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

3. Improvements in a wide array of other care processes that affect residents' quality of care and quality of life, including increased involvement of families and residents in care planning increase] use of advance directives, increased use of behaviour management programmes, increased involvement in activities and i decreased use of problematic interventions, such as indwelling urinary catheters and physical restraints;

4. Significant reductions in decline among residents in such areas as physical functioning in ADLs, cognitive status and urinary continence; and

5. A significant reduction in the number of nursing home residents who were hospitalized, with no increase in mortality.

Discussion

Strengths of the RAI

Clinicians have long recognized that comprehensive functional assessment of elderly subjects is central to maximizing their physical and cognitive functioning and their quality of life. Indeed, studies have established its utility in improving quality, reducing unnecessary nursing home placement and improving the functional well-being of elders in hospital, ambulatory and clinic settings [17-21]. With the RAI, we find that this process achieves similar results in long-term care facilities.

The evaluation of the RAI demonstrated its utility in improving the quality of care in US nursing homes. Further, we learned more about why it is effective from the perspective of long-term care administrators and directors of nursing. In two studies, the vast majority of nursing home administrators and directors of nursing or unit nurses who were surveyed reported that it improved assessment and care planning in their facilities, improved their ability to identify problems and improved their ability to determine whether care plans were achieving desired effects [22-25]. Further, it enhanced clinicians' knowledge and ability to intervene effectively in such areas as identification of delirium, dehydration and mood problems--areas that were typically under-diagnosed and under-treated prior to the implementation of the RAI. Similarly, another survey of nursing home staff in six states found that staff viewed the MDS as a useful tool for clinicians [26].

At the same time that administrators and nursing home staff were generally positive about the impact of the RAI on quality, about one-third of staff felt it did not improve quality. Moreover, between half and two-thirds of the staff felt that completing the RAI added to their paper-work burden, including even some of those who felt it improved quality of care. In addition, a recent study indicates that some facilities are experiencing significant difficulties using the RAI appropriately, resulting in inaccurate MDS data and poor use of the RAPs [27]. Thus, ensuring effective use of the RAI to improve quality of care and life for residents uniformly across facilities and implementing practices that minimize the burden on facilities requires additional work. At the same time, a summary of nursing home staff's views on why the RAI has proved clinically useful (Table 2) is instructive.