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

Table 2. Nursing home staff's views on why the
Resident Assessment Instrument (RAI) has proved useful

The RAI provides a holistic view of the resident as a
 person, not merely a list of nursing care needs, by
 including a focus on strengths, preferences and
 customary routines

The Minimum Data Set provides a comprehensive
 summary across the major functional domains, so
 that, for example, the resident's cognitive status
 can be considered in relation to his or her activities
 of daily living status, when deciding on the
 appropriate rehabilitation or restorative care plan
 intervention

The use of standardized definitions and response
 categories provides a common language across
 disciplines which facilitates multi-disciplinary team
 assessment and care planning

The Resident Assessment Protocols provide a
 systematic way to link assessment information to
 care plan decisions

The focus of the RAI assessment is on restoring and
 maintaining function, so it not only identifies current
 problems but also the risk for the development
 of new problems and identifies the potential for
 improved function. This facilitates more aggressive
 and affirmative care plan interventions

Finally, we find that because of its reliability, the RAI/MDS data can be used for a variety of purposes in addition to its original and primary goal of improving care. Facilities in the USA use it to determine staffing needs and for continuous quality improvement initiatives. Staff use it to support their clinical decisionmaking. Families and long-term care ombudsmen use it to help them understand and evaluate the care being provided to elders. Policy-makers use it to set nursing home payment rates that encourage access for heavy care residents and achieve greater equity across providers. State and federal inspection agencies use it to evaluate facilities' performance, using resident outcomes and key process quality indicators which allow them to more effectively target their quality assurance activities. Increasingly, researchers are also using it to examine the effects of various clinical interventions and to study policy-relevant issues, such as the relationship between cost and quality.

The international community and the RAI

The international long-term care community has also found multiple uses for the RAI. Starting in 1990, geriatricians and researchers in other countries began expressing interest in the RAI and its development in the USA. GEriatric assessment has a long history in European countries; thus, a systematic way of bringing this process to the care of elders in nursing homes was appealing to many of these geriatricians who learned of the RAI at professional meetings and from colleagues. Other researchers were drawn to the RUGs system as a means of paying nursing facilities appropriately for `heavy care' residents and discovered the RAI as part of the process of investigating use of RUGs.

Table 3 presents a summary of the main uses of the RAI in countries that participate in interRAI, an organization of geriatricians, academic researchers and other professionals committed to developing and using standardized assessment instruments to improve care for elders. In each of these countries, an interRAI member has taken lead responsibility for translating the MDS, the training or user's manual and, in most countries, the RAPs. (This has also included a process of `reverse translation' and comparisons between the original and twice-translated versions to reduce ambiguities or incompatibility across the versions.) Thus, versions of the RAI exist in 14 languages (most recently Chinese) and it is being actively used in several nations.