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

Content of the RAI

To achieve the goals set by Congress, the Health Care Financing Administration and the project team, we concluded that three things were needed [3, 4]. The first was a core set of assessment items that would provide a comprehensive picture of each resident's functional status, including the resident's strengths, preferences and needs. This is known as the Minimum Data Set for resident assessment and care screening (MDS). The second element was a set of specialized assessment protocols that are intended to more directly link the MDS information to care plan decisions. These are 18 condition-focused Resident Assessment Protocols (RAPs) which specify an additional, highly focused assessment if the resident's status, as revealed by the MDS, suggests a problem, risk for development of a problem, or potential for improved function. Such conditions are identified by applying a set of algorithms specified in each RAP area to a resident's MDS data. Facility staff then use the more specialized assessment guidelines found in the RAPs to identify potentially treatable causes and focus decisions about the resident's plan of care and services. (Table 1 summarizes the MDS domains and the 18 RAP areas.) The third element of the RAI is a user's manual with detailed specifications about how to complete the MDS and RAP assessment process (e.g. interviewing staff, residents and family members, reviewing records), item definitions, examples of coding options and clinical guidelines for using the RAPs to develop care plans [5]. In addition, the RAI includes a quarterly review that specifies a subset of MDS assessment items and is intended to monitor the resident's response to the care plan and determine whether sufficient change has occurred to trigger a more comprehensive assessment.

Development and testing of the RAI

We determined the domains to be included, using the areas specified by Congress, those reflected in other comprehensive instruments and those identified by expert clinicians as key to the functional welt being of nursing home residents. The clinical/research work groups then specified the items, definitions and response categories that were essential in each domain. After creating the first drafts, which were internally reviewed, the project team identified additional staff from nursing homes around the country and other well-known clinicians and researchers who were asked to review and comment on various drafts. This became an iterative process, with reviews leading to further revisions by the clinical workgroups--and reviews of the new drafts. Before the first field test of the MDS, 27 drafts and revisions were completed, based on reviews by hundreds of clinical experts and nursing home providers across the country. During the process of testing and retesting, elements of the RAI went through an additional 15 revisions with clinical reviews.

In addition to clinical reviews, we tested two versions of the MDS and RAPs in a total of 28 nursing homes in six states, using facility and research nurses, with dual assessments of more than 600 residents. These tests, including debriefing of facility staff who tested the RAI, were used to establish the face validity and inter-rater reliability of the RAI items and assessment protocols, to limit items to those considered essential to care planning by facility providers and expert clinicians, and to improve the training manual. The results of these tests and reliability of the final RAI/ MDS items are reported elsewhere [3, 6-8]. Figure 1 summarizes this development process.