Minimum Data Sets / Resident Assessment Instruments Tools for Building a Strnoger Health Care System

by Vern McClelland

Good information is the foundation of good health care. Decisions based on quality indicators, performance measures, and a clear understanding of population health issues can dramatically improve resident outcomes and cost efficiency.

To date, each Canadian province uses a different classification system or measurement tool. It has become evident that it is no longer acceptable, nor desirable, for health system administrators to operate their programs in isolation from the global community. Information technology using common 'language' such as Minimum Data Sets (MDS) has enabled worldwide research on the determinants of health and health practice.

Designing an Information System for the Next Century...

A 1998 national consultation involving over 500 stakeholders in the Canadian health system identified seven information priorities:

  1. the need for an integrated health information system
  2. regional and community information
  3. cost data
  4. evaluation information on alternative interventions and technologies
  5. performance information, including comparative data and benchmark indicators
  6. health indicators and trend information
  7. consumer expectations

The consensus was that to accomplish these objectives, data needs to be organized around persons rather than incidents or events.

In other words, a health system needs to emphasize client-centered care an support it with an information infrastructure that reveals the long-term effects of a multitude of sequential interventions. It also should be capable of measuring the impact of the environment and other determinants of health on an individual's well being. This demands a common core of data elements in a 'flowthrough' design.

Proving quality provision of care is becoming increasingly important in health services, as both not-for-profit and for-profit organizations are being held accountable for their actions. With the shift of emphasis by governments to serving more people in the community, it has become incumbent to be able to measure outcomes. By using the linked series of Resident Assessment Instruments (RAI) instruments, policy makers can monitor the impact of impairment, disability, disease, and health practice on quality of life and activities of daily living.

Such an integrated system requires a basic understanding of the individual's needs as they engage with the health system. The RAIs are composed of a set of questions and observations designed to gather information on each client in a record system - the MDS.

A series of RAIs linking home care, long term care, mental health services and acute care have been developed by an international network of over 30 researchers in 18 countries known as interRAI.

The RAI instruments provide information that can be used in a number of ways:

InterRAI is a nonprofit research consortium with members from North America, the Nordic countries, Western Europe, the Czech Republic and the Pacific Rim. A number of the world's leading health and geriatric specialists participate.

Consumer Expectations

Clients want health care providers to 'remember' baseline demographic information about them, have knowledge of previous interventions in order to support present care planning, be accountable for outcomes and generally be accessible. They want the assurance that the 'system' makes decisions on present and future care based on past service history and current best practices.

One of the greatest benefits of the MDS approach for long term care is the fact that it has been designed to trigger Resident Assessment Protocols (RAPS) to assess when an individual's needs should be investigated further by care providers.

RAIs can be applied in other venues such as Home Care where a similar set of protocol triggers have been validated as applicable in a Home Care environment.

Meeting Stakeholder Needs

In order for MDS and RAIs to be functional, they must be responsive to the demands and requirements of all jurisdictions in the care delivery process, from the internal health care stakeholders to the external users and funding agencies.

Internal Stakeholders

Executives and governance authorities indicate a need for:

Management personnel seek:

On the other hand, clinical staff typically look for:

External Stakeholders

Clients desire:

Families look for:

Governments strive to provide:

Providing Performance Information

InterRAI researchers and member agencies have invested an extraordinary amount of resources into the development of quality measures. With such measures, not only can a health authority compare facility to facility or region to region, care can be improved as a result of consistent data analysis and comparison with peers. Through this approach international benchmarking can be done on a host of quality-related performance indicators.

From the experience of care agencies such as Saskatchewan’s Prince Albert Health District that have fully implemented RAI/MDS, it often requires ten or more assessments before frontline staff begin to gain value from the new approach. They recommend that a facility implement the RAI in manual form first so that personnel become comfortable before moving to an automated platform.

Adopting a comprehensive case management software system targeted at the long term care sector, such as that offered by Winnipeg-based Momentum Health Information System’s Care Manager, facilitates ongoing MDS reporting without the perception of add-on responsibilities.

Once care-providing agencies begin to use the RAIs as the core element of their information system, there is a noticeable increase in ongoing improvement activities at all levels. The process quickly focuses where improvement is indicated. Each stakeholder group, both internal and external to the agency, becomes more aware of the need to gather evidence before making decisions. There is also heightened sensitivity to the needs of the residents/clients as well.

Resident Utilization Groupings

Delivering service based upon need, rather than just perpetuating current services, is the goal of any progressive care provider. Care-providing agencies gather information from three primary sources: the client himself/herself, family members, and the written care record. With continual movement of staff, the written record validates what is being done, when it was done, or why it wasn’t, and what the desired outcome is.

InterRAI has defined 44 categories of care organized into seven broader clinical or Resident Utilization Groupings (RUGs III): rehabilitation, extensive services, special care, clinically complex care, cognitive impairment, behavior problems, and reduced physical function.

RUGs III also provides better information for program management at the facility and regional level, allowing service structures to be targeted at specific populations in care. This leads an organization to allocate resources according to actual current need and not tradition. As it is based on the MDS in the written record and ongoing RAI, it is less open to manipulation in the budget process.

Total dollars available to fund health care are finite and allocation often becomes a contest between competing needs. While RUGS III does not increase the size of the whole pie, it can ensure that each slice is relative to the needs of that group of residents/clients with similar care characteristics.

Towards the Future

It is very possible that the RAI family of instruments could form the core of a truly integrated health system. The sharing of nonidentified data from millions of actual cases around the world already has led health researchers and clinicians to make recommendations on health policies that have significantly improved care. The proven reliability of MDS in long term care has led to the deployment of aligned versions for other sectors.

With the worldwide increase in the number of elderly persons expected over the next 25 years, countries will need assessment tools such as RAI/MDS to better understand and support the needs of their population’s most vulnerable members.