Keywords: self-harm, long-term care, risk factor

Objective: Self-harm is significantly associated with increased risk of suicide. People who are residing

in long-term care facilities (LTCF) and receiving home care (HC) services are, conceivably, at high-

risk of self-harm since their psychical and psychological needs for long-term care services are also risk

factors of suicide. In this study, we aim to examine the incidence of self-harm and investigate factors

associated with self-harm among people in long-term care in Ontario, Canada.

Methods: Routinely collected administrative data from long-term care settings were linked to electronic

health records from Ontario hospitals to identify risk factors of self-harm. Long-term care data were

collected using interRAI-LTCF and interRAI–HC, assessment tools for evaluating the needs, strength,

and preferences of people in long-term care settings. The initial sample included 3,628,261 assessment

records from 499,122 LTCF residents and 2,459,191 records from 901,586 HC clients, between 2003

and 2015.

Results: Self-harm records were identified in 1,833 LTCF residents and 4,517 HC clients,

corresponding to 3.7 and 5.0 cases per 1000 persons, respectively. In LTCF, highly significant risk

factors of self-harm included younger age (OR = 0.95; CI 0.94-0.96), separated or divorced (1.74; 1.28-

2.36), depression (2.28; 1.84-2.82), manic depression (2.61; 1.80-3.79), seizure disorder/epilepsy (1.67;

1.23-2.26), traumatic brain injury (3.32; 2.34-4.70), polypharmacy (2.85; 1.57-5.18), and pain (1.48;

1.18-1.85). In HC settings, additional risk factors were identified, including, male (1.31; 1.19-1.45),

psychiatric disorder (2.36; 2.13-2.63), tobacco abuse (1.92; 1.73-2.13), alcohol abuse (2.00; 1.56-2.57),

psychotropic medication (1.72; 1.53-1.95), higher score on the depression rating scale (1.65; 1.49-1.84),

and loneliness (1.30; 1.17-1.46). In addition, people with a higher level of functional and cognitive

impairment were associated with a lower risk of self-harm.

Conclusion: Several risk and protective factors were found to be significantly associated with self-harm.

The factors identified in this study can be used to develop a predictive algorithm for estimating the risk

of self-harm for people in long-term care. The resulting algorithm will be used as a supporting tool for

timely identification of at-risk individuals to facilitate effective intervention.

47

Depressive Symptoms and Associated Factors in Long-Term Care Facilities of Korea

Jae Yoon Yi1, Hongsoo Kim1,2,3

1Institute of Health and Environment, Seoul National University, Korea, Republic of (South Korea); 2Department of Public Health, Graduate School of Public Health, Seoul National University, Korea,

Republic of (South Korea); 3Institute of Aging, Seoul National University, Korea, Republic of (South

Korea)

Abstract summary: This study seeks to identify the factors associated with depressive symptoms using a

nationally representative dataset of long-term care facility residents in Korea.

Keywords: nursing home, depression, Korea

Depression is one of the most prevalent and disabling psychological conditions in old age. While some

tend to curtail the significance of depression in facility settings, the increase in the number of people

receiving long-term supports in facilities around the world call for the security of mental well-being of

this population in their new 'homes'. Therefore this study seeks to identify the factors associated with

depressive symptoms using a nationally representative dataset of long-term care facility residents in

Korea.

This study analyzes secondary data from 1,466 older adults residing in 91 long-term care facilities

across Korea. The data was collected using the interRAI Long-Term Care Facility Resident Assessment

(interRAI LTCF) system. A conceptual framework for the study was drawn through a comprehensive

literature review and utilized to create an analytic model consisting of demographic factors, health and

functioning, and social factors.

Of the analytic sample of 1,466 residents, 42% reported having significant depressive symptoms as

measured by the depression rating scale (DRS). Out of demographic factors, only the female gender

was associated with significant depressive symptoms. As for health and functioning, having moderate

level of cognitive impairment, and mild to excruciating pain were significant factors of depressive

symptoms. Finally, social factors associated with depressive symptoms were interpersonal conflict

within the nursing home, loneliness, and experience of a stressful life event.

This study revealed that a large proportion of long-term care facility residents in Korea exhibited

significant depressive symptoms. Furthermore, the multidimensional factors associated with depressive

symptoms in the facility indicate the need for a comprehensive approach to delivering care in the

nursing home. Strong association between depressive symptoms and interventional points such as pain

or social factors such as loneliness should be taken into account when designing healthy long-term care

models.

48

SESSION 13: HOME CARE 1

Chair(s): Chi-Ling Joanna Sinn

Implementation of Belrai in Nursing at Home organisation

Mia De Caluwe, Hilde Baetens

Wit-Gele Kruis van Oost-Vlaanderen, Belgium

Abstract summary: 10 year experience in the use of Belrai in projects implementation of Belrai in Nursing at

Home still a long way to go? The Use of Belrai in supporting casemanagers and carecoördinators in their new

roles

Keywords: experiences, implementation, challenges

In this practice oriented presentation, we provide a look back on using the BelRAI instruments in care

innovation projects over a period of ten years. We will show how we evolved to a multidisciplinary

assessment and the use of the Clinical Assessment Protocols for goal oriented care planning, with a

responsible person per goal. Second, we will talk about our experiences with BelRAI in home nursing

and about how the see the future. In the White & Yellow Cross home nursing organization, we currently

research the use of the BelRAI Screener for different types of patients, also for determining criteria for

when a full HC instrument is needed. Third, in care innovation projects, we work with a case manager

or care educator, and we will talk about the possible use of BelRAI to support this function.

49

Who Receives Publicly Funded Home and Community Care in Ontario?

Chi-Ling Joanna Sinn1,2

1University of Waterloo, Canada; 2Joseph Brant Hospital, Canada

Abstract summary: Across Canada, Ontario is the only province that has implemented the interRAI Home Care

(HC), interRAI Community Health Assessment (CHA), and interRAI Contact Assessment (CA). Learn about each

of the assessed populations, and specifically, the value of the CA as a general intake screener in home care

assessment practice!

Keywords: home care, assessment process, quality indicators

Across Canada, Ontario is the only province that has implemented the interRAI Home Care (HC),

interRAI Community Health Assessment (CHA), and interRAI Contact Assessment (CA). The HC and

CHA are standardised comprehensive assessments for adults receiving services in home and

community-based settings. The CA although much briefer follows the same interRAI standard, allowing

direct comparisons across the three populations. To date, there is little published evidence on Ontario’s

CA- and CHA-assessed populations.

The objectives of the present study are to describe the profiles of assessed clients and to investigate the

agreement between clinical items and scales captured in the CA and HC. This study utilises a

retrospective cohort of clients (age ≥18 years) newly admitted to Ontario’s publicly funded home care

program between April 1, 2016 and March 31, 2017 and assessed with the CA or HC (n=268,667) and

unique clients assessed with the CHA between April 1, 2015 and March 31, 2016 (n=15,307).

Assessed clients were categorised into mutually exclusive groups based on the type(s) of assessment:

CA only, HC only, CA and HC, and CHA. Clients assessed with the CA only were most likely referred

from hospital and receiving nursing or therapy services. Clients assessed with the HC only had the

highest number of impairments and likely receiving personal support services. The needs of CHA-

assessed clients may be best described at a level between the home care groups. Comparison of the

groups suggest that studies that focus on HC-assessed populations capture just one-third of Ontario’s

home care population.

For clients assessed with both the CA and HC, there was fair to moderate agreement in clinical items.

Agreement was higher among functional items and lower among items representing cognition and

caregiver distress. The Assessment Urgency Algorithm (AUA) from the CA predicted those who

received a follow-up HC. AUA levels were also associated with the Method for Assigning Priority

Levels (MAPLe) algorithm. Together, these results confirm that the CA is an effective intake screener

that provides essential decision support. Nevertheless, the CA does not replace the HC that is used to

guide a more comprehensive care plan.

50

Community-based data in Canada: a fiery solution

Christine McKenzie, Adrian Dalloo


Abstract summary: CIHI’s new community care reporting system developed to respond to a changing healthcare

landscape in Canada uses interoperable standards and data content standards to facilitate patient-centric continuity

of care across sectors and information quality for decision-makers.

Keywords: standards, interoperability, integrated

The Canadian Institute for Health Information (CIHI) is an independent, not-for-profit organization that

provides essential information on Canada’s health systems and the health of Canadians. We provide

comparable and actionable data and information that is used to accelerate improvements in health care,

health system performance and population health across Canada. As part of our mandate, CIHI

maintains a number of pan-Canadian health datasets built around the interRAI assessment standards.

The healthcare landscape in Canada is changing and jurisdictions are investing in new sources of data

and health information technologies. Health system decision makers need comprehensive, standardized,

and timely data that they can use to help inform care planning and quality improvement initiatives

across many sectors such as home care, long term care and community mental health.

This presentation will highlight how CIHI is addressing these data challenges in the community sector

and responding to stakeholders needs through the development of a modernized reporting system that

can encompass many sectors of care, and leverages interRAI’s integrated suite of assessment standards

and the iMatrix. The presentation will also demonstrate the value for stakeholders of incorporating

related data content standards and interoperable data exchange standards such as HL7 Fast Health

Interoperability Resource (FHIR®).

51

SESSION 14: EMERGENCY DEPARTMENTS

Chair(s): Connie Louise Schumacher

The DIVERT Scale clinical applications and care planning: Learnings from the DIVERT-

CARE Trial

Connie Louise Schumacher, Andrew P Costa


Abstract summary: An innovative approach to decision support using the DIVERT Scale for health promotion

strategies and optimizing chronic disease management. We describe clinical application of the scale, as used in

the DIVERT-CARE trial, including resources and care planning activities designed to target specific risk

indicators. Future recommendations for uptake are discussed.

Keywords: emergency avoidance, community, cardio-respiratory

Home care patients are a large population of vulnerable older adults who access care across settings,

experience high rates emergency department use, hospitalization, and have relatively poor access to

effective chronic disease management. The Detection of Indicators and Vulnerabilities of Emergency

Room Trips (DIVERT) scale identifies home care patients at risk for future Emergency Department

(ED) visits. The DIVERT scale facilitates case finding and provides an opportunity for preventive

actions. The intervention used in the DIVERT-CARE trial aimed to promote self-care, optimize

symptom management, and reduce subsequent ED visits. Following a thorough review of current

clinical guidelines, clinical expert and scientific review panel, and pilot study results, a toolbox of

resources were refined for deployment in the community.

As decision support, the most at risk patients are identified in the community and a plan of care is

tailored to the specific needs and goals of the patient. Cardio-respiratory symptoms figure prominently

in the high risk DIVERT groupings, evidence-based guidelines were leveraged to align the DIVERT-

CARE model to complement cross sectoral chronic disease management. A full suite of components

were developed; including a nurse-led self-management patient education and clinical support program,

and communication tools that facilitate collaboration and integration across sectors, thereby improving

continuity of care. This patient centered approach is designed to target the specific symptoms that

trigger the DIVERT scale risk indicators. Patient and frontline education included decision aids with

plain language actionable items, providing guidance for the trajectory of long term self-care. These

initiatives strive to promote early symptom recognition and build capacity to mitigate risk for

deterioration.

The community sector can address the needs and wishes of patients to remain in the home with

meaningful, coordinated, high level care. The DIVERT scale offers an opportunity for pre-emptive

identification and deployment of preventative service initiatives that optimize care and chronic disease

management. Informed by implementation of the DIVERT trial, practice application protocols were

designed. Clinical assessment protocols for the full spectrum of DIVERT scale scores are presented

with a focus on how the interRAI DIVERT scale can inform future directions and strategies for

emergency department avoidance.

52

Implementation of the interRAI DIVERT Scale: A Practical Application within the Health Care

System

Darly Dash, Connie L Schumacher, Andrew P Costa


Abstract summary: We describe a unique way of enhancing the utility of the interRAI DIVERT scale by

embedding practice into local systems. The processes used to collaborate with three public healthcare agencies is

discussed, along with how the DIVERT intervention was adapted to the local context and structures to enhance

long-term sustainability.

Keywords: implementation, program theory, emergency avoidance

In Canada, the interRAI assessment systems have been implemented in many sectors for clinical

assessment, funding decisions in a public health care system (HCS), and to publicly report on indicators.

However, the data remains under used as there are gaps in the system leading to uncertainty in how to

implement new tools at a systems level. The utility of the interRAI tools could be maximized so that it

is used more meaningfully to optimize care that clients receive and to enact change at the system level.

The Detection of Indicators and Vulnerabilities of Emergency Room Trips (DIVERT) scale is a clinical

tool that can identify home care clients at-risk for future emergency department visits. As the DIVERT

scale is a new tool and not used to its full potential, we leveraged a unique approach and our knowledge

of the HCS to address how DIVERT could be used. We aimed to address the needs of three large public

home care agencies across Canada by integrating DIVERT into work processes and adapting to the

local context.

Using principles of implementation science, each home care agency was engaged in a collaborative

relationship and was a partner in the process to promote uptake in practical frontline service delivery.

Based on the outcome scores of the DIVERT scale, a comprehensive and tailored intervention was

created for clients. This was done in conjunction with a needs assessment so that the intervention fit the

need, resources, and structure of each local HCS. In-person exercises amongst all partners facilitated

knowledge and adaptations of workflow, and development of an overarching program theory. This

program theory, represented via a logic model, remains true to the original design of the multi-

component intervention but also allows for adaptation and flexibility in the form of the intervention

components. By engaging in these processes, our intent was to ground DIVERT into the HCS to

enhance sustainability in the long-term. The useful contextual information obtained in this study can be

used in further spread and scale of DIVERT to other systems and organizations, and for other interRAI

based tools across jurisdictions.

53

Standardized assessment of older adults in Emergency Departments - The use of interRAI-ED

Screener and Contact Assessment in Iceland

Ingibjörg Sigurthorsdottir, Brynhildur Ingimundardottir, Hjördís Johannesdottir, Hlíf Guðmundsdottir,

Sigurlaug Thorsteinsdottir

Landspitali University Hospital, Iceland

Abstract summary: In Iceland we implemented the ED screener and the Contact Assessment in our Emergency

department. The InterRAI tools have given valuable information on the profile and situation of the older adults

visiting our ED, enabling appropriate level of service.

Keywords: emergency service, older adults, nursing care

Populations are getting older and the numbers of frail community dwelling older adults are increasing.

Studies indicate that older people choose to live indepentently (Hedman et.al 2015) but Emergency

Departments (EDs) face the challenge of serving this group who can be frail, with multi-morbidity and

everyday assistance needs. Minor illness or accidents easily disturb their delicate condition threatening

their independence, health and well-being. Studies show that repeated ED visits increase the risk for

adverse health outcomes and death among older people (Hastings et.al 2011). To ensure safe discharge

- for older adult from the ED, prevent revisits, inappropriate admissions and prevent their loss of

independence, we established the role of a GEM nurse in our department and use interRAI-ED Screener

and Contact Assessment for accurate recordings .

Methods: Data from the InterRAI ED Screener and Contact Assessment from November 2016 to August

2019 were collected and the results analyzed descriptively to assess the profiles and resource use of the

older adults receiving the care of GEM nurses at the ED at Landspitali University Hospital in Iceland

Results: At our ED about 818 patients with different profiles have received Contact assessment done

by GEM nurses leading to various resource use after he ED visit. The most common age group was 80-

90 years and women were in majority. The most common cause of visits was general malaise,

musculoskeletal symptoms and falls.

Conclusion: The InterRAI tools have given valuable information on the profile and situation of the older

adults visiting our ED, enabling appropriate level of service. The implementation may have prevented

repeated ED visits and unnecessary hospitalizations but further studies are needed.

References:

[1] Hastings et.al (2011). Older patients' understanding of Emergency Department discharge

information and its relationship with adverse outcomes. Journal of Patient Safety 7(1);19-25

[2] Hedman et.al. (2015). Life memories and the ability to act: the meaning of autonomy and

participation for older people when living with chronic illness. Scandinavian Journal of Caring

Sciences. https://doi.org/10.1111/scs.12215

54

SESSION 15: IMPLEMENTATION 2

Chair(s): Veronique Boscart

Supporting a community of practice

Brigette Meehan, Michele McCreadie

TAS, New Zealand

Abstract summary: Once interRAI was established in New Zealand, we found that our assessors and others using

the assessment information needed more than just training. In this presentation we discuss the activities developed

to embed interRAI in everyday practice and how we engage with our wider community of practice in New

Zealand.

Keywords: assessors, training, engagement

Agreeing a model of care, and how to access software and establish assessor training, are probably

among the immediate considerations when a country or jurisdiction is planning to implement interRAI

assessments. This was certainly the case for New Zealand during our period of implementation planning

and delivery.

Once interRAI assessment systems were established as business as usual and immediate education

needs met, we found that our community of assessors and others that use the assessment information

needed more than just training.

Our assessors needed repeated reassurance about the value of interRAI assessment and we also needed

to support the professionals who are not assessors but potential beneficiaries of the information from

the assessment, for example managers and administrators of facilities and health providers as well as

government agencies and the research community.

Recurring themes include cost versus value, the importance of embedding clinical change, support for

process efficiencies related to using assessment software and sector education related to using

aggregated information for planning, business efficiencies or research.

In this presentation we will discuss the activities developed to embed the use of the interRAI assessment

systems in everyday practice and how we engage with our wider community of practice in New Zealand.

55

Integrating the interRAI suite of tools into homecare practice in Ontario, Canada:

Implementation considerations for learning health systems

Margaret Saari1,2, Melissa Northwood1,2, Courtney Genge2, Diane Mitchell2, Paul Holyoke2


Abstract summary: This presentation will share and discuss key clinical practice, education, and leadership

considerations for organizations implementing interRAI instruments. Lessons learned regarding the introduction

of the interRAI Community Health Assessment into community-based transition, reactivation, and homecare

programs will be detailed.

Keywords: implementation, education, leadership

Background: SE Health, a diverse health care company with origins in home and community care,

undertook a corporate-wide initiative to transition from a service-providing organization to a learning

organization to respond to provincial changes in home care organization and structure. SE Health is

Canada’s largest social enterprise providing over 19,000 client visits every day across Canada. As part

of this initiative, SE Health has implemented interRAI instruments as the standard for assessment and

continuous quality improvement into new transition, reactivation, and homecare programs.

Objectives: This presentation will share and discuss key clinical practice, education, and leadership

considerations for organizations implementing interRAI instruments.

Design: A developmental evaluation was conducted of new transition, reactivation, and homecare

programs. The introduction of the interRAI Community Health Assessment to nursing and

interprofessional team practice was examined in these settings.

Findings: A number of learnings were generated. First, implementing interRAI as the means of

assessment—rather than discipline-specific, mostly paper-based tools—represents a major practice

change in both means and approach to gathering clinical information. Significant investment is required

in both clinical practice education and culture change support. Second, selecting the right technology is

critical to successful implementation. Platforms that are not clinically intuitive or interoperable with

existing electronic health records can hinder user acceptance of interRAI instruments. Both hardware

and software need to be available at start of implementation as changing practice is harder once routines

have been formed. Clinical outputs (scales and clinical assessment protocols) must be presented in

useable format to support care planning, preferably in patient-facing and plain language displays. Third,

education on using the interRAI instruments must be both theoretical and practical, including scenario-

based classroom learning and preceptorship at the point of care. Finally, the organizational culture

change that is required to integrate interRAI instruments in care and continuous quality improvement

takes leadership, time, and trust. Commitment to becoming a learning organization recognizes that

implementation is a journey, and learning will inform each subsequent iteration.

Conclusion and implications: Implementing interRAI instruments is a complex activity that must be

supported top down but implemented bottom up.

56

The Importance of RAI-MDS in Future Health Care Professionals’ Curriculum

Veronique Boscart, Rabia Raouf

Conestoga College, Canada

Abstract summary: Education on the Resident Assessment Instrument – Minimum Dataset (RAI-MDS) for long-

term care (LTC) in comprehensive geriatric assessments programs was identified and appraised using an

environmental scan, and interviews with college faculty and LTC staff. This poster presentation will explain why

more comprehensive education is needed on this topic.

Keywords: education, long-term care, capacity building

The rate of growth of the senior’s population in Canada has been increasing since 2011 – the year in

which the first of Baby Boomers turned 65 (Statistics Canada, 2019). With this increase, there is a

greater need for healthcare providers with the competencies and skills to address seniors’ care needs.

To that extent, HCPs must receive the appropriate training and education to care for this often complex

population. This poster presentation will present findings of a project aimed at gaining an understanding

of current training programs for comprehensive geriatric assessments in long-term care (LTC). More

specifically, it will identify any existing education and training that is associated with the Resident

Assessment Instrument – Minimum Dataset (RAI-MDS) tool in LTC. An environmental scan,

consisting of a curriculum mapping process and a scoping review of existing RAI-MDS training, and

interviews with faculty members at a community college and team members at LTC homes were

conducted. Findings indicated that current education provided to future HCPs and continuing education

available to practicing professionals is insufficient to develop a culture of decision informed quality

care, management and resource allocation. Considering the important role that the RAI-MDS

instrument plays in improving resident care in LTC settings, more comprehensive education is needed

on this topic.

57

SESSION 16: PALLIATIVE CARE 2


A comprehensive profile of palliative home care clients in Ontario: a population-based

retrospective cohort study using interRAI PC data

Kirsten Hermans1, Tara Stevens2, Joachim Cohen3, Anja Declercq1, John Hirdes4, Dawn Guthrie2

1KU Leuven, Belgium; 2Wilfrid Laurier University, Canada; 3VUB, Belgium; 4University of Waterloo,

Canada

Abstract summary: Home health care providers and policy-makers should be aware of home care clients’

characteristics and needs in order to provide high quality PC. Data collected routinely using the interRAI PC can

promote (advance) care planning and support decision-making to achieve this goal.

Keywords: palliative home care, comprehensive profile, interRAI PC

Background: Globally, the ageing population has led to increasing palliative care (PC) needs. Most

people nearing end-of-life express the wish to receive PC at home and eventually die there. In order to

provide quality PC, client preferences and needs surrounding end-of-life should inform the care plan.

Aims: This study provides an overview of socio-demographic, physical, psychosocial and spiritual

characteristics of palliative home care clients, stratified by prognosis.

Methods: A retrospective cross-sectional analysis was conducted using interRAI Palliative Care

(interRAI PC) data collected in Ontario between 2011 and 2018 (n=74,963). Descriptive analyses were

used and the sample was stratified by prognosis (<6 months: n=48,017; ≥ 6 months: n=26,946).

Standardized differences were calculated to identify meaningful differences between prognosis groups

(d=0-0.30: small effect size; d=0.30-0.50: medium effect size; d=0.50-1: large effect size).

Results: In this sample, 49.5% were female, 71.1% were ≥65 years, 83.2% had a diagnosis of cancer

and 64.1% had a prognosis of <6 months. Fatigue (75.6%), dyspnea (42.3%) and pain (39.6%) were

among the most prevalent health issues experienced. Developing pressure ulcers (d=0.42), health

instability (d=0.49), lack of perceived physical improvement (d=0.39) and the awareness of one’s

prognosis (d=0.72) had medium to large effect sizes when stratified by prognosis. However, small effect

sizes were found in several other characteristics, including: pain (d=0.15), falls (d=0.17), depression

(d=0.08), difficulty falling asleep (d<0.01), and caregiver distress (d=0.02).

Conclusion: Home health care providers and policy-makers should be aware of home care clients’

characteristics and needs in order to provide high quality PC. Data collected routinely using the

interRAI PC can promote (advance) care planning and support decision-making to achieve this goal.

This research highlights the increased prevalence of certain characteristics in the last 6 months of life.

However, many characteristics of people with a prognosis of <6 months are similar to those of people

with a prognosis of ≥6 months. This demonstrates the importance of early identification of PC needs

and suggests that those with a longer prognosis may also benefit from PC.

58

Care of the dying – The last health service Diakonhjemmet hospital, 1897-2017 (Oslo, Norway)

Liv Wergeland Sørbye

VID Vitenskapelige Høgskole, Norway

Abstract summary: We studied death and dying in a 130 years period using RAI-LTCF retrospectively. At start,

the doctors had few diagnostic aids. The standard of living and medical development gradually increased. Age

80+ at death, changed from 0-63%. However, it rarely seems easy to face death, despite better palliative care.

Keywords: hospitalization, historical development, palliation; dying

Introduction: The purpose of this study is to describe the historical development of treatment and care

at the end of life. In the late 1800s, major societal changes occurred. Increased population growth in the

big cities created the basis for tight living conditions, infectious diseases and increased malnutrition.

Both public and non-profit organizations had to help. In 1890, a diaconal institution starts a nursing

home for older men, and few years later a hospital.

Method: This survey includes archival and research data from the Deacon hospital (1897-2017). We

obtained permission according to legal and ethical rules. We used both qualitative and qualitative data,

including the medical record. The resident assessment tool for nursing home (www.interrai.org), was

used in 1997 and 2007. The assessments from 1977 and 1987 contain comparable basic data as in the

two last decades. For the archive data, (1897-1967 we used a constructed questionnaire. We have used

a descriptive content analysis of documentation for the last three days of life at the hospital.

Results: The documentation in the medical record was limited in the first decades. The hospital had

spare equipment’s at startup. Lack of professional skills, examination tools, surgery and drugs gave few

opportunities to prolong life. The medical treatments improved after the World War II. It was not until

the 1950s that nursing reports became part of the medical record. Electronic patient records from about

1980’ helped to provide a quick overview of the patient's situation. In the same decade, the hospice

philosophy and the development of palliative medicine emphasize "total care".

The increased standard of living and medical development have increased the proportion of aged at

death 80+ in Oslo, from 0 - 63%. The immediate cause of death changed from tuberculosis, cancer

diseases in the respiratory system.

Conclusion: In archive material, the staff did not record conversation about death and spiritual care, and

optimal symptom control were rare. About 1980’, the hospice philosophy reached Norway. However,

it is difficult to document that it is easier to face death in 2017 than in 1897, despite good palliative

care.

59

Hospitalization in the last days of life - could it have been avoided?

Liv Wergeland Sørbye1, Olaug Elisabeth Vibe2

1VID Vitenskapelige Høgskole, Norway; 2Sagenehjemmet

Abstract summary: We assessed nursing home patient for five years, RAI-LTCF, 110 died, of those 14 were

hospitalized. One has to distinguish between the chances for cure versus the start of the death process. The staff

may reassure the relatives that optimal palliative care will be provided in the nursing home.

Keywords: nursing home, hospitalization, dying

Background: In Norway, 50% of all deaths occur in nursing homes. We have limited knowledge about

elderly people being transferred from nursing homes (NH) to hospitals and die there.

Aim: To consider whether transfer to hospitals could have been avoided during a five-year period.

Method: We included 170 residents from spring 2013 to spring 2018; the study combined quantitative

and qualitative methods. We used the Resident Assessment Instrument for long-term care assessment

annually (www.interrai.org) and analyzed the quantitative data (www.raisoft.fi). After each death, we

interviewed the nurse who had followed the resident’s last days of life. The wishes of the significant

others during the last days before transferring to hospital were included. By combining the quantitative

and the qualitative data, we composed a description of the resident's situation. These cases were

reviewed in three focus group meetings, with other nurses who knew the residents.

Results: During the study period 110 of the 170 residents died. Fourteen of those (12.7%) spent their

last days in hospital. We measured the length of stay in NH and the residents’ age (mean and standard

deviation). The residents who were transferred to hospitals had a year longer stay in NH, 3.8 (2.2)

compared to 2.8 (2.3). Those who died in the hospital were also three years younger, respectively 86.1

(13.3) and 89 (7.3). The main reasons for hospitalization was an acute change in health condition of the

resident, the lack of filling out the "Advanced Directive" - where questions about possible

hospitalization were to be answered. In addition the desire for active life-extension treatment from the

relatives and insecurity of the staff.

Conclusion: To avoid unnecessary hospitalizations, the responsible physician and nurses should have

made an Advance Directive. If possible, one should listen to the significant other and the resident voices.

In an acute situation however, it could be a great support to have a written advance directive. It is

important to distinguish between what may be cured and what is a start of the death process. The staff

may be reassured the relatives that optimal palliative care will be provided in the nursing home.

60

Risk of Death Scale: A Death Prediction Model Based on Nursing Home Residents Admitted in

2011 and 2012

Elizabeth P Howard1,2, John N Morris2, Sabrina Egge3, Erez Schachter4, Fredrik Sjostrand3,5

1Boston College, United States of America; 2Marcus Institute for Aging Research, Hebrew SeniorLife; 3Hannover Re; 4Profililty, Inc.; 5Karolinska Institutet

Abstract summary: Risk of Death Scale was developed through longitudinal analysis of US nursing home

residents admitted in 2011 and 2012 and remaining in long term care for up to 12 months. The scale includes

measures of prognosis, treatments, diagnoses, clinical status, function cognitive status and age.

Keywords: risk of death, MDS 3.0, interRAI

Objective: To identify, among persons admitted to and remaining up to 12 months, in a long-term care

setting, those at more imminent risk of death, revealing the relevant risk factors and summarizing these

factors within a Risk of Death Scale.

Design: Longitudinal analysis of a national cohort of nursing home admissions from all United States

facilities during years 2011 and 2012.

Setting and Participants: Cohort included 1,536,842 admissions (764,002 for 2011, 772,840 for 2012).

Repeated assessments are required every 90 days, with an additional assessment at discharge. Follow-

up data over three years were examined.

Methods: The Risk of Death Scale is based on two sub-scales. One included five very high risk of death

measures. The second was composed of an additional eighteen risk factors. The dependent variable

against which these models were developed was death by 365 days. Death rates are described from

one-month post-admission to three years post-admission.

Results: The Risk of Death Scale has twelve graded levels. The lowest four categories of the scale (0-

3) represent approximately half the cohort and have one-year death rates that range from 3% to 15.5%,

whereas the mean of the entire cohort is 24.2% at one year. The upper four categories (8-11) represent

about 7% of the cohort and have one-year death rates ranging from 55.8% to 90.5%. The death rates

increased steadily across the scale scores, a pattern that held through the three-year post admission

period.

Conclusions/Implications: The Risk of Death Scale for new admissions to nursing homes rests on a

broad spectrum of 23 independent variables – including measures of prognosis, treatments, diagnoses,

clinical status, function, cognitive status, and age. Almost 10% of the sample (n=149,073) had a risk

score of 7 or greater and the average one-year mortality for this group was 68.6% (range of 47.5-90.5%).

61

SESSION 17: ACUTE AND POST- ACUTE CARE

Chair(s): Melinda Martin-Khan

Comprehensive geriatric assessment via telehealth utilising the interRAI AC-CGA tool for

residential aged care: a pragmatic trial

Melinda Martin-Khan1, Len C Gray1, Sanjoy Paul2, Ian A Scott3, Sisira Edirippulige1, Elizabeth

Beattie4, Trevor Russell1, Anthony Smith1, Deborah Theodoros1, Ruth E Hubbard1

1The University Of Queensland, Australia; 2University of Melbourne, Australia; 3Queensland Health,

Australia; 4Queensland University of Technology, Australia

Abstract summary: Pragmatic randomised trial with 413 participants (Intervention: 161; Control: 252). The

intervention group had weekly video conference geriatric consultation in the residential care facility. Although

the number of external visits was not significantly different between groups, there are other benefits to support

the use of telehealth geriatric clinics.

Keywords: long term care, geriatric, telehealth

Introduction: People residing in residential aged care facilities (RACFs) require high levels of care for

chronic multiple co-morbidities, cognitive and physical impairment and social and behaviour issues.

RACFs commonly rely on visiting general practitioners to provide primary care and, by referral, access

to other healthcare specialists. The availability of such care is often insufficient to meet the high health

care needs of residents. Telehealth is an alternative model of service delivery which may overcome

some of these limitations.

Aim: To examine the effectiveness of telehealth to reduce utilization of external health services by

residents in RACFs.

Method: A pragmatic randomised trial with two study arms was conducted over six months. The control

arm experienced usual care; the intervention group were referred for a videoconference (VC)

consultation with a geriatrician via a weekly telehealth clinic. A facility nurse completed the interRAI

Acute Care-Comprehensive Geriatric Assessment (AC-CGA) tool for the geriatrician to review the

report prior to the consultation, and both patient and nurse were linked in real time by VC for an

appointment with the geriatrician. External visits comprised hospitalisations, emergency department

(ED) visits and outpatient clinic attendances.

Results: Of the 1,569 residents, 413 participated in the study (Intervention: 161; Control: 252). There

were 281 video consultations; with 120 patients undergoing a review consultation in the intervention

group. After adjusting for cluster effects, the rate of external visits in the intervention group was 1.47

(95%CI 0.91-2.37) times greater than that in the control group, with 56% vs. 47% of residents having

1 or more external visits (p-value=0.12). More intervention residents had 1 or more hospitalisations,

ED visits and clinic attendances than control residents: 52% vs. 33%; 11% vs 9%; and 29% vs. 21%

respectively.

Conclusion: Telehealth geriatric consultations in RACFs using the interRAI AC-CGA tool did not

significantly reduce the number of external health care visits for residents. Further investigation is

needed in identifying other benefits conferred on residents and staff by telehealth consultations.

62

Effectiveness and variability in functional improvement of CVA patients in Post Acute Care

Units of Catalonia

Sergio Ariño-Blasco1, Mireia Espallargues-Carreras2

1Hospital General Universitario de Ganollers HGG, Spain; 2Agència de Qualitat i Avaluació

Sanitàries (AQuAS), Barcelona, Spain

Abstract summary: In order to assess the effectiveness of stroke rehabilitation in patients admitted to Post Acute

Care Units in Catalonia and variations in results of functional improvement across centres we performed an

observational, descriptive and comparative study of a retrospective cohort of consecutively admitted patients over

a period of 6 years.

Keywords: health system performance, outcomes research, regional variation

Objective: to assess effectiveness of stroke rehabilitation in patients admitted to Post Acute Care Units

(UMEs) in Catalonia and variations in results of functional improvement across centres.

Method: observational, descriptive and comparative study of a retrospective cohort of consecutively

admitted patients over a period of 6 years. Outcome variable is functional improvement defined by the

absolute gain between the dependence index in basic activities of the daily on admission and at

discharge in UME. Variability of functional improvement in different UMEs was analysed with crude

and standardized ratios stratified by comorbidity, severity and case mix applying the indirect rate

adjustment method.

Results: We analysed 11,471 stroke episodes from 78 UMEs in Catalonia. The median age was 80 years

(IQR 73-86), functional index on admission 13 (IQR 11-17) and 12 (IQR 6-15) at discharge, with an

average gain of 2.08 points and overall improvement in 46.3% of patients. Home discharged destination

was present in 6.912 (60.3%) cases. Rate of variation for functional improvement was RV5-95 = 12.6

and RV25-75 = 1.7 for crude data from the global population and RV5-95 = 2.53 and RV25-75 = 1.53

and Of RV5-95 = 2.96 and RV25-75 = 1.50 for standardized data stratified by severity and comorbidity

respectively.

Conclusions: The study shows that the percentage of improvement achieved in the UMEs of Catalonia

in acute cerebral vascular disease is 46.3%. Results are comparable to those obtained in other

international studies. There is an important variability in performance between UMEs that improves

using statistics to exclude extreme values, standardizing by severity and stratifying by RUGIII

isogroups

63

The interRAI Acute Care Instrument for Seniors in Canadian Hospitals: Findings of an Inter-

Rater Reliability Pilot Study

Veronique Boscart1, Linda Sheiban Taucar1, Michelle Heyer1, Tabitha Kellendonk2, Keia Johnson1,

Meaghan Davey1, Nancye Peel3, George Heckman4, John Hirdes4

1Conestoga College Institute of Technology and Advanced Learning, Canada; 2Registered Nurses

Association of Ontario; 3The University of Queensland; 4The University of Waterloo

Abstract summary: The InterRAI Acute Care instrument is a reliable for use by nurses to conduct a

comprehensive assessment. This instrument offers a standardized and efficient approach to assess for care and

intervention priorities and could prevent adverse outcomes in hospitalized older adults.

Keywords: reliability, interRAI, acute care

Background: Older adults are the biggest users of emergency departments and hospitals. However,

healthcare professionals are often ill equipped to conduct comprehensive geriatric assessments causing

missed opportunities for preventing adverse outcomes.

Purpose: To evaluate the inter-rater reliability of the interRAI Acute Care assessment instrument in

acute care hospitals in Ontario, Canada. This study was a subset of a larger collaboration, which sought

to test inter-rater reliability internationally (Gray et al., 2018).

Methods: This study evaluated the reliability of the interRAI Acute Care assessment instrument, which

was designed to facilitate a comprehensive nursing assessment for hospitalized adults. This cross-

sectional study was conducted in two hospitals in Ontario, Canada including one hospital in a rural

location (118 in-patient beds) and one hospital (200 general and acute medicine in-patient beds) in a

mid-sized city. Four research nurses were trained by the lead investigators in Australia and Canada to

perform and interpret assessments using the interRAI Acute Care assessment instrument. Sample

characteristics were described, and Cohen’s Kappa was calculated to derive the inter-rater reliability.

Assessment times to complete the instrument were collected as well.

Results: Most patients were admitted from a private residence, over one third of the patients were

hospitalized in the last 180 days, and a significant proportion of patients reported poor health. Most

hospitalized seniors presented with health complexities, including multiple comorbidities,

polypharmacy, recent hospitalizations, receiving supportive care at home for activities of daily living,

and challenges with mood, overall health and pain management. The Cohen’s Kappa score for the

instrument was 0.91. The time required for nurses to complete the interRAI AC ranged from 15 to 20

minutes, excluding chart reviewers.

Conclusions: The InterRAI Acute Care instrument is a reliable for use by nurses to conduct a

comprehensive assessment. This instrument offers a standardized and efficient approach to assess for

care and intervention priorities and could prevent adverse outcomes in hospitalized older adults.

Gray, L.C., Beattie, E., Boscart, V.M., Henderson, A., Hornby-Turner, Y.C., Hubbard, R.E., Wood, S.

& Peel, N.M. (2018). Development and testing of the interRAI Acute Care: A standardized assessment

administered by nurses for patients admitted to acute

64

SESSION 18: POLICY 1

Chair(s): Chris Perlman

A focus on equity: providing value from interRAI assessment for policy development

Brigette Meehan

TAS, New Zealand

Abstract summary: This presentation discusses insights identified from exploring New Zealand interRAI data

related to equity. It describes strategies that may directly influence policy and health outcomes, and reports on

some New Zealand-wide and local initiatives related to interRAI assessment and interRAI data that are designed

to support equity.

Keywords: equity, indigenous, data

The New Zealand health system performs well when investment is compared to outcomes (OECD) yet

we know people have differences in health that are not only avoidable but unfair and unjust.

A focus on equity recognises that people with varying levels of advantage require different approaches

and resources to get equitable health outcomes. This is different from equality where everyone is treated

the same.

The focus on equity is not new, equity underpins the Treaty of Waitangi signed in 1840 between Māori

and the British Crown, however, improving equity remains a challenge and a high Government priority.

In May 2018, the Minister of Health announced a review of the New Zealand health and disability

sector. The review provides an opportunity for interRAI information to inform new policy development,

not only to gain insights into equity for Māori, our indigenous population, but also the increasing

diversity of people in our country. In particular, the proportion of three major population groups are

projected to increase significantly in the 65+ aged group; Asian, Māori and Pacific peoples, and the

population overall is expected to become increasingly diverse from immigration growth.

This presentation discusses insights identified from exploring interRAI data related to equity. It

describes strategies that may directly influence policy and health outcomes, and reports on some

national and local initiatives related to interRAI assessment and interRAI data that are designed to

support equity.

interRAI assessments became mandatory in 2015 for access to home and community support services

and to inform care planning in aged residential care in New Zealand. Since then we have grown a rich

database of assessment information available for planning and research purposes.

This information has the power to influence how people age in our society. The use and dissemination

of this information alongside information from other sources, can provide an evidenced base for the

policy debate and decisions about health service delivery, particularly for our areas of interest, the

services older people access and the environments in which they are delivered.

65

Geo-spatial Applications for using interRAI Data to Inform Public Policy

Chris Perlman

University of Waterloo

Abstract summary: This presentation will demonstrate the utility of interRAI data for spatial analytics and

geographic information systems (GIS). Maps will show patterns of RAI-MH data for older adults with dementia

or problematic alcohol use, as well as caregiver distress from interRAI-HC data.The research and health system

planning implications will be discussed.

Keywords: GIS, spatial-analysis, system planning

Spatial analytics utilize data at area levels to understand patterns of relationships between the

characteristics of geographically defined areas and various outcomes. For instance, spatial analysis can

be used to understand how the economic status, urban density, and availability of green space relate to

the health of the population. From an equity perspective, we can also examine factors such as income

disparities and access to high quality healthcare. Overall, the applications of these methods are rare in

understanding patterns of health service use and need for vulnerable health populations. This

presentation will demonstrate how interRAI data can be useful for evaluating patterns of health service

use in relation specific geographic characteristics. The examples draw upon RAI-MH data for older

adults with dementia as well as older adults wth problematic alcohol use, as well as interRAI-HC data

for clients with distressed caregivers.The presentation will also exemplify the use Geographic

Information Systems to map out interRAI data. The policy and health system planning implications will

be discussed.

66

Visualising interRAI data

Michele McCreadie

TAS, New Zealand

Abstract summary: New Zealand interRAI assessors complete over 120,000 assessments each year contributing

to a rich body of data about older people, which is increasingly used by researchers and policymakers. In this

presentation, we will demonstrate the New Zealand interRAI data visualisation tool and share learnings from the

development of the tool.

Keywords: data, visualisation, demonstration

Some 746,000 people of the 4.9 million people who live in New Zealand are more than 65 years old.

Across the country, interRAI is the primary assessment instrument in aged residential care and to

receive home and community services.

interRAI assessors complete over 120,000 assessments each year contributing to a rich body of data on

the situation of older people in New Zealand. All interRAI assessments in New Zealand are completed

on a single national software platform and feed into a central data warehouse.

interRAI data is increasingly used by researchers and policy makers – and it is available online through

an interactive data visualisation.

The data visualisation, available on the public website, allows users to access interRAI data at national

and local level, as well as for population subgroups. The interactive nature of the tool means users are

in control of the information and can select the level of detail they desire.

Organisations and individuals can continue to request specific interRAI assessment data, and a suite of

reporting is available for healthcare providers – the basis for a growing body of research and care

improvements using New Zealand interRAI data.

In this presentation, Michele McCreadie, General Manager New Zealand interRAI Services, will give

a demonstration of the data visualisation and share learnings from the development of the tool.

67

SESSION 19: MENTAL HEALTH 2

Chair(s): Trevor Smith

Use of the interRAI Brief Mental Health Screener to enhance collaboration between the police,

health care and community mental health professionals

Ronald E. Hoffman

Nipissing University, Canada

Abstract summary: The interRAI Brief Mental Health Screener (BMHS) enables police officers to collect and

standardize their observations and permits the benchmarking of key indicators of major mental disturbances and

real time risk profiling while contributing to a more seamless collaborative relationship between police, hospitals

and community mental health service providers.

Keywords: mental, screener, police

This oral presentation will report on the use of the interRAI Brief Mental Health Screener (BMHS) to

screen and assess patient safety issues that creates a more seamless collaborative relationship between

police, hospitals and community mental health service providers. The BMHS is a valid predictor of the

characteristics of persons most likely to be taken to hospital by police officers and those persons most

likely to be admitted. It enhances the ability of police officers to identify persons with serious mental

disturbances while providing an evidence-based framework to standardize police officer observations.

It supports police officer and emergency department decision-making and because it is based on health

system data and written in health language it has the potential to help synchronize the criminal justice

and mental health care systems. There will be a brief discussion of the development and use of the

BMHS and the algorithms developed for the BMHS that include danger to self, danger to others and

inability to care for self. Next, there will be a discussion of how the information collected by the BMHS

is used to identify and benchmark key indicators of major mental disturbances and develop real time

risk profiling and how this information is conveyed to hospitals and community mental health service

providers.

68

Persons with mental health disorder and police contact: characteristics of youths and adults

based upon the interRAI Brief Mental Health Screener

Alicia Hoffman, Trevor Frise Smith, Greg Brown

Nipissing University, Canada

Abstract summary: The BMHS has been adopted by police services in Ontario, Canada. Until recently, analysis

of this data has been restricted to adults (persons 18 years of age or over). The current study analyzes BMHS

assessments from one police service comparing persons under 18 years of age with those 18 years and older.

Keywords: mental disorder, youth, police

It is estimated that one in five children and youth have experienced a mental health disorder (Mental

Health Commission of Canada [MHCC], 2013). It is generally accepted that undetected and untreated

mental health problems can lead to devastating lifelong consequences however, many factors have been

identified to account for why children and youth are not receiving the services they require. One of the

most obvious is simply missed opportunities by parents, school officials, physicians and frontline

service providers such as police officers to identify early signs of mental health problems. Police

officers in particular, are in a unique position in that as the eyes of the community, they are often the

only persons to observe early signs or indicators of serious mental health problems. In an effort to

capture and standardize police officer observations, the interRAI Brief Mental Health Screener (BMHS)

was developed to help identify the characteristics of persons with mental health disorders who have

contact with police officers (Hoffman, Hirdes, Brown, Dubin, & Barbaree, 2016).

The BMHS has been adopted by more than a dozen police services in the Province of Ontario, Canada.

Until recently, analysis of this data has been restricted to adults (persons 18 years of age or over). The

current study analyzes BMHS assessments from one police service comparing persons under 18 years

of age with those 18 years and older. This information could be used to identify early warning signs of

serious mental health problems among younger persons, facilitate early intervention and treatment,

inform community mental health service providers as to the type of mental health services needed and

assist in developing appropriate training for police officers and other frontline emergency response

personnel.

References:

[1] Hoffman, R., Hirdes, J., Brown, G. P., Dubin, J. A., & Barbaree, H. (2016). The use of a brief mental

health screener to enhance the ability of police officers to identify persons with serious mental disorders.

International journal of law and psychiatry, 47, 28-35. Retrieved from

http://www.sciencedirect.com/science/article/pii/S0160252716300449

[2] Mental Health Commission of Canada. (2013). Opening Minds: Interim Report. Retrieved from

http://www.mentalhealthcommission.ca/English/node/17491/

69

Continuity of care in mental health services and appropriateness of clinical assessment systems:

a scoping review

Vinciane Quoidbach1, Kathleen De Cuyper2, Anja Declercq2, Chantal Van Audenhove2

1European Brain Council; 2KU Leuven LUCAS, Belgium

Abstract summary: Discontinuity of care is a major public health issue as it is associated with patient’s poor

health outcomes. The sharing of patient-centred information that transcends care settings can have the potential

to enhance the delivery of mental health care for adults with severe mental illness.

Keywords: continuity of care, severe mental illness, clinical assessment systems

Introduction: People with severe mental illnesses (SMI) have multifaceted health and social needs

which are reflected in the complexity of services that have been developed to meet them. The shift

towards community mental health care as encouraged by mental health deinstitutionalization reforms

across Europe in the last decades has raised concerns about continuity of care for patients with severe

mental illness. Patients living in the community are likely to experience increasingly fragmented mental

health services, lengthy wait times, re-hospitalization, compulsory commitment, discontinuity of

treatment, poor social integration and other adverse events. The criterion for best quality care has

become the degree to which treatment delivered by separate services (in-patient psychiatry and out-

patient mental health community services) and professionals (psychiatrists, primary care clinicians, and

mental health professionals) is continuous and well coordinated.

Objective: Aim of the study is to undertake a scoping review of the literature in order to identify

obstacles and facilitators to delivering continuity of care at the level of direct care for patients with SMI.

Method: A systematic search of electronic databases for papers from North America and Europe and a

search for grey literature is conducted. The results of the scoping review will be discussed with experts

in the field.

Results: Based on the results of the scoping review, the authors present a research framework,

summarizing factors that affect continuity of care and the nature of evidence used to support these

claims. Web-based mental health assessment support using clinical information and communication

technology is one of the factors that will be discussed.

Conclusions: The scoping review attempts to reach consensus about the continuity of care concept, its

facilitators and barriers in the direct care for persons with SMI.

70

SESSION 20: FAMILY CARERS

Chair(s): Dawn Guthrie

Development and Validation of Caregiver Risk Evaluation (CaRE): A New Algorithm to Screen

for Caregiver Burden

Dawn M. Guthrie1, Nicole Williams1, Cheryl Beach2, Colleen J. Maxwell3, Deborah Mills4, Lori

Mitchell5, R. Colin Reid6, Jeffrey W. Poss3

1Wilfrid Laurier University, Canada; 2Fraser Health, Canada; 3University of Waterloo, Canada; 4Island Health, Canada; 5Winnipeg Regional Health Authority, Canada; 6University of British

Columbia-Okanagan, Canada

Abstract summary: This presentation outlines the development and testing of a new algorithm to screen for

caregiver burden in home care, the Caregiver Risk Evaluation (CaRE). It can be generated using six items from

the Resident Assessment Instrument for Home Care (RAI-HC), all of which are also embedded within the

interRAI HC.

Keywords: home care, caregiver burden, screening

Background. This project represents the initial steps to create and validate a decision-support tool to

assess the risk of caregiver burden, the Caregiver Risk Evaluation (CaRE) algorithm. Methods. A total

of 344 home care clients were assessed using the Resident Assessment Instrument for Home Care (RAI-

HC). Their primary caregiver completed the 12-item Zarit Burden Interview (ZBI), which was linked

to the RAI-HC for each client. Clients were followed for 12 months to determine the rate of long-term

care admission. Items from the RAI-HC considered for inclusion in the algorithm were correlated with

the ZBI score, were known risk factors in the literature or were suggested through input from caregivers

and clinicians. CaRE was created using interactive decision tree software, with the ZBI score as the

dependent measure. Results. In the sample, 48% of clients were aged 85+ years, 61.6% were female

and 39.4% were married. The CaRE algorithm includes six unique items from the RAI-HC (four related

to the caregiver, and two reflecting client characteristics). The algorithm has nine terminal nodes which

can be collapsed into four categories: low, moderate, high and very high risk of caregiver burden.

Compared to the low risk group, clients in the very high risk group were more likely to experience

difficulties completing ADLs (33.3% vs. 8.6%) and the primary caregiver and client both were more

likely to feel that the client would be better living in a different environment (51.2% vs. 9.6%). The

very high risk group had an odds ratio of 5.16 (95% confidence interval: 2.05-12.9) for long-term care

admission, relative to the low risk group, even after adjusting for client age, sex and regional health

authority. Discussion. The CaRE algorithm represents a new tool that can be automatically generated

using data elements within the RAI-HC or the interRAI HC. It can be used to support clinical decision-

making as home care clinicians proactively plan for the needs of clients and their caregivers.

71

Does functional and cognitive ability among home care clients predict levels of formal and

informal care?

Inga V Kristinsdottir

University of Iceland, Iceland

Abstract summary: InterRAI-home care data from 6 European countries reflect home care clients deteriorate

physically and mentally during the last decade. The majority of clients with reduced ability receive more help

from formal and informal caregivers than those with better ability.

Keywords: home care, older people, InterRAI-home care

Background: It is expected that older people living in their own homes will be frailer and have more

complex health problems in the years to come. To respond to these demographic changes and support

continued independent living health authorities need to design multifaceted home care services. This

calls for new knowledge related to how this group can be supported for continued living at home. The

overall aim of this paper is to describe the health condition and home care services provided to older

people in several European countries where long-term residence in private homes has been encouraged.

It was guided by the research question: How well have home care services in Europe responded to

changing health care needs among frail older persons?

Methods: This is a forward long-term and descriptive study. InterRAI-home care data were collected in

the AdHOC (2001-2003) and IBenC (2014-2016) studies. Five Europian countries participated in both

studies, which provides an opportunity for comparison. The InterRAI-HC assessment tool was used to

assess a random sample of home-care clients who were 65 years and older. Analytical statistics were

used for data analysis.

Results: The preliminary results indicate that both cognitive (measured on the CPS scale) and functional

ability (measured on the ADLH scale) of home care clients has deteriorated in most of the participating

countries over the last decade. It is also evident that formal service in the participating countries has

increased. Home care clients who score ≥3 on the ADLH or CPS scale receive significantly more

minutes of assistance both from formal and informal caregivers than those who score ≤2 on these same

scales.

Conclusion: Cognitive and physical ability among home care nursing clients in the participating

European countries declined from the AdHoc to the IBenc study. This indicates that the government's

policy of long-term residence has been realised and increased service needs have been met to some

degree. The result also provides direction in relation to how Iceland can develop services to meet the

needs of frail older people living in their own homes.

72

Does informal care and experienced stress increase use of services in six months after initial

assessment of an older person?

Anja Noro, Harriet Finne-Soveri, Mervi Kylmälä, Aleksandr Gerasin


Abstract summary: Older persons applying for services often have informal care available. If their informal

carers have care burden, it is associated with higher amount of services after six months. The RAI-system helps

also in identifying informal carers with high risk of stress so that they can be supported earlier.

Keywords: screening, older people, informal care

Aims: Increasing number of older people is assessed with RAI-system when they first contact client

guidance and services coordination authorities. Several of them have also informal care available and

some of informal carers have care burden. The aim of study was to find if informal care burden indicates

more services in six month follow-up.

Materials and methods: In screening potential need for services, 8971 older people over 64 years old

were assessed by RAI-system in 2017. They were followed up for six months after assessment. The

data of use of services was drawn from the care and death registers and was combined with RAI-

assessments. If the assessed person was not found as user, it was conclude that he or she did not have

any services. In the analyses were use frequencies, means and logistic regression.

Results: Of those applying for services (n=8971), 43% had one and 46% had two informal carers, and

12% did not have any. Of those informal carers, 15% indicated care burden. Of the older persons, in six

months one or more services were allocated to 16% of those without informal carers, and for one fifth

for those with informal carers. During next four months 4% (n=350) had died. Informal care burden

was highest both in the group that had died, or had one or more services. According to MAPLe

algorithm, those in higher need groups had significantly more services as well as in a group receiving

informal care had significantly higher amount of services if the informal carers indicated stress. These

findings stayed significant in logistic regression in which multiple use of services were analysed.

Conclusions: Older persons applying for services often have informal care available. The RAI-system

helps also in identifying informal carers with high risk of stress so that they can be supported earlier.

73

SESSION 21: MEDICATION

Chair(s): Luke Turcotte

Exercise therapy, and polypharmacy was associated with changes in frailty – a longitudinal

cohort study with 250,428 Canadian home care clients

Rasmus Tolstrup Larsen1, Luke Turcotte2, Rudi Westendorp3, Henning Langberg4, John Hirdes5

1University of Copenhagen, Department of Public Health, Section of Social Medicine, Denmark; 2School of Public Health and Health Systems, University of Waterloo, Ontario, Canada; 3Center for

Healthy Aging, Department of Public Health, Section of Social Medicine, University of Copenhagen,

Denmark; 4University of Copenhagen, Department of Public Health, Section of Social Medicine; 5School of Public Health and Health Systems, University of Waterloo, Ontario, Canada

Abstract summary: This longitudinal cohort-study investigated if exercise and polypharmacy was associated

with changes in frailty. In total, 250,428 home care clients were included in the analyses. Frailty was found to be

reversible and improvements happened significantly more often in clients receiving exercise therapy and

significantly less often in clients with polypharmacy.

Keywords: frailty, exercise, and polypharmacy

Importance: The health impact of frailty among older adults is the focus of increased attention. Clinical

studies suggest it is potentially reversible with exercise and may be worsened with polypharmacy.

Objective: This study aimed to investigate if exercise therapy and polypharmacy was associated with

changes in frailty states.

Design: Longitudinal cohort-study using client-level health information collected using interRAI home

care assessments. A Markov chain multistate transition logistic regression model was used to calculate

odds ratios for state transitions with exercise therapy and polypharmacy as independent variables.

Setting: Population-based study with home care clients.

Participants: Population-based sample of home care clients above 65 years of age.

Exposures: Participation in exercise therapy and polypharmacy. Participation in exercise therapy also

included participation in physical therapy and was coded as a binary variable based on partial or full

adherence to prescribed therapy. Polypharmacy was also coded as a binary variable based on the

occasional or regular use of nine or more medications during the seven-day assessment period.

Outcome: The outcome of interest was health state transitions within levels of the FI. Three categories

were used to define frailty states: non-frail (FI <0.21), pre-frail (0.21 ≤ FI ≤ 0.30) and frail (FI > 0.30).

Results: In total, 250,428 home care clients experiencing 402,005 frailty transitions were included in

the analyses. At baseline, 39.4% of clients were categorized as non-frail, 30.2% were categorized as

pre-frail and 30.4% were categorized as frail. Across baseline frailty states, polypharmacy was

associated with lower odds of transitioning to a less frail state, dying, entering long-term care, or

discontinuing home care services. Conversely, polypharmacy was associated with greater odds of

transitioning to a frailer state and hospital admission. For all baseline frailty states, clients that

participated in exercise therapy had greater odds of transitioning to a less frail state and discontinuing

home care services. For most baseline states, clients that participated in exercise therapy had lower odds

of death, hospital admission, and long-term care admission.

Conclusion: Frailty was found to be reversible and improvements happened significantly more often in

clients receiving exercise therapy and significantly less often in clients with polypharmacy.

74

Medication use and cognitive impairment among residents of aged care facilities in Australia

Leila Shafiee Hanjani1, Ruth E. Hubbard1, Christopher R. Freeman1, Leonard C. Gray1, Ian A.

Scott1,2, Nancye M. Peel1

1The University of Queensland, Australia; 2Princess Alexandra Hospital, Australia

Abstract summary: In this study we investigated the patterns of medication prescribing of 720 aged care

residents in Australia based on cognitive status (no, mild to moderate, and severe cognitive impairment) using

data collected with the interRAI™ Long-Term Care Facilities (LTCF) assessment instrument during telehealth-

mediated comprehensive geriatric consultations.

Keywords: potentially inappropriate prescribing, cognitive impairment, residential aged care

Background: Potentially inappropriate polypharmacy is common in Australian residential aged care

facilities (RACFs). This is of particular concern in people with cognitive impairment who, compared

with cognitively intact residents, are potentially more sensitive to the adverse effects of medications.

Aim: To compare the patterns of medication prescribing of aged care residents based on cognitive

status.

Methods: A secondary analysis was conducted of de-identified data collected using the interRAI™

Long-Term Care Facilities (LTCF) assessment instrument during telehealth-mediated comprehensive

geriatric consultations with 720 permanent RACF residents from May 2006 to October 2017. Residents

were categorised based on the Cognitive Performance Scale into 3 groups: cognitively intact, mild to

moderate impairment and severe impairment. The number of medications and the level of exposure to

polypharmacy, anticholinergic and sedative medications (as measured using the Drug Burden Index),

and potentially inappropriate medications (PIMs) (according to the Beers Criteria), and the use of

preventive and symptom control medications were compared across the three groups.

Results: Residents’ mean age was 83.4 ± 8.7 years and 65.4% were female. The median number of

medications taken was 10 (IQR 8-14) and 66.2% of residents were receiving polypharmacy. Compared

with those with cognitive impairment, cognitively intact residents were receiving significantly more

medications (median [IQR] 13 [10-16]) than those with mild to moderate (10 [7-13]) or severe (9 [7-

12]) cognitive impairment (p < 0.001). A greater proportion of the intact group were exposed to

polypharmacy (77.8% vs. 64.5% and 61.0% for mild to moderate and severe cognitive impairment

groups respectively (p = 0.005)). Overall, 82% of residents were receiving at least one anticholinergic

and sedative medication and at least 26.9% were exposed to one or more PIM, although the proportions

of those receiving such medications were not significantly different across the three groups. Of 7658

medications residents were taking daily, 21.3% and 11.7% were classified as symptom control and

preventive medications respectively with no significant difference among the cognitive groups in use

of these medications.

Conclusion: Our findings highlight the need for interventions that optimise prescribing in Australian

RACFs, with particular attention to those with impaired cognition.

75

Medication-Related EU InterRAI Research: What We Learnt on Medication Safety in Older

Adults from the EU ADHOC, SHELTER and EUROAGEISM FIP7 projects?

Daniela Fialová1,2, Jovana Brkič2, Eva Topinkova1, Jindra Reissigová3

1Charles University, 1st Faculty of Medicine, Department of Geriatrics and Gerontology, Czech

Republic; 2Charles University, Faculty of Pharmacy, Department of Clinical and Social Pharmacy,

Czech Republic; 3The Czech Academy of Science, Department of Statistical Modelling, Prague, Czech

Republic

Abstract summary: Results of large EU InterRAI projects ADHOC, SHELTER and EUROAGEISM FIP7

H2020 showed substantial diferences across EU countries and study sites in inappropriate prescribing in older

patients. Implementation of interRAI methods, geriatric assessment scales and clinical pharmacy medication

reviews may substantially improve appropriateness of drug prescribing in future decades.

Keywords: geriatric patients, inappropriate prescribing, large EU interRAI projects

Introduction: The majority of medications were not tested in RCTs (randomized controlled trials) in

older patients and knowledge on their appropriate dosing and indications in geriatrics are limited. The

large interRAI EU projects ADHOC, SHELTER and the EUROAGEISM FIP7 H2020 project focused

on broader description of potentially inappropriate prescribing in older patients (eg. polypharmacy, non-

geriatric dosing, inappropriate drug combinations etc.) in EU countries in different settings of care.

Methods: Databases of EU ADHOC project (AgeD in Home Care, 5th FP EC, 2001-2005, 2707 HC

clients 65+, 8 EU countries), SHELTER (Services and Health in the Elderly in Long-Term Care, 7th

FP EC, 2009-2014, 3965 long-term care residents 65+, 7 EU countries and Israel) and the

EUROAGEISM FIP7 H2020 project (2017-2022, 8 Central and Eastern EU countries, 450 older adults

65+/country, ambulatory, pharmacy and acute care) were analysed to describe different patterns of

inappropriate drug prescribing. Patients were prospectively assessed using RAI MDS-HC instrument,

interRAI LTCF tool or selected interRAI functional status scales combined with comprehensive

information on diagnoses, symptoms and medications.

Results: 95,1 % of EU home care clients (ADHOC project), 94.9 % of EU NH residents and 100 % of

patients in acute care (EUROAGEISM FIP7 H2020) used at least 1 medication; excessive

polypharmacy (9+/10+ medications) has been documented in 22.2 %, 23.7 % and 46.9 % patients,

respectively. The prevalence of PIM prescribing was found to be 19.8 % in ADHOC (Beers and Mc

Leod criteria), 60.7% in SHELTER (EU-7 PIM list) and 77.6% in the EUROAGEISM FIP7 H2020

project (combined EU-7 PIM list, STOPP/START and Beers criteria) with highly significant

differences across different countries and study sites.

Conclusion: Results of the large EU projects ADHOC, SHELTER and the EUROAGEISM FIP7 H2020

project showed substantial diferences across EU countries and study sites in inappropriate prescribing

in older adults. Implementation and combination of interRAI methods, geriatric assessment scales and

clinical pharmacy medication reviews may substantially improve appropriateness of geriatric drug

prescribing in future decades.

Support: H2020-MCSF-ITN-764632, QLK6-CT_2000-00002, FP7-HEALTH-F4-2008-201917, SVV

260417, PROGRESS Q42 Faculty of Pharmacy, Charles University

76

SESSION 22: COMPLEXITY OF CARE

Chair(s): Margaret Saari

Integrating mental health services into primary health care in India: pivot role of interRAI

instruments

Priyamadhaba Behera1, John P. Hirdes2

1All India Institute of Medical Sciences, Raebareli; 2University of Waterloo, Canada

Abstract summary: India has high burden of mental health disorders. Lack of standardized assessments and

measures at the community and health centres is one of the major challenges in delivering comprehensive mental

health services. This presentation will summarise the utility of interRAI instruments in health systems to deliver

comprehensive mental health services.

Keywords: mental health, interRAI instruments, India

Mental health is fundamental to health and is paramount to personal well-being, family relationships,

and successful contributions to society. It is related to the development of societies and countries.

Recent National Mental Health Survey (2015-16) of India reported a prevalence of 13.7% for any

mental disorders excluding tobacco use disorders in India. Translating it into real numbers, nearly 150

million people need active mental health interventions. Despite the fact that mental disorders have a

high burden, are found in women and men, affect at all stages of life, prevalent among the rich and

poor, and in both rural and urban settings, mental health services have been neglected in the past in

India. Fortunately, mental health has been able to secure a birth in the package of Health and Wellness

Centres, under Ayushman Bharat (Healthy India) program which has been launched in the alignment

with its National Health Policy 2017. Lack of standardized assessments and measures at the community

and primary health care level is one of the major challenges in delivering comprehensive mental health

services. To fill this gap, interRAI instruments are highly useful. The interRAI Brief Mental Health

Screener is an ideal tool which can be used by multipurpose workers (MPWs) at Health and Wellness

Centres. This presentation will summarise the utility of interRAI instruments in health systems to

deliver comprehensive mental health services. The standard assessment tools will not only improve the

coverage of mental health services, but also provide a platform for reducing social stigma of mental

disorders, screening for priority mental disorders at community level, ensuring compliance to treatment,

timely follow-up and community-based rehabilitation by mobilizing community support for diagnosed

cases.

77

Giving patients a voice: What does it mean when they don’t speak out? Dealing with self-

reported items in interRAI

Jason Ferris, Nancye Peel, Len Gray


Abstract summary: This is a methodological paper exploring missing data related to self-reported responses.

Currently, the Short Depression Rating (SDR) Scale requires valid responses for all 3 sub-questions in the Mood

and Behaviour section. We explore increasing sample size by allowing 1 missing response item in the SDR Scale.

Keywords: self-report, mood, algorithms

Across the suite of interRAI instruments it is not uncommon for assessment forms to include self-

reported items. While objective measures or nurse-clinician responses on an instrument may minimise

‘self-reported’ bias, it is necessary to capture the voice of the respondent. When this happens we risk

self-reporting bias. Responses are subjective and may include exaggerated or false responses as a result

of memory lapse, recall bias, social desirability, or even questionnaire design.

The aim of this presentation is to explore the characteristics of people who do not provide valid

responses to self-reported items and the impact on this for self-reported items that are used to create

scales. We present on self-reported responses relating to Mood and Behaviour scored in either the

interRAI Acute Care (AC) Assessment or the Acute Care for Comprehensive Geriatric (CGA)

Assessment. This section consists of two questions related to mood and health:

1. Self-reported mood consisting of three sub-questions – ‘In the last 24 hours, how often have

you felt…’

a) ‘little interest or pleasure in the things you normally enjoy’,

b) ‘anxious, restless, or uneasy?’,

c) ‘sad, depressed, or hopeless’

2. Self-reported health

These questions include non-informative responses option ‘8. Patient could not (would not) respond’

or ‘missing’. In this presentation we explore the characteristics of those who provided non-informative

responses to these items compared to those who provide valid responses. For example 2% of

respondents in the AC assessment and almost 10% of respondents in the GCA responded with non-

informative responses.

Moreover, the three sub-questions of ‘self-reported mood’ are used to produce the ‘Short Depression

Rating (SDR) Scale’. Currently any non-informative responses to either of these 3 sub-questions results

in no score on the SDR scale for the respondent. We explore the possibility of allowing one non-

informative response to a sub-question by up-weighting the SDR scale. We then compare the

characteristics of those who provide a valid response to all except one sub-question item to those who

provided valid responses to all 3 sub-questions. Finally, we discuss the value of allowing this up-

weighted SDR scale to increase the total sample population of ‘valid’ responses.

78

Autonomous but isolated: The self-reported quality of life of medically complex older adults in

transitional care

Margaret Saari1,2, Heather McNeil2, Courtney Genge2, Melissa Northwood1,2, Rosemary Georges2,

Diane Mitchell2, Paul Holyoke2


Abstract summary: Transitional care programs support clients with complex health and social situations to

optimize functioning and allow them to live as independently as possible. Understanding clients’ self-reported

quality of life provides staff and administrators with insights into the client experience and identifies opportunities

for program improvement.

Keywords: transitions, quality of life, medically complex

Background: Health has been defined as not only the absence of disease, but a state of complete

physical, mental, and social well-being. In this definition of health, especially for persons with chronic

conditions that impair physical or mental functioning, subjective quality of life is important to

determine. Transitional care supports clients with complex health and social situations with the goal of

optimizing their functioning to allow them to live as independently as possible. Therefore,

understanding and defining clients’ experiences, priorities, and goals is an important endeavour to

support person-centred care.

Objectives: To examine the self-reported quality of life of medically complex older adults receiving

care in a transitional care program in Ontario, Canada.

Design: This study is part of a larger prospective cohort study undertaken to generate a comprehensive

picture of a community-based transitional care program. Cross-sectional survey data, collected by a

trained interviewer, two weeks following admission, were examined for this presentation.

Setting and Participants: Clients admitted to a transitional care program in Toronto, Ontario between

Jun 1st, 2018 and May 31st, 2019, who were cognitively able to complete the survey (CPS <=2) and

agreed to participate, were included in the sample.

Measures: Demographic and self-reported quality of life data were extracted from the interRAI Self-

Reported Quality of Life Survey for Mental Health and Addictions and reported using descriptive

statistics.

Results: Findings showed that clients positively rated several aspects of their life, such as having

positive relationships with family and friends, feeling valued and respected by others and a having a

sense of autonomy/ability to make personal choices. Clients gave lower ratings to other aspects such as

having goals and activities that are meaningful to them, feeling involved in their home communities,

being motivated to participate in daily activities and having a hopeful or optimistic outlook on life.

Conclusion and implications: Results identify opportunities to improve care planning processes, group

programming, and the care environment to address clients’ mental, emotional, and social needs and

create a program that is truly person-centred.

79

SESSION 23: QUALITY OF LIFE

Chair(s): Veronika Vanden Abeele

Designing a Tablet-Based Application for and with Older Adults to Assist Them in the

Autonomous Completion of Quality of Life Questionnaires

Ine D'Haeseleer1, Peter Bernaers2, Nikki Dehennin2, Dominique Schreurs3, Bart Vanrumste1, Vero

Vanden Abeele1

1KU Leuven, e-Media Research Lab, Belgium; 2Zorg Leuven, Belgium; 2KU Leuven, ESAT-

TELEMIC, Belgium

Abstract summary: There are several questionnaires that poll for self-reported quality of life in older adults.

However, no studies investigated whether nursing home residents are able to complete these autonomously. This

study unveils the challenges when developing a tablet-based application, where older adults can fill out

questionnaires themselves.

Keywords: self-assessment, older adults, online questionnaire

Introduction. There are several questionnaires that poll for self-reported quality of life in older adults,

e.g. the Katz scale on self-maintenance or the interRAI Self-Reported Quality of Life (QoL). However,

these questionnaires are rarely filled out by older adults themselves. Rather, they are read out loud by

caregivers or independent third parties, who also write down the answers, and assist in interpretation

where necessary. This demands extra time and resources, where care budgets are tight already and

understaffing is common. As a result, measures of self-reported well-being and quality of life are taken

only sporadically. To the best of the authors’ knowledge, no research studies on self-assessment in

residents are available.

Objectives. Within this research study, we collaborated with older adults to investigate how to support

them in filling out these questionnaires themselves, e.g., interRAI QoL, via a tablet-based application.

In particular, we investigated what the essential user requirements are to be addressed by the application.

Additionally, we explored how to overcome age-related usability barriers and how to optimise the user

experience by adding gamification and visualisation methods.

Methods. Via a participatory design research method, 27 older adults living in a nursing home, 6

caregivers, 5 researchers and 148 ICT students collaborated to create various designs. Over the course

of three years, 22 alternative prototypes were designed, discussed and evaluated by older adults and

their carers.

Results. The direct outcome of this study is a variety of user interface designs and methods to address

age-related functional limitations and support complex processes such as user authentication or

selection of categories. However, this study also unveils the limits to autonomous self-reporting.

Moreover, it highlights that user adoption of such an application hinge on broader challenges, such as

an adequate infrastructure, installing trust in older adults and carers, and communicating its purpose.

Conclusion. This study highlights challenges and presents solutions to support older adults in

autonomously completing self-reports on quality of life. Additionally, it provides a deeper

understanding of how self-reports of quality of life may impact the ecosystem of a care setting.

80

Social isolation, loneliness, and mortality: a 3-year follow-up among new home care clients over

the age of 70

Kim Josefsson, Anja Noro, Aleksandr Gerasin, Satu Havulinna, Matti Mäkelä, Minna-Liisa Luoma


Abstract summary: We examined the associations of social isolation and loneliness with all-cause mortality in

Finnish RAI-data of all new home care clients 70 years and older in 2012-2014. Isolation and loneliness seemed

to be protective which is unexpected. Most probable explanation for this is the Finnish service system and

selection.

Keywords: older people, Finland, hazard ratio

Background: Extensive population based research has shown that socially isolated and lonely

individuals have a higher mortality risk than people with social contacts. There is little research that has

tested these associations in older age groups or among clients in home care.

Methods: We analyzed Finnish RAI-data of all new home care clients 70 years and older in 2012-2014.

Data were collected from 3 495 individuals. We examined the associations of social isolation and

loneliness with all-cause mortality using Cox proportional hazard models with time from client’s first

RAI-assessment after starting to receive regular home care as a timescale. The models were adjusted

using age, sex, reported diagnoses, self-reported health, CHESS-scale, cognitive functioning,

depression scale, daily smoking, and activity level.

Results: In the base models adjusted for age and sex, feeling lonely was not associated with mortality.

Social isolation told a different story. Living alone (HR .82 CI .73-.92), being alone the whole day (HR

.86 CI .76-.97), and withdrawing from activities (HR 1.41 CI 1.2-1.7) seemed to, against expectations,

lower a person’s mortality risk. After additional adjustments, feeling lonely was associated with lower

mortality (HR .81 CI .70-.93), living alone with lower mortality (HR .82 CI .73-.92), being alone the

whole day with lower mortality (HR .88 CI .78-.99), and withdrawing from activities was not associated

with mortality. Some minor sex differences existed. Feeling lonely was significant only for men, and

being alone the whole day only for women.

Conclusions: Several possible explanations for the unexpected results exist. It is possible that the high

risk individuals had already died, or that the stress of worrying about one’s old spouse is a factor, or

that the now lonely people have been lonely only for a short time thus biasing the estimates. The most

probable explanation, however, is the Finnish service system and selection. To whom and why care is

granted, when and why a person moves to residential care, and what kind of services different clients

receive are topics of further research. This study suggests that population based results cannot be

generalized to older people in care settings.

81

SESSION 24: HOSPITAL AND COMMUNITY CARE

Chair(s): Matthieu de Stampa

Clinical characteristics, care professionals’ intervention and care complexity for elderly patients

in hospital at home

Matthieu de Stampa

Assistance Publique Hôpitaux de Paris, France

Abstract summary: Elderly patients at home had complex needs with technical and multi-faceted care implying

coordination of stakeholders and support for caregivers. Implementing hospital at home allows to transferring

some geriatric patients from hospitalization to the home and helps the structuration of the geriatrics expertise

among the primary care services.

Keywords: hospital at home, elderly patients, geriatric practices

Introduction: the number of elderly patients in home care in France is currently increasing. Our

objective is to describe the clinical characteristics, the care professionals’ intervention and the care

complexity of this elderly population followed-up in hospital at home (HAH).

Methods: This is a cross-sectional study with a sample of 50 elderly patients aged 75 and over living at

home and followed-up in hospital at home in 2016 by the Assistance Publique Hôpitaux de Paris. The

collection of data used the interRAI-CA tool (Resident Assessment Instrument - Contact Assessment).

Results: The average age of the sample was 84 years with 48% women, 26% living alone and 96%

having a caregiver who had difficulty in caring in 33.3% of cases. Patients had numerous diseases with

68% of the sample who had cognitive difficulties with functional disabilities; Most of them reported

pain and 52% had unstable clinical situation. The main care interventions were complex wounds,

supportive care and palliative care with technical care and 80% of the sample mobilized more than 3

professionals. Care was considered to be of a high level of complexity for 74% of the elderly patients.

Conclusion: Our study showed that elderly patients had care complexity with technical and multi-

faceted care implying coordination of stakeholders and support for caregivers. Implementing the

hospital at home allows to transferring some geriatric patients from hospitalization to the home care

and helps the structuration of the geriatrics expertise among the primary care services.

82

Home-based primary care and emergency department use among home care patients with

functional impairments

Aaron Jones, Andrew P. Costa


Abstract summary: Home-based primary care can provide comprehensive, longitudinal care to patients who

have difficulty reaching traditional providers. We conducted a retrospective cohort study among home care

patients in Ontario, Canada, and found that receiving home-based primary care was associated with a reduction

in emergency department visits among patients with extensive functional impairments.

Keywords: home care, primary care, emergency department use

Background: Home-based primary care can provide comprehensive, longitudinal care to patients who

would otherwise have difficulty reaching traditional primary care providers. We examined the

influence of receiving home-based primary care on emergency department use among home care

patients with functional impairments.

Methods: We conducted a population-based, retrospective cohort study of long-stay home care patients

who received an interRAI assessment in Ontario, Canada, from October 2014 to September 2016 and

had an ADL Hierarchy or 2 or greater. Patients receiving home-based primary care were identified

using physician billing codes. Cox proportional hazards regression was used to examine the association

between home-based primary care and emergency department use within 6 months of the baseline

assessment, controlling for known confounders. We also explored whether severity of functional

impairment or age modified the effect of home-based primary care.

Results: The study cohort contains 98,329 home care patients with functional impairments, of which

12,967 (13%), were receiving regular primary care home visits. Home-based primary care exhibited a

hazard ratio of 0.98 (0.96-1.00) for all emergency department visits and 0.93 (0.87-1.00) for less urgent

visits. Among those with an ADL Hierarchy of 4 or greater, the hazard ratios of home-based primary

care were 0.91 (0.87-0.95) and 0.79 (0.69-0.90) for all visits and less urgent visits respectively.

Conclusion: Home care patients with extensive functional impairments receiving had a lower rate of

emergency department visits, particularly for less urgent visits. Expanding home-based primary care

programs for patients with extensive functional impairments could reduce emergency department use.

83

SESSION 25: NURSING HOMES 2

Chair(s): Eva Topinkova

Research on the Difference between Supply and Demand of Nursing Services for the Elderly

and the Content of Nursing Services in geriatric nursing faci

Guihua Xu, Yuexian Liu, Yulei Song, Weitong Li

Nanjing University of Chinese Medicine, Nanjing,China

Abstract summary: The care services of the geriatric nursing facilities is formed based on the interRAI

comprehensive assessment and the NIC. The results are objective, scientific and reliable, which can lay a

foundation for the standardized development and application of care services in geriatric nursing facilities.

Keywords: nursing services, difference, the elderly

Background: China's geriatric nursing facilities have not yet established a comprehensive care

assessment system, which affects the integrity and objectivity of the care services content, resulting in

actual services content may not match the needs and ability levels of the elderly. Method: Questionnaire

survey was conducted using the convenience sampling method to select the elderly in the three geriatric

nursing facilities in Jiangsu Province. The ability level was assessed by the elderly ability assessment

questionnaire, Care needs were assessed by the International Resident Assessment Instrument-Long

Term Care Facilities (interRAI-LTCF), Services delivery of the facilities was assessed by selfmade

questionnaire. The content framework of care services for the elderly in geriatric nursing facilities was

constructed based on the objective assessment results and the Nusing Intervention Classification (NIC)

through Delphi method. Results: The health problems of the elderly in the geriatric nursing facilities

involves multiple dimensions such as physical, psychological and social. The health problems of the

elderly with good ability were mainly “Clinical health problems” and “Depression”. While the

institutions only provide basic daily care, thus the care services for the good ability elderly were

misplaced. With the increase in disability, the types of daily care services were gradually transitioning

from simple to complex, the overall demand of the elderly can be met. For the clinical health problem,

the form of the care services supply was single and lack of specialization in cognitive and mental health

services. In response to the problem of insufficient social activities, it was rare to meet the social

participation needs of the elderly. Conclusion: The actual supply and demand of elderly care services

in the geriatric nursing facilities do not match. Hence the care services of the geriatric nursing facilities

is formed based on the interRAI comprehensive assessment and the NIC. The results are objective,

scientific and reliable, which can lay a foundation for the standardized development and application of

care services in geriatric nursing facilities.

84

Preliminary study of application of comprehensive assessment system among the elderly in

Chinese geriatric nursing facility based on interRAI-LTCF

Weitong Li, Yamei Bai, Guihua Xu

Nanjing University of Chinese Medicine, Nanjing,China

Abstract summary: To investigate the current situation of ability and nursing needs of the elderly and

corresponding inherent relationships with working-time of nursing services for the elderly, so that we could

establish a scientific and objective comprehensive assessment system for the elderly, which is suitable for Chinese

geriatric nursing facilities.

Keywords: application, comprehensive assessment system, working-time of nursing services

Background In the 21st century, the aging population in China has increased rapidly. At present, there

is no scientific grading system for the care of the elderly in China, and as a result, the health condition,

self-care ability and nursing needs of the elderly cannot be comprehensively reflected. Objective To

investigate the current situation of ability and nursing needs of the elderly and corresponding inherent

relationships with working-time of nursing services for the elderly, so that we could establish a scientific

and objective comprehensive assessment system for the elderly, which is suitable for Chinese geriatric

nursing facilities. Methods Our study was carried out from April through December 2018. Participants

were 725 elderly people who were selected from a geriatric nursing facility in Nanjing, Jiangsu

Province, China, by use of convenience sampling. They participated in a face-to-face survey with the

interRAI-LTCF which was led by qualified and well-trained assessors Working-time measurement was

used and the time of each of the basic nursing services was measured by stopwatches. In this study,

items of the scale were taken as independent variables while nursing time as dependent variables to

analyze the influencing factors of the length of nursing time for the elderly by means of variance

analysis, correlation analysis and regression analysis. Meanwhile, we analyzed the scale items using a

variety of objective screening methods, and we also evaluated the practicality of the assessment tool.

Results We found that 17 items in nine dimensions, including communication and vision, emotion and

behavior, functional status, self-control, disease diagnosis, health status, skin condition, treatment

course and social communication ability of the elderly, were significant influencing factors of nursing

time (P<0.05) and 122 items were related to the ability and care needs of the elderly. Conclusion Our

study had set up a system of standardized ability levels for the elderly through reasonable items,

providing the elderly with personalized health service projects in a targeted manner with different levels.

We expect to provide a reference to guide clinical reasonable allocation of nursing manpower and

improving the quality of life of the elderly as well as nursing quality.

85

Clinical implication of interRAI assessment in nursing homes: Lessons learned from the

SHELTER project

Eva Topinkova1,3, Daniela Fialova1,2, Helena Michalkova1,3

1Charles University, 1st Faculty of Medicine, Prague, Czech Republic; 2Faculty of Pharmacy in

Hradec Kralove, Department of Social and Clinical Pharmacy, Hradec Kralove, Czech Republic; 3University of South Bohemia in Ceske Budejovice, Faculty of Health and Social Sciences, Ceske

Budejovice, Czech Republic

Abstract summary: InterRAI LTCF assessment provides information to guide interventions and care for nursing

home (NH)residents. The paper presents clinical practice-relevant information from LTCF assessment as

evidenced from SHELTER project database and research papers. InterRAI LTCF represent a useful tool for

medical, nursing, therapeutical and pharmaceutical care

Keywords: LTCF assessment, SHELTER project, clinical implications

Background. InterRAI LTCF assessment provides information to guide interventions and care for

nursing home (NH)residents to health care professionals primarily nurses, nurse ‘aids, therapists etc.

However, long term institutions provide increasingly care for medically complex residents such as for

example residents in skilled nursing facilities, intermediate-stay and post-acute care facilities or

convalescent hospitals where physicians are regularly or permanently present. In some countries

specialists in geriatric medicine or long term care medicine are the primary treating physicians in LTCF.

The aim of the presentation is to show that clinically relevant information is available from LTCF

assessment as evidenced from NH research.

Design. Database and over 80 published research papers from the Services and Health for Elderly in

Long TERm care (SHELTER) project were reviewed. SHELTER, a 12 months prospective cohort study

was conducted in 57 NH in 7 EU countries (Czech Republic, England, Finland, France, Germany, Italy,

The Netherlands) and 1 non-EU country (Israel) and included 4156 residents, mean age 83.4 ± 9.4 years.

Results High level of clinical complexity as manifested by prevalent geriatric syndromes and

multimorbidity was found. Examples of clinically meaningful findings will be presented: Two studies

confirmed high prevalence of diabetes and obesity paradox even in very old diabetics (better survival

of overweight and obese diabetics), usefulness of influenza and pneumococcal vaccination for improved

1yr- survival was confirmed. Residents with dual – hearing and vision sensory impairment exhibited

faster cognitive decline which could be prevented by targeted therapy. Patients close to death who died

within next 6 month were not accurately prognosticated and informed (86%). Whole set of published

papers presented new data on medication in NHs, either individual classes (antipsychotics and their

interaction risks, benzodiazepins and fall risk, anti-osteoporosis medications, cardiovascular drugs) or

overall medication burden and polypharmacy as well as drug treatment in terminal dementia.

Conclusions InterRAI LTCF assessment is an useful instrument to guide highly individualized medical,

nursing, therapeutical and pharmaceutical care. InterRAI instruments present excellent tools for both

clinical practice, research and policy.

Acknowledgement. Supported by the European Commision 7FP grant No 223115, SHELTER

projectand interRAI Collaboration

86

SESSION 26: IMPLEMENTATION AND POLICY

Chair(s): Brant Fries

The Impact of Level of Care Policy on Access to Home Care in the US

Melanie E. Thomasson1, Mary L. James2, Brant E. Fries2

1University of Arkansas for Medical Sciences; 2University of Michigan

Abstract summary: State-specific thresholds control access to US home care. Five states translated their

threshold policies into algorithms comprised of HC items; these were applied to a HC dataset of individuals from

a sixth state, allowing an “apples to apples” comparison. We will compare the policies and consider the impacts

on access.

Keywords: home care, eligibility, access

Access to publicly-funded home care in the United States is controlled through the use of state-specific

medical eligibility thresholds. These “level of care” (LOC) criteria are designed to direct resources

toward individuals who are functionally or clinically “most in need.” Unlike financial eligibility

thresholds, which are stated in dollars and thus can be objectively measured, LOC policies often employ

very general terms (e.g., "cognitively impaired," "needs help with medication") and are subject to varied

interpretation, and comparability across state systems generally expected, but actually unknown. The

adoption of a common assessment system and use of computerized algorithms allows for the novel

comparison of such policies across jurisdictions. Five states that adopted the interRAI Home Care -

Arkansas, Maryland, Michigan, New Jersey, and New York - translated their LOC policies into

algorithms comprised of HC items, which were then used within their states to determine eligibility. To

enable an “apples to apples” comparison of the five policies, the states’ algorithms were applied to a

large HC dataset of individuals seeking public home care services from a sixth state (n=34,231). We

found that only 18% of individuals seeking home care met eligibility in all five states, while 16% did

not meet any state’s eligibility threshold;. Among the remaining 66%, there was substantial variation in

cross-state eligibility outcomes, allowing some individuals determined as substantially impaired in one

state not qualifying for assistance in another. In this presentation, we will describe similarities and

differences across the five states’ policies and consider the subsequent impacts on access to care.

87

Using the BelRAI Screener to assign a care budget to older people with care needs in Flanders

Evelien Moors, Anja Declercq

LUCAS KU Leuven, Centre for Care Research and Consultancy, Belgium

Abstract summary: The Flemish government considers basing the allocation of the Care Budget for Older People

with Care Needs on the scores of a BelRAI Screener assessment. To determine cut-off points on that Screener,

we collected data on non-medical costs and linked these data to a BelRAI Screener assessment.

Keywords: care budget, cut-off points, BelRAI Screener

The Care Budget for Older People with Care Needs is part of the Flemish Social Protection (FSP)

program since 2017. With this care budget, the Flemish government wants to provide a financial

allowance to elderly with a limited income and care needs, in order to compensate for the additional

non-medical costs that they have because of a reduction in their self-reliance. Just like for the other

parts of the FSP, the Flemish government works towards a phased introduction of BelRAI as a shared

suite of assessment instruments. One of the instruments in the suite is the BelRAI Screener. This is a

short screening tool that starts with five primary YES/NO questions on whether the person has problems

with IADL, ADL, cognition, mental health or behaviour. Only if the answer is ‘YES’ on a primary

question, the module on the topic in question opens. The BelRAI Screener is already being used for

another type of care budget for people with high care needs (not means tested). Vermeulen & Declercq

(2016) showed that the BelRAI Screener is a suitable instrument for replacing the currently used

medical-social scale. The Care Budget has five levels with higher allowances as the person becomes

more dependent. However, the correlation with the medical social-scale is low, and cut-off points could

not be matched. Very different scores can be found on the BelRAI Screener for the same score on the

medical-social scale. Since the cut-offs should represent higher care needs and higher non-medical

costs, a survey was filled out for 648 current beneficiaries. The survey asked about the non-medical

costs. Also, a BelRAI Screener assessment was carried out. Based on these data, five cut-off points

were determined and three questions were answered: (1) Does the existing flat-rate reimbursement

effectively cover (all) non-medical costs?, (2) Do non-medical costs increase with higher dependency

levels?, and (3) Which factors explain the level of non-medical costs?.

88

The value of the Systems Clinician Role to the interRAI experience

Yonggang{Peter} Tang, Lyn-Elizabeth Schofield

TAS, New Zealand

Abstract summary: The Systems Clinician role is unique, working at the interface between clinical service

delivery and interRAI software service. Knowledge and experience of software application and assessment is

essential. A case study of two upgrades will demonstrate the value this role can bring to the interRAI experience.

Keywords: user assistance, software processes, experience value

Systems Clinicians work at the interface between clinical service delivery and the interRAI software

service, which is invaluable in helping each understand the other's need and processes.

Systems Clinicians have a clinical background, experience as users of the national software system, and

knowledge of the interRAI methodology, as well being trained in the software application. This is a

unique role developed as the use of interRAI assessments progressed from a project to a national

mandated tool. Currently the New Zealand system has one hosted software provider. There are over

10,000 users, including assessors, allied health professionals and administrators, working from 722

organisations. Clients are based in both community and residential care, with assessment data feeding

into a live database accessible directly by users for customised analytics.

As former users and educators of the assessments, Systems Clinicians have an in-depth knowledge of

user processes and maintain their close relationship with the sector. This enables them to work with the

service desk to provide timely and accessible assistance with software troubleshooting, user

maintenance and auditing. Partnering with users Systems Clinicians can provide insights into analytics

and data use, and work with users to create purposeful software enhancements that meet their needs.

Knowledge of the software applications coupled with this sector experience allows for comprehensive

testing and productive feedback between users and software provider during software upgrades. This

presentation will use the experience of two software upgrades as a case study to demonstrate the benefits

and value this role adds to the user, the software provider, and client experience in the use of the

interRAI assessment tools.

89

SESSION 27: END-OF-LIFE


Using a standardized assessment to improve end of life outcomes: can we mitigate “bad

deaths”?

Nicole Williams1, Dawn M. Guthrie1, Gary Cheung2, John P. Hirdes3, Anne O’Callaghan2

1Wilfrid Laurier University, Canada; 2University of Auckland, New Zealand; 3University of Waterloo,

Canada

Abstract summary: A “bad death” was defined as significant signs/symptoms of depression, pain that is

excruciating, pain that is not well controlled, or loneliness if experienced within 30 days of dying. Individuals

who experienced a “bad death” were more likely to have a decline in functional ability and experience reduced

social engagement.

Keywords: bad death, home care, indicators

Background. There is a lack of consensus as to what constitutes a “good death”; however, it is generally

agreed that a “good death” is free from avoidable distress and suffering for the individual and their

loved ones. Our main objective was to identify potential factors associated with a “bad death”. Methods.

We analyzed data collected between 2007 and 2018 using the Resident Assessment Instrument for

Home Care (RAI-HC) for clients (18+) in Ontario, Alberta and British Columbia, Canada. The sample

included all individuals assessed within 30 days of death (n = 33,127). Individuals were identified as

having a “bad death” if they experienced at least one of the following indicators within 30 days of dying:

1) Depression Rating Scale score of 5+; 2) daily pain that is horrible or excruciating; 3) pain that is

excruciating and medications do not control it; or 4) self-reported loneliness. Results. In this sample,

36.6% of individuals experienced a “bad death”, with a mean time between their most recent assessment

and date of death of 16.7 days (standard deviation = 7.9). More than half of the sample (59.2%) had any

one indicator present, while 30.8% had any two, 8.7% had any three and 1.3% experienced all four

indicators. Individuals were more likely to experience a “bad death” if they had a decline in their

functional abilities in the last 90 days (87.3% vs. 77.7%; standardized difference [stdiff] = -0.25), had

a decline in their social activities and were distressed about it (29.7% vs. 13.9%; stdiff = -0.39) or

expressed conflict or anger with family/friends (19.3% vs. 11.0%; stdiff = -0.23). Conclusions. Some

potential factors associated with a “bad death” are amenable to change, for example through providing

medical and psychosocial support to address functional and social difficulties. Therefore, it is important

to continually assess individuals at the end of life to flag these potential issues so interventions can be

implemented to allow for the best quality of life for as long as possible.

90

Predicting Mortality for US Nursing Home Residents Using Machine Learning Modeling

Elizabeth P Howard1,2, John N Morris2, Sabrina Egge3, Fredrik Sjostrand3,4, Erez Schachter5

1Boston College, United States of America; 2Marcus Institute for Aging Research, Hebrew SeniorLife; 3Hannover Re; 4Karolinski Institutet; 5Profility, Inc

Abstract summary: Use of machine learning modeling increaces prediction accuracy by using a larger number

of clinical variables for a larger number of sub-samples. Applied to large health care data sets, this strategy offers

health care organizations and services an effective tool to support decisions regarding the allocation of resources.

Keywords: machine-learning, mortality, nursing home

Objective: Building upon prior, recent work that developed a Risk of Death Scale for long term care

residents, this project explored the use of machine learning to improve the precision of mortality

predictions. Specific aims were to: (1) apply machine learning modeling to build a mortality prediction

model for US nursing home residents; and (2) apply the new model using a large data set of long term

care residents to improve upon the accuracy and granularity of the prediction model.

Design: Longitudinal analysis of a national cohort of nursing home admissions from all United States

facilities during years 2011 and 2012, examined over 36 month period

Setting and Participants: Initial sample was 1,536,842 admissions (764,002 for 2011, 772,840 for

2012). Repeated assessments are required every 90 days, with an additional assessment at discharge.

Follow-up data over three years were examined.

Methods: Using the risk group designation determined by application of a risk of death scale, 12

independent subsets, representing each score for the scale. Then, for each of these 12 groups, for

illustration purposed we created 5 subsamples representing very low, low, medium, high and very high

risk of death comparatively.The dependent measure was mortality and the targeted time range for

evaluating patterns of mortality was 3 years, beginning when a person was admitted as a long-term care

resident.Building various profiles with each smaller subgroup consisting of multiple clinical assessment

items, all serving as independent variables.

Results: The results demonstrate further delination of the 12 risk categories. Most notable is the

variability in the mortality risk for the 2 through 5 risk scale scores. For example, the mortality rate for

those with a predicted score of 2 is 18.95% for those in the very low (Group A) group and extends to

52.43% for Group E, very high risk

Conclusions/Implications: Profiling based on a machine learning technique contributes to prediction

accuracy as it facilitates the use of a larger number of clinical variables and for a larger number of sub-

samples. Machine learning strategies of large health care data sets offer health care services better tools

in allocation of resources.

91

Predicting 90-day mortality and service use in community-based palliative care: a comparison

of the PPS and the interRAI PC

Kirsten Elke Hermans1, Dawn Guthrie2, Joachim Cohen3, Anja Declercq1, John Hirdes4

1KU Leuven, Belgium; 2Wilfrid Laurier University, Canada; 3VUB, Belgium; 4University of Waterloo,

Canada

Abstract summary: The developed model, combining the CHESS with other interRAI PC items is a good

predictor of 90-day mortality and service use in palliative home care patients. Based on this model, an extended

CHESS-index should be developed and implemented in the interRAI PC as to automatically generate mortality

predictions.

Keywords: interRAI PC, Prognosis, Palliative Home Care

Background: In home care, patients are not always recognized as actively or imminently dying.

Available instruments to predict mortality are often only being completed once a care professional -

usually the physician- estimates that the ‘terminal phase’ has started. Since physicians tend to over-

estimate prognosis and under-recognize palliative care needs, current tools are being used very late in

the disease trajectory. There is thus an emerging need for models, integrated into readily used

instruments, to automatically predict all-cause mortality and service use in the home care setting.

Aims: This study aims to evaluate a model extending the interRAI Changes in Health, End-Stage

Disease, Signs, and Symptoms Scale (CHESS) with other interRAI Palliative Care (interRAI PC) items

as compared to the Palliative Performance Scale (PPS) in order to predict the risk of 90-day mortality

and the number of nursing days among palliative home care clients in Ontario.

Methods: This is a population-based retrospective cohort study, using data from 2011 to 2018 on 80,261

unique individuals assessed with both the interRAI PC and the PPS. Logistic regression models were

used to evaluate the relationship between the predictor variables and 90-day mortality as well as the

number of nursing days. The chi-square test was calculated in order to test for goodness of fit. The c-

statistic provided information on the explanatory power of the models and their components. Survival

was examined using Kaplan-Meier curves.

Results: The CHESS score was a good predictor of 90-day mortality (c = .683; p<.0001) and the number

of nursing days (c = .607; p<.0001) as compared to the PPS (c = .692; p<.0001; c = .692; p<.0001). The

CHESS was better than the PPS in predicting 90-day mortality when combined with other interRAI PC

items (e.g., age, gender, ADL, IADL, nutritional intake, fluctuating consciousness, fatigue, pain, and

physical improvement potential) (c = .723; p<.0001).

Conclusion: The final model multivariable, extending the CHESS scale with other interRAI PC items,

is a good predictor of 90-day mortality and service use in palliative home care patients.

92


Chair(s): Caitlin McArthur

Developing a tool for sharing falls-related clinical information from home care with primary

care providers

Amanda Aguilar da Nova

University of Waterloo, Canada

Abstract summary: Health system fragmentation is thought to be one of the primary causes of falls, a geriatric

syndrome inadequately screened for and addressed in primary care. This study develops and evaluates a new tool

for sharing falls risk information from the interRAI-HC with primary care providers.

Keywords: health information exchange, falls, primary care

Health information exchange plays a vital role in the health sector. It contributes to efficiency,

continuity, and patient-centred care. Unfortunately, due to inefficient and inadequate information

sharing systems, communication between primary care providers and home care providers in the

province of Ontario is some of the worst in Canada and among all OECD countries. As a result, our

clinicians work inefficiently and test redundantly, valuable resources are wasted, and patient safety—

especially for frail seniors—is put at risk. In fact, health system fragmentation is thought to be one of

the primary causes of falls, a multifactorial geriatric syndrome and leading cause of death due to

unintentional injury. Additionally, due to time, workload, and knowledge constraints, falls are

inadequately screened for and addressed in primary care. This poor response to falls presents a need to

communicate clinical information related to falls risk to primary care providers of the most vulnerable

patients in a pragmatic, concise, and understandable way. In home care, the interRAI-HC regularly

collects standardized information on falls risk along with other clinical, functional, and care planning

information. Thus, the researchers of this study have, along with health system administrators and

primary care providers, developed a health information exchange tool for sharing clinical information

on the falls risk of home care clients and recommendations to action with primary care providers in

Ontario, Canada. In the World interRAI Conference, the preliminary results of in-depth interviews with

primary care providers assessing their views and feedback on the intervention will be presented. This

presentation will inform other researchers working with the interRAI on how to navigate health system

barriers and introduce interRAI information sharing to primary care providers such that it is useful and

relevant.

93

Development and validation of a scale to predict one-year incident fracture: The Fracture Risk

Scale Home Care (FRS-HC)

Caitlin McArthur1,2, George Ioannidis1,2, Micaela Jantzi3, Jonathan D Adachi1, Lora Giangregorio3,4,

John Hirdes3, Alexandra Papaioannou1,2

1McMaster University, Canada; 2GERAS Centre for Aging Research; 3University of Waterloo; 4Schlegel-UW Research Institute for Aging

Abstract summary: We developed the Fracture Risk Scale for home care (FRS-HC) that predicts one-year

incident hip fracture for home care recipients. The FRS-HC can be used to guide clinical care planning for home

care recipients at high risk for fracture.

Keywords: home care, fractures, scale

Objectives: To develop and validate a scale that predicts one-year incident hip fracture using the home

care resident assessment instrument (RAI-HC).

Design: A retrospective cohort study of linked population data.

Setting and participants: People receiving home care in Ontario, Canada between April 1st, 2011 and

March 31st, 2015. Home care recipients identified as end of life or receiving hospice care were

excluded.

Methods: Clinical data were obtained from the RAI-HC which was linked to the Discharge Abstract

Databased and National Ambulatory Care Reporting System to capture one-year incident hip fractures.

Seventy-five percent (n=238,011) of the home care recipients were randomly assigned to a derivation

and 25% (n=79,610) to a validation sample. A decision tree was created with the derivation sample

using known fracture risk factors. The final nodes of the decision tree were collapsed into 8 risk levels

and logistic regression was performed to determine odds of having a fracture for each level. c-Statistics

were calculated to compare the discriminative properties of the full, derivation, and validation samples.

Results: Approximately 60% of the sample were women and 54% were 80 years and older. A total of

11,526 (3.6%) fractures were reported over the 1-year time period. Of these, 5057 (43.9%) were hip

fractures. The proportion of home care recipients ranged from 0.6% (lowest risk level) to 4.9% (highest

risk level). HC recipients in the highest risk level had 9.2 higher odds (95% confidence interval, 8.0 to

10.7) of experiencing a hip fracture than those in the lowest risk level within one year. c-Statistics was

similar for the full (0.66), derivation (0.66), and validation (0.65) samples.

Conclusions: The FRS-HC predicts hip fracture over a one-year time period and should be used to guide

clinical care planning for home care recipients at high risk for fracture. Our next steps are to develop a

fracture risk clinical assessment protocol to link treatment recommendations with identified fracture

risk.

94

The influence of sensory and cognitive impairment on the risk of long-term care admissions

among home care clients in Ontario, Canada

Nicole Williams1, Dawn Guthrie1, Jennifer Campos2,3, Paul Mick4, Joseph B. Orange5, M. Kathleen

Pichora-Fuller3, Walter Wittich6,7, Marie Y. Savundranayagam5, Natalie A. Phillips8

1Wilfrid Laurier University, Waterloo, Ontario, Canada; 2KITE - Toronto Rehabilitation Institute –

University Health Network, Toronto, Ontario, Canada; 3University of Toronto, Toronto, Ontario,

Canada; 4University of Saskatchewan, Saskatoon, Saskatchewan, Canada; 5Western University,

London, Ontario, Canada; 6Université de Montréal, Montréal, Quebec,Canada; 7CRIR/Institut

Nazareth et Louis-Braille du CISSS de la Montérégie-Centre, Montréal, Quebec, Cana; 8Concordia

University, Montréal, Quebec, Canada

Abstract summary: Risk factors for long-term care (LTC) admission have been well document; however, little

is known about how sensory impairments, alone or in combination with cognitive impairment, relate to LTC

admissions. There appears to be a link between hearing impairment and the risk of admission to LTC.

Keywords: long-term care, sensory impairment, cognitive impairment

Background and Objectives: The objective of the study was to understand how sensory impairments,

alone or in combination with cognitive impairment (CI), relate to long-term care (LTC) admissions.

Research Design and Methods: This retrospective cohort study used existing electronic information

from two interRAI assessments; the Resident Assessment Instrument for Home Care (RAI-HC) and the

Minimum Data Set 2.0 (MDS 2.0), which is mandated for all LTC homes in Ontario. These assessments

were linked at the individual level for 371,696 unique clients aged 65+ years. The exposure variables

of interest included hearing impairment (HI), vision impairment (VI) and dual sensory impairment

(DSI) based on data from the most recent RAI-HC assessment. The main outcome was admission to

LTC. Survival analysis, using Cox proportional hazards regression models and Kaplan-Meier curves,

was used to identify risk factors associated with LTC admissions. Observations were censored if the

client remained in home care, died or were discharged somewhere other than to LTC. Results: In this

sample, 12.7% of clients were admitted to LTC, with a mean time to admission of 49.6 months (standard

error=0.20). The main risk factor for LTC admission was a diagnosis of Alzheimer’s dementia or related

dementia (hazard ratio [HR] = 1.87; CI: 1.83, 1.90). The main effects model also showed a significant

interaction between HI and CI, whereby individuals with HI but no CI had a faster time to admission

(40.5 months; HR=1.14) versus clients with both HI and CI (44.9 months; HR=2.11). Compared to

individuals with HI, no CI and who were not admitted to LTC, those with HI, no CI and were admitted

to LTC were more likely to live alone (63.3% vs. 49.1%; standardized difference (stdiff) = 0.29) and

have a child as their primary informal caregiver (63.7% vs. 53.9%; stdiff= 0.20). Discussion and

Implications: Although CI was found to be the main risk factor, it was not always the driving force for

LTC admission. It is imperative to continue to screen for and regularly assess older adults with HI as

there may be a link between HI and the risk of relocation to LTC.

95

SESSION 29: CARE PLANNING

Chair(s): Melissa Northwood

Improved Care by Integrating Evidence Based Protocols into an EHR Platform; Developing

Individualized and Recovery Based Plans of Care

Andrea Lucas1, Linda Adams2, Tan Nguyen3

1Waypoint Centre for Mental Health Care, Canada; 2Waypoint Centre for Mental Health Care,

Canada; 3Ontario Shores Centre for Mental Health Sciences, Canada

Abstract summary: Three of the four stand-alone psychiatric hospitals in Ontario, Canada partnered together to

create a mental health cluster, sharing standardized practices. This presentation will show how the partnership

improved care planning and patient care outcomes by integrating evidence-based protocols, Resident Assessment

Instruments (RAI-MH), and other assessments within the EHR.

Keywords: evidence-based, Individualized, care-planning

Ontario Canada has four psychiatric hospitals, three of these hospitals partnered together to create a

mental health cluster with standardized practices, documentation and a shared electronic health record.

The standardization process presented the opportunity to review and transform key practices and

documentation to align with current evidence and best practice. This presentation will demonstrate the

development of an improved care planning experience and improved patient care outcomes by

integrating evidence-based protocols, Resident Assessment Instrument (RAI-MH) and other

assessments, within the EHR platform; creating individualized, comprehensive and recovery-based

plans of care with clinical decision support. Utilizing an implementation science approach, clinicians

and patients were engaged in the development and creation of the patient’s individual recovery plan of

care. The completion of the RAI-MH and assessment tools, triggers the Clinical Assessment Protocols

(CAPs) as well as other care items. Once triggered, the clinician’s documentation addresses the CAP

and progress of the patient’s goals; each CAP has supporting interventions that will populate and guide

care on the worklist for clinicians. Since going live with the plan of care, all patients have a

comprehensive, evidence based and personalized care plan updated monthly. Thus, clinicians provide

evidenced informed care more consistently and patient outcomes can be monitored and acted on in a

timelier manner.

96

Clients' Own Goals for Care in Home Care and Long-Term Care Settings

Kim Josefsson, Aleksandr Gerasin, Anja Noro, Satu Havulinna, Matti Mäkelä


Abstract summary: We explored the goals and expectations the older persons express for their own care in home

care and long-term care settings in Finland (1101 clients using HC, 509 clients using LTC) in year 2018. It is

crucial that the nurses acknowledge these goals to provide good quality care.

Keywords: needs, Finland, person-centered

Background: Older people usually wish for flexible care that fully recognizes their individuality. Shared

decision making with care recipients while acknowledging subjective experiences, expectations, and

preferences, has been shown to be associated with high quality care. The aim of this study was to explore

the goals and expectations the older persons express for their own care in home care and long-term care

settings.

Methods: Recently, the Finnish home care (HC) and long-term care (LTC) RAI-instruments were

augmented with an open-ended question, “what are your own goals or expectations for your care”, with

each goal recorded separately. In this study, we describe the first responses to these questions in a

convenience sample of older Finnish people (1101 using HC, 509 using LTC), assessed in 2018. For a

quantitative analysis, the answers were grouped by hand into 13 categories. One answer could belong

to several categories. Ten categories were thematic (e.g. pain related), and three were “no goals /

couldn’t say”, “other”, and “strange / peculiar answer”.

Results: Most clients only expressed a single goal. An expected consequence of the lower physical and

cognitive performance in LTC was that about 31% (only 15% in HC) could or would not give an answer.

No categories were clearly more common than the others in LTC, with categories related to “Fitness”

(14.5%) and “Pleasurable activities” (12.8%) being the most popular ones. In HC, however, categories

related to “Everyday living” (24.1%), “Fitness” (21.7%), and “Living arrangements” (19.3%) were

more popular than the others. Although the answers were supposed to be expressed by the clients, some

answers were clearly goals set by the nurses.

Conclusions: The results showed that most older people in HC and LTC can express goals for their care.

It is crucial that the nurses acknowledge these goals to provide good quality care. The new Finnish RAI

question about client-expressed goals aims at giving a voice and channel to every client’s wishes.

97

The complexity of living with diabetes and urinary incontinence for older home-care clients: A

mixed methods study examining the need-services gap

Melissa Northwood1,2, Jenny Ploeg3, Maureen Markle-Reid3, Diana Sherifali3, Kathryn Fisher3

1SE Health, Canada; 2University of Waterloo, Canada; 3McMaster University

Abstract summary: This presentation will share the results of a convergent, mixed methods research study that

explored the complexity of living with diabetes and urinary incontinence for older adults receiving home-care

services in Ontario, Canada. Implications for home-care delivery, continuing education of interprofessional

providers, and future research will also be provided.

Keywords: home care, diabetes, urinary incontinence

Background: Urinary incontinence (UI) is a common complication of type 2 diabetes mellitus (T2DM)

for older adults (≥65 years) and is associated with reduced quality of life and risk of institutionalization.

However, little research has been conducted regarding older adults with T2DM and UI or how best to

provide home-care to support this population.

Objectives: To share the results and practice implications from a convergent, mixed methods research

study of older adults with T2DM and UI receiving home-care services in Ontario, Canada.

Methods: Data from RAI-HC assessments from 2011-2016 for long-stay (>60 days) older home-care

clients with diabetes (n=118,519) were analyzed to determine the prevalence and correlates of UI.

Qualitative interviews explored the experiences of 18 older home-care clients with T2DM and UI and

15 home-care nurses. Data sources were converged to understand the complexity—defined as the gap

between clients’ needs and the capacity of the health care system to meet those needs—of living with

T2DM and UI for older home-care clients.

Results: A third (33.7%) of older adults experienced daily or multiple daily episodes of UI. Correlates

of UI included: impaired function in activities of daily living (OR 5.31, 95% CI: 5.14, 5.50), cognitive

impairment (OR 2.37, 95% CI: 2.28, 2.47), female sex (OR 1.87, 95% CI: 1.82, 1.93), multiple (≥2)

chronic conditions (OR 1.83, 95% CI: 1.74, 1.93), distressed caregiver (OR 1.31, 95% CI: 1.27, 1.35),

making economic trade-offs (OR 1.23, 95% CI: 1.11, 1.34), and falls (OR 1.22, 95% CI: 1.19, 1.26).

The health-care system contributed to this complexity through: (a) minimal provision of nursing and

interprofessional home-care services; (b) task-focused structure of home care; (c) minimal

interprofessional collaboration; (d) lack of an integrated communication system; and (e) lack of

navigation to community resources.

Conclusion and implications: Providing health-promoting home care for older adults with T2DM and

UI requires a system-wide shift to a person- and family-centred approach including comprehensive

assessment, consideration of the social determinants of health, care coordination, and interprofessional

team collaboration to attend to the dimensions of complexity and ensure the needs of older adults and

their caregivers are met.

98

SESSION 30: CHILDREN'S INSTRUMENTS

Chair(s): Christina Vadeboncoeur

Entitlement to a Flemish healthcare budget: towards a BelRAI Screener for children and youth

Inge Neyens, Anja Declercq

KU Leuven, Belgium

Abstract summary: A BelRAI Screener for all adults with care needs has been developed to (1) select cases for

full assessment and (2) to determine who is entitled to the Flemish healthcare budget. This study develops a

screener for children and youth exclusively to determine which parents are entitled to the Flemish healthcare

budget.

Keywords: children, youth, screener

A BelRAI Screener for all adults with care needs has been developed to (1) select cases for full

assessment and (2) to determine who is entitled to the Flemish healthcare budget. This study develops

a screener for children and youth exclusively to determine which parents are entitled to the Flemish

healthcare budget.

In a first phase, we (1) searched inspiration in interRAI instruments to develop a draft version and a

manual and (2) conducted interviews with experts in existing assessment instruments for children and

youth. Secondly, we organized 4 expert panels with a diverse group of assessors and other experts to

explore their perspective on the relevance, effectiveness, efficiency and usability of the first draft of the

Screener (+manual). After reviewing these first drafts, 54 assessors completed 555 assessments in the

test version, based on observations and interviews with children, youth, their parents and now and then

input from schools. Based on the results of discriminant and ROC analyses, we further refined this test

version (+ manual) and scoring.

The new BelRAI Screener for children and youth comprises activities of daily living, cognition,

behavioral symptoms, attention, social participation and additional care for parents or other informal

caregivers. Scores need to be calculated differently for children/youth from 4 until 6 years old and from

7 until 18 years old.

Assessors and other experts consider this BelRAI Screener for children and youth as a short, complete,

just and fair assessment tool. Further implementation of this tool requires incentives for assessors to ask

for school reports and possibilities to exchange their experiences in order to complete the Screener in

exactly the same way. Its only use is determining the entitlement of parents to a healthcare budget. The

application of the BelRAI Screener for other purposes requires additional research.

99

Pilot Implementation of interRAI Pediatric Home Care Assessment Tool in Ontario

Christina Vadeboncoeur1,2,3, Megan Doherty1,2,3

1CHEO, Ottawa, Ontario, Canada; 2Roger Neilson House, Ottawa. Ontario, Canada; 3University of

Ottawa, Ottawa, Ontario, Canada

Abstract summary: Based on expressed desires from Pediatric Home Care agencies in Ontario, Canada, a Pilot

implementation of the interRAI Pediatric Home Care Assessment tool was undertaken. All 3 agencies who

adopted the tool felt it improved care. Full adoption is hindered by the lack of availability of Clinical Assessment

Protocols.

Keywords: pediatric, home care, feasibillity

Introduction: The interRAI Pediatric Home Care Assessment was developed for children aged 4-20

with complex medical needs in Texas, USA. Pediatric home care providers in Ontario, Canada

expressed interest in use of the assessment tool so that a common tool could be used in all regions. In

addition, providers want to improve information transfer when children transition to adulthood and the

RAI HC is currently used in all adults receiving home care in Ontario for more than 60 days.

Methods: All home care agencies (14) providing home care to children in Ontario were invited to

participate in the pilot project. Interested agencies were invited to an in person education session on use

of the assessment tool. A second invitation was sent for participation in an in person session which

could also be attended virtually.

A software vendor (AcuteNet) who provides the adult RAI HC assessment to home care agencies in

Ontario agreed to provide basic software for the pilot project.

Data collection started Feb 2017 and will continue until Feb 2019. The vendor provides de identified

data to the principle investigators on a monthly basis.

After the first year of data collection, a focus group session was held with each participating agency for

feedback on utilizing the assessment on an ongoing basis both related to the ease of use of the software

and the use of the assessment itself.

Results: Nine agencies participated in one of the two educational opportunities and three agencies used

the assessment tool as provided by the software vendor. As of Sept 2018 more than 400 assessment

have been completed, 300 from a single agency. Feedback from the focus groups was positive with the

large majority in favour of adopting the assessment to improve allocation of resources. All

spontaneously observed that addition of Clinical Assessment Protocols would improve care.

Conclusions and Future Steps: This project demonstrates the feasibility of adopting the Peds HC as a

common assessment tool in Ontario. Several Canadian provinces and a region in Italy have expressed

interest in adoption once Clinical Assessment Protocols and scales have beem developed.

100

interRAI Child and Youth Mental Health Screener (ChYMH-S) among Chinese migrant

children: A validation study

Shuang Lu1, Hao Luo1, Shannon Stewart2, Shimin Zhu3, Renhui Lyu1

1University of Hong Kong, Department of Social Work and Social Administration; 2Western

University, Faculty of Education; 3Hong Kong Polytechnic University, Department of Applied Social

Sciences

Abstract summary: Youth mental health has become an emerging issue in Chinese society, yet internationally

validated instruments for assessment among this population are lacking. This study applies the interRAI Child

and Youth Mental Health Screener (ChYMH-S) to the high-risk rural-to-urban migrant youth in China, and

examines the applicability of this instrument.

Keywords: child and youth, validation, China

Youth mental health has become an emerging issue in Chinese society. The young population in China

(age 0–14) totals 233 million, representing 12% of the world’s youth population. Growing up under

China’s one-child policy, massive rural-to-urban migration, and increasing divorce rate, many Chinese

youth live in migrant, left-behind, and single-parent families that impose mental health risks. Amongst

them, 85% (197 million) are at school age (6–18 years), who face even higher mental health risks due

to high family expectations for the only child and academic stress. Research has reported high mental

health problems in Chinese school-age children, ranging 11%–28%; one in ten Chinese school-age

children is estimated to have psychiatric disorders that warrant treatment.

Despite the urgent mental health needs of school-age children in China, current research lacks

internationally validated instruments for assessment among this population, which impedes global

comparison and professional mental health early assessment.

This study applies the interRAI Child and Youth Mental Health Screener (ChYMH-S) to Chinese

school-age youth. We focus on a high-risk population—rural-to-urban migrant youth, a population that

amount to 35.81 million in China, face multi-dimensional vulnerabilities (such as low family income

and exclusion from social resources), and present higher mental health problems than their peers. Our

objectives are to: 1) examine the cross-cultural applicability and suggest necessary adaptations of

ChYMH-S; 2) provide initial recommendations for comprehensive mental health assessment in Chinese

youth.

A total of 157 4th-5th-grade migrant students were recruited in Beijing. Each participant was

interviewed by trained assessors during school hours using the interRAI ChYMH-S instrument. To test

convergent validity, 115 randomly selected parents were invited to complete Child Behavior Checklist,

62 participants also completed Strengths and Difficulties Questionnaire, and other participants

completed Revised Children’s Anxiety and Depression Scale. The implementation process of ChYMH-

S in Chinese schools and the results suggest initial evidence that the ChYMH-S instrument appears to

be applicable and valid for Chinese youth. Our findings provide implications for promoting early

detection of mental health issues in Chinese youth, which is particularly relevant for those at high risk.

101

Implementation of an interRAI Family Carer Needs Assessment in a Pediatric Hospice

Ioana Alina Stochitoiu1, Brant Fries2, Christina Vadeboncoeur3,4

1Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada; 2Department of Health

Management and Policy, School of Public Health, University of Michigan, Ann Arbor, Michigan,

United States of America; 3Palliative Care Program, Children's Hospital of Eastern Ontario and

Roger Neilson House, Ottawa, Ontario, Canada; 4Department of Pediatrics, University of Ottawa,

Ottawa, Ontario, Canada

Abstract summary: This study is the first to implement the interRAI Family Carer Needs Assessment in carers

of children, seeking to evaluate and improve its ability to capture their needs. Positive feedback suggests the form

is feasible and gathers important information, with key adaptations identified to better fit a pediatric setting.

Keywords: pediatric, carer, assessment

Introduction: Family carers of children with serious illness contribute many hours of medical care in

addition to usual daily care. Their well-being is crucial to achieving optimal health outcomes for

children. However, assessing the needs and supports of family carers is not routine practice. The

interRAI Family Carer Needs Assessment allows for an understanding of the unmet needs, challenges,

as well as health and well-being of carers. This study is the first to utilize this tool in carers of children,

seeking to evaluate and improve its ability to capture their needs.

Methods: This is a prospective pilot study of a convenience sample of family carers of children with

serious illness receiving care at the Roger Neilson House pediatric hospice in Ottawa, Ontario. Thirty

carers have completed the self-assessment form. Additional feedback was sought inquiring about the

appropriateness of questions and missing information relevant to the pediatric setting. Responses were

analyzed using a mixed methods approach.

Results: All participants report the assessment identifies important information across multiple

domains. Questions flagged as unsuitable are related to age and ability of care recipients rather than

children as a group. Additional questions surrounding financial health, direct impact of caregiver

activities on pain and sleep, school supports, inclusion of longer recall time periods and use of scales

rather than dichotomous answers are identified as important adaptations. The most common unmet

needs in carers and care recipients were episodic relief from caregiving (n=17) and housing adaptation

(n=17), respectively. Overall, carers report a higher number of unmet needs in care recipients rather

than themselves, suggesting carers in this population may not be recognizing their own needs.

Conclusion: A comprehensive carer needs assessment form is feasible, and several key modifications

can improve its use in family carers of children. Positive feedback suggests the form can be utilized

seamlessly alongside adult versions and supports integration of interRAI instruments into a pediatric

setting. Further research linking a newly developed interRAI Pediatric Home Care Assessment with the

Family Carer Needs Assessment will determine its utility as a clinical tool in evidence-based family

centred care planning that can address unmet needs.

102


Chair(s): Chi-Ling Joanna Sinn

From Less Invisible to More Transparent: Outcomes of Formal Personal Support Services

among Long-stay Home Care Clients

Chi-Ling Joanna Sinn1,2

1University of Waterloo, Canada; 2Joseph Brant Hospital, Canada

Abstract summary: Personal support (PS) services account for up to 80% of formal direct care provided to older

adults; however, existing literature fails to demonstrate consistent client outcomes. In this study, receiving PS

services below a threshold was associated with greater odds of caregiver distress, long-term care placement, and

death.

Keywords: home care, personal support services, homemaking services

The Personal Support Algorithm is an interRAI algorithm that classifies need for personal support

services into six groups. Ontario (Canada) adopted the PS Algorithm in 2018. An Ontario working

group developed service guidelines for each of the PS Algorithm groups. The Framework of Hours is

expressed as a median and range of personal support services hours.

The objective of this study is to test whether the Framework of Hours can be linked to client and

caregiver outcomes related to remaining in the community. The outcome measures include caregiver

distress, moving to a cluster care residence, moving to a long-term care home, and death. This study

used home care assessment and administrative data provided by a health region in Ontario (third largest

in the province). Clients referred on or after January 1, 2010 and subsequently admitted for home care

services were eligible for the study. For each client, all RAI-/interRAI HC assessments completed on

or after January 1, 2013 were retrieved. Each HC assessment up to December 2017 was assigned to one

of three initial states based on the presence of caregiver distress. A period of up to 15 months was

allowed to observe a follow-up HC assessment or home care episode discharge. A Markov multi-state

transition model was fit by producing a series of multinomial logit models, one for each initial state.

The sample consisted of 57,208 observation pairs representing 30,625 unique clients. The independent

variable of interest was the quintile of PS/HM services, where the reference group was the 3rd quintile

that represents the median allocation within a given PS Algorithm group. Adjusting for baseline client

characteristics, providing less than the median PS/HM services significantly increases the odds of new

caregiver distress, moving to long-term care, and death. Among distressed caregivers, providing less

than the median PS/HM services significantly decreases the adjusted odds of resolving caregiver

distress. Among clients with non-distressed caregivers, providing more than the median PS/HM

services significantly decreases the adjusted odds of moving to cluster residence.

103

Validating Revised Index of Social Engagement (RISE) in Japan

Rumiko Tsuchiya-Ito1, Tomoaki Ishibashi1, Naoki Ikegami2

1Dia Foundation for Research on Ageing Societies; 2St. Luke's International University

Abstract summary: RISE was validated among a total of 1,384 residents in 14 facilities. Factorial validity was

validated by two factors, “group involvement” and “interaction with others”. The goodness of fit to the model was

0.932 for CFI and 0.121 for RMSEA.

Keywords: RISE, validation, Japan

Objective: To validate RISE (Revised Index of Social Engagement) in Japanese LTC facilities.

Method: 1,384 residents in 14 LTC facilities were assessed by interRAI LTCF from October, 2014 and

June, 2018. RISE is calculated from six items on social engagement in the assessment form. Validity

was evaluated by exploratory factorial analysis and conclusive factor analysis; convergence validity by

average activity time; distinguishing validity by average RISE scores according to cognitive levels.

Reliability was examined by using Cronbach’s α.

Results: Factorial validity was examined from two factor structures, “group involvement” and

“interaction with others”. The goodness of fit to the model was 0.932 for CFI and 0.121 for RMSEA.

RISE scores increased with activity time and were higher among those with normal cognitive

performance. Discriminatory validity was confirmed comparing average RISE scores of the cognitively

normal and cognitively low groups. The coefficient was 0.70 for the first factor and 0.72 for the second.

Conclusion: Although RISE did not meet some statistical standards for factorial validity, it showed

internal consistency, convergence validity and distinguishing validity. Its Japanese version could be

therefore be used.

This study was approved by the Ethics Committee of the Dia Foundation for Research on Ageing

Societies. All individual identifiers were deleted in making the analysis.

104

Predicting care intensity in geriatric homecare patients: a comparison of different measures

Gianlorenzo Scaccabarozzi1, Graziano Onder2, Roberto Bernabei2, Giacomo Pellegrini3, Matteo

Crippa3, Clara Onorina Colombo1, Fabio Lombardi1, Giorgio Beretta1

1Local social health authority (ASST) Lecco, Local Network of Palliative care, Lecco, Italy; 2Università Cattolica del Sacro Cuore, Rome, Italy; 3Fondazione Floriani, Milan, Italy

Abstract summary: CHESS-Lite has a high predictive value for identifying Homecare Intensity in geriatric

patients after discharge from hospital to home.

Keywords: CHESS, home care, care intensity

Background: Dependency in older ages is increasing. Many older persons receive care while living in

the community. We aimed to identify the predictive value of four clinical measurements to predict

Homecare Intensity in older patients over 90 days following discharge from hospital to home care.

Methods: We included 425 inpatients from the "Frailty Department - Local Palliative Care Network"

of the local social health authority (ASST) Lecco, Italy (mean age=75.4 years, SD=14.5; female 75.5%).

The InterRAI Contact Assessment Instrument was used to calculate four measures: Changes in Health,

End-stage disease, and Signs and Symptoms, light version (CHESS-Lite), activities of daily living

(ADL), frailty, and the Service Urgency Algorithm. Patients were followed for 90 days post-discharge

to calculate their Homecare Intensity coefficient (ratio of the number of days when any homecare was

provided during the period).

Results: Homecare Intensity was significantly correlated with CHESS-Lite, followed by the Frailty

Index and Service Urgency Algorithm. Using Receiver Operative Curves CHESS-Lite had a higher

Area Under the Curve (AUC) for predicting Homecare Intensity, but was best for predicting the highest

level of Homecare Intensity (≥0.8) AUC=0.71 (0.64-0.79). The Frailty Index also had an acceptable

AUC. ADL had the lowest AUC.

Conclusions: Health Instability measured with CHESS-Lite has a high predictive value for identifying

Homecare Intensity in geriatric patients after discharge from hospital to home, especially in those with

higher Homecare Intensity scores. Geriatric patients with high Health Instability should be focused on

at discharge to prioritize assessment and initiate timely services for homecare support.

105

SESSION 32: LONG TERM CARE 2

Chair(s): Dawn Guthrie

Profiling the characteristics of people who are comatose in Canadian long-term and complex

continuing care settings

Caitlin McArthur1,2, Margaret Saari3,4, Melissa Northwood1, Linda Sheiban Taucar5,6, Veronique

Boscart5,6

1McMaster University, Canada; 2GERAS Centre for Aging Research; 3Saint Elizabeth Health Care; 4University of Waterloo, Canada; 5Conestoga College; 6Schlegel-UW Research Institute for Aging

Abstract summary: We describe the sociodemographic, clinical, and treatment characteristics of people who are

comatose in Canadian complex continuing care (CCC) and long-term care (LTC) settings to inform resource and

care planning.

Keywords: long-term care, complex continuing care, comatose

Objectives: To describe the sociodemographic, clinical, and treatment characteristics of people who are

comatose in Canadian complex continuing care (CCC) and long-term care (LTC) settings, and to make

recommendations to promote comprehensive care planning for this population.

Design: Retrospective, cross-sectional analysis of population data.

Setting and Participants: All residents in the Canadian provinces of Alberta, Ontario, British Columbia,

Manitoba, Nova Scotia, Newfoundland, Saskatchewan, and the territory of Yukon with data available

from the fiscal year 2015 (April 1st, 2015 to March 31st, 2016).

Measures: Demographic, clinical and treatment variables were extracted from the Resident Assessment

Instrument – Minimum Data Set (MDS 2.0) and were reported using descriptive statistics.

Results: Of the LTC and CCC populations, 0.07% and 3.5% were identified as comatose, respectively.

Overall, people who are comatose in both CCC or LTC settings are younger and have a longer length

of stay than those who are not comatose. A higher proportion of people who are comatose experience

active infections and irregular bowel elimination patterns, and those who are comatose were more likely

to have a feeding tube, require oxygen therapy or suctioning than those who were not comatose.

However, a lower proportion of people who were comatose had documented pain. In LTC, one quarter

of people who are comatose were expected to die within 6 months.

Conclusion and implications: Although the prevalence of people who are comatose in LTC and CCC

settings is low, this population is complex and have significant care needs that require comprehensive

assessment and care planning.

106

Drug burden index and cognitive and physical function in aged care residents: a longitudinal

study

Hans Wouters1, Sarah Hilmer2, Jos Twisk3, Martina Teichert4, Helene Van Der Meer5, Hein Van

Hout3, Katja Taxis5

1University Medical Center Groningen, the Netherlands; 2University of Sydney, Australia; 3Amsterdam University Medical Center, the Netherlands; 4Leiden University Medical Center, the

Netherlands; 5University of Groningen, the Netherlands

Abstract summary: This longitudinal study among 4,624 Dutch aged care residents demonstrated that, over time,

cumulative exposure to anticholinergic and sedative medications was associated with poorer activities of daily

living and poorer physical activity. Careful monitoring of aged care residents with high cumulative anticholinergic

and sedative medication exposure is thus needed.

Keywords: physical function, anti-cholinergic drugs, sedative drugs

Objectives: Anticholinergic / anti-muscarinic and sedative medications (e.g. benzodiazepines) have

been found to be associated with poorer cognitive and physical function and mobility impairment in

older age. However, previous studies were mostly conducted among community-dwelling older

individuals and had often a cross-sectional design. Accordingly, our aim was to examine longitudinal

associations between cumulative exposure to anticholinergic and sedative medications and cognitive

and physical function among residents from aged care homes. Design: Longitudinal study. Setting and

Participants: 4,624 residents of Dutch aged care homes of whom data were collected between June 2005

and April 2014. Methods: Outcome measures were collected with the Long-Term Care Facilities

assessment from the international Residential Assessment Instrument (interRAI-LTCF) and included

the Cognitive Performance Scale, the Activities of Daily Living (ADL) Hierarchy scale, a timed 4-

meter walk test, distance walked, hours of physical activity, and days being outside. Cumulative

exposure to anticholinergic and sedative medications was calculated with the Drug Burden Index (DBI),

a linear additive pharmacological dose-response model. Associations were examined with linear mixed

models to take the potential dependence of observations into account (i.e. data were collected at repeated

assessment occasions of residents who were clustered in aged care homes). Analyses were adjusted for

sex, age, dementia, comorbidity (neurological, psychiatric, cardiovascular, pulmonary, and

oncological), fractures, depressive symptoms, and medications excluded from the DBI. Results: We

observed significant longitudinal associations between a higher DBI and poorer activities of daily

living, fewer hours of physical activity, and fewer days being outside. We found no significant

longitudinal association between a higher DBI and poorer cognitive function. Conclusions and

Implications: Over time, cumulative exposure to anticholinergic and sedative medications is associated

with poorer physical but not cognitive function in aged care residents. Careful monitoring of aged care

residents with high cumulative anticholinergic and sedative medication exposure is needed.

107

Older adults who develop new impairments in both hearing and vision are more likely to

experience cognitive decline over time

Dawn Guthrie1, Nicole Williams1, Jennifer Campos2,3, Paul Mick4, Joseph B. Orange5, M. Kathleen

Pichora-Fuller3, Walter Wittich6,7, Marie Y. Savundranayagam5, Natalie A. Phillips8

1Wilfrid Laurier University, Waterloo, Ontario, Canada; 2KITE - Toronto Rehabilitation Institute –

University Health Network, Toronto, Ontario, Canada; 3University of Toronto, Toronto, Ontario,

Canada; 4University of Saskatchewan, Saskatoon, Saskatchewan, Canada; 5Western University,

London, Ontario, Canada; 6Université de Montréal, Montréal, Quebec,Canada; 7CRIR/Institut

Nazareth et Louis-Braille du CISSS de la Montérégie-Centre,Montréal, Quebec, Canada; 8Concordia

University, Montréal, Quebec,Canada

Abstract summary: Little is known about how dual sensory impairment (DSI) influences outcomes such as

cognitive status. When compared with individuals who have persistent DSI over time, those who developed a new

impairment were more likely to be impaired in their cognitive status and to experience difficulties with

communication.

Keywords: sensory impairment, cognitive impairment, home care

Background. Older adults are likely to experience losses in sensory and cognitive functioning. However,

little is known about sensory-cognitive links in the population receiving home care. Our main objective

was to understand how the onset of a new dual sensory impairment (DSI; impairments in both vision

and hearing) influenced cognitive status and other outcomes. Methods. We analyzed data collected

using the Resident Assessment Instrument for Home Care for older (65+) clients in Ontario, Canada.

The baseline (T1) assessment was compared with re-assessments to identify the first point in time when

a new sensory impairment (SI) occurred (i.e., T2). Cognitive impairment (CI) was defined as a score of

one or higher on the Cognitive Performance Scale (CPS). We examined two unique cohorts: 1) those

with no baseline sensory impairments who developed new DSI (n = 3,271); and 2) those that had

persistent DSI at both T1 and T2 (n = 22,148). An absolute standardized difference (stdiff) of 0.2 or

higher between proportions was used to identify a statistically meaningful effect size. Results. At

baseline, those with persistent DSI were more likely to have CI (84.4%) versus 59.4% (stdiff= -0.58)

those with new DSI. Individuals who developed new DSI were more likely to experience a worsening

in their cognitive status, defined as any one-point increase on the CPS (57.5% vs. 23% in the persistent

DSI group; stdiff = 0.76). At baseline, the persistent DSI group had a higher rate of difficulty

understanding others (59.3% vs. 21.6%; stdiff = -0.83) versus those with new DSI. However, the new

DSI group were more likely to experience a change over time, with an absolute increase of 31.6%

between T1 and T2 (21.6% vs. 53.2%). Conclusions. Older home care clients with newly developed

sensory impairments are at increased risk for further cognitive decline and difficulties in

communication. Our findings reinforce the importance of assessment and monitoring in these older

individuals in order to flag early sensory changes so that evidence-based interventions can be

implemented to try and delay further losses.

108

SESSION 33: POLICY 2

Chair(s): Leon Geffen

A classification of fire evacuation ability of home care clients based on the RAI-HC instrument

Magnus Björkgren1, Frank Borg1, Tytti Oksanen2, Leila Mäkinen3

1University of Jyväskylä / Chydenius Campus, Finland; 2Pirkanmaa Rescue Department, Tampere,

Finland; 3Department of Health and Social Services, Tampere, Finland

Abstract summary: As more clients are being cared for in the community, concerns from fire safety perspectives

have been raised. Here we present a nine level risk classification based on the RAI-HC for determining the

evacuation ability of home care clients in the case of fire.

Keywords: RAI-HC, evacuation, risk-scale

Home care and community-based services are being increasingly promoted in elderly care to prevent

the need for institutional care. As more physically and cognitively dependent clients are being cared for

in the community, concerns from fire safety perspectives have been raised. The issue becomes whether

the home care client can evacuate safely from the residence in case of fire, where the available safe

egress time is estimated to be around 2 – 3 minutes. The objective of this study was to develop a

classification based on the RAI-HC assessment instrument for determining the evacuation ability of

home care clients in the case of fire. The evacuation ability was assessed by fire safety experts who

rated the evacuation ability of home care clients. This data was linked to the persons RAI-HC

assessment, which is a comprehensive assessment instrument of the person’s functional performance

and health status. The classification provides a reasonably accurate prediction of nine different risk

categories in home care. It can be used for screening home care clients to determine their evacuation

ability.

109

The Flint Water Crisis: Could interRAI have been the “canary in the mine?”

Brant E. Fries1,2, Mary L. James1, Maria J. Silveira2, Pil Park2, Angela Schmorrow2

1interRAI, United States of America; 2University of Michigan, USA

Abstract summary: This study examines the effects of the Flint Water crisis on older home care recipients

evaluated using the interRAI HC. It also shows that ongoing monitoring of HC data could identify major public

health problems

Keywords: home care, monitoring, outcome measurement

The City of Flint, Michigan is experiencing a highly-publicized public health crisis after its residents

had prolonged exposure to lead in the city’s water system. The majority of the news coverage addressed

the effects on children. In this study, we examine the effects on a different vulnerable population: adults

receiving home care services. Ongoing data from the Michigan Medicaid home care program provided

longitudinal information on 76 individuals in ZIP codes with known lead water contamination, and

assessed both before the water contamination in April 2013 and at least one year later. These individuals

were compared to 1,749 others from the same program in the five largest Michigan cities, with

concurrent assessments. We compared the percentage of participants with poor outcomes, as measured

by a worse follow-up score on each of five major scales, describing physical and cognitive function and

lead-related conditions. A substantially higher percentage of individuals in Flint had poorer outcomes

on four of scales: activities of daily living (ADL), a combined ADL and instrumental ADL (IADL)

scale, communication, and a count of five lead-related conditions. Scale components measuring

impaired short-term memory, several individual ADLs and IADL measures, fatigue, and unsteady gait

also showed substantially higher rates of decline or new incidence of problems.

It took over a year before the crisis in Flint was identified. While the results of our study may not be

surprising, more importantly they demonstrate that regularly monitoring the ready-available, reliable,

and complete assessment data on a subpopulation could be the “canary in the mine” to detect rapidly

major public health crises.

110

“They don’t care about us”: Older people’s experience of primary healthcare in South Africa

Gabrielle Kelly, Lindeka Mrengqwa, Leon Geffen


Abstract summary: We present findings from focus groups conducted in South Africa on older persons’

perceptions of primary care services. Older persons’ needs were overlooked and participants displayed low trust

in the healthcare system, suggesting the need for interventions that support patient-centred communication and

enable providers to understand older persons’ needs.

Keywords: primary care services, patient perceptions of care, South Africa

Background: As older people age, they have different health needs compared to younger people. South

African elder care policy places a strong emphasis on ageing in community rather than institutional

settings, but the primary healthcare system is not geared to address the health needs of older people

living in community settings.

Methods: This paper presents findings of nine focus groups conducted with community-dwelling older

adults in three areas (high, medium and low-income) in Cape Town, South Africa over 2 months in

2017. These discussions addressed primary health services available to older persons, their ability to

access these services and their expectations and experiences of care.

Results: Findings showed that while participants in the high-income area had few challenges accessing

quality care or support services, services available in lower-income areas were much less responsive

and participants displayed low trust in the healthcare system, feeling that their needs were overlooked.

Participants who experienced poor doctor patient communication often failed to comply with treatment,

while those who experienced patient-centred communication, either through the private sector or NGO-

public sector partnerships had better perceptions of care.

Conclusions: Older persons’ complex health needs cannot be adequately addressed by a process-driven

approach to care. Supporting patient-centred communication and care may help health workers to

understand older persons health needs and improve patient understanding, trust and co-operation. This

paper suggests the importance of community support services in enhancing health access and

developing systems that enable healthcare providers to better understand and respond to older persons’

needs in resource-constrained settings.

111

SESSION 34: TRANSITIONS

Chair(s): George Heckman

Leveraging interRAI tools and co-design methods to support caregivers in a transitional care

program

Margaret Saari1,2, Heather McNeil2, Courtney Genge2, Melissa Northwood1,2, Rosemary Georges2,

Diane Mitchell2, Paul Holyoke2


Abstract summary: Caregivers of individuals in transitional care programs face tremendous challenges and value

supportive care for themselves, as well as the persons in their care. InterRAI tools, used in conjunction with

qualitative methods, can be used to understand caregiver strengths, needs and priorities and codesign programs

that meet their needs.

Keywords: transitions, community care, co-design

Background: Globally, healthcare systems face challenges in ensuring older adults and their caregivers

receive the right care, in the right place, at the right time. Gaps in health and social services and

insufficient discharge planning have led to negative patient and caregiver experiences during transitions

in care. To facilitate improved hospital to community transitions, a large community care organization

partnered with an acute care hospital to establish a transitional care program in Ontario, Canada.

Objectives: To describe the needs and perspectives of caregivers caring for patients admitted to a

transitional care program and share a novel approach to iterative program design and quality

improvement.

Measures: Demographic, health status and well-being variables were extracted from the interRAI

Caregiver Assessment and reported using descriptive statistics. Qualitative data were collected through

field notes and artifacts generated in co-design workshops.

Design: Guided by the Participatory Research to Action Framework (PR2A) Framework, a mixed-

methods realist evaluation was undertaken to understand caregivers’ experiences as well as program

processes. Quantitative analysis of interRAI data and qualitative analysis of workshop data were

combined to provide an understanding of caregiver needs and inform program design and quality

improvement activities. Data from these research activities were then fed back in a co-design process

to create person-centered care planning processes that met both client and caregiver needs.

Results: Of those with identified caregivers, distress was highly prevalent in this population. Caregivers

reported a lack of information sharing and expectation setting prior to program admission. Once

admitted, program components caregivers identified as important included: involvement in care

planning from the point of admission, inclusion of caregivers in program activities, and proactive

discussions and preparations for transition to home.

Conclusion and implications: Caregivers in this type of environment face tremendous challenges and

value supportive care for themselves, as well as the persons in their care, during this transition period.

InterRAI tools, used in conjunction with the PR2A framework and qualitative methodologies, can be

used to co-design routine operations in community-based transitional care programs.

112

Predicting health transitions among newly admitted home care recipients with heart failure

George Albert Heckman1,2, John P Hirdes2, Paul C Hébert3, Andrew Costa4, Robert S McKelvie5

1University of Waterloo, Ontario, Canada; 2Schlegel University of Waterloo Research Institute for

Aging, Ontario, Canada; 3Département de Médecine, Université de Montréal, Québec, Canada.; 4Department of Clinical Epidemiology and Biostatistics, University, Ontario, Canada; 5Department of

Medicine, Western University, Ontario, Canada

Abstract summary: Heart failure is common among home care clients, many of whom have unstable health

based on the interRAI CHESS scale. Both a diagnosis of heart failure and higher CHESS scores are associated

with 6-month hospitalization or death, though the impact of heart failure is greatest at lower CHESS scores.

Keywords: heart failure, home care, care transitions

Objectives: To understand how a heart failure (HF) diagnosis and health instability predict health

transitions, hospitalization, and mortality among newly admitted home care clients.

Design: Retrospective cohort study of linked administrative data in Canada, including the Home Care

Reporting System, the Discharge Abstract Database for hospitalized patients, and National Ambulatory

Care Reporting System to track emergency department visits.

Setting and Participants: Older adults, aged 65 years and above, admitted to home care in Ontario,

Alberta and British Columbia, Canada, from 2010-2016.

Measures: Multistate Markov models were used to estimate adjusted odds ratios for transitions to

different states of health stability, hospitalization, and death, stratified by HF diagnosis and the interRAI

Changes in Health and End-stage disease Signs and Symptoms (CHESS) score, at 6 months following

admission to home care.

Results: The final sample included 286,232 patients, 34,950 of whom had a HF diagnosis. Compared

to those without HF, patients with HF were older, more often men, functionally impaired, and had

greater baseline health instability. A diagnosis of HF predicted worsening health instability,

hospitalizations and mortality. The effect of heart failure on hospitalizations and death was strongest

for low baseline health instability (CHESS=0; OR 1.47, 95% Confidence interval 1.36-1.58, and OR

1.47, 95% CI 1.36-1.58, respectively), vs. moderate instability (CHESS=1-2; OR 1.34, 95% CI 1.29-

1.38, and OR 1.36, 95% CI 1.24-1.48), vs. high instability (CHESS≥3; OR 1.08, 95% CI 1.02-1.13, and

OR not significant). The magnitude of the impact of a heart failure diagnosis declined with higher

baseline health instability.

Conclusions/Implications: A diagnosis of heart failure and health instability provide complementary

information to predict health transitions and adverse outcomes, and may have utility in designing

chronic disease management interventions in home care.

113

Introducing progressive strength training program in Singapore’s elder care settings

Magnus Björkgren1, Frank Borg1, Ken Tan2, Gerd Laxåback1, Lisette Nygård1

1University of Jyväskylä / Chydenius Campus, Finland; 2Pulsesync Ltd.

Abstract summary: The use of progressive strength training among the elderly has become an accepted part of

evidence-based practice for preventive and rehabilitative care. Here we describe a Finnish-Singaporean cross-

border project, Gym Tonic which aim is to promote and implement progressive strength training together with

systematic assessments of physical function.

Keywords: resistance training, elderly care, assessment technology

Background: The use of progressive strength training among the elderly has become an accepted part

of evidence-based practice for preventive and rehabilitative care. While research has shown the

importance of exercise and physical activity for health, the challenge remains to get people, especially

the elderly, to exercise and to introduce exercise in different care settings and practices. Here we

describe a Finnish-Singaporean cross-border project, Gym Tonic which aim is to promote and

implement progressive strength training together with systematic assessments of physical function. The

project is unique in that it provides a holistic approach to implementing strength training by offering

training, support, and technology solutions for various elder care organizations.

Results: The Gym Tonic concept was progressively implemented in 24 elder care locations in Singapore

including residential homes, day rehab/care centres, and senior activity centres within 2 years. While

each location was provided with training, support, gym equipment and technology solutions, it remained

for individual site to reach out and enrol elderly to the program, to perform assessments, and to direct

the progressive strength training. Based on data from the first two years of implementation,

improvements in lower body muscle strength were found in Leg Curl (ave 11.1-48.8%), Leg Extension

(ave 10.2-24.0%) and Hip Abduction/Hip Adduction (ave 7.0-15.8%). Of the trained therapists, 95%

strongly agreed or agreed to some extent that the implementation had been successful.

Conclusions: While many evidence-based types of research and practices have shown the importance

of strength training, the challenge remains on how to implement it systematically and on a large scale.

While the implementation was initially challenging and required lots of hand-holding and support, Gym

Tonic has demonstrated that this is feasible to implement progressive strength training on a large scale

across different elder care settings as the approach yielded consistent improvement rates in muscle

strength comparable to results from randomized clinical trials (meta-analysis studies). Significant

improvement rates in muscle strength were found in all three types of sites. The data support a 3-month

training intervention as an effective way of introducing strength training for the elderly.

114

SESSION 35: CASE-MIX

Chair(s): Lynn Martin

Developing a case mix services matching system for long term care in Hong Kong

Terry Lum, Gloria Wong, Jennifer Tang, Hao Luo, Mandy Lau

The University of Hong Kong, Hong Kong S.A.R. (China)

Abstract summary: We implemented a project to develop a new case mix system for Hong Kong between 2013

and 2017. We collected interRAI assessment data and staff time management data from 1,642 older people. In

this presentation, we will present the new case mix system for Hong Kong.

Keywords: case mix, interRAI-LTCF, interRAI-HC

Objectives: We implemented a project to develop a new case mix system for Hong Kong between 2013

and 2017. In this presentation, we will the new case mix system for Hong Kong.

Methods: We adopted the interRAI-LTCF and HC instruments and translated them to Chinese and

culturally adapted them to Hong Kong. Using these instruments, we collected longitudinal assessment

data from 1,044 nursing home residents and 598 community care services users. We also conducted a

staff time measurement (STM) to collect services use data from them. In the STM for nursing homes,

we collected total minutes of care for each care activity over 24 hours and for seven consecutive days.

The seven day STM data were later converted to monthly data for easy comparison. For each care

activity, we also collected the type and number of staff involved. For community care, we collected the

STM data for a month from the billing records of the services providers, including both the types of

services, staff involved, and total minutes.

Results: The median care time for nursing home residents was 10,300 minutes per month. Among them,

12% were professional care time (e.g. nursing care time) while 88% were supportive care time (e.g.

bathing care). The median care time for community care was 966 minutes, among them, 13% were

professional care time and 87% were supportive care time. Based on the assessment and STM data, we

developed seven case mix groups: reduced physical functions, behavioral problems, impaired cognition,

clinically complex, special care, extensive care, and special rehabilitation. We also calculated the

median care time associated with each case mix group. Finally, based on the case mix groups and the

associated care time, we developed a services matching formulate to better match the needs of frail

elders to the most appropriate services.

Conclusion: The STM data and the assessment data together allow us to develop a case mix system

based on the clinical profiles of local elders. The new case mix system allows better allocation of limited

LTC resources based on clinical profiles of frail elders.

115

A case-mix system for adults with intellectual and developmental disabilities

Lynn Martin1, Brant Fries2, Mary James2, Michael Head3, Pil Park2

1Lakehead University, Canada; 2University of Michigan, USA; 3Pinckney, USA

Abstract summary: A case-mix system for adults with intellectual and developmental disabilities (IDD) was

developed using population-level interRAI ID data linked to paid service claims. The system’s 33 unique groups

explain 26% of the variance in the cost of supports, and could be used to support fair reimbursement based on

individuals’ needs.

Keywords: case-mix, interRAI ID, intellectual disability

Background: Ensuring that health and social services are provided with judicious use of public funding

is a key concern of governments worldwide. Adults with intellectual and developmental disabilities

(IDD) receive social and disability supports in the community (e.g., own home, group home) and in

institutional settings. There is growing recognition that payment systems must recognize the differences

in support needs of individuals.

Aims: This presentation describes a case-mix system developed using population-level data in the state

of Arkansas that could be used to allocate funding in the context of supporting adults with IDD in

various home settings. Comparisons are made according to type of setting in which the person received

supports (i.e., own/family home, group home, staff home, or institution).

Methods: Data on personal, social, functional, and clinical characteristics and needs were collected

using the interRAI ID assessment system, which were linked to paid service claims. Automatic

interactions detection was used to sort individuals into distinct resource utilization groups. Each unique

group is associated with a case-mix index (CMI), which provides a standardized relative measure of the

cost of supports for each group.

Results: The resulting case-mix system has 33 unique final groups, and explains approximately 26% of

the variance in the cost of supports, which is consistent to other case-mix systems in health and social

services sectors. The CMIs had a 4 to 1 range across the full sample. With the average CMI set at 1.0,

there were significantly more individuals in the higher cost groups in institutional settings (mean CMI

1.26) than in community group homes (mean CMI 1.06); however, considerable overlap was also found

in that every case mix type was found in all four home settings.

Conclusion: The results suggest that this case-mix system could be the foundation for an approach to

reimbursement that is based on individuals’ needs and, therefore, stands the test of “fairness” in they

eyes of individuals with IDD, family members, advocates, providers, and political entities.

116

Symposia SYMPOSIUM 1: USING INTERRAI 'BIG DATA' TO PROMOTE PERSON-

CENTERED APPROACHES, PRACTICES AND SYSTEMS

Chair(s): Lynn Martin


protocols that provide information on the strengths, preferences, and needs of individuals. So why is it

that the first question every interRAI fellow gets is: “Is interRAI person-centered?” This symposium

focuses on the ways in which the interRAI suite of instruments and systems facilitate not only person-

centered approaches to meaningful shared decision-making in health care and social services, but also

the creation of responsive and person-directed policies and systems. Participants will have the

opportunity to weigh in on their own experiences with collecting, interpreting, and using interRAI data.

Objectives of the symposium:

Participants will learn about:

person-centeredness at the levels of the individual, organization, and system;

differences between “administrative data” and “administratively held clinical data”; and

the ways in which interRAI data supports person-centered approaches, practices, policies, and

systems.

Participants will leave with:

an understanding of how their own approaches to collecting, interpreting, sharing, and using

interRAI data play the biggest role in person-centeredness; and

concrete examples of ways in which interRAI data can be disseminated and used to promote

meaningful shared decision-making processes between those providing and those receiving

supports and services.

Keywords: person-centered, big data, decision-making

Symposium presentation 1: Using interRAI “big data” to promote person-centered approaches,

practices and systems

Lynn Martin (Lakehead University, Canada)

For the last several decades, person-centered approaches and practices have become foundational in the

fields of health care and social services. Similarly, that people receiving services should have the

opportunity to participate in decisions with providers about goals, supports, and services is also

recognized – though the extent to which this occurs is somewhat debatable. However, it is safe to say

that “person-centeredness” is the everyday practice of providers, administrators, and decision-makers.


protocols that provide information on the strengths, preferences, and needs of individuals. This means

that person-centeredness is also the foundation on which interRAI assessment systems are built. So why

is it that the first question every interRAI fellow gets is: “Is interRAI person-centered?”

117

This interactive presentation describes person-centeredness at the level of the individual, organization,

and system. It also addresses the ways in which “big data” are understood and used by providers,

administrators, decision-makers and researchers. Finally, it will offer insights into the ways in which

the interRAI suite of instruments and systems facilitate not only person-centered approaches to

meaningful shared decision-making in health care and social services, but also the creation of

responsive and person-directed policies and systems. The role of clinicians, administrators, and

decision-makers in applying person-centered thinking and action to the collection, interpretation, and

application of interRAI information will also be discussed.

Symposium presentation 2: Using interRAI “big data” to promote person-centered approaches,

practices and systems

Christopher Perlman (University of Waterloo, Canada)

There is a lot of information that exists in clinical contexts that is not always shared with persons

receiving psychiatric care, such as information on mental status, functioning, support systems, health

behaviours, and safety issues. Data from the interRAI MH may be too technical for persons with

complex mental illness to understand. This is a problem because this information might be useful for

individuals to better understand their own strengths and needs, prioritize their goals of care, and

empower them as active partners in care. Therefore, there is a need to break down the technical nature

of the data into meaningful information for the person.

The presentation will provide an overview of the types of clinical data that is commonly available across

inpatient psychiatric care settings in Ontario, Canada, the challenges and barriers to accessing these

data in care, and the opportunity to leverage technology to help persons in care make better use of these

data. We will describe our co-design methodology and preliminary findings for developing the patient

decision aid for “Ensuring Uptake of RAI Evidence and Knowledge by All” (EUREKA). After a

presentation of the EUREKA project, we will divide the audience into working groups to discuss and

report back ideas on the design, content, and implementation of a decision aid to empower shared

decision making.

118

SYMPOSIUM 2: CROSS NATIONAL RESEARCH WITH INTERRAI MENTAL

HEALTH INSTRUMENTS: CURRENT AND FUTURE INITIATIVES


interRAI was founded as an international organization with the goal of supporting cross-national

collaboration in the development, refinement, implementation and use of assessment systems for

vulnerable populations. interRAI's initial instruments, which focused on older adults in nursing homes

and home care, have been the subject of numerous cross-national studies (e.g., Ad Hoc, Shelter, IBenc),

but most research on its mental health instruments has been conducted in North America. This

symposium will provide participants an overview of current multinational research efforts related to

interRAI clinical assessments and quality of life tools for mental health and addictions. These studies

illustrate the benefits and insights to be gained from multinational research. In addition, planning is

underway and funding is being sought for the Community Mental Health Outcomes project which will

be the first large scale mutlinational research effort with interRAI's community-based mental health and

addictions instruments. As part of that effort, pilot projects have been undertaken to examine the

potential use of these instruments in low resource environments.

Participants in this symposium will learn about the design considerations for conducting multinational

studies with interRAI systems. In addition, they will understand the psychometric properties of

interRAI's clinical assessment and quality of life tools in an international context.

Keywords: cross-national research, community mental health, cultural factors

Symposium presentation 1: Psychometric Properties of the interRAI Self-Reported Quality of

Life Scale: A Multi-national Study

Luo, Hao (University of Hong Kong); Hirdes, Alice (Lutheran University of Brazil); Heikilla, Jyrki

(University of Turku); De Cuyper, Kathleen (KU Leuven University); Van Audenhove, Chantal (KU

Leuven University); Saari, Margaret (SE Health); Hirdes, John (University of Waterloo, Canada)

The aim of this research is to develop and validate a self-reported QoL instrument for inpatient and

community mental health settings. Data have been collected from diverse research sites in Canada,

Russia, Finland, Brazil, and Hong Kong, using the interRAI Quality of Life Survey for Mental Health

and Addictions. The survey was administrated to 1505 study participants, including 644 participants

from community mental health settings, 544 from inpatient settings, and 317 from the general

community. We randomly divided the sample into a training sample of 70% of participants and a testing

sample of 30% of participants. The training sample was used to identify the factor structure and the

testing sample was used to validate the factor model. The factor structure of the scale was identified

using principle component analysis (PCA), exploratory factor analysis (EFA), and confirmatory factor

analysis (CFA). The internal consistency were also assessed.

PCA and EFA of the training sample pointed to a 23-item scale with four dimensions: relationship,

hope, support, and activity. This four-factor model is supported by CFA of the test sample. The

goodness-of-fit statistics RMSEA, CLI and TFI were 0.044 (95% CI 0.037-0.051), 0.989, and 0.987,

respectively. The estimate of Cronbach’s alpha was 0.90. The estimates of Cronbach’s alpha for the

four domains ranged from 0.66 to 0.86.

119

Syposium presentation 2: Quality of Life in Brazilian Community Mental Health Services

Hirdes, Alice (Lutheran University of Brazil); Hirdes, John (University of Waterloo); Ferlin, Elton

(Hospital de Clínicas de Porto Alegre)

Brazil is officially designated as an upper middle income nation; however, the current economic climate

of this country has imposed considerable hardship on its citizens. In addition, Brazil's mental health

services have begun a major reform with an increasing emphasis on community based mental health

services through a primary care approach. While there are many positive features to these changes, there

are limited resources to support these services.

As part of the multinational pilot study of the interRAI Quality of Life for Mental Health and Addictions

(QOL-MHA) 312 community mental health clients in Rio Grande du Sol were interviewed to gain their

perspectives on their lives. The results were informative on their own, but being able to place the

Brazilian findings in an international context provided additional value. This presentation will provide

a detailed examination of QoL-MHA results considering both the new scales for this instrument as well

as the performance on indvidual items. Although all mental health sites in the study had less positive

results than were found with the general healthy sample of Canadians not receiving mental health

services, the Brazilian CMH clients has the highest rates of clients reporting that they were hopeful

about the future, compared with community and inpatient samples from Canada, inpatients from Russia

and Finland, and community clients in Hong Kong. In addition, despite high levels of poverty and crime

in many Brazilian neighbourhoods, about 80% of these individuals reported that they had a good place

to live. This was the second highest rate in the samples examined. Finally, despite the limited resources

available to Brazilian community mental health agencies, over 95% of clients reported that the staff in

those agencies supported their recovery. The lowest rate for this item was about 62% in Finnish CMH

clients. These results demonstrate that quality of life for persons with mental illness is not simply driven

by the resources available to their service agencies.

Symposium presentation 3: Reliability and Validity of the interRAI Community Mental Health

in Three Countries

Hirdes, John (University of Waterloo); Fries, Brant (University of Michigan); James, Mary (University

of Michigan); Heikilla, Jyrki (University of Turku)

The interRAI Community Mental Health (CMH) is a comprehensive assesssment of the strengths

preferences and needs of adults living with mental illness in community settings. The instrument was

originally developed in Canada, but pilot studies in Finland and the United States provide opportunities

to examine the psychometric properties of these instruments cross-nationally.

The samples included in this study were 8,667 CMH clients from the provinces of Ontario and

Newfoundland in Canada; 1,506 CMH clients in Finland; and 2,689 CMH clients in the United States.

Reliabilities were evaluated using the Cronbach's alpha statistic for internal consistency of parallel form

scales, including the Depressive Severity Index, Positive Symptoms Scale, Negative Symptoms Scale,

Mania Scale, Aggressive Behaviour Scale, ADL-Short Form, and Instrumental Activities of Daily

Living Summary Scale. All seven scales met or exceeded cut-offs for acceptable reliability in all three

countries, with the exception of the ABS scale in New York. This latter finding was probably the result

of an attenuated distribution of the items for that scale.

Convergent validity was examined by considering the patterns of associations between variables of

interest. For example, the relationship between typical symptoms of psychiatric diagnoses and the

presence of those diagnoses were examined using logistic regression models. As would be anticipated,

cognitive performance was highly associated with diagnoses of neurocognitive disorders; misuse of

120

prescription medications, substance use, drinking to intoxication, number of drinks in a single sitting

and CAGE scores were strongly associated with substance related and addictive disorder diagnoses.

These results provide initial evidence for the cross-national utility of the interRAI CMH; however,

efforts are now underway to undertake a large multinational study of mental health and quality of life

outcomes in CMH settings. Participants will learn about the plans for this study and will be invited to

express interest to collaborate in the proposed research.

Symposium presentation 4: Community Mental Health in India: A pilot study in West Bengal

Banerjee, Sumona (University of Calcutta)

In India, the first National Mental Health survey was conducted in 2015-16 by the National Institute of

Mental Health and Neurosciences. According to this report, nearly 150 million Indians need mental

health care services, but less than 30 million are seeking care. The evaluation of the mental health

systems points to a lack of a public health strategy and also several under-performing components

(Gangadhar, 2016). The magnitude of the problem has been identified. Medical practitioners, on the

one hand, are preparing themselves for the challenge of sheer numbers of persons who need medical

attentionfor mental health problems. Social scientists, on the other hand, have a critical role in the

identification of socio-economic and cultural factors that may be causal in nature, the quality of life of

the affected persons and the factors that affect their proper treatment and access to resources and

infrastructure.

The underlying objective of this study is to conduct a pilot study with three tools in the interRAI mental

health suite: a) the interRAI Brief Mental Health Screener (BMHS), which is a simple screening tool

that can be used by mental health workers who are not regulated health professionals; b) the interRAI

Community Mental Health (CMH) assessment, which is designed to be used by nurses or social workers

to support care planning development; and c) the interRAI Self-reported Quality of Life Survey for

Mental Health and Addictions (QoL-MHA), which is a self-reported survey aimed at measuring the

psychosocial dimensions of recovery and mental illness. The study will be used to make appropriate

adaptations of these instruments for use in India. To fulfill this basic objective, an overview of the

present status of the patient community, the care services and resources is examined.

This presentation will include a discussion of the cultural and contextual factors that must be addressed

to permit use of interRAI systems in India's mental health services. In addition, it will report on the

prelminary results from pilot projects of the BMHS and QoL-MHA that are underway in the state of

West Bengal.

121

SYMPOSIUM 3: DEVELOPMENT AND VALIDATION OF AN OPTIMIZED

PHOTOGRAPH-SUPPORTED INTERRAI ORAL HEALTH-RELATED SECTION

Chair(s): Joke Duyck

Background and objectives: An oral health-related (ohr) section is included in the LTCF and HC

versions of the interRAI suite (ohr-interRAI). It registers dental prosthesis use, damaged teeth, gum

inflammation, pain, chewing problems and dry mouth. Previous studies have shown that the ohr-

interRAI and related precursor versions fail to detect care-requiring oral conditions. Research on the

reasons for this failure found that test content validity of the items is not adequate. The general approach

of caregivers to assess oral health is inappropriate to detect care needs and completion of the ohr-

interRAI is further impeded by shortcomings of the instrument itself and by aspects related to the

assessment situation.

The presented project aimed at exploring the validity of the ohr-interRAI section and to optimize this

section so that non-dental caregivers can identify clients who need help with oral hygiene or need

referral to a dentist.

Methods: This is a mixed methods research using qualitative approaches to validate the ohr-section as

well as quantitative analysis to measure the relation between oral health and general health and to

develop prediction models. A first draft of the photograph-supported items and utilization guidelines

was revised based on 7 in-depth interviews with caregivers acquainted with the ohr-interRAI.

Results: The new optimized oral health related section of the interRAI consists of 9 photograph-

supported items with associated utilization guidelines, as well as a video training. Sensitivity,

specificity, inter- and intra caregiver reliability and the effect of the video-training will be presented at

the interRAI conference.

Keywords: oral health, general health, validation study

Symposium presentation 1: The oral health‐related section of the interRAI: Evaluation of test

content validity by expert-rating and potential reasons for inaccurate assessments

Krausch-Hofmann, Stefanie (KULeuven, Population Studies in Oral Health - Department of Oral

Health Sciences, Leuven/Belgium); de Almeida Mello, Johanna (KU Leuven LUCAS - Centre for Care

Research and Consultancy , Leuven/Belgium); Declerck, Dominique (KULeuven, Population Studies

in Oral Health - Department of Oral Health Sciences, Leuven/Belgium); Declercq, Anja (KU Leuven

LUCAS - Centre for Care Research and Consultancy , Leuven/Belgium); De Lepeleire, Jan (KU Leuven

Academic Centre for General Practice - Department of Public Health and Primary Care,

Leuven/Belgium); Dung Tran, Trung (KU Leuven Biostatistics and Statistical Bioinformatics Centre

(L-BioStat) - Department of Public Health and Primary Care, Leuven/Belgium); Lesaffre, Emmanuel

(KU Leuven Biostatistics and Statistical Bioinformatics Centre (L-BioStat) - Department of Public

Health and Primary Care, Leuven/Belgium); Duyck, Joke (KULeuven, Population Studies in Oral

Health - Department of Oral Health Sciences, Leuven/Belgium, Leuven/Belgium)

Objectives: To explore the failure of the oral health‐related section of the interRAI (ohr‐interRAI), this

study investigated test content validity (A.) and reasons for inaccurate assessments (B.).

Background: Poor oral health negatively affects quality of life and is associated with a number of

systemic diseases. The interRAI instruments, internationally used for geriatric assessment, should

122

accurately detect oral conditions that require care. Previous research showed that the ohr‐interRAI and

related precursor versions do not achieve this goal.

Materials and Methods: (A.) A group of 12 experts rated completeness, relevance, clarity of wording

and feasibility of the ohr‐interRAI. Content validity indices were calculated per item (threshold 0.78).

(B.) Focus group discussions with 23 caregivers were organized. A semi‐structured question guide

made sure that all topics of interest were covered. Qualitative content structuring analysis was applied

after transcription.

Results: (A.) Experts agreed on the relevance of the items on chewing, pain, gingival inflammation and

damaged teeth. They regarded none of the items as worded clearly and only prosthesis use and pain

were considered to be assessable by untrained caregivers. All experts agreed that the ohr‐interRAI was

incomplete. (B.) Focus group discussions revealed that in the care environment oral health had low

priority. Aspects related to the ohr‐interRAI itself and aspects related to the assessment situation

impeded the oral health assessment. The approach of the caregivers to complete the ohr‐interRAI was

inappropriate to accurately detect oral care needs.

Conclusions: Findings challenge test content validity of the ohr‐interRAI and reveal reasons for

inaccurate assessments.

Symposium presentation 2: Cross-Country Validation of the Association Between Oral Health

and General Health in Community-Dwelling Older Adults

de Almeida Mello, Johanna (KU Leuven LUCAS - Centre for Care Research and Consultancy ,

Leuven/Belgium); Dung Tran, Trung (KU Leuven Biostatistics and Statistical Bioinformatics Centre

(L-BioStat) - Department of Public Health and Primary Care, Leuven/Belgium); Krausch-Hofmann,

Stefanie (KULeuven, Population Studies in Oral Health - Department of Oral Health Sciences,

Leuven/Belgium); Meehan, Brigette (Technical Advisory Services (TAS), interRAI New Zealand); van

Hout, Hein (Department of General Practice and Elderly Care Medicine, Amsterdam Public Health

research institute, Amsterdam UMC, VU University Medical Center, Amsterdam, The Netherlands.);

Turcotte, Luke (School of Public Health and Health Systems, University of Waterloo, Waterloo,

Canada); van der Roest, Henriette G. (Department of General Practice and Elderly Care Medicine,

Amsterdam Public Health research institute, Amsterdam UMC, VU University Medical Center,

Amsterdam, The Netherlands.); Garms-Homolová, Vjenka (Department of Economics and Law, HTW,

Berlin University of Applied Sciences, Berlin, Germany); Jónsson, Pálmi (Faculty of Medicine,

University of Iceland and Department of Geriatrics, Landspitali National University Hospital,

Reykjavik, Iceland); Onder, Graziano (Fondazione Universitaria Policlinico A. Gemelli, IRCCS,

Università Cattolica del Sacro Cuore, Italy); Finne-Soveri, Harriet (Helsinki City – Department for

Social Services and Health Care, Sweden); De Lepeleire, Jan (KU Leuven Academic Centre for General

Practice - Department of Public Health and Primary Care, Leuven/Belgium); Declerck, Dominique

(KULeuven, Population Studies in Oral Health - Department of Oral Health Sciences,

Leuven/Belgium); Lesaffre, Emmanuel (KU Leuven Biostatistics and Statistical Bioinformatics Centre

(L-BioStat) - Department of Public Health and Primary Care, Leuven/Belgium); Duyck, Joke

(KULeuven, Population Studies in Oral Health - Department of Oral Health Sciences, Leuven/Belgium,

Leuven/Belgium); Declercq, Anja (KU Leuven LUCAS - Centre for Care Research and Consultancy ,

Leuven/Belgium)

Objective Oral health is known to be associated with general health, but longitudinal relationships

between oral health and general health indicators have not yet been fully explored in international

research. Setting and participants The sample consisted of 3 longitudinal databases: a sample from

Belgium from the Protocol 3 project (n = 8359), a combined sample from 6 European countries (n =

2501) from the IBenC study (Belgium, Finland, Iceland, Germany, Italy, and the Netherlands), and a

123

sample from New Zealand (n = 15,012). All clients were 65 years or older and received long-term home

care services. Methods Bayesian models were used to analyze the associations between 3 oral health

indicators (chewing difficulty, non-intact teeth, and dry mouth) and 4 aspects of general health

(activities of daily living functioning, cognition, depression, and health instability). In addition, the

models explored the associations between current oral health and general health status and future oral

health and general health status. Results Clients who had poorer oral health had a higher risk of suffering

from poor general health. Especially chewing difficulty was associated with all general health indicators

in all data sets (odds ratios > 1). Dry mouth and non-intact teeth showed significant associations with

almost all general health indicators. Additionally, having poor oral health (respectively general health)

was predictive of poor general health (respectively oral health) at future assessments (significant cross-

lagged parameters). Conclusions/Implications The results point out the need of the inclusion of oral

health assessment and advice from dentists or oral health practitioners into the multidisciplinary

conversation. In addition, identifying older people with oral health problems is essential in order to

provide treatment and monitoring. Raising awareness for oral health is important, and policy makers

should foster oral health promotion and care for older adults in order to keep them in good health.

Symposium presentation 3: Assessment of Oral Health conditions presented on clinical

photographs - Differences between dentists and non-dental caregivers


Health Sciences, Leuven/Belgium); Dung Tran, Trung (KU Leuven Biostatistics and Statistical

Bioinformatics Centre (L-BioStat) - Department of Public Health and Primary Care, Leuven/Belgium);

Declerck, Dominique (KULeuven, Population Studies in Oral Health - Department of Oral Health

Sciences, Leuven/Belgium); de Almeida Mello, Johanna (KU Leuven LUCAS - Centre for Care

Research and Consultancy , Leuven/Belgium); Declercq, Anja (KU Leuven LUCAS - Centre for Care

Research and Consultancy , Leuven/Belgium); Lesaffre, Emmanuel (KU Leuven Biostatistics and

Statistical Bioinformatics Centre (L-BioStat) - Department of Public Health and Primary Care,

Leuven/Belgium); De Lepeleire, Jan (KU Leuven Academic Centre for General Practice - Department

of Public Health and Primary Care, Leuven/Belgium); Duyck, Joke (KULeuven, Population Studies in

Oral Health - Department of Oral Health Sciences, Leuven/Belgium, Leuven/Belgium)

Background: Photographs might aid non-dental caregivers to recognize pathology and oral health

proplems when inspecting the mouth of care-dependent individuals. This study evaluated whether the

assessment of oral health-related conditions presented on photographs systematically differed between

dentists and non-dental caregivers.

Methods: One-hundred-and-seventy-nine photographs were taken showing conditions from perfect

health to severe pathology for six oral-health aspects. A segmented Visual Analogue Scale was applied

to assess the condition presented on the photographs. The benchmark was established by three experts.

Photographs were assessed by 32 dentists and by 164 non-dental caregivers. Linear mixed effects

models and generalized linear mixed effects models were fitted and mean squared errors were computed

to quantify differences between both groups related to the benchmark.

Results: For the different oral health aspects, absolute distances from the benchmark were 1.13

(95%CI:1.03-1.23) to 1.51 (95%CI:1.39-1.65) times higher for the caregivers than for the dentists.

The odds to provide a lower score than the benchmark (underestimation) were higher for the dentists

than the caregivers for oral hygiene (OR=0.72, 95%CI=0.62-0.84) and teeth (OR=0.74; 95%CI=0.61-

0.88). For gums (OR=1.39; 95%CI:1.22-1.59) and palate/lips/cheeks (OR=1.22; 95%CI=1.07-1.40) a

reverse relationship was found. Over all assessments, the variance in caregiver scores was 1.9

(95%CI:1.62-2.23) times higher compared to the dentists.

124

Conclusion: Small but significant systematical differences were found between dentists and non-dental

caregivers regarding the assessment of oral health-related conditions presented on clinical photographs.

When photographs are used to aid non-dental caregivers with the oral health assessment, these

visualizations should be complemented with comments to facilitate accurate interpretation.

Symposium presentation 4: Development and Validation of an Optimized Photograph-Supported

InterRAI Oral Health-Related Section


Health Sciences, Leuven/Belgium); Dung Tran, Trung (KU Leuven Biostatistics and Statistical

Bioinformatics Centre (L-BioStat) - Department of Public Health and); Declerck, Dominique

(KULeuven, Population Studies in Oral Health - Department of Oral Health Sciences,

Leuven/Belgium); de Almeida Mello, Johanna (KU Leuven LUCAS - Centre for Care Research and

Consultancy , Leuven/Belgium); Declercq, Anja (KU Leuven LUCAS - Centre for Care Research and

Consultancy , Leuven/Belgium); Lesaffre, Emmanuel (KU Leuven Biostatistics and Statistical

Bioinformatics Centre (L-BioStat) - Department of Public Health and); De Lepeleire, Jan (KU Leuven

Academic Centre for General Practice - Department of Public Health and Primary Care,

Leuven/Belgium); Duyck, Joke (KULeuven, Population Studies in Oral Health - Department of Oral

Health Sciences, Leuven/Belgium)

Background: Previous studies have shown that the ohr-interRAI and related precursor versions fail to

detect care-requiring oral conditions. Research on the reasons for this failure found that test content

validity of the items is not adequate. The general approach of caregivers to assess oral health is

inappropriate to detect care needs and completion of the ohr-interRAI is further impeded by

shortcomings of the instrument itself and by aspects related to the assessment situation.

This research aimed to develop and validate an optimized photograph-supported ohr-interRAI and a

video training to enable non-dental caregivers to identify clients who need help with oral hygiene or

referral to a dentist.

Methods: A group of 12 experts first discussed requirements and test content of the new instrument.

Photographs to support the items were taken from older long-term care residents and from patients at

the Department of Dentistry at the University Hospitals Leuven. A pool of 179 photographs was

collected that included a variety of conditions from perfect health to severe pathology. In a second step,

conditions shown on the photographs were assessed by 35 dentists and the most clear and consistently

assessed photographs were selected for the instrument. A first draft of the photograph-supported items

and utilization guidelines were revised, based on 7 in-depth interviews with caregivers acquainted with

the ohr-interRAI.

A video training with 9 short clips was produced to emphasize the relevance of oral health and to convey

the skills to complete the optimized ohr-interRAI.

Measurement properties of the optimized instrument and the effect of the video-training were evaluated

in a study with 260 care-dependent individuals residing in 9 long-term care facilities who each were

assessed by a dentist and by 4 caregivers.

Results: The optimized ohr-interRAI consists of 9 photograph-supported items, associated utilization

guidelines, and a video training. Sensitivity, specificity, inter- and intra caregiver reliability and the

effect of the video-training are being evaluated.

125

SYMPOSIUM 4: THE INTERRAI CHECK-UP SELF REPORT VERSION: A NEW

ASSESSMENT SYSTEM FOR PRIMARY CARE


The interRAI family of assessment instruments has historically focused on clinician-led assessments

for various sectors of the health system. These instruments have been marked by strong psychometric

properties and a capacity to support multiple uses by multiple audiences.

However, in some contexts it may not be feasible or necessary to require a registered health professional

to complete an assessment of a person's needs. For example, in low resource nations or subregions,

there may not be an adequate supply of health professionals or sufficient funds to permit widespread

assessment of vulnerable populations. In other service settings, the level of complexity and needs of the

target population may be relatively "light" such that severe health and functional problems are relatively

rare. In this context, the person's self report may provide an appropriate data source for first level

screening. Finally, some individuals or caregivers who are not yet in contact with the formal health

system may wish to obtain information about their health needs and how those compare with persons

receiving services. A self-report tool that is self-administered may empower individuals to obtain

information about their own health and the service options that may be available to them.

The objective of this symposium is to provide participants with an overview of the conceptualization

and development of the interRAI Check-Up Self Report version. It will also report on testing of the

psychometric properties and feasibility of use of the Check-Up with diverse older adult populations.

Finally, it will use Check-Up data to examine the impact of poverty to illustrate the substantive use of

Check-Up data to address policy and clinical practice issues.

Participants will understand where the interRAI Check Up Self Report version fits in the interRAI suite

of instruments, as well as what are the strengths and limitations of this new system.

Keywords: Self report, primary care, community health centres

Symposium presentation 1: Conceptual and methodological overview of the development of the

interRAI Check Up Self Report Version

Hirdes, John P (University of Waterloo, Canada)

All interRAI assessment systems require interaction with the person being assessed in order to obtain

the individual's perspective on his/her health and well-being. The clinician led interRAI assessments

include items that are coded based exclusively on the person's self-report, but most instruments also

consider other information sources. A self-report only instrument has appeal for use in low resource

environments, with "light" care populations, and for use by persons who may not be in contact with the

health system. This presentation will outline interRAI's research efforts to test self-report items in

telephone surveys, face-to-face interviews, and self-administered kiosks. This will include a discussion

of how the interRAI Check Up differs from other self-report survey tools that are not compatible with

the interRAI suite. The presentation will also include a discussion of where it would and would not be

appropriate to rely on a self-report only method of assessment.

126

Symposium presentation 2: Psychometric properties, feasibility, and acceptability of the interRAI

Check Up Self-Report

Hogeveen, Sophie (University of Waterloo); Iheme, Linda (University of Waterloo); Geffen, Leon

(SIFAR, Cape Town); Heckman, George (University of Waterloo); Morris, John (Hebrew Senior Life);

Hirdes, John (University of Waterloo)

Two studies were used to evaluate the interRAI Check Up Self Report version. In a study of about 150

community dwelling older adults in Khayalitsha South Africa, the Check Up was administered by lay

interviewers. Results of that interview were then compared with clinician-led assessments of the person

by a primary care nurse. About 90% of the self-report and clinician-rating item pairs had weighted

kappa values of .40 or higher indicating acceptable agreement and almost 40% of items pairs had

weighted kappas over 0.70 indicating excellent agreement. Second, a study of 159 older adults in

Ontario home care, community health agencies, and social service agencies showed that only 6% found

the self-report Check Up to be moderately or very difficult to use and 96% felt it covered their health

needs moderately well or more. Their quantitative ratings and qualitative statements indicated the

instrument was feasible and acceptable for use.

Symposium presentation 3: Pensions or pills? The relationship between poverty and health

indicators as measured by the interRAI CheckUp self-assessment

Geffen, Leon (SIFAR, Cape Town); Kelly, Gabby (SIFAR, Cape Town); Hogeveen, Sophie (University

of Waterloo); Hirdes, John (University of Waterloo)

Poverty and poor living conditions significantly exacerbate the degenerative effects of ageing and older

people are considerably more vulnerable to poverty. This paper assesses the relationship between

poverty, measured in terms of reported financial trade-offs made by older persons and health indicators

in Cape Town, South Africa. Over 1800 people were assessed using the interRAI Check Up self-report

in three areas around Cape Town: Mamre, Bishop Lavis and Khayeltisha.

Logistic regression models adjusted for age and sex examined the relationships between economic

trade-offs and a variety of health outcomes. The outcomes where poverty had adjusted odds ratios of

1.50 or greater include: poor self-rated health, negative mood, problems sleeping, severe pain, unstable

health, life stressors, loneliness and fatigue. The clear impact that poverty has on health supports the

case for providing or extending social protection in the form of non-contributory pensions to older

people in low and middle income countries.

127

SYMPOSIUM 5: BELRAI 2.0: THE IMPLEMENTATION OF THE INTERRAI

INSTRUMENTS IN BELGIUM

Chair(s): Isabelle van der Brempt

During this symposium the presenters will give an overview of the aspects done and/or planned in order

to implement interRAI instruments in the Belgian care setting. The BelRAI 2.0 protocol agreement will

be discussed and a state of affairs will be given. The way of data transfers using the BelRAI 2.0 web

application will be demonstrated and a view of what can be done with the data at the organization and

policy level will be showed. During the presentations, the audience will hear the governments point of

view.

Keywords: implementation, Belgium, BelRAI

Symposium presentation 1: BelRAI 2.0 protocol

van der Brempt, Isabelle (FPS Public Health, Belgium); Crabbe, Daniel (NIHDI); Anzizy, Tombofeno

(FPS Public Health/NIHDI); Van Eenoo, Liza (FPS Public Health/NIHDI); Dicker, Dominique (FPS

Public Health); Goemans, Mireille (FPS Public Health/NIHDI); Steurbaut, Kristof (SMALS)

Belgium exists of a federal government and six federated entities. In 2018, all these entities have

approved the BelRAI 2.0 protocol agreement to implement the interRAI instruments in the Belgian care

setting. The main aim of this implementation is to optimize the quality of care for persons with complex

care needs. Six interRAI instruments were translated in the three Belgian languages and were called the

BelRAI instruments. A BelRAI 2.0 web application was built and can be used for free by care

professionals. The BelRAI instruments can be used across all care setting and can be filled out

individually or multidisciplinary. It will also became possible for clients to access their BelRAI

assessments. Next to the translated interRAI instruments, care professionals can also use two screener

instruments: the BelRAI screener to indicate whether the need for care is complex or high to such an

extent that it is appropriate to use a comprehensive instrument; and the Palliative Care Indicator Tool

to screen whether it is more appropriate to use a BelRAI Palliative Care instrument. In order to use the

BelRAI instruments across the different types of care professionals and across the care settings in a

standardized way, BelRAI train-the-trainer trainings were developed. During this presentation the

aspects of the BelRAI 2.0 protocol agreement will be further discussed and the state of affairs of for

example the BelRAI train-the-trainer trainings and other implementation initiatives will be given.

Symposium presentation 2: BelRAI 2.0 web application and structure

van der Brempt, Isabelle (FPS Public Health); Crabbe, Daniel (NIHDI); Anzizy, Tombofeno (FPS

Public Health/NIHDI); Van Eenoo, Liza (FPS Public Health/NIHDI); Dicker, Dominique (FPS Public

Health); Goemans, Mireille (FPS Public Health/NIHDI); Steurbaut, Kristof (SMALS)

By means of a case we will show how the BelRAI instruments can be used multidisciplinary and across

the care settings at client level. Next, the BelRAI 2.0 architecture will be discussed. The audience will

see how the BelRAI instruments can be used in the BelRAI 2.0 web application or/and in other software,

and whatever software is used, all data will be collected in a central BelRAI 2.0 database. Finally, we

will give a demonstration of the BelRAI 2.0 web application.

128

Symposium presentation 3: BelRAI 2.0 data warehouse and privacy aspects

van der Brempt, Isabelle (FPS Public Health); Crabbe, Daniel (NIHDI); Anzizy, Tombofeno (FPS

Public Health/NIHDI); Van Eenoo, Liza (FPS Public Health/NIHDI); Dicker, Dominique (FPS Public

Health); Goemans, Mireille (FPS Public Health/NIHDI); Steurbaut, Kristof (SMALS), Roel Heijlen

(Sciensano)

Since the collected data will also be used for policy and research aims, we developed a BelRAI data

warehouse. Therefore, it is extremely important that the legal provisions regarding care and the privacy

of the client are respected. During this presentation we will explain how these laws are respected, how

the BelRAI data will be stored in the BelRAI 2.0 data warehouse, and how organizations, federated

entities and researches can use these data. We will end this presentation with an overview of the

collected BelRAI data.

129

SYMPOSIUM 6: WHAT CAN WE LEARN FROM THE IMPLEMENTATION OF

THE INTERRAI SUITE IN SEVEN COUNTRIES? CASE STUDY RESEARCH ON

PROCESS CHARACTERISTICS AND LESSONS LEARNED

Chair(s): Anja Declercq

Background: In the past years, many countries have shown interest in the interRAI Suite of instruments,

as a set of standardized, evidence-based assessments validated for different care settings. The main

purpose of this research is to describe the recent implementation process of the interRAI Suite in seven

countries: Belgium, Switzerland, France, Ireland, Iceland, New Zealand and Japan.

Methods: The study applied a case study methodology with the focus on the implementation strategies

in each country. Principal investigators gathered relevant information from multiple sources and

summarized it according to the specific aspects of the implementation process. Important elements in

this process are adoption, implementation, practical use and sustainability.

Results: The research describes the process of implementation of the interRAI Suite and compares their

characteristics across countries. The main steps taken into implementation are presented, as well as the

main advantages and disadvantages perceived by the users. Barriers to implementation were present in

all countries and they are summarized in this research.

Conclusion:The introduction of standardised assessment instruments such as the interRAI Suite can

provide evidence to inform decision-making and to support benchmarking. In practice, the use of

evidence is a process that requires a cultural shift from caregivers and policy makers at all levels of

health and social service delivery. This research can shed light on the advantages and pitfalls of using

the interRAI Suite of instruments and proposes some approaches to overcome difficulties.

Keywords: implementation, interRAI Suite, continuity of care

Symposium presentation 1: Towards continuity of care and evidence-based decision making: The

implementation of the interRAI Suite in Belgium

de Almeida Mello, Johanna (LUCAS - Centre for Care Research and Consultancy, KULeuven, Leuven,

Belgium); Declercq, Anja (LUCAS - Centre for Care Research and Consultancy, KULeuven, Leuven,

Belgium)

Background: In 2003, the Belgian government decided that a comprehensive assessment instrument

was needed in the care sector. The instrument had to meet the following criteria: (1) international

validation; (2) adaptable to different settings; (3) holistic; (4) provide input for care plan; (5) improve

multidisciplinarity; and (6) facilitate continuity of care. Four instruments were tested during the

INTERFACE project and the interRAI Suite came out as the most suitable option meeting all those

criteria.

Process: Between 2006 and 2009, the interRAI Home Care-HC, the interRAI Long-Term Care

Facilities-LTCF, and the interRAI Acute Care-AC instruments were tested. In addition, the interRAI-

HC was used as a mandatory evaluation instrument for innovative home care interventions participating

in a national study called Protocol 3 (2010-2017).

Recently, the interRAI Palliative Care-PC instrument was evaluated in Belgian nursing homes and a

screener instrument (BelRAI Screener) was developed for the Belgian home care setting. This short

screening determines whether a person should receive a full interRAI-HC assessment based on a

validated cut-off.

130

The testing is now extended to the sectors of Mental Health and Rehabilitation and a social supplement

for the interRAI Suite is being created.

Currently, Belgium is working on the national mandatory implementation of the interRAI-HC and

LTCF instruments, as well as of the BelRAI Screener. This implementation occurs in a stepwise way,

as many caregivers will need training in the whole territory.

Methods: During the research phase, as early adopters were testing the instruments, systematic feedback

was gathered to evaluate feasibility of scaling up the use of the assessments and to pave the way for

national implementation.

Conclusion: In Belgium, the interRAI Suite of instruments is being tested and implemented in different

settings. As the recorded information can be electronically transferred, data sharing across organizations

and settings is fostered, ensuring continuity of care and facilitating multidisciplinary collaboration.

In the last years, increasing efforts focused on the creation of a secured IT-platform where professional

caregivers can fill out the interRAI instruments. Compatibility between the existing electronic clinical

records and the BelRAI IT-platform is essential. Since 2018, a training package is being developed and

train-the-trainers sessions are being organized.

Symposium presentation 2: A Swiss Health Policy Programme building continuity of care by

bridging clinicians, researchers and decision-makers

IH Wellens, Nathalie (General Directorate of Public Health Service Canton Vaud, Department of

Public Health and Social Affairs, Lausanne, Switzerland); Monod, Stéfanie (General Directorate of

Public Health Service Canton Vaud, Department of Public Health and Social Affairs, Lausanne,

Switzerland); Grandchamp, Chantal (General Directorate of Public Health Service Canton Vaud,

Department of Public Health and Social Affairs, Lausanne, Switzerland); Audard, Marjorie (General

Directorate of Public Health Service Canton Vaud, Department of Public Health and Social Affairs,

Lausanne, Switzerland); Matos Queiros, Alcina (General Directorate of Public Health Service Canton

Vaud, Department of Public Health and Social Affairs, Lausanne, Switzerland)

Background: To reinforce continuity and coordination of care, canton Vaud Switzerland has launched

a policy programme to foster a common language across the healthcare system.

Methods: The roadmap has 4 main phases. In the PREPARATION (2014~2015), the interRAI language

and digital data platforms were consolidated in a legal framework. Awareness of early decline detection

and sharing of uniform functional data has been promoted. Current assessment systems and their use

were examined. During the PILOT PHASE (2016~2018) trained staff used interRAI tools in routine

practice in multicenter exploratory studies in 5 home care facilities and 12 nursing homes, with

emphasis on care planning and preventive actions. Mixed methods evaluated acceptability and

feasibility. In a second wave (2018~2019), more cantons participated in research comparing the

resource allocation of the current system with interRAI in 19 nursing homes. A third wave (2018~2021)

includes specific healthcare structures such as short term or day care, hospital discharges, emergency

inpatient and home visits, mental health foyers, etc. In the POLICY PHASE (2020~2021) several

cantons collaborate to outline implementation strategies with regard to the legal frameworks, cost

simulations, training programmes, timelines, insurers negotiations, etc. In the IMPLEMENTATION

PHASE, the interRAI Check Up, in complement to MDS-HC, was adopted in all Vaudois public home

care services (2019). Meanwhile, the national associations are preparing the nationwide upgrade of the

MDS-version to the interRAI Suite (2019~2022).

Main findings: The Swiss landscape is complex with multiple actors, cantonal policies, three national

languages, and varying rhythms.

131

The small-scale pilots have attracted larger interest. To maintain the focus on clinical utility, continued

efforts are required.

This Public Health Programme creates synergies between health professionals, researchers, associations

and decision-makers on local, federal and international levels. The ambition to bridge these “worlds” is

threefold: increasing acceptability, ensuring coherence, and achieving measurable results addressing

stakeholders’ policy. The long-term goal is to move from use in silos towards care coordination.

Ultimately, quality monitoring and evidence-based policies are envisioned.

Conclusion: As the stepwise construction of large-scale adoption evolves, the programme will

continuously fuse clinical, academic, and political expertise to innovate the health system in anticipation

of demographic changes.

Symposium presentation 3: A review of the implementation of interRAI in Ireland

Vereker, Natalie (interRAI Ireland, HSE, Ireland); O Regan, Imelda (interRAI Ireland, HSE, Ireland)

Background: In 2010 the Older Persons department of Ireland’s Health Service Executive (HSE)

established a Working Group to select, pilot and recommend a single assessment tool or suite of tools

to be utilised for the assessment of older people nationally in Ireland.

Following a pre-pilot study in 2012 across Community Care, Long Term Care and Acute care, the

Working Group selected the interRAI suite as the most fit-for-purpose for use in Ireland. Government

approval was obtained in 2013, and two procurement exercises were completed with vendors appointed

to develop the interRAI IT system and associated eLearning component.

Objectives: interRAI is being introduced in Ireland on a phased bases with initial implementation

focusing on older people with more complex needs. As part of the pre-implementation planning for

interRAI, a multi stakeholder multi-disciplinary group was established to adopt interRAI forms and

manuals for use in Ireland.

The first phase of the IT-system development commenced in 2014. In preparation for the national

implementation, a pilot of the interRAI system commenced in May 2016 in three sites. This involved

the training of personnel who then assessed patients using the interRAI-HC over an 11 month period.

The pilot evaluated the training and education programmes, implementation processes and assessment

data from the pilot sites.

Following conclusion of the pilot, national implementation of interRAI within Services for Older

People commenced. An implementation framework was established which details the requirements

from both a top down and bottom up approach. National implementation of interRAI Ireland is

progressing and is expected to increase in pace in 2020 following the re-procurement of an interRAI

IT-software vendor.

Conclusion: The pilot, and subsequent implementation of interRAI identified a number of challenges

and issues around interRAI implementation:

The impact of Information and Communication Technology (ICT) - both hardware and software issues.

National policy and ideally supporting legislation is required. Guidelines for these services should

incorporate interRAI assessment outputs to inform service urgency, wait lists/ prioritisation, appropriate

placement, and levels of care.

Training – importance of training for successful implementation.

132

Regional and local management support is also critical in planning, driving and supporting interRAI

implementation.

Symposium presentation 4: Implementation of a Standardized Comprehensive Assessment Tool

in France: A Case Using the InterRAI Instruments

de Stampa, Matthieu (Assistance Publique Hôpitaux de Paris, Hospitalisation à Domicile, Unité Mixte

de Recherche (UMR) 1168 INSERM, UVSQ, VIMA (Vieillissement et Maladies Chroniques), InterRAI,

France); Cerase, Valérie (Institut Maladie Alzheimer (IMA), Centre Départemental de Gérontologie,

interRAI, France); Bagaragaza, Emmanuel (Pôle Recherche SPES « Soins Palliatifs En Société »,

Maison Médicale Jeanne Garnier, Unité Mixte de Recherche (UMR) 1168 INSERM, UVSQ, VIMA

(Vieillissement et Maladies Chroniques), InterRAI, France); Lys, Elodie (Centre Départemental de

Gérontologie, InterRAI, France); Alitta, Quentin (Centre Départemental de Gérontologie, InterRAI,

France); Gammelin, Cedric (Centre Départemental de Gérontologie, InterRAI, France); Henrard,

Jean-Claude (Université de Versailles, Saint-Quentin en Yvelines, InterRAI, France)

Background: The improvement of quality of care requires a standardized and comprehensive

assessment tool but implementation is challenging.

Purpose: We have reported on the development of the interRAI instruments in France from the onset to

the mandatory use at the national level. We also have identified in the literature and in practices,

incentives and barriers for the implementation of this integrated clinical information system in long

term care.

Results: Three periods in the interRAI instruments development were identified over the last twenty

years. The first one was a research approach about improving quality of long term care. The second one

was an experimental clinical use into an integrated care model with case management. The third one

was a call for tenders issued by a French national agency, and the choice to use the interRAI-HC (Home

Care) for all case managers. The main incentives and barriers that were identified include the national

context, the target population, the providers involved and the impact on their practice, the interRAI

instrument characteristics, training and leadership.

Conclusion: This historical overview of the development of interRAI instruments in France gives health

care organizations pertinent information to guide the implementation of a standardized and

comprehensive assessment tool.

Symposium presentation 5: Thirty years of interRAI in Japan

Ikegami, Naoki (Health Policy and Management, School of Medicine, Keio University, interRAI, Japan)

Introductory phase (1991~93): interRAI instruments were first introduced to Japan in 1991 when RUG-

III was validated. At that time, long-term care (LTC) was delivered by different types of providers. The

policy goal was to introduce case-mix based payment. The study showed that the differences in costs

(care time) were less than the US because providers did not have any incentive to admit heavy care

cases. Using only the subset of items needed for RUG grouping was criticized as not being sufficient.

Care planning instrument phase (1993~96): The full MDS and RAPs were used in the 1993 study. Care

planning was introduced for the first time in Japan. The results were generally well received. In the

1996 government’s fee schedule revision, LTC hospitals received a bonus payment if care plans were

drawn for each patient. However, hospitals were not inspected on how fully the MDS assessments were

made and the RAPs requirements were adhered.

133

Designing LTC Insurance (1997~2000): After the LTCI was legislated in 1997, policy focused firstly

on designing a questionnaire for evaluating the eligibility levels that will set the ceiling for the benefits

beneficiaries would be entitled to receive in community settings, and for case-mix-based payment in

institutional settings. RUG-III was considered to be too complex. The second policy issue was to draw

care plans in community settings. The MDS-HC was chosen as one of among several instruments to

draw care plans.

LTCI implementation (2000~): The role of care managers turned out to be that of a travel agent: to

organize services in response to demands of those who are eligible. Thus, although provider

organizations, such as that of visiting nurses, developed their own assessment form, none were

systematically used. The government has not required the submission of data based on systematic

assessment

Current state: There has been renewed interest in collecting data to evaluate quality and outcomes. The

interRAI versions have been translated, two software made available, and 15 providers have contracted

us to calculate their QI.

Symposium presentation 6: Where Angels Fear to Tread: New Zealand’s implementation of the

interRAI suite of instruments

Meehan, Brigette (Technical Advisory Services (TAS), interRAI New Zealand)

This presentation will describe the key factors that have driven implementation of the interRAI suite of

instruments over a 20 year period when governments, health leaders, models of care, the economic

climate and societal values in New Zealand have all undergone significant changes. It will describe the

infrastructure required for sustained national implementation and the approaches used to encourage

multiple stakeholders to value the interRAI assessment process and the data it produces.

In 2003 the New Zealand health sector identified a gap between current and best practice in older

persons assessment. This led to a considered decision to introduce the interRAI Home Care assessment

with the aim of helping older people to live at home as long as possible. Implementation appeared to

be a relatively straightforward solution to meet the concerns of the day by replacing one assessment

system with another. However, engaging the hearts and minds of the sector to embrace clinical change

is a more complicated and time-consuming process than was anticipated.

Fast forward to 2020, six interRAI assessments are in daily use in New Zealand, there is wide sector

engagement, and the data from those assessments informs decisions at individual, local and national

levels. We have learnt that a multi-layered approach is needed for effective implementation

accompanied by realistic timeframes and a vision for the future. Success builds success. We continue

to have ambitious plans for the future, including the introduction of other interRAI instruments and

digital learning. Implementation never stops.

Symposium presentation 7: interRAI implementation in Iceland

V Jónsson, Pálmi (Faculty of Medicine, University of Iceland and Department of Geriatrics, Landspitali

National University Hospital, Reykjavik, Iceland)

The content and quality of nursing home care in Iceland were almost completely unknown in the early

1990s. Costs were considerable, and the financing of nursing home care was variable. The permanent

staff of Iceland's Ministry of Health soon secured political support for exploring the utility of the RAI

system in elderly care. The ministry established a national IceRAI steering committee with key players

from health and social services. Nursing home staff were systematically trained in the use of the

134

instrument and supported through the assessment process. Based on its experience with a pilot study,

the Ministry of Health decided to mandate the use of the RAI system in all of Iceland's nursing homes.

Implementation of the RAI has had several spinoff effects. It was decided that all nursing home care

should be financed based on the RAI resource utilization groups (RUGs). Other spinoff effects include

the monitoring of quality of care and the generation of clinical guidelines for identified problem areas.

Some components of the RAI system are still underutilized in Iceland, which shows that systemic

change is a long-term development, not a sudden revolution.

A pilot study of home care was conducted in 1997, and again 2001–2 as a part of a broader European

study. The InterRAI HC instrument has now been implemented country wide based on regulation as

the NH instrument, but rather on a voluntary bases by individual county councils. Hence, the

implementation has taken longer time and is incomplete. Additionally, the MH system was introduced

to the Department of Psychiatry at the University of Iceland, but administrative support has been limited

and the system is currently largely dormant. From the AC interRAI system the ED screener and the ED

Assessment has been implemented as well as the PAC system on one unit. The AC instrument itself has

been computerized and will soon enter a pilot phase.

Six years ago, with then Medical Director of Iceland, support for the implementation was withdrawn

and implementation has been delayed. It appears that interest may be now on the rise.

I see the interRAI tools as key to progress in care of people with chronic illnesses in Iceland where the

instrumentation could foster now pathways of improved care for these people. For this to happen,

support needs to be renewed and infrastructure strengthened. In this talk I will visualize how the

interRAI system might influence radically the care of people with chronic illnesses in Iceland.

135

SYMPOSIUM 7: NATIONAL PERSPECTIVES ON ACUTE CARE UTILIZATION

Chair(s): Melinda Martin-Khan

Introduction: To achieve improvement in both patient outcomes and comprehensive hospital quality, a

large scale change in processes is required. Utilising a new assessment system in a hospital brings

comprehensive challenges. This symposium describes the utilisation of the Acute Care (AC) suite in

regions around the world, and subsequent observations.

Objective: To describe the challenges and opportunities of the utilisation of the interRAI AC suite.

Utilisation of the interRAI AC in New Zealand

Susan Wood, New Zealand Government

The interRAI AC was developed in collaboration with the nursing and IT team in New Zealand

for integration with their existing interRAI assessment systems. Significant work has been

undertaken to link the interRAI AC with the existing health care system.

Utilisation of the interRAI AC/AC-CGA in Canada

Associate Professor George Heckman, Dr. Veronique Boscart, University of Waterloo

Canada has comprehensive implementation of interRAI instruments through many provinces

as a standard aspect of health care delivery and reporting. Work to identify where the AC suite

can add value to the existing arrangements has highlighted opportunities and challenges.

Utilisation of the interRAI AC/AC-CGA in Australia

Dr. Melinda Martin-Khan, University of Queensland

The interRAI AC-Comprehensive Geriatric Assessment (CGA) has been in use in Queensland

hospitals for some years. Recently the AC was trialled in a QLD hospital. It is now being

implemented in hospitals in two QLD districts, and across the State of Tasmania.

Utilisation of the interRAI AC Suite in Europe

Dr. Nathalie Wellens, Etat de Vaud

Utilising aspects of the AC suite for interdisciplinary use and data sharing. Belgium: The iAC-

CGA incorporated into a web-based eHealth platform has been tested in acute geriatric units.

The test was a novel in transferring standardized data between home care services, nursing

homes and hospitals and in centralizing medical, functional and nursing data. Implementation

has proven not evident. Switzerland: Initial implementation utilising scales from the AC to link

with community based assessments as a pre-cursor to full implementation.

Conclusion: It is anticipated that the learning outcomes from the symposium will lead to an

understanding of the opportunities and challenges connected with large scale utilisation.

Keywords: Acute Care, Implementation, Nursing

Symposium presentation 1: Integration of the interRAI AC in One Hospital in New Zealand

Wood, Susan (New Zealand Government)

Introduction: New Zealand utilises interRAI assessments for access to home based support, residential

care services and initial pilot work in palliative care. The Accident Compensation Commission of New

Zealand (ACC), which funds care required following an accident or treatment injury, is developing a

case payment system using the interRAI Acute Care (AC). Work is overseen by the New Zealand

National interRAI Board.

136

The ACC fund over $M560 a year in pressure injury management. As part of their Treatment Injury

Prevention work programme they have funded District Health Boards to improve hospital and

community practice. The Canterbury District Health Board (CDHB) admits approximately 60-80

patients a month with pre-existing pressure injuries. CDHB has used funding to develop the additional

pressure injury dataset to supplement the interRAI admission and review assessments (interRAI AC) to

predict and manage a pressure injury in hospital.

Method: An expert group in tissue viability, quality improvement and policy development identified

the data set required for ongoing pressure injury prediction, prevention and management in a mixed

adult population in a tertiary hospital setting. The data flow, the viewing of data, and the frequency of

review requirements amongst the other various assessments completed by nurses was compiled and

provided to the software vendor.

Results: The data provided in the interRAI AC covers much of the dataset required. These were arranged

alongside the additional data required. These included any period of time of immobility, overall skin

condition, invasive or fixative devices, nutrition, medicines, and comorbidities that were rolled up into

physical sensory deficits and circulatory disorders as well as clinical impression.

Any risk identified then triggers the full skin assessment and wound management record to come up for

completion, with data collected already prepopulated and the remainder to be recorded.

interRAI AC is being integrated into the usual care workflow at Christchurch hospital New Zealand.

Conclusions: It is important to ensure that the new instrument is part of usual workflow, providing new

clinical value. Matching the data flow to the workflow assists with integration of the interRAI data into

other more detailed assessments in the acute care setting.

Symposium presentation 2: Utilisation of the interRAI AC/AC-CGA in Canada

Heckman, George (The University of Waterloo); Boscart, Veronique (The University of Waterloo)

Introduction: Canada has comprehensive implementation of interRAI instruments through many

provinces as a standard aspect of health care delivery and reporting. Work to identify where the AC

suite can add value to the existing arrangements has highlighted opportunities and challenges.

interRAI in Canada currently uses assessment systems in homecare, long term care, community and

mental health. There are a range of different assessment tools used in these settings. Some have been

used in hospital to support discharge planning for homecare clients.

The Acute Care suite has assessments that support screening and assessment in the Emergency

Department (ED), comprehensive geriatric assessment (CGA) and a nursing assessment on admission

to hospital. All have been utilised in Canada with preliminary testing in the hospital setting.

Method: Patients are screened on admission to the hospital (either through ED or admission to the ward)

utilising the interRAI ED Screener of the AC. Patients with assessments that trigger risk alerts are

prioritized for more detailed assessment such as the ED Contact Assessment (CA) or the AC-CGA.

Results: The ED Screener was administered on admission to the ED (N=5,000). For those patients that

were identified as at risk (n=1,400), an ED CA was completed (while the patient was in ED). The CA

screens patients for additional risk, and prioritized for assessment. Nine-hundred patients were

identified as ‘at risk’ and requiring a specialist consultation. A registered nurse completed the interRAI

AC-CGA for these patients prior to a consultation with a geriatrician.

In a separate study, a registered nurse completed 100 interRAI AC on patients in hospital at admission.

137

Conclusions: It is challenging to introduce a new instrument into an existing environment already

operational with pre-existing instruments. It is important to ensure that the new instrument is providing

new clinical value. The Acute Care suite is designed to meet the needs of in-hospital patients and

supports geriatric care.

Symposium presentation 3: Utilisation of the interRAI AC/AC-CGA in Australia

Martin-Khan, Melinda (The University of Queensland)

Introduction: The interRAI Acute Care(AC) suite includes, but is not limited to, the AC nursing

assessment and the original instrument the AC-Comprehensive Geriatric Assessment (CGA). The AC-

CGA has been in use in Queensland hospitals for some years as part of an initiative funded by the

Queensland government for Queensland Health. Recently the AC was trialled in a QLD hospital (QEII,

Queensland Health).

Method: Large scale implementations require significant high level collaboration and funding support

to be successful. Assessment systems need to electronic and a partnership with a software provider

needs to be established (or in-house programming). If the system is to be integrated with existing

information system, significant lead time is required prior to implementation.

Results: Over 6,000 assessments have been completed in QLD with the interRAI AC-CGA.

Implementation plans for the AC instrument occurred at a time when health care policy in Australia

supported standardised electronic assessment, piloting testing was complete, funding support was

available and organisation personnel were seeking solutions. Awareness of the assessment at a nursing

level is varied across each organisation. It is now being implemented in hospitals in two QLD health

districts (as a standalone instrument), and across the State of Tasmania (embedded within the electronic

data collection system of the hospitals).

While the instrument remains the same, working groups have been established to discuss the

implementation of the instrument within each organisation as a unique solution needs to be designed to

accommodate the removal of existing assessments, and the incorporation of the new assessment into

the clinical workflow. The process can take up to two years.

Conclusion: Utilisation of the AC instruments occurs when multiple factors ensure that an organisation

is ready to implement the changes required for adoption to be a success. Top down and bottom up

implementation support is one significant component of success.

Symposium presentation 4: Utilisation of the interRAI AC Suite in Europe

Wellens, Nathalie (Etat de Vaud)

A number of opportunities have arisen to utilise aspects of the AC suite for interdisciplinary use and

data sharing. The Belgian web-based software system (BelRAI-software) was developed to enable

clinicians to interpret the output and communicate the patients’ data across wards and care

organisations.

Method: Belgium: The purpose of the study was to evaluate the advantages and disadvantages of the

implementation of the interRAI AC instrument as a comprehensive geriatric assessment instrument in

an acute hospital context. In a cross-section multicentre study on four geriatric wards in three acute

hospitals, trained clinical staff (nurses, occupational therapists, social workers, and geriatricians)

138

assessed 410 inpatients in routine clinical practice. The BelRAI-system was evaluated by focus groups,

observations, and questionnaires.

Switzerland: The purpose of the implementation was to support long term utilisation of interRAI

assessment instruments in the Swiss health care system. Key scales were identified for initial

implementation as a part of standard care to support the familiarisation of interRAI nomenclature for

clinical reporting and risk assessment.

Results: Belgium: BelRAI assessments (n=159) were exchanged with homecare organisations (n=127)

and nursing homes (n=32). Two surveys of health professionals were completed (n=16/20; n=19/20) to

evaluate the feasibility of the software in clinical practice in acute care.

The primary strengths of the BelRAI-system were a structured overview of the patients’ condition early

after admission and the promotion of multidisciplinary assessment. Implementation has proven not

evident.

Switzerland: Two scales were chosen for implementation in the initial trial.

Conclusion: Belgium: The iAC-CGA incorporated into a web-based eHealth platform has been tested

in acute geriatric units. The test was a novel in transferring standardized data between home care

services, nursing homes and hospitals and in centralizing medical, functional and nursing data.

Switzerland: Initial implementation utilising scales from the AC to link with community based

assessments as a pre-cursor to full implementation.

139

SYMPOSIUM 8: BELRAI AS PART OF THE FLEMISH SOCIAL PROTECTION

POLICY: HOW TO GET FROM POLICY TO IMPLEMENTATION

Chair(s): Kathleen De Cuyper

In 2018, the federal and regional governments of Belgium confirmed their commitment to the national

implementation of BelRAI. BelRAI is the Belgian version of the internationally validated interRAI

comprehensive assessment system. The interRAI instruments first and foremost are used for assessing

the needs of vulnerable people and to underpin care planning. Next, the interRAI output can be used for

organizational management, such as quality monitoring and adjusting staffing levels. Third, when the

instruments are used nation or region wide - which will be the case for BelRAI - the output can also be

used by governments for developing and monitoring policy.

In this symposium, we look at the Flemish Social Protection in particular. We explain what steps need

to be taken in order to use BelRAI in the FSP in an evidence- and practice-based way. After a general

introduction about what Flemish Social Protection is, we introduce three studies in different care

settings - rehabilitation care, mental health care and home care - that focus on the different phases of

implementing BelRAI in the Flemish Social Protection.

Keywords: BelRAI, Flemish Social Protection, implementation

Symposium presentation 1: BelRAI in the Flemish Social Protection

Moors, Evelien (LUCAS KU Leuven - Centre for Care Research and Consultancy, Belgium); Declercq,

Anja (LUCAS KU Leuven - Centre for Care Research and Consultancy)

With the sixth state reform in Belgium, long-term care became a regional responsibility, while "cure"

mainly remained federal. In order to prevent fragmentation of these transferred responsibilities and to

implement a coherent policy across the various sectors, Flanders opted to create the Flemish Social

Protection scheme.

One of the main features of Flemish Social Protection is the use of the Belgian version of the interRAI

Suite of instruments – called BelRAI - in all sectors involved. Data about the care needs of the person

follows the person through home care, residential elderly care, mental health care and rehabilitation

care. In a later phase, also child and youth care will be included.

The decree on Flemish Social Protection states that in the longer run, the assessment should also be

used for determining personal budgets for care users, by means of for example the Resource Utilization

Groups (RUGs) in nursing homes. Moreover, the ways of financing should be made as similar as

possible over the different sectors. At the moment, however, financing is very different between sectors,

and there is still a long way to go. In the first talk, we will explain which steps are needed to reach that

goal.

Symposium presentation 2: The development of the BelRAI Rehabilitation instrument: Lessons

learned

Van Regenmortel, Jasmine (LUCAS KU Leuven - Centre for Care Research and Consultancy);

Declercq, Anja (LUCAS KU Leuven - Centre for Care Research and Consultancy); Van de Velde,

Dominique (Faculty of Medicine and Health Sciences, UGent)

140

Objective: The interRAI assessment system does not include an instrument for long-term rehabilitation

(LTR) as we now in Belgium. The most common diagnoses in the Flemish LTR are neurological and/or

orthopedic conditions, hearing problems and/or visual impairments.

The Policy Research Centre Welfare, Public Health and the Family developed a BelRAI Rehabilitation

instrument for adults, with a clear link to the International Classification of Functioning, Disability and

Health (ICF) of the WHO.

Method: We used a mixed-method design in two large phases. The first phase identified the most

important domains that should be covered in the instrument according to the different stakeholders.

Data were gathered in focus groups and interviews with experts, healthcare professionals and clients.

The second phase was a pilot testing phase, in which the caregivers completed the instrument in

practice. The aims were (1) to find consensus about the content (validity) of the instrument and (2) to

identify implementation possibilities. Input of the caregivers who completed the instrument, was

collected by means of focus groups and an attitude questionnaire about the use and content of the

instrument.

Results: The first phase led to an instrument that combines ICF and interRAI, with core items and with

elaboration modules for specific topics and specific target groups. However, that instrument was far too

long for use in daily practice. No consensus was found with the stakeholders on how to trim it down.

The second version still contained over 1,700 items. This version was tested, on paper, in 105 cases.

In a third phase, the researchers developed a theoretical framework for deciding which items should be

in the final version of the instrument. Based on this framework and on the analyses of the 105 test

assessments, a new, shorter and acceptable instrument was developed. This theoretical framework and

an overview of the third phase instrument will be presented.

Symposium presentation 3: A participatory trajectory to prepare the evaluation of the BelRAI

(Community) Mental Health instruments in 61 Flemish mental health care settings

Van Horebeek, Hanne (LUCAS KU Leuven - Centre for Care Research and Consultancy); De Cuyper,

Kathleen (LUCAS KU Leuven - Centre for Care Research and Consultancy); Hermans, Kirsten

(LUCAS KU Leuven - Centre for Care Research and Consultancy); Declercq, Anja (LUCAS KU Leuven

- Centre for Care Research and Consultancy); Van Audenhove, Chantal (LUCAS KU Leuven - Centre

for Care Research and Consultancy)

Background: In 2017, a pilot study was conducted in order to test the usability and feasibility of the

BelRAI Community Mental Health Care (CMH) instrument in 13 mental health care (MHC) settings in

Flanders. Additionally, the attitudes of care professionals towards the use of the instruments were

evaluated. After this pilot study, a number of objections and concerns about the content, the usability

and the privacy regulations were formulated by the sector. Before evaluating and implementing the

BelRAI MH and CMH instruments on a large scale, there is thus a need to meet necessary preconditions.

Aims: This study aimed to explore the necessary preconditions for an optimal evaluation of the BelRAI

(C)MH instruments in MHC in Flanders (Belgium).

Methods: A qualitative study was conducted, using a participatory research approach. Seven working

groups were organized with 49 care professionals from 7 types of MHC organizations (care

professionals from sheltered living initiatives; psychiatric nursing homes; nursing homes with a

department for people with a severe mental health disorder; psychosocial rehabilitation centers;

rehabilitation centers for people with an addiction disorder; mobile MHC teams; and forensic

departments of psychiatric hospitals) in order to map preconditions for an optimal evaluation of the

141

BelRAI (C)MH instruments. Data were gathered between October 2018 and February 2019 in 14

meetings, and were thematically analyzed and synthesized.

Results: This study resulted in a number of preconditions for an optimal evaluation of the BelRAI

(C)MH instruments in MHC organizations in Flanders (Belgium), including: 1) The development of a

concrete implementation plan; 2) The use of research software that prevents data sharing within and

between (care) organizations and governments; 3) The addition of an ‘extended’ Addictions

Supplement and a Social Recovery Supplement; 4) Generating hypotheses about BelRAI items that are

possibly not relevant for the Flemish MHC sector; 5) The elaboration of inclusion- and exclusion criteria

of study participants.

Conclusion: The preconditions that were determined in this study will be considered when evaluating

the use of the BelRAI (C)MH instruments in 61 MHC organizations in Flanders (Belgium) in 2020.

Symposium presentation 4: The development and evaluation of a social supplement for the

BelRAI instruments to assess the social context of persons with care needs in home care

Van Doren, Shauni (LUCAS KU Leuven - Centre for Care Research and Consultancy); Hermans,

Kirsten (LUCAS KU Leuven - Centre for Care Research and Consultancy); Declercq, Anja (LUCAS

KU Leuven - Centre for Care Research and Consultancy)

The Flemish government approved of a nation-wide implementation of BelRAI in different settings.

However, the BelRAI instruments mainly focus on intrapersonal factors (e.g. health status; mood). And

in home care, interpersonal factors - the social context - also have an impact on a person’s care needs

and care demands. This is why the aim of this study is twofold. First, we develop and evaluate a Social

Supplement for the BelRAI instruments to answer the complex care and support questions in Flemish

home care. Second, we determine the preconditions for an implementation of BelRAI and the Social

Supplement in home care.

By means of a literature review, nine focus groups, and eleven expert panels with care providers, care

users and policy makers from the home care sector, we looked at the various social and environmental

factors that may have an influence on care needs and care demands. The results were used as a guide

for the development of the first version of the Social Supplement. Additionally, stakeholders reflected

on the preconditions for a successful implementation of the BelRAI instruments and the Social

Supplement in home care. These preconditions were taken into account during the planning of the test

phase.

The test version of the Social Supplement consisted of four modules: Environmental assessment, Social

engagement, Psychosocial wellbeing, and Informal care and support. A thousand persons receiving

home care in Flanders were assessed using the BelRAI Screener and BelRAI Social Supplement.

Our findings show that knowledge about the social context of person is essential when drawing up an

effective care plan, but varies among the different home care services. In addition, we see that open

communication between participating care professionals and researchers is crucial for evaluating and

refining the BelRAI Social Supplement training package.

This study results in a validated Social Supplement for the BelRAI instruments in Flanders. An optimal

implementation of the BelRAI instruments and Social Supplement in home care requires - among other

things - a thorough and consistent training process, direct dialogue with professionals, an integration of

the BelRAI instruments in daily practice, and the availability and compatibility of the appropriate

hardware and software.

142

SYMPOSIUM 9: INTERRAI EDUCATION PICK ‘N’ MIX: A SAMPLE OF

EDUCATIONAL APPROACHES AND TRAINING METHODS FOR INTERRAI

FROM AROUND THE WORLD

Chair(s): Julie Descamps and Brigette Meehan

Improving the quality of life and care for vulnerable people through a system of comprehensive

assessments starts with the correct and qualitative instrument use. Completing an interRAI assessment

accurately leads to individual and system-wide opportunities from an informed care plan, transparent

measurement of outcomes, accurate quality indicators of the service provided, policy development, till

streamlined payment systems and research discoveries.

Therefore, creating and maintaining a consistent and integrated education programme, including

follow-up support for the assessor, is a crucial component of all outputs that are based on interRAI data

integrity.

The main objective of the symposium is to share education approaches, methods, and processes as a

source of inspiration for new and experienced interRAI educators and policy makers from various

countries using interRAI assessments. Presenters from Australia, Belgium, Canada, Ireland, New

Zealand and Switzerland will contribute to this symposium.

The presentations are followed by a panel conversation with the possibility to ask questions.

Keywords: education, training, implementation

Symposium presentation 1: Training in the interRAI Acute Care: Same, same…but different?

Experiences from Australia

Pimm, Bonnie (University of Queensland)

Training is a critical ingredient of a successful interRAI assessment system implementation to preserve

the reliability of the instrument and the quality and accuracy of data. The recent addition of a new

instrument—the interRAI Acute Care-- within the interRAI suite has created a unique challenge for

provision of education and training to assessors and other clinical stakeholders.

A move away from the traditional model of a single assessment being completed at a particular period

of time, to a model of continuous real time assessment such as the Acute Care instrument provides,

places an unprecedented demand on Educators and Trainers. Designed to be administered by nurses

requires that nursing staff on all shifts throughout a 24 hour timeframe within a busy hospital

environment must have adequate knowledge to complete an assessment and utilise the applications for

provision of ongoing care, including care planning. Other team members who will be reading and

interpreting information, such as Specialist and Multi-disciplinary staff, must also be able to access

training efficiently.

At the same time, training must incorporate other key elements such as software instruction and process

change, including integration with existing nursing admission processes to better identify, plan and

deliver care.

Therefore, previous methods of education used with other instruments such as extensive face-to-face

learning over periods of hours or days, are not necessarily viable for training in the Acute Care

instrument.

143

Development of new models of training are critical to successful implementation of systems which

provide the ability for continuous assessment performed by a large number of staff with a high turnover.

Symposium presentation 2: The training and follow-up programme for BelRAI Screener in

Flanders, Belgium

Descamps, Julie (Kwaliteitscentrum voor Diagnostiek)

Belgium has already a long history of conducting research on the use of the interRAI/BelRAI

instruments through various projects. In 2018 the different governments (federal government, regions

and communities) agreed upon a protocol describing their collaboration in using the BelRAI

instruments. In Flanders, the government plans to implement the instruments as a part of the Vlaamse

sociale bescherming (Flemish social security), using it in different care settings. The BelRAI Screener,

a screener for the Home Care assessment, is the first instrument that will be implemented.

The Kwaliteitscentrum voor Diagnostiek (Centre of Excellence in Diagnostics) is a scientific research

and knowledge centre that aims to facilitate and improve assessment practices in Flanders. Besides

research and consultancy, information dissemination is another mission, which includes organising

training and supervision.

For the implementation of interRAI/BelRAI in Flanders it is the core task of the Kwaliteitscentrum voor

Diagnostiek to provide training and follow-up of the qualitative use of the instrument, and to develop

an implementation plan.

This presentation will focus on the training programme ‘BelRAI Screener’ that was developed in

collaboration with different stakeholders and tested and evaluated in a pilot project. This programme

had to be tailored to the specific context of the assessors and their needs (e.g. how to perform the

interview with the assessed person). These aspects of content will be discussed, as well as the chosen

methods for training and follow-up.

By attending this presentation, the participant will gain a clear insight into the training programme

developed for ‘BelRAI Screener’.

Symposium presentation 3: InterRAI Education: The Canadian Experience

St. Louis, Geri (Canadian Institute for Health Information); Damiano, Natalie ([email protected])

The Canadian Institute for Health Information (CIHI) provides education in Canada for several

interRAI instruments: the interRAI-HC and RAI-HC, interRAI LTCF and RAI-MDS 2.0, interRAI CA,

and the RAI-MH. Education is delivered through a blended learning approach, including both

instructor led training and self-study across multiple media and is intended to support CIHI stakeholders

across the implementation lifecycle.

This presentation will showcase the newly developed 3-part education program for the interRAI-LTCF

and HC, and the modules included to support various stakeholders from the pre-implementation phase,

through implementation and in the post-implementation maintenance phase. Insights gained through

over 15 years of education delivery to support interRAI instruments.

144

Symposium presentation 4: interRAI Ireland National Educational Programmes - From Theory

to Implementation

McDermott-Scales, Linda (Health Service Executive); Vereker, Natalie (Health Service Executive)

In 2016, the Irish Health Service Executive launched the IT-based, interRAI Home Care assessment

system as the new national standard to comprehensively assess the health and social care needs of

people seeking access to state-funded Home Support Services (HSS) and the Nursing Home Support

Scheme (NHSS). This paper details the design and implementation of a national training programme to

support this implementation across acute and community sectors in the Irish health system. The training

programme has been rolled out nationally on a flexible basis to meet the specific needs of the various

staff that use the assessment framework.

The aim of this paper is to share the Irish experience to date of developing and implementing the various

educational strategies used by the HSE to support the interRAI assessment framework.

The objectives of this project were to scope international training initiatives used to support the interRAI

assessment training frameworks in other jurisdictions; to determine the staff to be targeted and what

their educational requirements would be; and to develop a quality assured interRAI training programme

to meet the needs of all stakeholders.

A number of educational approaches were identified through the review of international programmes

and a consensus was reached on requirements, within a multidisciplinary context, to tailor these to the

Irish context. This paper outlines the programme design and implementation to date, including the

methodologies applied, the type of interRAI training model used, the quality assurance process and the

accreditation process by relevant professional bodies. The fundamental tenets of this approach are based

on the programmes underpinning philosophy, its associated values and principles, transformative adult

learning approaches and on-going continuous quality improvement.

Upon reflection on the design and implementation of this project, it is important to acknowledge and

explore the educational opportunities and challenges encountered in building and supporting a digital

community of integrated interRAI healthcare practice.

Symposium presentation 5: InterRAI Education and Support Services in New Zealand

Meehan, Brigette (Technical Advisory Services (TAS))

This presentation will discuss critical components for interRAI educational programmes and how these

contribute to quality standards and it will describe lessons learned from our experience of tailoring

interRAI education with different customer groups. In particular it will highlight our approach to

building sustainability; at a person level, the challenge of providing sufficient education and support so

the person takes ownership of their learning and competency, and at a systems level, embedding the use

of interRAI knowledge for day to day planning and funding decisions so that competent assessment is

in the interest of all stakeholders in the health system.

The interRAI Education and Support service in New Zealand has two main components. One

component relates to quality standards for education delivery and the second relates to delivering

interRAI education.

The standard’s framework includes key protocols for the use of interRAI assessments and minimum

educational standards for training different customers across the sector.

interRAI services provide two major types of education service; a delivery arm that provides training

to assessors, managers, clinical leaders and end users of the assessment information and an accreditation

145

programme where providers employ their own trainers that train assessors to interRAI Services

standards.

Our span of interest covers many assessments in the integrated suite; home and community assessments

(Contact, Community Health, and Home Care assessments), the Long Term Care Facilities, Palliative

Care and most recently Acute Care assessments. With a small population of just under five million and

national requirement to use the assessments within the health system it is not uncommon for assessors

to require training and ongoing support in multiple assessment instruments.

Symposium presentation 6: Training formats tested and used in Switzerland: Experiences from

pilot projects to nationwide implementation

Wellens, Nathalie IH (Department of Public Health and Social Affairs, Canton Vaud)

Clinical decision-making is enhanced by reliable data. But not only that, skills in patient centred care

planning, shared decision making, patient involvement and interprofessional comanagement are also

essential. Therefore, interRAI training goes beyond learning the correct coding of items.

In Switzerland, the old MDS generation was introduced about 15 years ago. In public home care, it is

used mainly as a clinical tool to guide care planning. While in nursing homes, it serves merely as an

administrative tool to allocate financial resources. The gradual update to the latest generation interRAI

Suite is in full preparation. Some regions have also decided to start from scratch by introducing multiple

interRAI instruments. Besides, single projects are launched in specific local healthcare structures.

Does one training formula fit all?

Objectives: Various scenarios of training processes will be shared summarizing the elements to be

considered when pencilling programs in diverse contexts.

Challenges in program management: Whether it is a small-scale pilot project or a national roll-out,

training must be given special attention as it is a key determinant of successful uptake.

Illustrations of various Swiss training approaches will be discussed, highlighting the implications for

project management, such as feasibility, sustainability and expected results.

Each project or implementation has its own particularities and constraints. Based on the lessons learned,

this presentation lists the important parameters to be taken into account when tailoring future training

accordingly.

Contextual elements make designing and setting up training curricula a rich experience: care settings

and their structures; maturity in assessment; skill-mix grade-mix of both trainers and participants; scope

and use of assessments; political and legal context, availability of trainers and/or interRAI expertise,

program size, budget and timeline, etc.

Different packages can be created with a wide variety of lengths, (digital) media types, degree of self-

study, levels of understanding, variety of pedagogical methods, content modules, competency training,

quality control, attention to deepening and follow-up, updates, etc.

In conclusion, let’s not only focus on boosting the quality of data collection. but rather design training

frameworks that reinforce the quality of use of the assessment system that are embedded in the context.

146

SYMPOSIUM 10: INTERRAI ROLL-OUT IN RESIDENTIAL CARE: PRACTICAL

EXPERIENCES IN BELGIUM AND THE NETHERLANDS

Chair(s): Bert Paepen, Pyxima

Even though Belgian and Dutch governments support interRAI as a suitable geriatric assessment

instrument there is no mandatory use of the instrument today in residential care facilities. This means

that most facilities decided to use interRAI as a support for their care diagnosis and early care planning.

Even then, experience teaches us that a successful and long-term sustainable interRAI rollout in

residential care is only feasible if existing workflows in the organization are adapted accordingly. This

requires a change management process to be implemented in addition to the typical training efforts for

introducing such new instruments.

This symposium will demonstrate several practical case experiences introducing interRAI in residential

care facilities in Belgium and The Netherlands. Care professionals, involved in the introduction process

and the day-to-day operations, will explain first-hand how they have rolled out the interRAI method in

their facility. They will talk about the rollout tempo in their organizations, assessment teamwork,

multidisciplinary team meetings, training approach, hardware, software and many other real-life

experiences.

From pitfalls to best practices: this symposium is intended for an audience of care professionals and

scholars who are considering implementing interRAI or who are interested in practical experiences from

others in doing so.

Keywords: rollout, The Netherlands, Belgium

Symposium presentation 1: TRENTO: interRAI-pioneering care facility and home care

innovator

Onselaere, Bart (Zorgnetwerk TRENTO, Belgium); Verhoost, Filip (Zorgnetwerk TRENTO, Belgium)

Caring for 226 residents Care Network TRENTO is a mid-size long-term care facility situated between

Ghent and Antwerp. With an active involvement in early Belgian interRAI pilot projects TRENTO was

one of the very first “BelRAI” pioneers. Their home care innovations embody a close cooperation

between different partners in which interRAI plays a key role. Based on the interRAI CAPS the

multidiscipline care team defines a proactive care plan focused on improvement and client involvement.

This collaborative and preventive approach has resulted in postponing the long-term care facility

admission moment for the participating clients by an average of 350 days.

Using BelRAI screener and BelRAI HC already in the home care situation, the facility care team already

has a client history upon admission. After 4 to 6 weeks a full BelRAI LTCF assessment is being

conducted, prior to a multidiscipline client meeting. Results are discussed with the client and family;

goals and actions are linked to priority CAPs. This approach has significantly improved the quality of

care plans, client involvement, communication between care providers and interaction with family.

Every six months, or faster, a follow-up assessment is being conducted. Results feed into a care follow-

up document based on CAPs. Using the Pyxicare software on tablets, the team has been able to reduce

the assessment time by a factor three, with a current average duration of 30-45 minutes for a first

assessment and 15 minutes for a follow-up assessment. Also, using the tablet at family and client

meetings, the interRAI based follow-up is being made insightful and transparent.

147

Symposium presentation 2: OCMW Gent - Zuiderlicht: Confidant approach using interRAI for

elderly residents with a psychiatric background

Parmentier, Oryza (OCMW Gent, Belgium); Snauwaert, Vicky (OCMW Gent, Belgium)

Zuiderlicht is long-term care facility located in Gent, caring for senior residents often with a psychiatric

history. It is a new facility who has started using interRAI early 2018.

Following a coordinated care approach, each resident within Zuiderlicht is being assigned a “confident”

or in other words a “plus attendant”. This can be a caregiver, nurse, occupational therapist, or even a

maintenance employee, who devotes extra attention to this resident. It is not a matter of job title, but

about the match between employee and resident. The plus attendant is the first point of contact for

residents and family and devotes extra attention to their needs.

He or she knows the resident best and is therefore the person in charge to complete the interRAI

assessments. InterRAI is therefore not the task of just a few employees: everyone is being involved.

Given the recent start-up of Zuiderlicht, not every employee has yet received the relevant training.

Therefor not all residents have been classified with interRAI. Nonetheless, newer employees already

use the interRAI terminology in part: the individualized objectives that are set forth for a resident are

categorized by the caregivers referring to an interRAI CAP. This way, interRAI fits perfectly in our

complete care approach.

Symposium presentation 3: Omring: Software as a facilitator for interRAI rollout in 25

residential care locations

Franquinet, Daphne (Omring, The Netherlands); van der Neut, Erik (Omring, The Netherlands);

Verheijden, Suzanne (Omring, The Netherlands)

Omring care is built on the conviction that the client comes first and starts with a clear interaction

between nurses, our clients and their close relatives/family. As an early adopter in The Netherlands,

Omring has been using interRAI for 10 years with various degrees of success.

Web based registration tools were simply not practical, and nurses regarded them as an administrative

burden. Nurses were not able to complete an assessment together with the client and relatives. At times,

they were even compelled to complete them during their night shifts.

As a result, the care planning was not tailor made but was rather representative of the nurse’s ideas than

of their client’s wishes.

A client can be followed through all care situations. Information can be gathered from one single source,

resulting in easier and straightforward communication.

The implementation in Omring started in the summer of 2018. We have trained 300 nurses, paramedics

and therapists. Working with the application is very easy but to fully understand how interRAI

instruments can support daily care is not easy. It demands multiple (repeated) training and coaching on

the job.

We have developed an e-learning tool that contains tutorials, animation, video and tests. Management

can follow the results. This way the need for an external trainer can be reduced to 1-2 sessions. Annually

they can organize a refresher course.

Omring also develops a “collected data” dashboard and we investigate our quality indicators to improve

our quality of care.

148

SYMPOSIUM 11: CAN WE IDENTIFY BEST PRACTICE ORGANISATIONS

CARING FOR VULNERABLE OLDER CARE RECIPIENTS? FINDINGS FROM

THE IBENC STUDY

Chair(s): Hein van Hout and Henriëtte van der Roest

Background: How can we increase the sustainability of health care systems in the context of an

increasing demand for health care by growing numbers of older people and a shrinking working force?

We may learn from best practices that are able to produce good outcomes with limited resource use.

Aim: In IBenC we developed a method to identify best practices in care delivery for older home health

care recipients within and across countries and characterise home health care providers.

Design: We collected longitudinal data on health, functioning and resource use on 2884 older

community dwelling home health care recipients served by 33 home care organisations from six

countries (Belgium, Finland, Germany, Iceland, Italy, and the Netherlands). We also collected

characteristics of the participating organisations and the job experiences of their care staff (N=1067)

which was used to develop and characterise models of care delivery.

Quality of care Outcomes were two summary measures on quality of home care produced by the

participating organisations:(1) The Independence Quality Scale (IQS), reflects organisations

performance on maintaining functional independence and engagement of their care recipients; (2) the

Clinical Balance Quality Scale (CBQS) reflects an organisation’s performance to improve functioning

of their care recipients relative to other organisations.

Costs of resource utilisation over a period of six months was estimated per recipient and aggregated per

organisation, care model, and country.

Job experiences of home care professionals comprised the Copenhagen Psychosocial Questionnaire and

Scheduling Dissatisfaction.

Results: Quality and cost of care differed substantially between organisations and countries. We

distinguished care models by using three characterising factors: (1) level of patient-centred care

delivery, (2) availability of specialised care professionals and (3) monitoring of care performance.

These factors were also related to organisations’ efficiency (quality for costs).

Impact: The novel method for benchmarking outcomes and costs provides insight into the performance

of home health care delivery. Since increasing numbers of home health care providers across the world

utilise interRAI tools in their routine care, applications developped in IBenC can support benchlearning.

Keywords: interRAI-HC, Quality of home care, Cost of resoucre use

149

Symposium presentation 1: Signs of inequality? Variations in resource utilizations of home health

care by vulnerable older persons within and across six European countries

van Hout, Hein (Amsterdam University medical center, Netherlands); Declercq, Anja (Lucas KU

Leuven); Garm-Homolova, Vjenka (HTW Berlin, Germany); Finne-Soveri, Harriet (THL, Helsinki,

Finland); Jónsson, Palmi (Landspitali University Hospital, Reykjavik, Iceland); Onder, Graziano

(UCSC University Catholic University of Sacred Heart, Rome, Italy); van der Roest, Henriette (Trimbos

Institute, Utrecht, Netherlands)

Most countries aim to allocate home health care to those in need in a fair and equal way. Equal allocation

implies that the amount of home care a person receives would reflect the level of health impairment and

the need for resources. It is not clear whether countries succeed in attaining this.

Our objective was to explore signs of (un)equal home health care provisioning across care organizations

and across European health countries.

We used data of the IBenC study collected from 2884 older community care recipients from 33

organizations in six Western-European countries (www.ibenc.eu). We benchmarked differences of

provided and expected formal care time across organizations and countries. Expected formal care hours

were estimated by multiplying the overall sample’s mean formal hours with recipients’ case mix

weights from interRAI’s resources utilization group profiles.

We found substantial variations in provided formal care time among organizations both within and

across countries that could not be explained by the case mix differences of recipients. This implied

presence of inequality of home care provisioning. These findings may alert professionals and

policymaking striving for equal home health care provisioning for dependent older persons.

Symposium presentation 2: What are best practices in home care? Outcomes of a novel

benchmark method based on quality and cost of care utilization

van der Roest, Henriette (Trimbos Institute, Utrecht, Netherlands); van Lier, Lisanne (Amsterdam

University medical center, Netherlands); Onder, Graziano (UCSC University Catholic University of

Sacred Heart, Rome, Italy); Declercq, Anja (Lucas KU Leuven); Garm-Homolova, Vjenka (HTW

Berlin, Germany); Finne-Soveri, Harriet (THL, Helsinki, Finland); Jónsson, Palmi (Landspitali

University Hospital, Reykjavik, Iceland); van Hout, Hein (Amsterdam University medical center,

Netherlands)

Background: The financial constraints and scarcity of formal and informal carers that are expected in

the future, may jeopardize the quality and availability of home care. In addition evidence base on

characteristics contributing to efficient home care delivery lacks. This hinders sound policy making on

sustainable home care delivery. This study aimed to identify best practices in home care in an

international context, and presents a novel benchmark method based on quality and costs of care

utilization. In addition organizational characteristics associated with efficient (high quality, low costs)

home care delivery are explored.

Methods: This study is part of the IBenC project. Home care organizations and clients were enrolled in

six European countries. Organizational characteristics were collected at baseline. Client data was

collected at baseline and six month follow-up, using the interRAI Home Care instrument. This

instrument generates two case-mix adjusted quality of care summary measures (interRAI Home Care

Independence Quality Scale (HC-IQS), and Clinical Balance Quality Scale (HC-CBQS)), and enables

cost of health care utilization estimations. Both quality outcomes were combined with cost of care

utilization, forming two benchmarks. Differences between characteristics of efficient and inefficient

organizations were explored.

150

Results: Twenty-two home care organizations and 2356 clients were included in the analyses. Five

organizations were efficient in care aimed at prevention and maintenance of functional decline (HC-

IQS), and had less clients, smaller catchment areas, more registered, and less licensed practical nurses

per client, in comparison to inefficient organizations. Seven organizations were efficient in improving

client functioning (HC-CBQS). Compared to inefficient organizations, they had more clients in care,

larger catchment areas and staff size, provided more often formal disease management, performance

bonuses, and public accountability.

Conclusion: The developed methodology has the potency to provide evidence based support for health

care policy and home care organizations for the arrangement of sustainable home care provisioning.

Symposium presentation 3: Do Job experiences of care professionals impact quality of home care?

van Eenoo, Liza (Lucas KU Leuven); van der Roest, Henriette (Trimbos Institute, Utrecht,

Netherlands); van Hout, Hein (Amsterdam University medical center, Netherlands); Garm-Homolova,

Vjenka (HTW Berlin, Germany); Declercq, Anja (Lucas KU Leuven)

Introduction: Do job experiences of professionals determine the quality of care outcomes of their care

recipients? Previous studies suggest an association between job satisfaction and quality of care. In the

IBenC study we explored associations between job experiences of home care professionals, such as job

satisfaction, and quality of home care.

Methods: The job experiences were measured with the Copenhagen Psychosocial Questionnaire and

Scheduling Dissatisfaction. These scales were filled out by the 1067 home care professionals from 33

organisations from six countries (Belgium, Finland, Germany, Iceland, Italy, and The Netherlands). The

quality of these organizations’ care outcomes was calculated using interRAI HC assessments on 2884

older care recipients at baseline and 6 months follow up. Quality of care was expressed in two interRAI

quality of home care summary scales (3rd generation): (1) improving functioning (Clinical Balance

summary Scale); (2) Functional maintenance and prevention of functional decline (Independence

Quality summary scale). Stepwise multiple regression analyses were performed to identify the strongest

associations.

Results: Job satisfaction and dissatisfaction with work schedules modestly associated with quality of

care summaries with beta’s between 0.09 and 0.37. Job satisfaction and the Scheduling Dissatisfaction

Scale were positively associated with quality of care outcomes regarding improvement of functioning

(Clinical Balance summary Scale), but negatively if the quality of care was better for functional

maintenance.

Conclusions and/or implications: Job satisfaction and dissatisfaction with work schedules were he job

outcomes most strongly associated with the two quality of care summary scales. However, the directions

of the associations differed per summary scale. This raises questions : Are care professionals with lower

job satisfaction less motivated to improve the functioning of their clients? Or, is care aimed at

maintenance of functioning less satisfying for professionals? This study shows that professionals’

experiences matter for the quality of care. Further research is needed to better understand the different

associations found.

151

SYMPOSIUM 12: INTERRAI IN FINLAND: 20 YEARS AND GOING STRONGER -

IMPACT ON LEGISLATION, LEADERSHIP & MANAGEMENT, QUALITY OF

CARE

Chair(s): Ulla Harriet Finne-Soveri and Minna-Liisa Luoma

This symposium will highlight different policies and practices from individual to national level, in

Finland

PART I

1. Introduction to Finnish interRAI work during 20 years

2. Confirming RAI skills for practice and research

3. interRAI knowledge on national level - from data to policies and legislation

4. Attempts to create RAI-based payment systems

PART II

5. Leading rehabilitative care – what and how

6. RAI assessments for identifying different cultures among clients

7. Quality of care through interRAI glasses

8. Closing remark

Keywords: Training, Benchmarking, Practice

Symposium presentation 1: Introduction to Finnish interRAI work during 20 years

Finne-Soveri, Ulla Harriet (Institute for Health and Welfare); Luoma, Minna-Liisa (Institute for Health

and Welfare); Noro, Anja (Institute for Health and Welfare); Havulinna, Satu (Institute for Health and

Welfare); Bjorkgren, Magnus (Chydenius Institute); Vähäkangas, Pia (Gerofuture); Heikkilä, Jyrki

(University of Turku); Heikkilä, Rauha (Institute for Health and Welfare); Hammar, Teija (Institute for

Health and Welfare); Gerasin, Alexandr (Institute for Health and Welfare); Mäkelä, Matti (Institute for

Health and Welfare); Andreasen, Paula (Institute for Health and Welfare)

We introduce (3 slides) different levels the social and health sector + research with successful interRAI

activities, in Finland. InterRAI work started, in 1994, in long-term care facilities (LTCFs) as two

research projects, which 6 years later were launched for clinical practice. 1) Chydenius Institute to carry

out training 2) nurses to perform assessments for care planning purposes, 3) RAIsoft.ltd software to

collect data and calculate scales, and 4) National Institute for Health and Welfare to maintain

benchmarking system with semiannual feedback reports. The original consortium with 3 local

authorities (Helsinki, Kokkola, Porvoo) gradually expanded to fully or partially cover most of the

regions in the country. Today the number of annual assessments has grown (2000 ->62 000, in LTCFs

and HC), and is accompanied by instruments for mental health, intellectual disabilities, and children to

form a basis for evidence based practice, care /case, management, and service planning.

152

Symposium presentation 2: Confirming RAI skills in practice - today and tomorrow

Havulinna, Satu (Institute for Health and Welfare); Heikkilä, Rauha (Institute for Health and Welfare)

To establish reliability and evidence based individual care planning, a correctly performed standardized

assessment is a requirement. The assessment is primarily created for care planning purposes.

Secondarily these data can be used for management, service planning, regulatory services, teaching and

training, and above all, for research. This presentation will introduce attempts to confirm adequate

assessment skills, and comprises 1) InterRAI expert training network, created by Rauha Heikkilä with

her team (THL) 2) National benchmarking (created by the THL team) – and its impact 3) a recently

launched internet-based national training – tool (created by Satu Havulinna and her team, THL)

available for all users, in Finland

Symposium presentation 3: interRAI knowledge on national level - from data to policies and

legislation

Noro, Anja (Institute for Health and Welfare)

Systematic assessment and RAI-data collection of all clients receiving LTC or HC services, within one

or several geographical area, forms a beneficial basis for national level service planning. Examples of

case/care management on regional level, following impact of elderly care legislation and estimating

nurse/resident ratio will be given. Regulatory systems are discussed

Symposium presentation 4: Attempts to create RAI-based payment systems

Björgren, Magnus (Chydenius Institute)

Two cities (Helsinki and Oulu) participated a pilot study in order to create RAI-based payment systems

for long-term care facilities. Results are discussed.

Symposium presentation 5: Leading rehabilitative care – what and how

Vähäkangas, Pia (Gerofuture); Niemelä, Katriina (Gerofuture)

Pia Vähäkangas (Ph.D, R.N.) and Katriina Niemelä (R.N.) have 20 years of experience in leading small

and big units, in elderly care, with RAI. Their experience extends from individual care planning and its

follow-up to leading elderly care for a town or city. Leading nurses to perform rehabilitative care wit

interRAI tools, is discussed.

Symposium presentation 6: RAI assessments for identifying different cultures among clients

Siponkoski, Silva (City of Helsinki) On behalf of the AILI-network

In order to organize person centered care in LTCFs, also in groups, cultural thinking might help. e.g.

residents in the same age-group have experienced for example war/post war period. People with same

occupation may benefit from reminiscing together etc. AILI-network, in different organizations and

parts of Finland, has generated ideas how to utilize RAI assessment for creating activities that would

interest LTCF residents.

153

Symposium presentation 7: Quality of care through interRAI glasses

Finne-Soveri, Ulla Harriet (Institute for Health and Welfare); Noro, Anja (Institute for Health and

Welfare); Silvennoinen, Ann-Sofie (City of Porvoo)

Quality of care is a complicated issue exposed to multidimensional criticism within organization and in

media. In city of Porvoo a leading and management system for elderly care was created in order to

involve the whole organization from front line nurses to leaders - including politicans and elderly care

council to work together for better care.

Symposium presentation 8: Closing remarks

Luoma, Minna-Liisa (Institute for Health and Welfare)

What did we learn during all these years

154

SYMPOSIUM 13: THE INTERRAI ACUTE CARE: DEVELOPMENT,

VALIDATION, IMPLEMENTATION, EVALUATION, AND INTEGRATION INTO

PRACTICE

Chair(s): Len Gray

The interRAI Acute Care is designed to support assessment of adults admitted to acute care settings and

forms the centre-piece of the interRAI Hospital Systems for an integrated system across the hospital

continuum of care.

Objectives of the symposium are:

1. To describe the process of development of a standardized assessment administered by nurses

for patients admitted to acute care

2. To present the results of field testing of psychometric properties

3. To present the outcomes from evaluation of an implementation trial

4. To discuss integration within the interRAI hospital suite

Keywords: Minimum data set, acute care, continuity of care

Symposium presentation 1: Development of the interRAI Acute Care: A standardized assessment

administered by nurses for patients admitted to acute care

Gray, Leonard C. (The University of Queensland)

Introduction: Timely, expedient, and high quality assessment of patients is critical to the optimal

planning and management of patients during their stay in the acute care setting. At admission to an

acute care hospital, all patients undergo routine nursing assessment. As well as administrative data and

physiological measures, assessment generally includes functional and psychological evaluation and risk

appraisal to inform the nursing care plan. Despite the value of comprehensive assessment of patients on

admission, the process is often sub-optimal due to a lack of standardized assessment practices.

Objective: This presentation reports on the development of a concise, integrated assessment for patients

admitted to acute care: the interRAI Acute Care.

Methods: Two international expert panels of clinicians and health scientists collaborated to establish

design parameters:

Determine the immediate patient issue(s) that require a nursing care plan response

Indicate risk of potential future adverse events or outcomes

Identify clinical problems that require further assessment/referral

Enable completion within 20 minutes for most patients

Provide data to enable discharge planning

Apply to all adult inpatients

Enable assessment to be completed in a computerized environment to support applications for

screening, scaling and quality measures.

Using clinical observations and a variety of derivative applications sourced from the interRAI research

collaborative repository, the panels constructed a draft instrument which was subsequently field tested

to examine feasibility, resource requirements and inter-rater reliability. The system was revised to its

final form, the interRAI Acute Care, after feedback and review from international interRAI members.

155

Results: Constructed using 56 items, the interRAI Acute Care required a median of 15 minutes to

complete. Inter-rater reliability tested on 130 paired assessments was substantial to almost perfect for

78% of the clinical items and moderate for the remaining 22% of items. A sub-set of 30 items from the

admission assessment comprised the discharge assessment.

Conclusion: The interRAI Acute Care has been shown to be an efficient nursing assessment instrument

with good psychometric properties. Implementation in a digital environment enables documentation

and care planning to comply with standards for quality of care in the general adult hospital population.

Symposium presentation 2: Profiles of patients in acute care: findings from field testing of

interRAI Acute Care

Peel, Nancye M. (The University of Queensland)

Introduction: Underpinning standards for developing a comprehensive care plan is the need to identify

- early in the admission process - cognitive, behavioural, mental and physical problems, social and other

circumstances to address the complexity of the patient’s health issues and risk of harm. The interRAI

Acute Care system includes clinical observations of functional and psychosocial issues, supported by

software to derive diagnostic and risk screeners, and scales to measure and monitor severity.

Objective: The aim was to investigate the prevalence of functional and psychosocial problems in

hospitalised adults, to compare prevalence rates across age groups and to assess their impact on

discharge outcomes.

Methods: A prospective observational cohort study was conducted in four Australian hospitals,

including a large tertiary referral facility, a regional community hospital and two small rural hospitals.

Patients aged 18 and over, admitted to general medicine, surgical, oncology and orthopaedic wards were

eligible to participate. Trained research nurses assessed patients at admission using the interRAI Acute

Care instrument, entering data in a web-based application operated on tablet computers. Length of stay

and discharge outcome were recorded from medical records.

Results: The median age of patients (n=910) was 66 (range 18 to 99 years), and 47.7% were female.

While 64.6% of patients aged ≥ 70 years had at least one classic geriatric syndrome (cognitive

impairment, dependency in activities of daily living, history of falls or incontinence), similar problems

were prevalent in younger cohorts (34.6% in those aged <50 and 38.9% in those aged 50-69 years). Of

17 health issues assessed across multiple domains, only 26 patients (2.9%) had no problems.

Independent of age, gender and Comorbidity Index, having a greater number of problems was

significantly associated with an adverse discharge outcome, OR 1.19 (95% CI: 1.09-1.29); for each

additional problem, the length of stay increased by 6.7% (95% CI: 4.3%-9.2%).

Conclusions and Implications: The high prevalence of functional and psychosocial problems across the

age range of patients indicates that universal screening and assessment is warranted for all adult patients

to aid in care planning to meet patient needs both in acute care and post discharge.

Symposium presentation 3: Implementation and evaluation of the interRAI Acute Care: a

standardized system to assess functional and psychosocial issues in hospitalised adults

Pimm, Bonnie (The University of Queensland)

Introduction: Following development and testing of the interRAI Acute Care instrument, a ‘whole of

hospital’ implementation and evaluation trial was planned. The objectives were to compare the interRAI

AC assessment system with usual practice (paper-based nursing assessment processes) in regard to

156

completion and timeliness of assessments, recording of key risk factors, documentation burden and

feasibility of incorporation into nursing practice.

Methods: The implementation of the interRAI Acute Care used a quality improvement, multi-strategy,

mixed methods approach to support assessment by nurses of adults admitted to a 200-bed public

hospital in Australia. The theoretical approach used to guide implementation was the Promoting Action

on Research Implementation in Health Services (i-PARIHS) framework. Empirical data, surveys, and

qualitative feedback were used to measure process and impact outcomes using the RE-AIM evaluation

framework (Reach, Efficacy, Adoption, Implementation and Maintenance).

Results: In comparison to usual practice, the interRAI assessment system and supporting software was

able to improve the integrity and compliance of nurse assessments in identifying key risk domains (39%

missing data in pre-implementation assessments compared with 1% missing data on interRAI

assessments). In regard to timeliness of assessment, pre-implementation chart audits indicated that 62%

of assessments were completed within 24 hours of admission to the ward, compared with 87% of

interRAI admission assessments. Paper forms screened 82 clinical items (10 duplicated) compared with

56 interRAI clinical items; using the interRAI assessment reduced documentation burden without loss

of fidelity. Qualitative feedback from nurses in relation to staff engagement and behavioural intention

to use the new technology was mixed.

Conclusions: There were significant challenges associated with implementation of practice change in

acute care, including heavy workloads, competing demands, and complexity of the care environment.

Contract delays resulted in implementation coinciding with roll-out of the Electronic Medical Record

system, with consequent loss of staff engagement and additional training burden on nurses. Despite

challenges to implementing a system-wide change, evaluation results demonstrated considerable

efficiency gains in the nursing assessment system. To maximize successful implementation of the

interRAI AC, the findings suggest the need for interoperability and compatibility with other information

systems, access to training and continued management support.

Symposium presentation 4: Standardising Assessment across the Hospital Continuum: the

interRAI Hospital Systems

Martin-Khan, Melinda G. (The University of Queensland)

Introduction: Hospital patients increasingly undertake a complex journey across the hospital continuum,

including pre-admission clinics, the emergency department, acute inpatient care, post-acute care and

community outreach programs. Clinical information that underpins assessment and care planning varies

among and within hospitals. This results in poor item reliability, large data burden, poor compliance,

interrupted information flow across the continuum, and little likelihood of computerisation and use of

data for real-time or post-hoc analytics.

Approach: Since 2009, our team, led by Professor Len Gray, has undertaken a major international effort

to create a complete set of integrated assessment tools designed to overcome these problems. This

effort has been supported by the interRAI international research collaborative. System design is guided

by a series of principles:

Clinical systems are designed for day to day clinical use by clinicians, but with a view to

secondary application for administrative functions.

Data should be collected once, and used for multiple clinical and administrative functions

(including diagnostic and risk screeners, scales to measure and monitor problem severity,

prompts for care planning, quality indicators and casemix tools).

157

Clinical observations must be extensively tested for face validity, inter-rater reliability and

consistency across cultural groups and clinical settings.

Released at an international launch in Brisbane in 2017, the interRAI Acute Care forms the centre-piece

of the interRAI Hospital Systems, which also includes specialist systems for older patients in the

emergency department, geriatric units and geriatric consultation services and post-acute care and

rehabilitation. Systems for pre-admission clinic and hospital outreach services will soon be released.

These systems share a common set of clinical observations and scalar measures, facilitating

communication and transfer of information across the continuum, and enabling monitoring of progress

from “pre-morbid” status to post-acute community settings.

Conclusions: The interRAI hospital systems provide, for the first time, an integrated approach to

assessment and data acquisition across the entire hospital continuum. The impending availability of big

data, particularly if linked to other systems (SnowMed CT; ICD; DRG), will provide an opportunity to

improve the performance of clinical decision support tools, predictive models, quality indicators and

casemix systems.

158

SYMPOSIUM 14: USING INTERRAI TO SUPPORT CARE PLANNING IN

MENTAL HEALTH CARE

Chair(s): Chantal Van Audenhove

The interRAI suite of instruments evaluates care needs of vulnerable persons in health care and welfare

services in a consistent and standardized way. More specifically, interRAI instruments mainly assess

caregivers’ perspectives on the symptoms, needs, and preferences of care users. The output of the

instruments can be used to support both care planning at the level of caregivers and care users as well

as quality management at the level of services, networks and governments. In this way, the interRAI

consortium wants to promote evidence-informed clinical practice and policy decision-making. It is vital

that the interRAI output supports the development and evaluation of the care user’s care plan. Therefore,

studies on the usability of interRAI instruments for care planning are an essential part of the

implementation process of the instruments in daily practice.

In this symposium, we discuss how interRAI output can be used to support care planning in mental

health care. We will also focus on specific target groups within mental health care, namely forensic

patients and care users with an intellectual disability.

Questions that will be discussed are:

How can the combination of the interRAI instruments and an instrument for therapeutic security

triage support care planning in forensic mental health care?

How does the interRAI ID instrument support life planning for care users with an intellectual

disability?

How did the interactive process between researchers and caregivers enhance the quality of the

BelRAI education program on the use of interRAI to support care planning in mental health

care?

During this symposium, the audience will gain ideas about underpinning care plans by the combination

of (1) expertise from the care user and his context, (2) expertise from the caregivers and (3) evidence-

based input from interRAI.

Keywords: Life planning, care planning, training

Symposium presentation 1: Combining BelRAI and DUNDRUM to support care planning in

Flemish forensic mental health care

Habets, Petra (Knowledge Centre Forensic Psychiatric Care (KeFor), Public Psychiatric Hospital

Rekem, Belgium); Jeandarme, Inge (Knowledge Centre Forensic Psychiatric Care (KeFor), Public

Psychiatric Hospital Rekem, Belgium); Van Horebeek, Hanne (LUCAS KU Leuven - Centre for Care

Research and Consultancy, Belgium); De Cuyper, Kathleen (LUCAS KU Leuven - Centre for Care

Research and Consultancy, Belgium); Hermans, Kirsten (LUCAS KU Leuven - Centre for Care

Research and Consultancy, Belgium); Declercq, Anja (LUCAS KU Leuven - Centre for Care Research

and Consultancy, Belgium); Van Audenhove, Chantal (LUCAS KU Leuven - Centre for Care Research

and Consultancy, Belgium)

Background: The forensic field has seen many changes in Flanders (Belgium) recently. New high

security facilities were opened, together with a long stay facility and new wards for forensic patients

with an intellectual disability. However, forensic patients are not easily being transferred to a facility

with a lower security level or to regular mental health care (MHC). Moreover, facilities and disciplines

159

use different terminologies to indicate the same security and care needs. Therefore, collaborations

between caregivers in order to give the most efficient and humane treatment is not always warranted.

This leads to a lower continuity and quality of care. In 2018, the Belgian federal and regional

governments confirmed their commitment to the national implementation of the BelRAI assessment

system. This assessment system consists of instruments for use in all sectors of well-being and health,

including forensic MHC. However, this system only assesses care needs, while security needs are

equally important to measure in order to support care planning in forensic MHC.

Aims: The aim of this study is to identify an instrument to support decision-making with regard to the

therapeutic security triage. The Flemish government intends to ask caregivers to use this instrument in

the future, in combination with the interRAI (Community) Mental Health instruments and the forensic

supplement, in order to support care planning in forensic MHC.

Method: The instrument to support therapeutic security triage was identified based on a literature study

of comprehensive assessment systems that have been studied in forensic MHC since 2000. The results

of the literature study were discussed with the federal and Flemish government.

Results: The results from the literature study showed that the DUNDRUM-toolkit was the most

empirically validated of the available instruments. The DUNDRUM-toolkit that was recently translated

into Dutch. Ideas on how the DUNDRUM-toolkit combined with the interRAI instruments can support

care planning in Flemish forensic settings - including the transfer between security levels - will be

discussed.

Conclusion: The combination of the interRAI (Community) Mental Health instruments, the Forensic

Supplement and the DUNDRUM-toolkit presents possibilities to support coordination and continuity

of care in forensic MHC.

Symposium presentation 2: From care planning to life planning: Using the interRAI ID to support

achievement of personal goals

Martin, Lynn (Department of Health Sciences, Lakehead University, Canada)

For the last several decades, person-centered approaches and practices have become foundational in

health and social services. In particular, significant gains have been made in the field of intellectual and

developmental disability (IDD) services: the planning of supports and services has gone from being

done for individuals, to being done with individuals. In some jurisdictions, the term “person-directed

planning” has been introduced to further empower individuals to drive the planning process – planning

is done by the individual, with the support of others. This is especially important, given that adults with

intellectual disability disorder (IDD) often have a support plan not for services during a particular period

of time (e.g., post surgery or hospitalization), but rather for supports that will help them in their daily

lives to achieve their goals. As such, in the field of IDD, the focus is on life planning.

This presentation focuses on use of the interRAI item related to “Personal goals” as the basis of planning

conversations and any resulting support plans. In doing this, the person’s goals remain the focus, and

provide the context in which areas of need identified by the interRAI assessment should be framed or

addressed. The presentation will provide a concrete example of how interRAI scale scores, triggered

Collaborative Action Plans (CAPs), and other items can be used to support planning that is focused on

achievement of individual goals.

160

Symposium presentation 3: Flemish training program on the use of BelRAI to support care

planning in mental health care

Nelis, Sabine (Thomas More, University of Applied Sciences, Belgium); Dejonghe, Caroline (Thomas

More, University of Applied Sciences, Belgium); Van Horebeek, Hanne (LUCAS KU Leuven - Centre

for Care Research and Consultancy, Belgium); De Cuyper, Kathleen (LUCAS KU Leuven - Centre for

Care Research and Consultancy, Belgium); Hermans, Kirsten (LUCAS KU Leuven - Centre for Care

Research and Consultancy, Belgium); Declercq, Anja (LUCAS KU Leuven - Centre for Care Research

and Consultancy, Belgium); Van Audenhove, Chantal (LUCAS KU Leuven - Centre for Care Research

and Consultancy, Belgium)

Background: In 2018, the Belgian federal and regional governments confirmed their commitment to the

national implementation of the BelRAI assessment system. ‘BelRAI’ is the Belgian version of the

internationally validated interRAI suite of instruments. BelRAI output supports both care planning at

the level of care users and caregivers as well as quality management at the level of services, networks,

and governments. In the sector of mental health care (MHC) in Flanders (Belgium), the evaluation and

implementation of BelRAI is only in its starting phase. Part of the first phase of the research and

implementation process is the training of caregivers to use BelRAI to support care planning.

Aims: To describe the development and evaluation of an education program on the BelRAI

(Community) Mental Health instruments.

Method: As part of a large-scale usability study in MHC in Flanders (Belgium), researchers developed

a 2,5 day education program for caregivers to learn to use BelRAI in order to support care planning.

The program consists of 1,5 days of education and two half days of group supervision. This education

program is partly based on the federal train-the-trainer BelRAI education program.

Results: One hundred ten caregivers from MHC were trained during eight cycles of the BelRAI MHC

education program. The supervision sessions resulted in useful input from the caregivers that lifted the

BelRAI MHC training to a higher level. Insights in, and critical comments on how caregivers are trained

to use BelRAI to support care planning will be discussed.

Conclusion: Delivering the BelRAI MHC training program resulted in an interactive process between

researchers and caregivers that enhanced the quality of the education program.

161

SYMPOSIUM 15: THE INTERRAI MENTAL HEALTH AND ADDICTIONS SUITE

OF INSTRUMENT: FROM RESEARCH TO “REAL WORLD” USE


interRAI instruments comprise an integrated assessment and screening system spanning all age groups

across care settings. Symposium participants will learn about the research underlying these instruments

and the experience of a Canadian health region regarding implementation issues and practical benefits

for mental health stakeholders.

Overview of development of interRAI mental health and addictions suite – John P. Hirdes, PhD FCAHS

(Chair), University of Waterloo, CANADA – an introductory overview of the full suite of interRAI

mental health and addictions instruments. This will include a discussion of the development process to

create these instruments and evidence about their psychometric properties.

interRAI Addictions Supplement for Inpatient and Community Mental Health – Chris Perlman, PhD,

University of Waterloo, CANADA – Over 135,000 inpatient and community assessments provide

evidence for use of interRAI systems to address addictions issues among mental health service users

(e.g., patterns of substance use, health and social outcomes, care planning needs). Detailed results will

also be reported from the interRAI Addictions Supplement pilot with over 500 clients.

Mental health and addictions issues among children/youth in diverse care settings – Shannon Stewart,

PhD, Western University, CANADA – Over 95,000 interRAI Child/Youth Mental Health assessments

illustrate the needs and experiences of children/youth in three major settings: residential mental health

services, community mental health programs, and youth justice facilities. Needs are substantial across

settings, but are particularly pronounced in youth justice where mental health services are relatively

limited.

Use of interRAI Brief Mental Health Screener by Police Services – Ron Hoffman, PhD, Nipissing

University, CANADA – Over 72,000 interRAI BMHS screeners completed by police officers illustrate

the clinical issues addressed by police as well as the decision support tools they may use to determine

need for emergency hospital services or diversion to community mental health services.

interRAI Mental Health and Addictions Suite in the “Real World” – Paula Reaume-Zimmer, Bluewater

Health, CANADA – The practical experiences of two mental health services in Ontario, Canada will

be used to illustrate the factors to consider when implementing the full suite of interRAI instruments as

well as the benefits to individuals, families and the health system.

Keywords: Mental health and addictions, implementation, continuum of care

Symposium presentation 1: Use of interRAI Brief Mental Health Screener by Police Services

Hoffman, Ron (Nipissing University)

Over 72,000 interRAI BMHS screeners completed by police officers illustrate the clinical issues

addressed by police as well as the decision support tools they may use to determine need for emergency

hospital services or diversion to community mental health services.

162

Symposium presentation 2: interRAI Addictions Supplement for Inpatient and Community

Mental Health

Perlman, Chris (University of Waterloo)

Over 135,000 inpatient and community assessments provide evidence for use of interRAI systems to

address addictions issues among mental health service users (e.g., patterns of substance use, health and

social outcomes, care planning needs). Detailed results will also be reported from the interRAI

Addictions Supplement pilot with over 500 clients.

Symposium presentation 3: Mental health and addictions issues among children/youth in diverse

care settings

Stewart, Shannon (Western University)

Over 95,000 interRAI Child/Youth Mental Health assessments illustrate the needs and experiences of

children/youth in three major settings: residential mental health services, community mental health

programs, and youth justice facilities. Needs are substantial across settings, but are particularly

pronounced in youth justice where mental health services are relatively limited.

Symposium presentation 4: interRAI Mental Health and Addictions Suite in the “Real World”

Reaume-Zimmer, Paula (Bluewater Health)

The practical experiences of two mental health services in Ontario, Canada will be used to illustrate the

factors to consider when implementing the full suite of interRAI instruments as well as the benefits to

individuals, families and the health system.

163

SYMPOSIUM 16: USING BELRAI IN FLANDERS: EXPERIENCES FROM HOME

CARE

Chair(s): Ann Baeyens

During this symposium, the presenters show their experiences with different BelRAI instruments in

home care. They demonstrate pros and cons from different projects in practice and from three angels.

Keywords: Home care, BelRAI screener, primary care

Symposium presentation 1: Plus value of Belrai for the operation of Social Work Services and

Home Care Services

Baeyens, Ann (CM Landsbond, Belgium)

The Social Work Services of the Flemish mutualities and the Home Care services have been involved

in implementation and research projects on different parts of the BelRAI Suite for several years. Belrai-

Home Care has been tested in several regions. A Belrai-screener was developed and is being used for

allocating the Care Budget. A need for a specific module for children, along with a module to assess

contextual elements was shown. In our role as non-(para)medical actors in care, we discuss the plus

values of BelRAI for our clients and our daily practice. This is a story about multi-disciplinarity, sharing

data and communicating in a care and support team, and about the value of social work in working with

BelRAI.

Symposium presentation 2: Why does home care need a ‘social module’?

Brusselaers, Walter (Familiehulp, Belgium)

In order to conceptualise the need for care, physical, psychological and emotional characteristics of the

person have to be taken into account. These characteristics are measured by means of the BelRAI Home

Care instrument, and also partly by the BelRAI Screener. Demographic and socio-economical aspects

however also matter. Since Home Care Services often are the first access point to formal care, these

services need to be able to detect and measure care needs, determine which and what amount of support

the person needs and gets at the time of assessment, and asses whether the person is satisfied with this

help. Social Care Services also have a need for more items than currently included in the BelRAI

instruments in order to help people clarify their demand for help. A social module can be the solution

to this problem. The Home Care Services report on the importance of such a module for practice, and

demonstrate the current state of affairs.

Symposium presentation 3: Digitalising primary care: motivation and ambition

Brusselaers, Walter (Familiehulp, Belgium)

Putting the client first is a mission shared by all active in primary care. However, realising this mission

in daily practice is a challenge: introducing a uniform assessment instrument and a digital care and

support plan, high quality training for assessors and making data sharing between actors possible are

necessary. The digitalisation of primary care is happening fast in Flanders. From 2021 on, the BelRAI

Screener will have replaced the BEL Profile Scale. In 2022, the BelRAI Home Care instrument and the

social module follow. The Home Care Services and the assesors for allocating the Care Budget are first

164

in experiencing this transformation. Other actors follow at a later point in time. A precondition is the

development of a Flemish IT platform on which the BelRAI instruments are available and with which

data sharing in line with the General Data Protection Regulations is possible. The digital care and

support plan must allow for formulating care goals. Last, but not least, the assessors and caregivers need

to receive high quality training. In short, a challenging transition is about to happen.

165

Poster presentations POSTER SESSION 1

Quality of life of Family Caregivers in Poland

Ilona Barańska, Violetta Kijowska, Katarzyna Szczerbińska

Unit for Research on Aging Society, Department of Sociology of Medicine, Chair of Epidemiology

and Preventive Medicine, Jagiellonian University Medical College, Kraków, Poland

Abstract summary: The promising results of study conducted in a sample of 157 caregivers of community-

dwelling older people (60+) enrolled in 2017 from the registry of the Municipal Social Care in Krakow using a

prototype of the InterRAI Caregiver’s Quality of Life questionnaire. Good base to develop a Caregiver’s Quality

of Life scale.

Keywords: quality of life, caregivers, older people

Introduction. The study has been conducted in a sample of 157 caregivers of community-dwelling older

people (60+) enrolled from the registry of the Municipal Social Care in Krakow.

Materials and methods. Data were collected in 2017 by social workers employed in that Centre, using

InterRAI Caregiver’s Quality of Life tool questionnaire. The median age of caregivers was 57; 72.0%

of them were women, 57.0% were married or in partnership, 68% were child or child in law; 63.7%

lived with them together, and 53.5% took care of recipient for more than 35 hours per week. They cared

for older adults at median age 83, mostly women.

Results. Most of caregivers had good IADL performance, but 39.5% reported they were exhausted so

couldn’t carry out activities, 23.6% had unsteady gait when walking, 26.0% reported major stress in

last 90 days, 64.1% sleep disorders, 37.0% acute health problems, 43.0% conditions making their

physical and psychological functioning unstable. Overall, 56.1% assessed their health as fair or poor.

In ca. 40% of respondents caregiving challenged them putting major stress, financial difficulties, and

other care responsibilities, lack of time for enjoyable activities, education or work, and insufficient

family support.They called most often for episodic relief from caregiving (42%), transportation

assistance (22.1%), and financial and legal advice (18.5%). Many of caregivers felt trapped: 59.2%

could not go where they wanted, 34.0% could not be alone when wished, without hope for future

(20.4%), neither sense of pride (19.8%), nor feeling their relationship improved (25.0%), and no

understanding by healthcare professional (27.4%).

Conclusion. The caregivers reported challenges of caregiving, needs for support and low quality of life.

The preliminary results of the study are promising providing a data to develop a Caregiver’s Quality of

Life scale.

166

The RAI-HC Switzerland : from individualized data analysis to aggregate analysis. Experience

of the Geneva home care institution

Catherine Busnel, Fanny Vallet, Christina Gueinchault

institution genevoise de maintien à domicile, Switzerland

Abstract summary: Based on a large volume of RAI-HC Switzerland collected each year (more than 15,000

RAI-HC) The Geneva home care institution (imad) carried out a descriptive analysis relating to the last half of

2018 on a sample of 5531 patients. The RAI-HC provides interesting individual and collective clinical indicators.

Keywords: assesment, home care, analysis

Aging populations associated with the increasing prevalence of chronic diseases and co-morbidities

tend to make it more difficult for patients to receive home care. To best respond to this evolution, Swiss

aid and care institutions rely on the global assessment of the health needs of the population receiving

care through the Swiss Resident Assesment Instrument Home Care (RAI-HC). The Geneva home care

institution (imad) has chosen to train its 650 referent nurses in its routine use as well as in the

establishment of an individualized and targeted intervention plan based on the results of the RAI HC.

Based on a large volume of RAI-HC Switzerland collected each year (more than 15,000 RAI-HC) imad

carried out a descriptive analysis relating to the last half of 2018 on a sample of 5531 patients. The data

obtained make it possible to indicate the frequency of deficits in health areas such as 62.7% for pain

alarms, 56.8% for falls alarms and 44% for alarms on the fragility of family carers. These analyses,

supplemented by socio-demographic details provided on this population, make it possible to specify the

population followed for care and to determine priority areas for clinical development. These results are

presented annually to the 40 home support teams in order to also increase the quality of assessment and

individualized care data. All the results obtained are important for several reasons: 1) by establishing

the frequency of deficits in the health domains investigated, 2) in knowing the profiles of beneficiaries

of home-based care and 3) in developing preventive action and health promotion. The RAI-HC provides

interesting individual and collective clinical indicators.

167

Research on mood state and its influential factors among community elderly derived from

interRAI home care (HC) Assessment

Yifan Cao, Lingshan Wan, Jia Xue, Hansheng(Corresponding Author) Ding

Shanghai Health Development Research Center (Shanghai Medical Information Center), People's

Republic of China

Abstract summary: This 2-year cohort study aims to investigate the mood state and its influential factors by

sampling 4,855 community elderly over 60 years old in shanghai.Variables derived from interRAI HC Assessment

were applied to do analysis. The mood states of elderly is affected by their frequency of outgoing and self-reported

health.

Keywords: mood state, influence factors, interRAI

Objective: Apart from physical health, mental health is also a cornerstone to providing quality care to

the elderly. The purpose of the study was to explore the mood state and influencing factors of the elderly

in community, in order to improve the physical and mental health of the elderly and better satisfy the

psychological needs of the elderly that might be overlooked.

Methods: A 2-year cohort study, cluster sampling method was used to sample 4,855 elderly people,

who were over 60 years old and participated in the study for 2 consecutive years, living in one certain

community of Shanghai Jing’an District. The level of Self-reported mood (Question of Section E. 2a)

were applied as dependent variable, other related possible influence factors (e.g identification

information, activity level, transportation, self-reported health) in the HC assessment form were

selected as independent variable, using SAS statistical software to do a chi-square test and Logistic

regression analysis.

Results: After removing the missing value, a total of 4,303 individuals were obtained. Among them,

56% of the elderly reported they become less interest or pleasure in things they normally enjoy. The

frequency of outgoing and self-reported health had a significant effect on mood states of the elderly.

The more frequent elderly went out, the more likely they were able to maintain their mood states. As

well as those elderly who self-reported a better health condition.

Conclusion: The findings show the mood states of elderly is affected by their frequency of outgoing

and self-reported health. Indicate we should pay more attention to the mood states of these elderly with

lower outgoing frequency and the poor self-reported health. In addition, carry out more mental health

related care services to encourage them to attend outdoor activities and maintain an optimistic mind.

168

InterRAI-ID in adults with Down syndrome: global functioning measures

Angelo Carfi', Emanuele Rocco Villani, Graziano Onder, Roberto Bernabei

Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Italy

Abstract summary: Adults with Down syndrome (DS) age prematurely and share many similarities with the

older population. In the present study we describe the global functioning phenotype of a population of 200 adult

subjects with DS assessed multidimensionally with the InterRAI-ID instrument at our institution, and discuss its

possible determinants.

Keywords: intellectual disability, Down syndrome, functioning phenotype

Backround: Down syndrome (DS) is characterized by premature aging and adults with this condition

present patterns of comorbidities and deficits often observed in the older population. Geriatric

conditions, cognitive deficits, disability, symptoms of withdrawal or anhedonia, aggressive behavior

and communication problems are common. Cognitive assessments are given much attention in this

population, on the contrary, global functioning measures are often overlooked. Aim of the present study

is to describe the global functional phenotype, and its determinants, in a population of adult subjects

with DS.

Methods: Adults with DS were assessed in the geriatric day hospital of our institution with the

multidimensional evaluation tool InterRAI-ID. Global functioning scales available within the InterRAI-

ID instrument were calculated and included: functional hierarchy (FUNh), cognitive performance scale

(CPS), depression rating scale (DRS), aggressive behavior scale (ABS), communication scale

(COMM), social withdrawal scale (ANHED).

Results: We present data from 220 individuals (37.0±12.4 years of age, 97 (44.1%) females). 90(40.9%)

individuals were older than 40 years. Global functioning measured with FUNh scale resulted in 52.2%

of subjects with mild to moderate impairment in instrumental activities, 37.2% transitioning between

instrumental and self-care impairment, 10.6% with important self-care deficits. In multivariate analysis,

CPS and age showed the strongest association with FUNh (b=0.20, p<0.001), while in the group of

individuals with mild to moderate cognitive impairment also COMM showed significant association.

Conclusions: Adults with DS display a highly variable global functioning phenotype that is largely

influenced by cognitive impairment. In those with a better preserved cognition, communication skills

could significantly impact global functioning and could represent an important area of intervention.

169

Predictors of Quality of Life in Children and Adolescents receiving Mental Health Services

Angela Celebre1, Shannon Stewart1, Laura Theall2, Natalia Lapshina1

1Western University, London ON, Canada; 2Child and Parent Resource Institute, London ON,

Canada

Abstract summary: Quality of life (QoL) is significantly reduced in children and youth with mental health

problems. This study examined the association between mental state indicators (e.g., depressive and anxiety

symptoms) and QoL in this vulnerable population. Certain mental state indicators differentially predicted QoL at

both the overall and sub-domain level.

Keywords: children and youth, quality of life, mental state indicators

Children with mental health problems have a significantly worse quality of life (QoL) in comparison to

typically developing children, or those with physical health conditions. However, research identifying

factors associated with QoL in this vulnerable population is quite scarce. To address this gap in the

literature, 347 clinically referred children and youth (ages 7-18 years old) were assessed using the

interRAI Child and Youth Mental Health Assessment (ChYMH) and Self-report Quality of Life- Child

and Youth Mental Health (SQoL-ChYMH). Hierarchical multiple linear regression analyses revealed

that after controlling for age, gender, and patient status, children and adolescents with higher depressive

symptoms reported lower overall QoL. At the sub-domain level, higher depressive symptoms was

associated with lower basic needs and individual QoL; furthermore, higher anhedonia and depressive

symptoms were associated with lower social QoL. In contrast, no mental state indicators were

associated with QoL pertaining to services (i.e. school and treatment). Due to the paucity of research

examining predictors of quality of life in children and youth with mental health challenges, this study

will contribute to the field in assisting service providers and further providing implications for practice.

170

The sense or nonsense of geriatric screening at the emergency department: accuracy of three

screening tools

Pieter Heeren1,2,3, Els Devriendt1,2, Nathalie IH Wellens1,4, Mieke Deschodt1,5, Johan Flamaing1,2,

Marc Sabbe1,2, Koen Milisen1,2

1KU Leuven, Belgium; 2University Hospitals Leuven, Belgium; 3Research Foundation Flanders,

Belgium; 4Direction Générale de la Santé Canton Vaud, Switzerland; 5University of Basel,

Switzerland

Abstract summary: Accurate identification of older adults who can benefit from geriatric interventions during

emergency department stay is controversial. The interRAI Emergency Department Screener© (iEDS) is a

relatively new screening tool for this purpose. This study compared its accuracy for predicting hospitalisation and

unplanned readmission to those of two other tools.

Keywords: acute care, emergency department, geriatric screening

Introduction: We aimed to compare the diagnostic accuracies of the Identification of Seniors At Risk

(ISAR), the Flemish version of Triage Risk Screening Tool (fTRST), and the interRAI Emergency

Department Screener© (iEDS) for predicting hospitalisation and unplanned emergency department

(ED) readmission at 30 and 90 days post discharge among older (≥ 70 years) community dwelling adults

admitted to the ED.

Methods: The ‘usual care’ cohort of a prospective, monocentric, quasi-experimental study, ‘Unplanned

Readmission prevention by Geriatric Emergency Network for Transitional care’ (URGENT), was

analysed (n=794 with median age 80 years and 55% female) [1, 2].

Sensitivity, specificity, accuracy and area under the receiver operating characteristics curves (AUC)

were categorized as low (≤0,69), moderate (0,70-0,89) or high (≥0,90).

Results: For the prediction of hospitalisation, occurring in 67% of patients, all screening tools (at cut-

off 2) had moderate to high sensitivity (ISAR: 0.90; fTRST: 0.76; iEDS: 0.80) combined with very low

specificity (0.22-0.32), low accuracy (0.61-0.67) and low AUC (0.56-0.62).

For the prediction of readmission at 30 and 90 days post discharge, occurring in 12% and 22% of

patients respectively, all screening tools (at cut-off 2) had moderate sensitivity (ISAR: 0.84-0.86;

fTRST: 0.71-0.75; iEDS: 0.82-0.84) combined with very low specificity (0.14-0.27), very low accuracy

(0.22-0.39) and low AUC (0.49-0.53).

Key conclusions: None of the screening tools accurately predicted the outcomes, when used as stand-

alone index. Older adults who can benefit from additional geriatric interventions should rather be

identified with ED-specific minimum geriatric assessment strategies instead of score-based screening

tools.

References:

[1] Devriendt E., Heeren P., Fieuws S., Wellens N., Deschodt M., Flamaing J., Sabbe M., Milisen K. (2018).

Unplanned Readmission prevention by Geriatric Emergency Network for Transitional care (URGENT): protocol

of a prospective single centre quasi-experimental study. BMC Geriatrics 18:244. DOI:s12877-018-0933-x.

[2] Heeren P., Devriendt E., Fieuws S., Wellens N., Deschodt M., Flamaing J., Sabbe M., Milisen K. (2019).

Unplanned Readmission prevention by Geriatric Emergency Network for Transitional care (URGENT): a

prospective before-after study. BMC Geriatrics 19:215. DOI:10.1186/s12877-019-1233-9.

171

Enhancing facility staff skills in use of RAI – Development of a First-line Management Tool

Suvi Anita Kuha1, Katriina Niemelä2, Pia Vähäkangas3, Anja Noro4, Outi Kanste1

1University of Oulu, Finland; 2Coronaria Hoiva Oy, Finland; 3Gerofuture Oy, Finland; 4National

Institute for Health and Welfare (THL), Finland

Abstract summary: First-line manager has an important role in ensuring staff skills in assessment and use of

data provided by RAI system. The aim of the study is to research first-line managers’ ability to assess employees

skills in the use of RAI data in long-term care facilities in Finland.

Keywords: RAI, first-line manager, care plan

Background: Resident Assessment Instrument (RAI) is widely used in Finland in elderly care services.

RAI provides a structured, standardised approach to care planning. RAI helps nurses to gather

information on a person’s functional ability. First-line manager has an important part ensuring staff

skills both in assessment and use of data provided by RAI system. Earlier studies have not shed light

on the issue, how properly first-line managers assess their facilitys staff’s skills using RAI.

Objectives: This study discusses first-line managers’ ability to assess their staffs skills in the use of RAI

data in long-term care facilities.

Material: Data derived for this quantitative, cross-sectional study is based on a questionnaire sent to the

first-line managers (n=19) working in a private long-term care facility in Finland in autumn 2019 and

on the facilitys's residents' care plans (n=95) obtained at the same time. The questionnaire was derived

from the First-line Management Tool developed earlier (Niemelä et al 2018). Approval from the unit

managers was obtained for the study.

Methods: The Management Tool assists the facility to achieve the highest level of RAI utilization. It

guides the manager by classifying RAI skills in four categories: (1) expertise in RAI implementation in

general, (2) expertise in RAI assessment, (3) expertise in care planning and (4) expertise in monitoring

RAI quality outcomes. Data for this study is derived from the category of care planning variables. The

results of the questionnaire are presented by mean scores and confidence intervals (95%). The care

plans (n=95) are analysed using deductive content analysis. Information obtained from the

questionnaire and results obtained from the content analysis will be compared in the third phase of the

study.

Results: Results will be available at the beginning of 2020. We believe that the information could be

useful in both managing implementation of RAI and developing training interventions for ude of RAI.

In addition, information is useful in developing knowledge-based management of facility level and

ensuring quality of care plans. Results will be published as an article in an international scientific

journal.

172

Integrating Service Resources through Implementing InterRAI-LTCF Assessment

Jin Liang

Kunming elderly rehabilitation service center, People's Republic of China

Abstract summary: To provide whole-person care for the disabled and mentally retarded elderly by using

interRAI-LTCF assessment and integrating front-line service teams such as doctors, nurses, rehabilitation,

therapists and caregivers with limited resources.

Keywords: limited resources, caregivers, care

Ours is a privately funded residential care facility for the physically or intellectually impaired old

persons in the city of Kunming, Yunnan Province. Like many facilities of the same kind in China, we

are facing the challenges of lack of an adequately trained workforce and being excluded from the public

financial support. In order to provide good care to the old persons in our facility, we made an effort to

employ interRAI-LTCF assessment in the operation of care provision in the passed year. Our workforce

benefited through learning the RAI language, unifying the terminology, and following the same

standards. Better case management and coordinated teamwork were facilitated under the guidance of

assessments. Senses and skills of risk prevention were developed among care providers and managers

to ensure quality of care provided. More importantly, we built a detailed and workable procedure that

guided, step by step, the frontline caregivers to carried out the care plans generated from the LTCF

assessments. As a result, the quality of services were standardized as well as ensured, and we as an

institution, gained reputation from the local community for good service provision. This initial

experience of implementing LTCF assessment left much confidence among us in providing quality care

for the residents with limited resources in the foreseeable future.

173

Could having an intellectual and developmental disability be an independent risk factor for

polypharmacy?

Frishta Nafeh1, Amy Choi1, Hélène Ouellette-Kuntz1, Lynn Martin2

1Queen's University, Canada; 2Lakehead University, Canada

Abstract summary: Higher prevalence of polypharmacy is reported for adults with IDD, though studies do not

control for known covariates. We examined whether IDD is an independent risk factor for polypharmacy in a

home care sample. Multimorbidity and cognitive impairment may be more important risk factors for

polypharmacy than presence of IDD.

Keywords: intellectual disability, multimorbidity, polypharmacy

Background: Adults with intellectual and developmental disabilities (IDD) have high burden of

multimorbidity, defined as two or more physical or medical conditions. As such, they often use multiple

medications concurrently – commonly referred to as polypharmacy. While prevalence of polypharmacy

is reported as being higher among adults with IDD than in the general population, most studies have

not considered the impact of factors that could also play a role in polypharmacy (e.g., age, sex, living

arrangement, behaviour, functioning, and health status).

Aim: This study sought to determine whether the presence of IDD is an independent risk factor for

polypharmacy among older adults.

Methods: Data are based on the RAI Home Care assessments of a sample of 93 adults with IDD (40

years) and 142 adults without IDD; where the comparison sample without IDD was restricted based on

age and living arrangements. Multivariate logistic regression was used to assess the relationship

between IDD and polypharmacy while controlling for a number of demographic (age, sex, living

arrangement), functional (level of cognitive impairment), behavioural (any challenging behaviour), and

clinical (Alzheimer/dementia diagnosis, mental health diagnosis, and multimorbidity) factors.

Polypharmacy was defined as taking 5 or more medications concurrently.

Results: The prevalence of polypharmacy was significantly higher among the comparison sample

without IDD (79.5%, versus 53.8%; p<.01). The multivariate logistic regression model revealed that

IDD was associated with lower odds of polypharmacy (OR=0.36; 95% CI 0.14-0.94), as was

Alzheimer/dementia diagnosis (OR=0.31; 95% CI 0.11-0.84); multimorbidity was associated with an

over twofold increase in the odds of polypharmacy (OR=2.14; 95% CI 1.52-3.00) and level of cognitive

impairment with a fivefold increase in those odds (OR=5.02; 95% CI 1.36-18.50).

Conclusion: In the samples assessed for home care, those with IDD tended to be younger, have fewer

physical conditions, and lower odds of polypharmacy compared to the sample without IDD. Additional

research is needed using more representative and larger samples – in home care settings and in the

general community, to more fully understand the relationship between IDD and polypharmacy in the

context of multimorbidity and other important factors.

174

A new algorithm to predict risk of first-time falling among home care clients

Ayse Kuspinar1, John P. Hirdes2, Katherine Berg3, Caitlin McArthur4, John N. Morris5

1School of Rehabilitation Science, McMaster University, Hamilton, ON, Canada; 2School of Public

Health and Health Systems, University of Waterloo, Waterloo, ON, Canada; 3Department of Physical

Therapy and Rehabilitation Sciences Institute, University of Toronto, Toronto, ON, Canada; 4GERAS

Centre for Aging Research, McMaster University, Hamilton, ON, Canada; 5Hebrew Senior Life,

Institute for Aging Research, Boston, MA, USA

Abstract summary: This study developed a new algorithm (1stFall) to predict risk of first time falling in home

care clients who have not fallen in the past 90 days. The 1stFall algorithm demonstrated good predictive validity

and the potential to inform fall risk management and prevention in home care clients.

Keywords: falls, home care, machine learning

Background: Predicting falls in individuals without a prior fall event is critical for primary prevention

of injuries. Identifying and intervening before the first fall could be an effective strategy for reducing

the high personal and economic costs of falls among home-care clients. The purpose of this study was

to derive and validate a prediction algorithm for first-time falls (1stFall) among home care clients who

had not fallen in the past 90 days.

Methods: Decision tree analysis was used to develop a prediction algorithm for the occurrence of a first

fall from a cohort of home care clients who had not fallen in the last 90 days, and who were

prospectively followed over 6 months. Ontario home care clients who were assessed with the Resident

Assessment Instrument-Home Care (RAI-HC) between 2002 and 2014 (n=88,690) were included in the

analysis. The dependent variable was falls in the past 90 days in follow-up assessments. The

independent variables were a range of variables from the RAI-HC. The validity of the 1stFall algorithm

was then tested among home care clients in 4 Canadian provinces: Ontario (n=38,013), Manitoba

(n=2738), Alberta (n=1226) and British Columbia (n=9566).

Results: The 1stFall algorithm identified 6 distinct risk categories for first time fallers from low to high

risk. Fall rates were 5% for individuals in group 1 (low risk) and 34% for individuals in group 6 (high

risk).The variables used to discriminate between fall risk levels included primary mode of locomotion

indoors, unsteady gait, age, sex, Cognitive Performance Scale, Activities of Daily Living Hierarchy,

Pain Scale, and bladder incontinence. In the validation sample, fall rates and odds ratios increased with

risk level in all provinces examined.

Conclusions: To our knowledge, this is the first study to develop an algorithm to predict a first-time fall

event in home-care clients who have not fallen in the past 90 days. The 1stFall algorithm demonstrated

good predictive validity and the potential to inform fall risk management and prevention in home care

clients.

175

Personal, clinical and functional characteristics of patients with multimorbidity receiving home

care referrals in Ontario, Canada

Amanda Mofina1, Joan Tranmer1,2, Jordan Miller1, Catherine Donnelly1

1Queen's University, Canada; 2Institute for Clinical and Evaluative Sciences

Abstract summary: This study uses linked health administrative data to explore the characteristics of individuals

with multimorbidity who are recently discharged from the hospital. Specifically, understanding the clinical profile

of those with multimorbidity who would benefit from rehabilitation therapy could support the therapists’ role

beyond single condition cases and influence referrals.

Keywords: multimorbidity, rehabilitation, home care

Background: Multimorbidity refers to the co-occurrence of two or more chronic conditions, wherein no

one condition is considered the central disease. Individuals with multimorbidity access the health care

system more frequently and are at an increased risk for poor health outcomes, increased emergency

department visits and hospital admissions/readmissions. Occupational therapists (OT) and physical

therapists (PT) are uniquely positioned to provide the necessary supports and skills to address the

complex functional needs of this population. Understanding the characteristics of those who receive or

do not receive OT or PT services can assist in understanding who would most benefit from these

services.

Purpose: The aim of this study is to describe and compare the characteristics of patients with

multimorbidity discharged from acute or inpatient rehabilitation units in Ontario across three groups:

1) patients referred to home care rehabilitation therapy; 2) patients who do not receive rehabilitation

therapy upon referral to home care, and 3) patients who do not receive home care.

Methods: This is a retrospective cohort study that will use linked data from multiple health

administrative data sources (e.g., discharge abstract database, Resident Assessment Instrument-Home

Care dataset, national rehabilitation reporting system) housed within the Institute for Clinical and

Evaluative Sciences (ICES). The cohort will consist of any individual with multimorbidity who was

discharged from an Ontario hospital, acute care or inpatient rehabilitation unit, between the years of

2007 and 2015. Multimorbidity will be defined as having two or more chronic conditions from a list of

18 priority chronic conditions. Measures of function will include items such as activities of daily living,

instrumental activities of daily living, and mobility. Descriptive statistical analysis will be used to

describe and compare personal and clinical characteristics across the three groups.

Anticipated Results: Preliminary data analysis of demographic, clinical and functional characteristics

will be presented.

Significance: The proposed research aims to provide population-level data to support the role of

rehabilitation therapy beyond single condition cases. The results have potential policy and clinical

practice implications with respect to better understanding the clinical profile of those with

multimorbidity who would benefit from rehabilitation therapy and subsequent pathway referrals.

176

Physicians views on the interRAI-HC for home care information exchange

George Heckman1,2, Aein Zarrin1, Amanda Aguilar da Nova1

1University of Waterloo, Canada; 2UW-Schlegel Research Institute for Aging

Abstract summary: This study examines the views, opinions, and recommendations of 10 physicians for

developing a computerized decision support system for information exchange with home care supported by

clinical information collected by the RAI-HC.

Keywords: computerized decision support system, physician, health information exchange

Introduction. Use of a system-wide standardized clinical assessment to facilitate information-sharing is

an essential component of an integrated healthcare system. Use of the Resident Assessment Instrument

for Home Care (interRAI-HC), a standardized clinical assessment and decision support instrument,

results in positive outcomes, such as improved care planning, greater collaboration among providers,

and reduced client morbidity. Thus, the interRAI-HC can be used by primary care physicians to support

clinical decision making, reduce duplicate testing, and improve quality of healthcare delivery overall.

Less understood is how information from the interRAI-HC can be presented to support primary care

practices.

Methods. For this study we conducted semi-structured 20-minute interviews with 10 physicians

practicing in Southern Ontario, Canada. Participants were asked open-ended questions exploring

various topics including what primary care physicians understand of the interRAI-HC.

Results. Most described the interRAI-HC as comprehensive, informative, and underutilized, claiming

that such tools reflect a clients’ condition realistically. However, the physicians also reported concerns

that the interRAI-HC is time consuming to complete and analyze. Additionally, while the majority saw

potential in the interRAI-HC, half questioned its clinical relevance or indicated a need to “hone in” on

clinically relevant aspects of the tool. Various physicians also expressed reservations about interRAI-

HC outcome scales, including the depression, pain, and activities of daily living scales.

Discussion. Usability difficulties, acceptance issues, and failings in interface design unrelated to the

ability of the system to provide clinically relevant information may contribute to poor use of clinical

information generated by the interRAI-HC. Improving education efforts in addition to this will be vital

to increasing information use. Sharing the results of interRAI-HC assessments with primary care

physicians may be well received for improving communication, collaboration, and integration with

home care, but lack of trust and understanding the interRAI-HC will be a roadblock that needs to be

addressed.

177

Trends and Characteristics Associated with Cannabis Use in Inpatient Psychiatry, 2007 to 2017

Chris Perlman1, Mark Ferro1, David Hammond1, Shannon Stewart2, Nawaf Madi3, Amy Porath4

1University of Waterloo; 2Western University; 3Canadian Institute for Health Information; 4Canadian

Centre on Substance Use and Addiction

Abstract summary: Using a retrospective cross-sectional design, we examined RAI-MH data for 139, 005

persons in inpatient psychiatry in Ontario, Canada. Prevalence of cannabis use increased between 2007 and 2017

across all ages, genders, and diagnostic groups.

Keywords: cannabis, substance use, psychiatry

The liberalization of cannabis policies has been occurring for some time in Canada. There are concerns,

and some optimism, that legal frameworks may create safer public policies in light of the complex

relationship between cannabis and mental illness. To understand these complexities at a population

level we examined trends in cannabis use among persons admitted to inpatient psychiatry in Ontario,

Canada between 2007 and 2017.

Using a retrospective cross-sectional design, we examined RAI-MH data on 139, 005 persons,

representing all index admissions to inpatient psychiatry in Ontario. We report on patterns of cannabis

use in the 30 days prior to admission and DSM IV/V cannabis use disorders by age, gender, and DSM

IV/V diagnoses, by year.

Prevalence of cannabis use increased between 2007 and 2017 across all ages, genders, and diagnostic

groups. For instance, the prevalence among males was 20% in 2007 and 31% in 2017, 27% in 2007 and

48% in 2017 among those age 18-24, and 15% in 2007 to 30% in 2017 among those with schizophrenia.

In addition to numerous demographic and clinical factors associated with cannabis use, multivariate

logistic regression (c=0.86) identified several significant interactions: substance use disorders by age;

schizophrenia by sex; schizophrenia by first-episode status; and age by year interactions.

While the nature of cannabis use, medicinal vs. recreation, was unknown the trends related to age and

schizophrenia are particularly concerning. This analysis has implications for the monitoring and

evaluation of impending recreational cannabis policy-reform on cannabis use in individuals in inpatient

psychiatry.

178

Factors associated with discharge from an in-hospital geriatric rehabilitation ward to the

community within 30 days of admission

Konstantin Shcherbak, Rakel Valdimarsdottir, Helga Atladottir, Palmi V. Jonsson

Landspitali - The National University Hospital of Iceland, Reykjavik

Abstract summary: Understanding predictors of successful geriatric rehabilitation is needed for effective patient

selection. Factors that independently associated with discharge were IADL capacity and ADL scores, sex, distance

walked in the last 3 days, diagnoses of non-Alzheimer’s dementia, cancer or exacerbation of heart failure, severe

pain, medication count and need for isolation.

Keywords: geriatrics, rehabilitation, discharge

Background: There is a high demand for in-hospital geriatric rehabilitation in Iceland. Better

understanding of predictors of successful rehabilitation is needed for effective patient selection.

Methods: interRAI Post-Acute Care (PAC) data collected over 3 years at a geriatric rehabilitation ward

was analyzed using logistic regression. Most patients referred to the facility from an acute care hospital

were motivated for a short-term comprehensive geriatric assessment (CGA), treatment and

rehabilitation, but were unable to be discharged home directly. The main outcome measure was

discharge to the community within 30 days of admission compared with longer rehabilitation, re-

hospitalization, nursing home transfer or death.

Results: Data from 562 patients’ first admissions was analyzed. The mean age was 83.6 years and 60.1%

were female. Successful study outcome was registered in 372 patients. Factors that were independently

associated with discharge to the community in multivariate analysis were lower IADL capacity score

and lower ADL short scale score (zero indicates best scores), female sex, farthest distance walked in

the last 3 days, absence of diagnoses of non-Alzheimer’s dementia, cancer or exacerbation of heart

failure, absence of severe pain, fewer medications and no requirement for isolation in the first 3 days.

This model did not explain all existing variability in outcome (pseudo R2=13.3%). Interestingly, many

of highly subjective measures were significantly associated with discharge in univariate analysis, such

as believe of a person (OR=2.64 [95% CI 1.31-5.33]) or healthcare provider (OR=3.38 [95% CI 1.50-

9.77]) that he/she is capable of improved physical function, having a support person who is positive

towards discharge (OR=1.78 [95% CI 1.07-2.96]) or longer projected time to discharge (OR=0.38 [95%

CI 0.20-0.77). Many of the traditional predictors of rehabilitation were not significantly associated with

the outcome, such as pre-morbid IADL/ADL, prior living arrangement, delirium, depression or level of

cognitive dysfunction.

Conclusion: interRAI-PAC data allows analysis of factors that might predict outcome of CGA and

rehabilitation and more efficient selection of patients admitted to post-acute care. Pre-selection of

motivated patients without terminal illnesses and local discharge practices might bias generalizability

of the results.

179

Nutrition-Related Issues Are Prevalent Among Palliative Home Care Clients in Ontario,

Regardless of Diagnosis

Tara Lindsay Stevens1, Guthrie Dawn1, Heather Keller2

1Wilfrid Laurier University, Canada; 2University of Waterloo, Canada

Abstract summary: Palliative approaches to nutrition care at the end of life are essential in the prevention of

suffering and the enhancement of quality of life for persons with a variety of life-limiting illnesses. This research

aims to understand the nutritional needs of palliative home care clients, with and without cancer.

Keywords: nutrition, home care, palliative care

Palliative approaches to nutrition care at the end of life are essential in the prevention of suffering and

the enhancement of quality of life for persons with a variety of life-limiting illnesses. Palliative care

literature often focuses on individuals with cancer. It is critical to understand the nutritional needs of

palliative home care clients, with and without cancer.

This study represented a cross-sectional secondary data analysis of existing interRAI Palliative Care

(iPC) data for unique Ontario home care clients assessed between 2011 and 2018 (n=74,963).

Frequencies and standardized differences (stdiff) were presented for cancer (n=62,394) and non-cancer

(n=12,569) diagnostic groups. The non-cancer group was divided into sub-groups (e.g., circulatory,

respiratory, musculoskeletal, metabolic/endocrine, digestive, and nervous/mental/behavioral

disorders). An absolute stdiff of >0.20 was used to identify statistically meaningful differences.

Of this sample, 16.7% were ≥85 years of age, 49.5% were female, 64.1% had a prognosis of <6 months

and 48.5% had ≥ 3 co-morbidities. A large proportion of the sample (41.4%) required assistance with

eating (cancer=37.6%, non-cancer=60.1%; stdiff=0.46); in the non-cancer sub-groups the prevalence

ranged from 55.5% among those with digestive disorders to 72.6% among clients with

nervous/mental/behavioural disorders. In this sample, 28.3% required a modified mode of nutritional

intake due to swallowing issues (e.g., minced diet, oral/parenteral tube feeding— cancer=25.8%, non-

cancer=40.4%; stdiff=0.31); the non-cancer groups ranged from 33.5% among those with respiratory

disorders to 56.8% among those with nervous/mental/behavioural disorders. However, most nutrition

issues experienced in this sample were similarly prevalent (stdiff<0.20) across groups (cancer/non-

cancer). Overall, 27.3% ate one or fewer meals on at least 2 of the last 3 days (cancer=27.3, non-

cancer=28.6%), 35.7% reported not feeling satiated or full (cancer=36.1%, non-caner=34.1%), 39.8%

had dry mouth (cancer=40.1%, non-cancer=38.4%), 38.6% experienced constipation (cancer= 39.5%,

non-cancer=33.7%), and 18.4% reported feeling thirsty (cancer=18.8%. non-cancer=16.0%).

The use of a standardized assessment for palliative home care clients highlights the prevalence of key

nutritional issues that are amenable to change. These results highlight the similarities between those

with and without cancer with respect to their nutrition-based needs, indicating the need to focus further

research and care guidelines towards those with life-limiting illnesses, regardless of diagnosis.

180

Domestic Violence and Polyvictimization: Associated Difficulties and Areas of Need Among

Children and Youth

Shannon Stewart, Ashley Toohey, Natalia Lapshina

University of Western Ontario, Canada

Abstract summary: We sought to examine the relationship between children’s experience of witnessing domestic

violence (DV) and polyvictimization. Our findings add to evidence that DV co-occurs with other types of

victimization and highlight that the effects of DV are wide-reaching. Further, we identify specific areas of need

for those exposed to DV.

Keywords: domestic violence, polyvictimization, trauma

Research has shown that children who experience domestic violence and abuse are at much higher risk

of experiencing physical and mental health problems, social skill deficits and other life stressors. The

purpose of this project was to examine the relationship between children’s experience of witnessing

domestic violence and polyvictimization across a number of sites across the Province of Ontario. A

total of 14,545 participants (3,978 who had witnessed domestic violence) were recruited from over 70

secure custody sites and mental health facilities in Ontario, Canada. Data was collected using the

interRAI Child and Youth Mental Health (ChYMH) assessment. Group comparisons were completed

to examine types of trauma experienced, internalizing and externalizing problems, medical conditions,

and family factors such as caregiver distress and disruptions in care. Among our sample, we found that

over 70% of children and youth in our sample who had witnessed domestic violence had experienced

multiple types of trauma. We also found that children and youth who had witnessed domestic violence

were less likely to have basic needs met in childhood, experienced more mental and physical health

difficulties, more problems with family functioning, and more bullying by peers. Findings from this

research highlight that domestic violence is multifaceted and adds to existing evidence that domestic

violence co-occurs with other types of victimization. Further, our findings identify specific areas of

need for children and youth exposed to domestic violence and underscore the importance of intervention

that takes into account the wide-reaching effects of domestic violence.

181

Factors Associated with Caregiver Distress in Young, Vulnerable Children

Shannon Stewart1, Ashley Toohey1, Jeff Poss2

1University of Western Ontario; 2University of Waterloo

Abstract summary: Caregiver well-being plays an important role in children’s development and research has

highlighted a number of factors impact distress levels among caregivers. Using Ontario data based on the interRAI

0-3 Early Years assessment, an algorithm was developed to help identify caregivers who are at greatest risk of

experiencing caregiver distress.

Keywords: caregiver distress, early childhood, algorithm

Caregiver well-being plays an important role in children’s development and research has highlighted

that a number of factors impact distress levels among caregivers. The purpose of this study was to

develop and validate an algorithm for identifying caregivers who are at greatest risk of experiencing

caregiver distress. Ontario data based on the interRAI 0-3 Early Years assessment was analyzed to

identify predictors of distress among caregivers of children up to 47 months. The Caregiver Distress

algorithm was a good predictor among this sample and provides an evidence-based decision-support

tool that may be used by clinicians to inform their selection of supports and services for families.

182

The use of the interRAI-CMHSwiss for adults receiving a practical assistance at home: a

Genevan project

Fanny Vallet, Franck Mauduit, Christina Gueninchault, Catherine Busnel

institution genevoise de maintien à domicile, Switzerland

Abstract summary: Home assistance for people with psychiatric disorders can be complex and necessitate a

specific assessment to support the clinical analysis of the situation. Using the interRAI-CMHSwiss, in association

with the multidimensional complexity scale (COMID) were proposed with 13 patients at the Geneva Institution

for home care.

Keywords: mental health, home care, complexity

Context: The Geneva Institution for home care and assistance (imad), in collaboration with the

University Hospital of Geneva have set up a pilot project to optimize the quality of services to adults

under age 65 living at home; who have a temporary mental suffering; and who receive only practical

assistance (e.g., household help, daily management). Home assistance for people with psychiatric

disorders can be complex and necessitate a specific assessment to support the clinical analysis of the

situation. In the context of the pilot project, a standardized assessment was proposed using the interRAI-

CMHSwiss, in association with the multidimensional complexity scale (COMID) elaborated by imad.

Objective: This research attempts to provide avenues for thought about the contribution of the interRAI-

CMHSwiss as a multi-faceted assessment of the complexity of the psychiatric/mental health situations

receiving practical assistance at home.

Method: Twelve assessments with the interRAI-CMHSwiss (data set collection only) and with the

COMID were performed by a nurse as part of the pilot project « home services of daily living

organization in a context of psychiatry/mental health » lead at imad and which offers rehabilitation

services. The analyses are mostly descriptive and qualitative regarding the clinical experience of the

use of the interRAI-CMHSwiss.

Results: The responses at the interRAI-CMHSwiss in view of the responses at the COMID allow to

describe the main features of the complexity of the situations included in the pilot (e.g., chronic pain,

caregivers, number of professionals). In another part, some sections specific to the RAI-CMHSwiss

allowed for a complementary qualitative analysis of mental health factors (e.g., mood, behavioral

manifestations, awareness of the disorders). Otherwise, the interRAI-CMHSwiss supports the clinical

reasoning by the clarification of the motives for interventions, the specificities of rehabilitation services

and the potential needs for additional services.

Conclusion: This research highlights the contribution of the interRAI-CMHSwiss to assess

psychiatric/mental health situations at home in a comprehensive way, even when no somatic care is

required. This tool allows to investigate different facets of the complexity of these situations, to deepen

the clinical evaluation and to give some possibilities on the potentials for rehabilitation.

183

Factors associated with caregiver distress among home care clients in New Zealand: Evidence

based on data from interRAI Home Care Assessment

Rebecca Abey-Nesbit1, Shauni Van Doren2, SangNam Ahn3, Linda Iheme4, Nancye Peel5

1University of Otago, New Zealand; 2LUCAS - KU Leuven, Belgium; 3University of Memphis, United

States; 4University of Waterloo, Canada; 5University of Queensland, Australia

Abstract summary: Informal caregivers play a fundamental role in maintaining the health, wellbeing and quality

of life of people living at home. In this study we look at the prevalence and different characteristics on client-,

caregiver-, and health service level related to caregiver distress in New Zealand.

Keywords: caregiver distress, geriatric assessment, home care

Objective: To identify factors associated with caregiver distress among home care clients in New

Zealand.

Methods: The cohort consisted of 105,978 community-dwelling older people aged 65 and older

receiving home care in New Zealand. Assessments ranged between 5 July 2012 and 1 June 2018.

Caregiver distress was defined as answering “Yes” to one or more indicators of informal caregiver

distress: Informal helper(s) is unable to continue caring activities; Primary informal helper expresses

feelings of distress, anger, or depression; and Family or close friends report feeling overwhelmed by

person’s illness. Bivariate and multivariate logistic regressions were used to identify risk factors

associated with caregiver distress.

Results: Caregiver distress was found in 39,9% of home care clients. Multivariate analyses identified

client characteristics such as sex, marital status, prognosis, inadequate pain control, cognitive decline,

bladder incontinence, nutritional issues, depressive symptoms, and aggressive behavior as having

significant risk of caregiver distress. Relationship of primary caregiver to client, and hours of informal

care time were significant caregiver characteristics. Hospitalizations within 90 days, and more than 3

home care nurse visits per week were also significant.

Conclusion: Caregiver distress affects approximately 40% of home care clients in New Zealand. This

may lead to adverse outcomes for the caregiver and the client. Experiencing caregiver distress is

mediated by characteristics of clients, caregivers, and health services. Care planning around alleviating

some of these burdens may help to reduce the number of caregivers experiencing distress. As well as

efficient communication between formal and informal caregivers about this care plan.

184

Promoting integrated home care service system based on interRAI-HC assessment

Lei Zhang, Zhong Wang

Beijing Tsinghua Changgung Hospital

Abstract summary: Supported by Beijing Municipal Health Committee, the Public Health Research Center of

Tsinghua University and Beijing Tsinghua Changgung Hospital have collaboratively promoted the use of

interRAI-HC assessment in Beijing’s ten health organizations, aiming at exploring the suitable assessment tools

for integrating services for the old Chinese.

Keywords: interRAI-HC, Beijing, practice

Most of the time, the elderly live in their own families and communities. However, due to changes in

physical conditions and disease conditions, they need to receive professional and diversified services in

different places such as hospitals of different levels, community health centers, and pension centers. At

present, these different institutions in our country are not well integrated, and there are problems in

service connection, medical insurance payment and service supervision, which lead to obstacles in

obtaining continuous services for the elderly at home. One of these problems is the lack of

comprehensiveness and coherency assessment tools for identifying the needs of the elderly. Therefore,

it is of practical significance to explore the suitable assessment tools for integrating services for the old

Chinese.

Since August 2018, the Public Health Research Center of Tsinghua University and the Department of

General Practice of Beijing Tsinghua Changgung Hospital have collaboratively promoted the use of

interRAI-HC assessment in regulating services for the old persons. The effort was a program supported

by Beijing Municipal Health Committee. Ten health organizations, including community health centers,

hospitals and nursing homes located in eight administrative districts of the city were involved. The

purpose of our effort is to make the communication among different health care facilities possible with

a shared identification of the needs of the old persons so that the transfer of services can be made more

appropriate and convenient.

After the training of the health workers in the above-mentioned organizations, 148 assessments were

made on qualified senior citizens by August 2019. While the analysis of the data enable us to better

understand the health needs of these older people in the community, we also expect these data to provide

us with guidance in making better clinical care plans in these cases. At present, we attempt to continue

our effort to implement interRAI-HC assessment system in service integration in these facilities and put

forward relevant suggestions for regulation improvement to the municipal government.

185

Integrating Clinical Rehabilitation Care with interRAI-PAC to Improve the Quality of Life of

the Old Patients

Ying Zhao, Liqing Yao, Ying He

The second Affifiated Hospital of Kunming Medical University, People's Republic of China

Abstract summary: In the case of lack of well trained professionals, the implementation of interRAI-PAC played

an important role in regulate the clinical behavior of the health workers of different backgrounds and ensure

acceptable quality of rehabilitative services.

Keywords: interRAI-PAC, clinical rehabilitation care, health workers

Supported by the provincial Bureau of Science and Technology, the faculty of the Department of

Rehabilitation at Kunming Medical School No. 2 Hospital has been building a platform for integrating

care delivery and standardizing clinical evaluation and documentation, clinical management,

counselling and referral mechanisms. We made an effort to implement interRAI-PAC as an effective

instrument in our hospital and affiliated local health facilities to regulate clinical care provision for the

aged patients. Currently more than 30 health workers from our department and other 10 hospitals

associated received training on managing RAI-PAC assessments. The available assessments constantly

reminded us some neglected problems of the patients and raised the senses of risk prevention at the

clinical setting. In addition, the assessments also led us to a more comprehensive understanding of the

patient so that rational and appropriate care plans for intervention became a reality. In the case of lack

of well trained professionals, the implementation of RAI-PAC played an important role in regulate the

clinical behavior of the health workers of different backgrounds and ensure acceptable quality of

rehabilitative services. As our project will continue in the following years, we can expect our effort to

continue till the establishment of a feasible information system for better rehabilitation care provision

in our hospital and in the local health care institutions.

186

POSTER SESSION 2

Benchmarking tool for client guidance and service coordination

Janne Asikainen, Aleksandr Gerasin, Rauha Heikkilä, Matti Mäkelä

Finnish Institute for Health and Welfare (THL), Finland

Abstract summary: The Finnish Institute for Health and Welfare, in collaboration with four regional or municipal

authorities, developed a RAI-based benchmarking tool for client guidance and service coordination. It can be used

to follow client flows and to evaluate the service coordination decisions made for different client groups.

Keywords: services, coordination, benchmarking

Aims: The Finnish population is ageing rapidly and this has put a pressure for a major reform of the

structures of the social welfare and health care services system. One response has been to develop

regional centers for client guidance and service coordination to ensure available, equal and well-timed

services for those in need. The Finnish Institute for Health and Welfare (THL), in collaboration with

four regional or municipal authorities, developed a RAI-based benchmarking tool for client guidance

and service coordination. The aim was to build a database from which service organizers can see

different service needs and profiles of client groups in service coordination, what services they actually

were receiving afterwards and what happened to their functioning.

Materials and methods: Data for the pilot development were based twelve months of RAI Home Care

assessments from client guidance and service coordination units.

The assessment data were classified on six different dimensions: service provider, time, service needs

segment, informal caregiver status, cognition, and ADL.

To track the actual service received, the RAI assessments were linked to the health and social care

registers of THL, and to the register of deaths.

The reporting indicators were percentages and averages of client groups. Indicators were formed for

service guidance situation, for indicating change in functioning and for the service status (home care,

hospital visits, residential care, and also death) after follow-up period.

The data data were reported through web-based reporting interface developed in THL.

Results: The result of this collaborative development was a benchmarking database for client guidance

and service coordination. It can be used to follow client flows and to evaluate the service coordination

decisions made for different client groups. The tool also includes different views for different user

groups, for example for workers in guidance level and for management.

Conclusions: The database has been now tested in organizations and the feedback was positive. The

tool supports service harmonizing, guidance and criteria development. It also makes possible to

compare service quality between organizers in Finland.

187

Analyses of Potentially Inappropriate Cardiovascular Medication Use in Acutely Hospitalized

Older Patients in the Czech Republic

Jovana Brkić1, Petra Gajdošová1, Veronika Kubíková1, Jindra Reissigová2, Daniela Fialová1,3

1Department of Social and Clinical Pharmacy, Faculty of Pharmacy in Hradec Králové, Charles

University, Czech Republic; 2Department of Statistical Modelling, The Czech Academy of Science,

Czech Republic; 3Department of Geriatrics and Gerontology, 1st Faculty of Medicine, Charles

University, Czech Republic

Abstract summary: The aim was to determine the prevalence of potentially inappropriate cardiovascular

medication (CV PIM) use among hospitalized older patients. Data were collected from medical records, and

interviews using a comprehensive instrument (interRAI scales, information on diagnoses and medication use).

CV PIM use was high, documented in 77.6 % of patients.

Keywords: potentially inappropriate medications, older patients, acute care

Aim: The aim of this study was to determine the prevalence of potentially inappropriate cardiovascular

medication (CV PIM) use in older patients in acute care in the Czech Republic. This study is a part of

the FIP7 program of the Horizon 2020 EuroAgeism project.

Methods: The study was conducted in two acute care geriatric departments in two bigger cities (Brno

and Hradec Kralové) in the Czech Republic. Data collection took place from August 2018 to January

2019. Patients 65 years and older admitted to hospital were included. We excluded patients who were:

cognitively impaired, communicatively impaired, terminally ill, or admitted to the intensive care unit.

Data were collected from medical records and interviews with healthcare professionals and patients

using a comprehensive instrument that includes interRAI functional status assessment scales and other

comprehensive information on diseases, symptoms, medication use and utilization of healthcare

services. CV PIMs were analyzed using consensus‐based explicit criteria, namely Beers criteria 2019,

Screening Tool of Older Person’s Prescriptions (STOPP) version 2 , Screening Tool to Alert doctors to

the Right Treatment (START) version 2 and EU(7)-PIM list. Overall, 99 criteria were applied.

Results: Of the 288 patients assessed, 57 % (164) were women. Overall, 77.6 % of patients were

exposed to CV PIMs. The highest prevalence of CV PIMs was identified by START criteria version 2

(63.2 % of older patients), followed by EU(7)-PIM list (31 %). The lowest prevalence was documented

using Beers criteria 2019 (16.1 %).

Conclusion: The results of this study show that CV PIM use is highly prevalent among older

hospitalized patients in the Czech Republic.

Support: This project has received funding and support from the European Union´s Horizon 2020

research and innovation programme under the Marie Sklodowska-Curie grant agreement No 764632,

SVV 260417 and PROGRESS Q42 scientific program of the Faculty of Pharmacy, Hradec Králové,

Czech republic.

188

Physical and Social Activity of Older Nursing Home Residents with and without Dementia in

South Korea: status and contributing factor

Seungyeon Chun1, Hongsoo Kim1,2,3

1Graduate School of Public Health, Seoul National University, Korea, Republic of (South Korea); 2Institute of Health & Environment, Seoul National University; 3Seoul National University Institute of

Aging

Abstract summary: Physical and Social activity is critical for maintaining the health and well-being of older

nursing home residents. The purpose of this study was to examine the current status of PA, SA and related

individual and institutional factors among older nursing home residents with and without dementia in South Korea.

Keywords: nursing home older resident, physical and social activity, quality of life

Aim(s): Older adults in the Nursing home are at risk for low physical activity (PA) and social activities

(engagement; SA). WHO (2010) recommends PA to all older people, not only to those who are healthy

but also to those who have limited mobility. SA is critical component of quality of life of older nursing

home residents. PA and SA may interact with each other in their relationship with quality of life in the

frail and vulnerable population. Although the number of older residents in Korea is steadily increasing,

there are lack of research and information on this subject. The purpose of this study was to examine the

current status of PA and SA and related factors among older nursing home residents with and without

dementia. Method(s): This is a secondary data analysis study of a nationwide survey of 92 Nursing

homes in Korea, and the study sample includes older residents with dementia and without dementia.

The level of PA was measured by PA time and whether or not residents had an outdoor activity over

the past 3 day, SA was measured by revised index for social engagement (RISE). Descriptive statistics

was performed to describe the residents, institutional characteristics and current status of PA and SA

participation levels. Multi-variate analyses were performed by taking into account the factors related to

PA and SA according to individual, institutional characteristics. Result(s): More than half of the sample

in both groups had no or less than 1 hour of PA and did not have any SA. About one out of four older

people in our sample had no outdoor activity over the past 3 days regardless of whether or not they had

dementia. There were differences in individual- and institutional level factors relating PA and SA

between dementia and non-dementia groups. Conclusion(s): Study findings provide evidence on the

lack of PA and SA among older nursing home residents, and it is necessary to make efforts and plans

for improving activities.

189

Living will and its associates in LTCFs , in 2019 and earlier

Ulla Finne-Soveri1, Paula Andreasen1, Anja Noro1, Dimitrije Jakovljevic2, Teija Hammar1

1Institute for Health and Welfare, Finland; 2Attendo Finland

Abstract summary: Among long-term care residents prevalence of living will has increased more than ten-fold

during 15 years. The older the residents (with female sex) and the better the cognition of the resident the more

likely he/she had the living will. We found no negative impact on caring procedures.

Keywords: living will, advance care planning, LTCFs

In Finland, older people have been encouraged, in the media more than two decades, to create a written

living will. In 2015, a national random sample of deceased LTCF residents unveiled that approximately

40% those who had died in LTCFs 3 months prior to data collection, had had a living will.

Methods: We used interRAI data, stored in the institute for Health and Welfare, to find out the

prevalence of living will in LTCFs in 2005 through 2019. We also analyzed 1, whether there were

differences between levels of care, and 2, whether the care of those with the living will differed from

those have it not, in 2019. Chisq analysis and several multiple logistic regression analyses, using SAS

statistical software were used. RESULTS: There were 468 645 assessments using MDS 2,0–NH

instrument during 2000 to 2019, in the data base. Living will was registered to 2% of the residents, in

2005 (n=7 215) and correspondingly to 22% in 2019 (n=23 086). In 2019 living will was not associated

with any measured caring procedure apart from rehabilitative care. Living will was associated with

female sex, oldest age group, long length of stay, and assisted living (p<0,001). A negative association

was found with cognitive decline, never married, married, and widowed. The c-statistics for the

regression analysis was only 0.572.

Conclusions: Among LTC residents, living will has become more prevalent during past years. It seems

not to have any negative impact on care

190

Implementation of forms and protocols of InterRAI-MH in the mental health network

Manuel A Franco1, Henriette Van der Roest2, Juan L Mjñoz1, Esther Parra3, Juan C Fiorini1, Rafael

Rodriguez-Calzada1

1University Rio Hortega Hospital and Zamora Hospital, Spain; 2Institute of Mental Health and

Addiction (Trimbos-institute), Utrecht, the Netherlands; 3Fundacion. Zamora. Spain

Abstract summary: For working in comunity care it´ll be necesary to implement a tool for managing it. InterRAI-

MH is a good solution and therefor we started a project for implementing the interRAI in the mental health network

in Spain. Most of mental health workers consider interRAI a good solution.

Keywords: implementation, comunity care, mental health

Currently, the model of care of people with severe mental disorders are changing from

institutionalization (sometimes forever) to community care. However, it´s mean that they tend to receive

services in multiple settings across the health care continuum, raising the complexity for managing it.

Indeed, services and supports offered to the person are often fragmented, uncoordinated, and

inadequate. No provider is likely to address all of health and psychosocial concerns at a single point in

time or over the person’s lifetime. Consequently, the most relevant challenge is to coordinate the social

and health networks in charge of care, and of course all providers working on it. InterRAI-MH can be

a good chance for working out all challenges.

Therefore two years ago, we started the way for implementing the interrail in the mental health network,

facing all challenges for achieving the use and acceptation by the professionals. The methodology has

been the follow:

1. Translation of the all forms and manuals related to Mental health.

2. Check the coherence of all psychopathological terms with the others interRAI tools already

translated to Spanish. When we have found differences three psychiatrist and psychologist were

consulted for choosing the best choice.

3. Link every item to one or several mental health workers depending on their training.

4. Work groups with every tool for identifying the way for being used in clinical settings.

5. Design the way for being used in the mental health network.

We present the results of a questionnaire about the strenghs and weakness of interRAI for managing

the community care. More than 90% consider the interRAI as the best way for working in the

community care. The most important difficulty is the time and access to the data in every time. We are

going to work in a system integrated with other activities for improving the implementation.

191

Using RAI to enhance implementing and planning efficient fall prevention among home and

residential care clients

Satu Havulinna

FInnish Insitute for Health and Welfare, Finland

Abstract summary: RAI provides plenty of information for falls prevention, however, it is often underused. We

present how to identify risk groups from RAI-benchmarking data to implement and target effective falls

prevention. We also present the tool developed to help recognize clients fall risk factors to plan and follow-up

individually tailored fall prevention programs.

Keywords: falls, implementation, prevention

Aim: Both RAI-assessment and RAI-benchmarking data is often underused in planning and

implementing falls prevention. Wiht this work, we show how RAI-benchmarking data can be used to

reveal groups prone to falls among home and residential care clients.

We also present the tool, called RAI-IKINÄ, which was developed to derive multifaceted information

on client’s individual fall risk factors from RAI-assessment.

Materials and Methods: All RAI-assessments done in Finland are compiled to form a national database

administered by Finnish Institute for Health and Welfare (THL). From this database THL produces

RAI-benchmarking data. For this paper, we used benchmarking data of home and residential care clients

75-years and older in 2018 and used measures for falls, ADLH (Activities of Daily Living Hierarchy)

and CPS (Cognitive Performance Scale).

RAI-IKINÄ identifies clients individual fall risk factors from RAI-assessment data and is based on

Scott Fall Risk Screen1. Adaptation was permitted by developers and done in collaboration with RAI

user organizations in Finland.

Results: On average, 25 % older home care clients and 10% residential care clients had at least one fall.

For clients admitted within recent year, fall rates were 30% and 15 %, for home and residential care

clients respectively. Among home care clients, those with both major ADL impairment (ADLH 3-6)

and major cognitive decline (CPS 3-6) fall rate was higher (30%) than among clients with no ADL

limitations regardless cognitive level (20-22%). In residential care, highest fall rate (15%) was among

clients with mild ADL impairment (ADLH 1-2) together with mild or severe cognitive decline (CPS 1-

6).

Conclusions: RAI-assessment and -bencmarking data provides variety of useful information for falls

prevention. Benchmarking can be used to target prevention and follow the results of preventive work.

RAI-IKINÄ tool have shown to be useful tool to assist home and residential care staff in planning

individually tailored fall prevention programs.

References:

[1] Scott Fall Risk Screen (SFRS), Nov 12, 2012 Dr. V. Scott, Senior Advisor Fall & Injury Prevention,

B.C. Injury Research & Prevention Unit

192

Translation and adaptation of the interRAI emergency screener for psychiatry instrument for

the Brazilan context

Alice Hirdes1, Luis A. Cabral1, Luiz C.P. Marrone1, John P. Hirdes2

1Lutheran University of Brazil, Brazil; 2University of Waterloo, Canada

Abstract summary: In Brazil, there is a demand for patients with psychiatric symptoms seeking emergency

services in general hospitals, the assessment are done by professionals who are not specialists in psychiatry.

Objective: this research aimed to translate and culturally adapt the interRAI Emergency Screener for Psychiatry

instrument for use in general hospitals.

Keywords: emergency screener, psychiatry, general hospital

In Brazil, there is a growing demand for patients with psychiatric symptoms seeking emergency services

in general hospitals. The assessment of these patients are usually done by professionals who are not

specialists in the mental health field, who also do not have specific psychiatric assessment tools for

diagnosis and intervention. Objective: this research aimed to translate and culturally adapt the interRAI

Emergency Screener for Psychiatry instrument for use in general hospitals. Method: this is a

quantitative, cross-sectional and descriptive study. Translation, back-translation, evaluation by two

independent judges, elimination of language discrepancies and incorporation of suggestions into the

final Portuguese version were performed. One hundred interviews were conducted in a general hospital

emergency room in the metropolitan area of Porto Alegre, Rio Grande do Sul State, Brazil, from March

to August, 2019. Results: preliminary results show that depressive symptoms (81%) and manic

symptoms (59%), anxiety symptoms (57%) and psychoses (36%) are the most prevalent symptoms that

motivated emergency consultations; most patients never used drugs (51%); never used injecting drugs

(99%), among which they use, cannabis was the most used drug (25%) and cocaine or crack (22%).

Regarding the ideation or attempt of self-harm, 40% never had a self-injurious ideation or attempt, 25%

of the patients considered having done an act of self-harm and 35% made a recent attempt to self-harm.

Among the prevalent provisional diagnoses are mood disorders (50%); anxiety disorders (39%); sleep

disorders (19%); schizophrenia and other psychotic disorders (11%) and mental disorders due to general

medical conditions (10%). Conclusion: there were some discrepancies between the symptoms of

emergency care provided by non-mental health professionals who request psychiatric assessment within

24 hours and the provisional diagnosis, a hypothesis for the under-diagnosis may be due to patient

assessment being performed by psychiatric residents.

References:

[1] Rabinowitz T.; Hirdes JP.; Curtin-Telegdi N.; Martin L.; Smith TF.; Morris JN.; Berg K.; Björkgren

M.; Declercq A.; Finne-Soveri H.; Fries BE.; Frijters D.; Gray L.; Henrard J-C.; Ljunggren G.; Steel

K.; Szczerbinska K.; and Topinkovà E. interRAI Emergency Screener for Psychiatry (ESP).

Assessmente Form and User´s Manual. Version 9.1. Washington DC: interRAI, 2013.

193

Korean Human Milk Tracking System Using Bar-code for Management of Localized Human

Milk Banks

Nam Mi Kang1, Nam Soo Oh2, Won Ho Hahn3, Hyun Soon Park4

1Department of Nursing, KonKuk University Chungju-si, Korea; 2CNSCARE Co., Ltd.; 3School of

Medicine, Soon Chun Hyang University; 4College of Nursing, Kangwon tourism University

Abstract summary: The aim of the study is to find and recommend a standard system ensuring the safety and

easily acceptable to mothers and general health care facilities.The standardized systematic process to manage

Korean Human Milk Bank and a design of Bar-code label was developed.

Keywords: bar-code, human milk bank, tracking

Human milk is well known to have lots of advantages for infants in nutritional, protective, and

developmental aspects. However, some of infants are not accessible to their own mothers’ human milk.

WHO strongly recommended the pasteurized donor milk as the first option for such infants. For the

effective and safe supply of pasteurized donor milk, numerous human milk banks are established and

very actively operating globally. For the safety and effective function of the human milk bank, very

specialized methods for each country is warranted including the donor selection, collection, storage,

processing, recipient selection, and distribution. The aim of the current study is to find and recommend

a standard system ensuring the safety and easily acceptable to Korean mothers and general health care

facilities in Korea. Methods We reviewed the literatures and the previous surveillance studies for the

issues of the Korean human milk banks to explore the requests on the establishment of human milk

bank in Korea. following the results, the authors designed the bar-code based human milk bank

management and tracking system that is suitable in Korea.

In a previous studies, the safety and the easy accessibility of the human milk bank were the most

important issues in the Korean mothers. To minimize the concerns on the safety of donated human

milks, the full tracking system from the donor to the recipients is applied. Moreover, the system was

optimized to enhance the function of the localization of the human milk banks. conceptual bar-code

label system was developed to meet the Korean mothers requests.

In conclusion, the standardized systematic process to manage Korean Human Milk Bank and a design

of Bar-code label for Korean Human Milk Bank Management System was developed. The current

system would be most appropriate design for localization model of Korean human milk bank. We hope

this novel model would help for the activation and effective operation of human milk bank in Korea.

This research was supported by Basic Science Research Program through the National Research

Foundation of Korea (NRF) funded by the Ministry of Education [No. 2017R1D1A1B03034270].

194

Health condition and nutritional status of cognitively impaired long-term care residents – a

comparison between skilled and non-skilled nursing facilities

Violetta Kijowska, Ilona Barańska, KatarzynaHealth condition and nutritional status of cognitively

Szczerbińska

Jagiellonian University Medical College, Chair Epidemiology and Preventive Medicine, Department

of Sociology of Medicine, Krakow, Poland

Abstract summary: 455 residents with cognitive impairment(CI) from 11 SNFs and 12 non-SNFs in Poland. The

study sample differed in functional, nutritional status and some psychotic symptoms, but not in presence of chronic

diseases, inappropriate behaviors and aggression. The level of CI was associated with physical and psychological

decline and nutritional status.

Keywords: long-term care, cognitive impairment, health status

Background. There are two types of long-term care facilities (LTCFs) in Poland: skilled nursing

facilities (SNFs) with care assistants, nurses and physicians available 24/7, and non-skilled nursing

facilities (non-SNFs) with care provided by care-assistants, nurses and family doctors. Residents with

cognitive impairment (CI) can stay both in non-SNFs and SNFs and constitute up to 2/3 of the people

receiving institutional care in Poland.

Aims: This study aims to describe differences in health, functional, nutritional and psychological status

of residents with CI depending on the facility type and the level of CI among LTC residents. Factors

increasing their chance to stay in SNF compared to non-SNF were searched.

Material and methods. The study sample was comprised of 455 residents (randomized out of 1035

residents with CI) recruited from two representative large cross-sectional samples of 11 SNFs and 12

non-SNFS in Poland. Data was collected using the InterRAI Long-Term Care Facilities Assessment

System questionnaire, which is a validated and widely used tool enabling comprehensive geriatric

assessment of people receiving LTC services. We applied logistic regression analysis to identify

potential factors increasing the chance of these residents to stay in SNF or non-SNF.

Results. The SNF residents more frequently had worse functional and nutritional status, and psychotic

symptoms than non-SNF ones, while they did not differ significantly in health status, frequency of

behavioral problems, and aggression level. The higher presence of functional disability (ADL, bowel

and bladder incontinence), nutritional decline (BMI status, problems with swallowing, aspiration,

pressure ulcers), and psychological problems (aggression, resistance to care, agitation, hallucinations

and delusions) were associated with more severe CI status. The multivariate analysis showed that the

level of CI severity did not increase the chance to stay in SNF compared to non-skilled ones, but ADL

dependency did (OR=1.52, 95%CI=1.31-1.76).

Conclusions. The level of CI is significantly associated with physical, psychological and nutritional

functioning of the residents and thus may have an impact on care services demand. Therefore, it should

be considered when making the decision where – in SNF or non-SNF – a patient with CI should be

placed.

195

Prevalence of cognitive impairment among long-term care residents – a comparison between

skilled and non-skilled nursing facilities in Poland

Violetta Kijowska, Ilona Barańska, Katarzyna Szczerbińska

Jagiellonian University Medical College, Chair Epidemiology and Preventive Medicine, Department

of Sociology of Medicine, Krakow, Poland

Abstract summary: 1.589 residents from of a representative sample of 23 long-term care facilities (LTCFs) in

Poland were assessed with a Cognitive Performance Scale (CPS) to define the presence of cognitive impairment

(CI). A high prevalence of CI was observed with significantly higher rates in skilled nursing facilities compared

to non-skilled ones.

Keywords: cognitive impairment, dementia, long-term care facilities

Background: While dementia has become one of the biggest challenge for long-term care institutions

(LTCFs) in Poland, where the people aged 65 and over constitutes more than 75% of residents, large

scale nationwide comparative studies in particular for older adults with dementia in LTCFs, hardly

exist.

Aims: This study aims to compare the prevalence of cognitive impairment (CI) suggesting the

possibility of dementia and its symptoms among residents of skilled nursing facilities (SNFs) and non-

skilled nursing facilities (non-SNFs) in Poland.

Methods: It was a cross-sectional survey of a country representative sample of 23 LTCFs providing

care for older and chronically ill persons across Poland, randomized in terms of LTCF type,

geographical region, bed capacity and ownership status conducted in the years 2015-2016. In total, 1587

residents were included: 626 residents in 11 NHs and 961 residents in 12 RHs. All individuals were

assessed with a Cognitive Performance Scale (CPS) using a cut-off of ≥2 points to define the presence

of CI. Descriptive statistics and the chi-square test were used.

Results: The median age was 80 years, 67.7% were women. Overall, 65.2% of LTC residents (n=1035)

were identified as having CI, ranging from 59.2% in non-SNFs to 74.5% in SNFs, after excluding

residents with a coma. Furthermore, the prevalence of severe CI was significantly higher among SNFs

than non-SNFs residents (respectively, 41.2% and 20.5%), specifically impairment of: being understood

by others (44.6% vs 24.7%), procedural memory (72.3 vs. 55.2%), long-term memory (56.5% vs

32.1%), short-term memory (46.8% vs 33.4%), situational memory (40.2% vs 26.4%) and severely

impaired capacity of a daily decision making (44.7% vs 21.5%).

Conclusions: The results from our study show the existence of a serious problem of a high proportion

of LTC residents with impaired cognitive functioning. That seems to be now the greatest challenge for

LTC sector in Poland, since both specialist programmes for residents with dementia, and specialist

dementia care settings are still very rare in our system. Therefore we call for more attention to be paid

to better recognition of CI in LTC residents, regardless of the facility type.

196

eQC Project: Identifying Patients with Cognitive Impairment on admission to Acute Care

utilising the interRAI Acute Care (AC) Assessment instrument

Melinda Martin-Khan1, Len C Gray1, Nancye M Peel1, Elaine Pascoe1, Ruth E Hubbard1, Tracy

Comans1, Yvonne Hornby-Turner1, John Hirdes2, Amanda Henderson1,3, Julia Crilly3,4, Nicole

Gillespie1, Brant Fries1, Veronique Boscart5, Elizabeth Beattie6, Linda Schnitker6, Ellen Burkett1,7,

Frederick Graham6,7

1The University of Queensland, Australia; 2University of Waterloo, Canada; 3Queensland Health,

Australia; 4Griffith University, Australia; 5Conestoga College, Canada; 6Queensland University of

Technology, Australia; 7Queensland Health, Australia

Abstract summary: The interRAI AC will be implemented at 8 hospitals as a facility wide nursing assessment

system administered on admission to adult patients, reviewed at handover and discharge. Quality Indicators will

be provided for clinical use. Staff will identify patients with CI or dementia, and patients at risk of poor outcomes.

Keywords: acute care, cognitive impairment, nursing

Introduction: The interRAI Acute Care (AC) nursing assessment tool was pilot tested in adult admitted

hospital patients (aged 18 and over) and identified that 24.3% of patients had short term memory

problems, common across all age groups, not just the elderly. For those patients who may have

cognitive impairment (CI), it can be difficult to detect without the use of a screening tool. A strategy

designed only for patients with CI adds significant burden. A “universal” system that also deals

specifically with the issues related to CI is desirable. The aim of the eQC project is to conduct a large

scale implementation and evaluation of an assessment and care planning system to improve the care

and support of people with dementia in hospital.

Method: The interRAI AC (including clinical screeners) will be implemented as a facility wide nursing

assessment system administered to all adult patients (18 years and older) at admission, reviewed at

handover and discharge as part of a large scale hospital/s implementation. Quality Indicators will be

scored automatically using assessment data.

Staff will identify patients with CI or dementia, and patients at risk of poor outcomes, using the

electronically generated assessment data which is also linked to other hospital administrative data.

Sites are Australian hospitals in Tasmania (Royal Hobart Hospital, Launceston General Hospital, North

West Regional Hospital, Mersey Community Hospital) and Queensland (Rockhampton Hospital;

Mount Isa Base Hospital, Cloncurry Hospital, Normanton Hospital).

Conclusion: The interRAI AC is being implemented as as an electronic nursing assessment system to

improve the care of patients with dementia (or CI). The project will examine nursing admission

documentation time, the identification of patients with CI, delirium risk prevention activities and

changes in care planning.

197

Characterizing the Advance Care Directive Gap among older adults in Australia

Tracy Comans1, Leila Shafiee Hanjani1, Bertha Lee2, Lacey Loomer3, Kathleen Norman4, Nancye

Peel1, Melanie Thomasson5

1University of Queensland; 2Curry College School of Nursing; 3Brown University; 4University of

Waterloo; 5University of Arkansas for Medical Sciences

Abstract summary: Advance care directives (ACDs) allow patients to pre-specify preferences in the event of

incapacitation, and are associated with higher satisfaction and lower costs. interRAI Acute Care for

Comprehensive Geriatric Assessments (AC-CGAs) collected in Australian hospitals were used to identify

characteristics associated with having a treatment-limiting ACD among older adults with complex needs.

Keywords: acute care, advanced care directives, end-of-life

An advance care directive (ACD) is a written record of a person’s preferences for future care in the

event that they cannot communicate the wishes themselves. An ACD can record a person’s life goals,

directions about care and treatment (e.g. do-not resuscitate), and can formally appoint a health care

proxy to make health care decisions. ACDs are a living document that can be updated as your health

status changes but are most important at end-of-life. ACDs are associated with higher patient and family

satisfaction and lower healthcare costs. In Australia, the uptake of ACDs has been reported to be low,

at around 14% nationally. The government has sought to increase these rates through a national policy

framework and, in some states, standardized forms.

The aim of this study was to identify what functional, psychosocial, and demographic characteristics of

older Australian patients were associated with having an ACD. The data included 5,361 completed

Acute Care for Comprehensive Geriatric Assessments (AC-CGAs), collected from 25 acute care

hospitals in the state of Queensland, Australia. We used logistic regression to identify characteristics

associated with having any treatment-limiting ACD (e.g. do-not-resuscitate, do-not-intubate). We found

that the prevalence of ACDs were low but increased over time, from 5% to 30% in 2006 and 2016,

respectively. Overall, 16% of patients had some form of ACD, with the majority of them having an

order for do-not-resuscitate (15%) and do-not-intubate (14%). We found patients who were living alone

[Adjusted odds ratio (AOR) 0.71, 95% Confidence Interval (CI) ,0.54-0.94], had severe pain [AOR

0.68, 95% CI 0.57-0.99], recent history of falls (2 falls in 30 days compared to no falls) [AOR 0.64,

95% CI 0.48-0.68] or were without a legal guardian [AOR 0.58, 95% CI 0.46-0.75] were less likely to

have a treatment-limiting ACD. Our study suggests that there are patient groups that may have less

access to information about comfort care choices and could be targeted with information upon hospital

admission.

198

Epidemiological And Clinical Characteristics Of Adults In Inpatient Geriatric And General

Psychiatry Across Ontario, Canada

Jerrica Little1, Konstantin Shcherbak2, Jo Ann Iantosca3, Alice Tran4, Juan Luis Munoz5, John Hirdes1

1University of Waterloo, Ontario, Canada; 2Landspitali - The National University Hospital of

Iceland; 3Western University, Ontario, Canada; 4University of Queensland, Australia; 5University of

Salamanca, Spain

Abstract summary: Factors in RAI-MH associated with admission into general versus geriatric psychiatry units

in Ontario, Canada were analyzed. Functional and cognitive impairments along with medical comorbidities were

major drivers behind admissions into geriatric psychiatry units, not entirely consistent with the definition of

geriatric psychiatry as attending to complex mental disorders

Keywords: geriatric psychiatry, inpatient psychiatry, RAI-MH

Background: Medical and psychiatric comorbidities are prevalent among older adults and due to an

ageing population, the need for specialized geriatric psychiatric care in Canada is increasing. To date,

little is known about the epidemiological and clinical profile of older adults identified as a geriatric

psychiatry patient and/or treated in geriatric psychiatry units. Population-level data of admissions to

geriatric psychiatry units is especially scarce. In Ontario, all adults admitted to psychiatric hospitals for

more than 3 days are assessed, providing a unique opportunity to examine geriatric psychiatry patients

and units.

Methods: Resident Assessment Instrument – Mental Health (RAI-MH) data for adults aged >50 years

admitted to inpatient psychiatry units in Ontario from 2010 to 2018 was analyzed (n=59,355). Patients

being treated in geriatric psychiatry units were compared against those in general psychiatry units.

Descriptive statistics were used to analyze demographic and clinical characteristics. Logistic regression

models were conducted to determine factors associated with admission to a geriatric psychiatry unit.

Results: Older age and lower educational obtainment were significantly higher among those in geriatric

psychiatry units; sex and marital status were insignificant. Living in a nursing home prior to admission

was also associated with higher odds compared to a private home (OR=2.25). Medical comorbidities

also demonstrated significantly higher odds (OR=1.28). Older adults with aggressive behaviour, ADL

impairment, and cognitive impairment had higher odds of admission to geriatric psychiatry units, while

those with greater positive symptoms of psychosis, social withdrawal, substance abuse, and depression

had lower odds. Staff also reported more frustration in providing care for - and more hostile interactions

with - patients who were in geriatric psychiatry.

Discussion: The results from this study suggest that functional and cognitive impairments along with

medical comorbidites are all major determinants of entering geriatric psychiatry units. Some

discrepancy is observed with the statement from the Canadian Academy of Geriatric Psychiatry where

geriatric psychiatry is defined as a psychiatric specialty focusing on complex mental health conditions,

and physical function or medical comorbidities are not mentioned in the definition. Those challenging

patients might be in need of even more comprehensive care.

199

Factors associated with ADL improvement after in-hospital comprehensive geriatric assessment

and geriatric rehabilitation (interRAI Post-Acute Care)

Konstantin Shcherbak, Rakel Valdimarsdottir, Helga Atladottir, Palmi V. Jonsson

Landspitali - The National University Hospital of Iceland, Reykjavik

Abstract summary: Not everyone will improve in ADL function despite CGA and rehabilitation. Improvement

in ADL score was registered in 34% of 330 subjects (mean age 83.7 years, 60.3% female). Factors associated with

ADL improvement were short-term memory, self-reported health, recent hip fracture, ADL function at

presentation and surprisingly, vision impairment.

Keywords: geriatrics, rehabilitation, outcome

Background: Frail elderly people are an increasing proportion of patients in acute care hospitals. Post-

acute care is often needed before discharge home. Despite comprehensive geriatric assessment (CGA),

focused treatment and rehabilitation not everyone will show improvement in physical function. This

study analyzed factors known at the admission to post-acute care that were associated with improvement

in interRAI ADL long scale score during the stay.

Methods: interRAI Post-Acute Care instrument (PAC) data collected over 3 years at a geriatric

rehabilitation ward in Reykjavik, Iceland was analyzed using logistic regression. Most patients referred

to the facility from an acute care hospital were motivated for a CGA, treatment and short-term

rehabilitation but were unable to be discharged home directly for various reasons. The main outcome

measure was improvement in ADL long scale score of at least 1 point.

Results: Data from 562 patients’ first admissions were analyzed. Two hundred and thirty two patients

had ADL long scale score 0 at admission and were excluded. The breakdown of ADL hierarchy score

of remaining 330 subjects was as follows (scores 0 to 5): 14.5%; 46.2%; 23.9%; 7.3% and 3.0%. Mean

age was 83.7 years (SD 0.36 years) and 60.3% were female. Positive outcome was registered in 34%

subjects. Factors that were negatively associated with ADL improvement in multivariate analysis were

impaired short-term memory (OR=0.58 [95% CI 1.07-1.23], p=0.038) and worse self-reported health

(OR=0.69 [95% CI 0.52-0.91], p=0.009). Recent hip fracture and worse ADL function at presentation

(higher ADL long scale score) were associated with increased odds of ADL improvement (OR=3.76

[95% CI 1.32-10.7], p=0.013 and 1.15 [95% CI 1.07-1.23], p<0.001, respectively). Surprisingly,

moderate vision impairment was positively associated with ADL improvement (OR=3.36 [95% CI

1.47-7.69], p=0.004) and likely represent better pre-morbid adaptation mechanisms. Current model did

not explain all existing variability in outcome (pseudo R2=11.4%).

Conclusion: Icelandic PAC data shows that both objective and subjective measures are associated with

ADL improvement. People who require extensive assistance at admission might have greater potential

for improvement. ADL improvement is only one aspect of CGA and rehabilitation and further study

using combined outcome measures is needed.

200

Supporting Flemish care professionals to address complex care and support needs in home care

by developing and evaluating a BelRAI Social Supplement

Shauni Van Doren, Kirsten Hermans, Anja Declercq


Abstract summary: This abstract describes the development and evaluation of a Social Supplement for the

BelRAI instruments in collaboration with both policymakers and care professionals to facilitate a smooth

implementation of BelRAI in the Flemish health and social care landscape.

Keywords: instrument development, social care, home care

In 2015, the Flemish government opted for a wide implementation of BelRAI in different settings to

adopt an integrated and person-centered care approach. Home care services will use the BelRAI

Screener, a short-form assessment with 5 questions and respective elaboration modules. Its focus,

however, lies on intrapersonal factors (e.g. IADL, ADL, and cognitive problems). While these factors

are an integral part of a person’s care needs, the social context or interpersonal factors also plays an

important role in designing a realistic care plan. The aim of this study is to develop, test and evaluate a

Social Supplement for the BelRAI instruments to answer these complex care and support questions in

Flemish home care.

By means of a scoping review, nine focus groups, and eleven expert panels with caregivers, care users

and policy makers from the Flemish home care sector, social and environmental factors that have an

influence on care needs and care demands of persons living at home were identified. These factors were

used as a guide to develop a first version of the BelRAI Social Supplement and an accompanying

manual. Additionally, different stakeholders and advocacy groups were asked to review both the

instrument and the manual and provide us with feedback on the contents of the texts. After addressing

their remarks, a preliminary test of the Social Supplement with about 50 assessments was conducted to

refine the instrument as well as the testing procedures.

The test version of the Social Supplement consists of 100 items in 4 modules: Environmental

assessment, Social engagement, Psychosocial wellbeing, and Informal care and support. In 2019, 100

care professionals received training to test and evaluate the Social Supplement in combination with the

BelRAI Screener, by assessing 1000 persons receiving home care in Flanders.

Our preliminary findings show that all participants regard knowledge about the social context of persons

with care needs as indispensable when drawing up a care plan. However, the growing diversity in home

and social care recipients proves to be a challenge to create an instrument that is suitable and relevant

for the broad range of care users in Flanders home care.

201

Who are the frequent attenders among primary care patients with multiple chronic disorders?

A cross-sectional study including interRAI self-report CU

Mieke JL Bogerd, Pauline Slottje, Marcel E Reinders, Hein PJ van Hout

Amsterdam UMC (location VUmc), the Netherlands

Abstract summary: Background: Within the multimorbid population the workload of General Practitioners

(GPs) is significantly related to a small group of frequent attenders (FAs). It is unclear whether these FAs differ

from multimorbid persons who consult less frequently. This study compares the characteristics and needs of

multimorbid patients between FAs and non-FAs.

Keywords: chronic diseases, multimorbidity, frequent attenders

Background: Of people living with chronic diseases 52% suffers from multiple chronic disorders.

Patients with multimorbidity often receive highly fragmented care that may lead to inefficient,

ineffective, and potentially harmful treatments. In addition, within this multimorbid group, it is well

known that the workload of General Practitioners (GPs) is significantly related to a relatively small

group of patients who consult their general practice very frequently. It is unclear whether these frequent

attenders (FAs) differ from multimorbid persons who consult less frequently. More knowledge on the

characteristics and needs of this particular group is warranted in order to identify FAs, organize tailored

chronic care and to reduce frequent attendance if appropriate and possible. The aim of this study is to

compare the characteristics and needs of patients with multiple chronic disorders between FAs and non-

FAs.

Method/design: A cross-sectional study in fifteen Dutch family practices using comprehensive self-

assessments of 1147 patients with three or more chronic disorders was linked to their GPs’ electronic

medical files. In this study, multimorbidity is defined as having three or more chronic disorders.

Frequent attendance is defined as general practice consultation at least twenty times during the last two

years. Patient characteristics include demographics (age, gender, marital status, level of education),

(combination of) chronic disorders, as well as self-reported variables such as patient experience with

chronic primary care, quality of life, self-rated health, functional ability, mobility, social participation,

health literacy and health skills, level of self-reliance, and resource use (inside and outside primary

care). A linear regression model will be used to compare characteristics between the multimorbid FAs

and non-FAs.

Results: The results will be presented at the conference.

Discussion: This study will provide insight in the characteristics and needs of multimorbid FAs in

primary care which might help us identify and develop interventions to tailor care and reduce frequent

attendance (if appropriate) more effectively.

202

eaRly dEmentiA Caregiving supporT (REACT) program: study protocol for experiment and

evaluation with interRAI instrument through the Medical Research

Shanshan Wang, Johanna de Almeida Mello, Anja Declercq


Abstract summary: Early dementia caregiving support is relevant but insufficient, we aim to test and evaluate

the REACT intervention adapted from an evidence-based intervention (NYUCI) by using interRAI and BelRAI

instruments. We hypothesize this early intervention would improve outcomes and promote health in informal

caregivers.

Keywords: healthy ageing, informal caregivers, early dementia

Background: Healthy Ageing has been a shared vision to achieve the 2030 Agenda for Sustainable

Development. Informal caregivers of persons with dementia are experiencing poorer health and early

caregiving support prevents the adverse outcomes. However, supportive service for early caregivers is

insufficient and unavailable. Given the recognized benefits of the NYU Caregiver Intervention

(NYUCI), we develop a modified NYUCI named “REACT: eaRly dEmentiA Caregiving supporT”.

This project aims to test the intervention and evaluate it in the Flemish context of care.

Methods: Under the Medical Research Council framework (MRC), this study covers developmental,

experimental and evaluation phases. In the developmental phase, we will translate and adapt the NYUCI

guideline and training program to the Flemish context. In the experimental phase, early dementia will

be screened through the interRAI Cognitive Performance Scale (CPS) with scores 1, 2 or 3 (range 0-8)

and 128 informal caregivers will participant a randomized controlled trial. The experimental group

(N=64) will receive the REACT intervention while the control group (N=64) will receive the usual care.

In the evaluation phase, baseline and follow-up (4, 8 and 12 months) assessments will be performed

using the BelRAI Screener, BelRAI Social Supplement and the interRAI Family Carer Needs

Assessment. They will provide data to evaluate (a) the main outcomes of informal caregivers: behavior

and attitudes changes, client-carer relationship, social relationship, psychological problems, self-rated

health, self-efficacy, life quality, and (b) the secondary outcomes of persons with early dementia:

Activities of Daily Living (ADL), Instrumental ADL (IADL), behavioral problems and cognition.

Discussion: If improved outcomes and maintained benefits are found, the REACT program could

specifically serve informal caregivers of persons with early dementia to better address elevated

emotional and practical challenges, promoting their well-being and health. This research will also form

evidence concerning ‘early dementia caregiving support’ and the ‘Decade of Healthy Ageing from 2020

to 2030’.

203

Reliability and validity of the InterRAI Cognitive Performance Scale across health care

settings: a protocol

Harriet Rachel Elizabeth Wilson, Melinda Martin-Khan

University of Queensland, Australia

Abstract summary: Evaluating the quality of the validity and reliability studies of the interRAI Cognitive

Performance Scale across health care settings (acute care, home care, long term care) has not yet occurred. We

aim to synthesise current literature of the reliability and validity across services to benefit clinician confidence in

the CPS.

Keywords: reliability and validity, cognitive performance scale, health care services

Introduction: Cognitive impairment is when a person has trouble remembering, learning new things,

concentrating, or making decisions that affect their everyday life. It can be detected using a standardised

assessment (or scale) prior to formal assessment for diagnosis.

The Cognitive Performance Scale (CPS) was developed as part of the interRAI minimum data set

instruments to assess an individual’s cognitive status. The CPS measures cognition on a scale of 0

(cognitively intact) to 6 (very severe impairment) and offers the additional advantage of accurate

screening for both dementia and delirium.

The CPS is embedded within an interRAI assessment instrument. Validation and reliability of the CPS

as part of the assessment instrument improves clinician confidence in the utilisation of the scale in that

setting. Evaluating the quality of the validity and reliability studies of the CPS across health care settings

(acute care, home care, long term care) has not yet occurred and would be beneficial to support clinician

confidence in the CPS.

Objectives: To synthesise current literature evaluating the reliability and validity of the interRAI

Cognitive Performance Scale across health services.

Method: This systematic review searched Medline, CINAHL, Web of Science, PubMed and Cochrane

databases accessed September 2019. All studies utilising the CPS as a cognition test and referenced

diagnostic, reliability, feasibility, validity or development of the tool were included. No restrictions

were placed on initial electronic searches.

Upon removal of duplicates, two reviewers (HW, MMK) will independently screen at title, abstract and

full text level for studies of relevance according to the inclusion/exclusion criteria.

Studies will be excluded if reference is made to the implementation, model or translation of the CPS;

the acronym CPS is not representative of “Cognitive Performance Scale”; or due to language barriers.

Conclusion: We will base conclusions only on findings from the quantitative or narrative synthesis of

studies included in this review. We will make recommendations for clinical practise in health services

if appropriate, and discuss implications for future research of the application of the Cognitive

Performance Scale whilst identifying any gaps in research regarding the development or validation of

the CPS.

204

The long-term effect of pain on future health complaints: Analysis of a national sample of

Canadian nursing home residents

Harriet Rachel Elizabeth Wilson1, Riccardo Calvani2, Nicoda Foster3, Beibei Xiong4, Yvonne

Hornby-Turner1

1University of Queensland, Australia; 2Catholic University of the Sacred Heart, Italy; 3McMaster

University, Canada; 4University of Northern British Columbia, Canada

Abstract summary: Pain is a major health issue in nursing home residents. Results show that pain is associated

with the presence of health complaints after one year in cognitively intact and mild impaired residents. Therefore,

effective management of pain is critical to long-term quality of life and care of nursing home residents.

Keywords: pain, health complaints, nursing home residents

Introduction: Pain is a major health issue in older people residing in nursing homes and is associated

with mood and psychological distress in cognitively impaired elderly residents (Castillo et al., 2013).

There is a significant lack of literature that investigates the effects that pain has on mood and

psychological distress in relatively cognitively intact nursing home residents and the contributing effect

on their healthcare needs. The aims of this study were two-fold:

a) What is the long-term effect of pain on psychological symptoms for Canadian nursing home

residents with mild to no cognitive impairment?

b) Does the level of cognitive impairment act as a mediator to the effects of pain on long-term

psychological symptoms?

Methods: Secondary analysis was carried out using a national sample of residents in Canadian Long-

Term Care facilities with data collected using the InterRAI Long-Term Care assessment (RAI-LTC).

Residents were assessed using the instruments Cognitive Performance Scale (CPS, 0-7), Pain Scale (0-

3) and repetitive health complaints (0-2) for mood and psychological distress. All residents with a CPS

score ≤2 at baseline and whose stay >14 days were included in the final sample of 103,356, with

repeated assessments at 3 months and thereafter. Results were analysed using descriptive statistics, Chi-

square test and ordinal logistic regression analyses.

Results: Reported pain decreased from 47% to 42% after one-year follow up, however health

complaints increased from 13% to 22% in the same period and 40% of residents were more likely to

complain if they had pain at baseline. The results show that pain is associated with the presence of

health complaints after one year of nursing home residency in both cognitively intact and mild

cognitively impaired residents.

Conclusion: The effective management of pain is critical to the long-term quality of life and care of

older nursing home residents.

References:

[1] Miranda-Castillo, C., Woods, B. & Orrell, M. (2013). The needs of people with dementia living at

home from user, caregiver and professional perspectives: a cross-sectional survey. BMC Health

Services Research, 13(43). doi:10.1186/1472-6963-13-43.

205

A pilot study of using interRAI-AC-CGA in senior adults undergoing selective lumbar surgery

Haiyan Xie, Keyi Yu, Yaping Chen

Peking Union Medical College Hospital, People's Republic of China

Abstract summary: A nurse-based interRAI-AC-CGA utilizing program was explored in orthopedic ward of

Peking Union Medical College Hospital. It was helpful in tracing functional status changes of senior inpatients

undergoing selective lumbar surgery during perioperative period, as well as to find out factor related to length of

hospital stay.

Keywords: comprehensive geriatric assessment, interRAI, perioperation

Objective: Tracing functional status changes of senior inpatients undergoing selective lumbar surgery

during perioperative period and analysis factors related to length of hospital stay (LOS).

Methods:From April to June, 2019, a nurse-based comprehensive geriatric assessment(CGA) program

was explored in orthopedic ward of Peking Union Medical College Hospital by using interRAI

(international resident assessment instrument)-AC( acute care)-CGA. A convenient sampling was

utilized to collect patients e≥70 years old, who was admitted for selective lumbar surgery. Patients were

excluded if they were younger than 70, with unstable medical status, undergoing other type or

emergency surgery, or refused to be assessed. A well trained nurse was sent to do interRAI assessment

in 1st and 14thday after admission, as well as one day before discharge. At the same time, daily follow-

up was done to record status of pressure ulcer, delirium, fall, infection, pain,and nutritional support,

until discharge.Doctors were blinded to the assessment.

Result: Totally 30 cases were included with average age 76±3.69 years old（range from 72 to 87）,

and female occupied 73.3% (22 cases). At admission, patients with polypharmacy (≥5 kinds of

medication routinely )were 9 cases (30%), while before discharge, the number become to 22 cases

(73.3%).

Changes of scales of ADL hierarchy,IADL performance, communication, pain, cognition

performance(CPS) and pressure ulcer (PURS) at admission and pre-discharge were analysis.The results

showed that dependent rate for ADL elevated from 20% to 30%. Dependent rate of IADL performance

was 30%.Rate of daily pain but not severe elevated from 3.3% to 10%. Rate of mild cognition

impairment elevated from 13.3% to 16.7%. Average length of hospital stay (LOS) was 15.13±7.50

days( range from 4 to 42 days), and average days between admission and operation was 5.34±2.30 days

(range from 0 to 12 days). Multifactor logistic regression analysis demonstrated that ADL dependent,

polypharmacy, pain scores, and comobidities were related to LOS.

Conclusion: In order to shorten LOS, functional assessment should be performed in selective surgery

old patients. More suitable patients should be selected to accept the operation and precise care plan

should be made before and after operation according to interRAI-AC-CGA.

206

Reliability of Chinese version interRAI long term care and a pilot study of application analysis

in three kinds of long term care settings

Haiyan Xie1, Yu Liu2, Fan He1, Xiaomei Pei3

1Peking Union Medical College Hospital, People's Republic of China; 2China Medical University

School of Nursing; 3Tsinghua University School of Sociology

Abstract summary: For the first time, reliability of Simplified Chinese version interRAI-LTCF was tested by

our research team in mainland of China, with very good result. Furthermore, we use interRAI-LTCF in three kinds

of long term care settings, and found out the scales were helpful in functional status assessment.

Keywords: long term care, reliability, functional assessment

Reliability of Chinese version interRAI long term care and a pilot study of application analysis in three

kinds of long term care settings

Objective: To test reliability of Simplified Chinese version interRAI-LTCF (international resident

assessment instrument- long term care facilities), and to perform a pilot study in different settings.

Methods: Translation from English to Simplified Chinese and adaption of culture diversity in interRAI-

LTCF were done according to international standard procedure. Assessor will be qualified only after

they passed the 6 hours face to face training course, three simulated cases test and two real cases test.

A convenient sampling was utilized to collect 82 old residents in three kinds of long term care settings,

which included nursing home, geriatric unit in acute care hospital and community long term care

facilities, by qualified assessors from 2014 to 2016. Furthermore, 30 residents were chosen by random

in one of nursing homes, and twice assessments for the same resident were performed by two assessors

independently during three days. Internal consistency of major scales and inter-rater reliability were

testified.

Result: Major scales of ADL (activities of daily life), depression, communication, cognition, pressure

ulcer and pain were tested. Internal consistency of most scales were good with Cronbach׳s index higher

than 0.70(0.70-0.93), except pain scale was lower (0.602). Inter-rater average reliability was as good as

0.72, while inter-class correlation of depression and pain scales were lower than 0.70(0.67 and 0.47,

respectively).Distribution of Dependency of ADL(53%, 56% and 30%, respectively), polypharmacy

(33%, 25% and 20%, respectively) and comobidities (55%, 91% and 50%, respectively) among nursing

home, geriatric unit in acute care hospital and community long term care facilities were significantly

different(P＜0.01) . Further analysis revealed that 10 percent of totally ADL dependent residents and

20 percent of residents with polypharmacy still stayed in community, while 20 percent of ADL

independent residents lived in nursing home.

Conclusion: Simplified Chinese version interRAI-LTCF was good at reliability and can be used in

different long term care settings. It was helpful in assessing functional status of senior residents who

had long term care needs.

207

The Sequelae of Psychological Symptoms Exhibited by Children Exposed to Trauma: A

Developmental Perspective

Annie Yang, Susan Rodgers, Alan Leschied, Shannon Stewart

Western University, Canada

Abstract summary: Children who experience complex trauma exhibit a myriad of symptoms beyond the criteria

outlined in a PTSD diagnosis. The present study will examine the age specificity of trauma-related symptoms

across several domains including: dysregulation in affect, physiology, behaviour, attention, and cognition,

disturbances in self-concept, attachment difficulties, and post-traumatic spectrum symptoms.

Keywords: developmental trauma, children and adolescents, ChYMH

Children who experience chronic trauma often exhibit a myriad of symptoms beyond the criteria

outlined in a PTSD diagnosis. Van der Kolk (2006) proposed a separate diagnosis of Developmental

Trauma Disorder (DTD) to account for the diverse clinical presentations found among children who

have experienced complex trauma. The proposed DTD diagnostic criteria demonstrate significant

overlap with Cook and colleagues’ (2005) domains of impairment in children who experience complex

trauma. Both models include self-regulatory difficulties across several domains. Specifically,

dysregulation in affect, physiology, behaviour, attention, and cognition, disturbances in self-concept,

attachment difficulties, and post-traumatic spectrum symptoms. It has been argued that DTD, as a

diagnostic entity, is more developmentally sensitive when compared to PTSD. Despite this, there is no

age-specificity of symptoms stipulated in the diagnostic criteria of DTD. Further research on how

trauma reactions present in children across different ages is necessary to provide the empirical

foundation to support the theoretical framework of a developmental trauma diagnosis. The present study

aims to: 1) Determine whether the symptom profiles of children who have experienced trauma present

differently by age; and 2) Explore the trauma-related symptoms present in early childhood, late

childhood, and adolescence, for individuals who have experienced complex trauma. Data from the

interRAI ChYMH has been obtained from mental health agencies across Ontario for an estimated 9,000

children and adolescents who have a history of trauma. ChYMH items will be factor analyzed by age

group to determine how symptoms cluster. Understanding symptom presentations of children who

experience trauma at different stages of development will inform the establishment of developmentally

appropriate interventions for children and adolescents accessing mental health services across Canada.

208

http://www.worldinterrai2020.org/

Documents

ABSTRACT BOOK...Prior to joining CIHI in 2014, Mr. O’Toole spent more than 20 years in the Ontario public sector, including as deputy minister of Natural Resources, deputy minister