Development of the nursing home Resident Assessment Instrument in the USA - Continuing and Rehabilitative Care for Elderly People: A Comparison of Countries and Settings

Age and Ageing, Nov, 1997 by Catherine Hawes, John N. Morris, Charles D. Phillips, Brant E. Fries, Katherine Murphy, Vincent Mor

Introduction

This paper describes the content and development of the nursing home Resident Assessment Instrument (RAI), including the testing for reliability and validity in the USA. It also summarizes the effects of its clinical use to assess nursing home residents and develop individualized care plans. In addition, it mentions other uses of the RAI data in the USA, such as for payment using resident classification systems and to generate outcome-oriented quality indicators. Finally, it briefly summarizes the process by which this innovation has been diffused across other nations and the status of RAI use in other countries.

Genesis of the RAI

The RAI was part of a set of reforms enacted by the United States Congress in the Omnibus Budget Reconciliation Act of 1987 (OBRA-87). The RAI and other OBRA-87 provisions were the most sweeping reforms to how nursing homes were regulated since the onset of federal payment for nursing home care with the passage of Medicare and Medicaid programmes in the mid-1960s. Their enactment was generated by recognition of changing standards of clinical care in the industry, concerns about continuing problems in nursing home quality and widespread recognition that existing federal and state regulatory systems were ineffective.

In an effort to address these problems, in 1983 Congress asked the National Academy of Sciences and its Institute of Medicine to examine nursing home quality and report on how to improve nursing home regulation. The Institute of Medicine formed a committee of experts and after a 2.5-year study and a series of hearings, the committee issued its report [1, 2]. One of its central recommendations was the development of a uniform, comprehensive resident assessment system.

The Institute of Medicine committee argued that a uniform, comprehensive assessment of each resident was essential to improving the quality of care in the nation's nursing homes [1]. The committee viewed comprehensive functional assessment as the cornerstone of individualized care planning that would focus on helping each resident attain and maintain their maximum practicable functioning and well-being. In addition, the committee argued that the resident-level data from such assessments were essential to the development of outcome-oriented measures of quality and the implementation of resident-focused quality assurance systems.

Congress enacted most of the committee's recommendations, including resident assessment, as part of OBRA-87. It gave authority to develop the resident assessment instrument and regulations governing its use to the federal agency responsible for setting nursing home standards, the Health Care Financing Administration. The RAI was developed by a research consortium under contract with that agency [3]. (The contract was between the Health Standards Quality Bureau, Health Care Financing Administration and Research Triangle Institute in North Carolina. The Institute's collaborators included the Hebrew Rehabilitation Center for Aged in Boston, MA, the Center for Gerontology and Health Care Research at Brown University, Providence, RI and the Institute of Gerontology at the University of Michigan at Ann Arbor.)

The new assessment regulations, originally slated for implementation in October 1990, were fully implemented in Spring 1991 and now apply to more than 90% of all nursing homes in the USA. They require use of the RAI when the resident is first admitted to a nursing home and at least annually thereafter to assess the resident and develop the resident's plan of care.

Process of RAI development

The RAI development team began work in October 1988. To aid it, the project team established 18 clinical work groups. These work groups included geriatricians, gero-psychiatrists, nurses, social workers, dieticians, physical, occupational and speech therapists, recreational therapists, dentists, nursing home operators, resident advocates and researchers. Our first task was to articulate the goals that would guide development of the RAI and be responsive to the congressional mandate for a uniform, comprehensive functional assessment. Thus, we wanted an instrument whose main use was clinical--to focus attention on a view of the `whole' person, to encourage restorative and rehabilitative care and to guide care plans. Further, the RAI was intended to facilitate communication and problem-solving among a multi-disciplinary team of caregivers (e.g. nurse, physician, social worker, therapist, dietician) by creating a common `language' and understanding of the resident. We also recognized that the RAI should be feasible for use in the average nursing home, which often lacked access to geriatricians, mental health professionals and sometimes even licensed therapists. Finally, the RAI items had to be reliable across users (inter-rater reliability).

Achieving these goals involved several major activities, including: (i) reviewing existing instruments; (ii) determining the domains to be included and the items, definitions and response categories to be included in each domain; (iii) establishing the reliability and validity of the instrument; and (iv) developing training materials to accompany the assessment instrument. As shown in Table 1, this was an iterative and interactive process.