A person-specific standardized assessment instrument - Continuing and Rehabilitative Care for Elderly People: A Comparison of Countries and Settings

Age and Ageing, Nov, 1997 by Knight Steel, Sylvia Sherwood, Miel W. Ribbe

The next century will demand that long-term institutional care be better integrated into the health care system as a whole. More co-ordination of care among community and institutional resources will be required to facilitate effective and innovative programmes for respite care, night and weekend admissions for a limited period of time, crisis intervention, short-term rehabilitation and special care units for individuals with, for example, Alzheimer's disease and AIDS. The striking country-to-country variation in the way long-term care institutions are utilized, as demonstrated by Frijters et al. [1], will likely be minimized. As noted, some countries have already established assessment teams to evaluate an individual's need for admission to a long-term care facility. Although cultural differences may persist to a degree, as is true of so much that has followed the introduction of worldwide information services in almost all human endeavours, similarities among people and their needs will likely begin to overshadow differences. A nation will continue to utilize its resources according to its own traditions but each will have the capability of scrutinizing their use in a way never before possible.

Although each of the papers published in this volume might stand alone, when they are laid back to back a much greater appreciation of the Resident Assessment Instrument (RAI) methodology and what it can do for all who are ageing and for the countries in which they reside, is made possible. First, as all developed countries struggle to provide care over the long term to the ever enlarging older population, each nation will truly be able to benefit from the experiences of others. The use of a standardized cross-national assessment tool will permit comparable information bits to be transported across borders and utilized, both to develop a constructive cost-efficient health care policy locally and to improve quality of care in, and outside of, institutions far distant from the sites where the data were collected [2]. Outcomes of care will be able to be compared and may be expected to be similar throughout the developed world with markers of quality stable across nations, as presented by Schroll et al. in this supplement [3].

Second, person-specific studies will likely gain in importance over site-specific analyses. The resident assessment instrument as presently used in nursing homes in the USA and in many European nations opens the way for an individually focused approach, for not only does it address the physical and psychiatric status of each person but it contains domains directed to the personal interests, routines and social milieu of those evaluated. By adapting it for both home care and acute hospital care use (presently in progress) with much overlap of questions it becomes increasingly a `transportable' person-specific instrument. Information will be obtained which will allow for a recognition of individual needs regardless of the location in which the data were collected. This will almost certainly assure both better individual care and more targeted utilization of health care resources.

In Japan, for example, at present few older people reside in purpose-built long-term care institutions and beds originally intended for acute care are being used for elderly individuals for extended periods of time [4]. With the parent support ratio (the number of people 80 years of age and over per 100 people 50-64 years of age) more than tripling from 13 to 45 in just 35 years in Japan, data provided by a transportable comprehensive assessment tool will make it possible to discover where resources might be better utilized so as to care for this rapidly enlarging group of frail elderly people [5]. Such a policy direction is clearly essential as well for those family members who must pay the costs of that care.

Third, the further development of the RAI instrument specifically for use in the home setting will permit comparisons of care plans and patient outcomes for those in need of continuing care--be that a few days or years. By more clearly delineating an individual's needs, home care services can be more effectively applied, perhaps allowing more people to remain at home. Home care services in many countries are often inadequate in scope and poorly configured to meet the needs of those they are designed to serve. They may be designed to respond to reimbursement policies rather than patient needs. In most developed nations home health care services and home-based social support services remain quite separate and distinct entities [6]. At present, there are striking differences in the way these services are provided. In the case of social services, in many European countries the client has the power to order them, assuming that they can afford them, while health care services must be prescribed by a physician. The interdigitation of services so as to be both effective and efficient is too often sorely lacking. A comprehensive screening instrument is essential to progress in this regard.