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interRAI Assessment System for Mental Health: An integrated suite of instruments

interRAI Assessment System for Mental Health: An integrated suite of instruments. John P. Hirdes, PhD Professor School of Public Health and Health Systems University of Waterloo. Agenda. Introduction to interRAI mental health instruments Applications of interRAI assessments

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interRAI Assessment System for Mental Health: An integrated suite of instruments

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  1. interRAI Assessment System for Mental Health:An integrated suite of instruments John P. Hirdes, PhD Professor School of Public Health and Health Systems University of Waterloo

  2. Agenda • Introduction to interRAI mental health instruments • Applications of interRAI assessments • Clinical practice and performance measurement • Care planning protocols • Quality Indicators • Clinical Example in Forensics

  3. interRAI • Who • International, not-for-profit network of ~60 researchers and health/social service professionals • What? • Comprehensive assessment of strengths, preferences, and needs of vulnerable populations • How? • Multinational collaborative research to develop, implement and evaluate instruments and their related applications

  4. interRAI Countries Europe Iceland, Norway, Sweden, Denmark, Finland, Netherlands, France, Germany, Switzerland, UK, Italy, Spain, Czech Republic, Poland, Estonia, Belgium, Lithuania, Russia Portugal, Austria North AmericaCanada US Mexico Central/ South AmericaBrazil,Chile Peru Pacific Rim Japan, China, Taiwan, Hong Kong, South Korea, Australia, New Zealand Singapore South Asia, Middle East & AfricaIndia, Israel, LebanonGhana

  5. interRAI Network of Excellence in Mental Health • 25 member network within interRAI focused on mental health and intellectual disabilities • Active research and implementation in 12 countries • 2013 iNEMH meeting in Maastricht • Partnership with EFP and TBS facilities in NL pilot study

  6. The interRAI Family of Instruments • Mental Health • Inpatient • Community • Emergency Screener • Forensic Supplement • Child & Youth • Correctional Facilities • Brief Mental Health Screener • Community Health Assessment • Functional supplement • MH supplement • Deafblind supplement • AL supplement • Intellectual Disability • Home Care • Contact Assessment • Nursing Homes, Complex Continuing Care Hospitals • Acute Care • ED Screener • Palliative Care • Post-Acute Care-Rehabilitation • Subjective Quality of Life • Long term care • Home and community care • Mental Health

  7. Implementation & Testing of interRAIInstruments in Canada RAI 2.0 RAI-HC RAI-MH interRAI CMH interRAI ESP interRAI PC interRAI ID interRAI ED/AC interRAI CA interRAI CHA interRAI AL interRAI SQoL DB Solid symbols – mandated or recommended by govt; Hollow symbols – research/evaluation underway

  8. Canadian Institute for Health Information Data Holdings based on interRAI Assessments • Data submitted by 2012-13 • Mental health - 721,882 assessments on 224,494 unique patients • Home care – 1.6 million assessments on 648,024 unique clients • Nursing home- 2.7 million assessments on 647,078 unique residents • … and this is without all provinces submitting data and not all implementations complete!!

  9. What Makes the interRAI Instruments an Integrated System? • Common language • consistent terminology across instruments • Common theoretical/conceptual basis • triggers for care plans • Common clinical emphasis • functional assessment rather than diagnosis • Common data collection methods • professional assessment skills • clinical judgment of best information source • Common core elements • some domains in all instruments (e.g., ADL, cognition) • Common care planning protocols • for sectors serving similar populations

  10. Integrated Mental Health Information System 18+ Mainly elderly 4-17 CA CF Screen ESP BMHS

  11. New Admissions by Patient Type, Ontario 2005-2008

  12. Applications of interRAI’s Assessment Instruments:One assessment … multiple applications Case-mix Single Point Entry Care Plan Resource Allocation Evaluation Best Practices Risk Management Assessment Balance incentives Outcome Measures Quality Indicators Patient Safety Quality Improvement Public Accountability Accreditation

  13. interRAI Mental Health Clinical Assessment Protocols (CAPs)

  14. Mental Health CAPs: The Research Effort • International consultation • Feedback through interRAI Fellows and collaborating agencies • International experts participate in CAP revision • Extensive review by interRAI ISD Committee and iNEMH • Literature reviews and examination of best practices • Examination of new research on CAP topics • Search of English language and non-English language BPGs • Aimed to find international consensus on clinical approach • Extensive analyses of interRAI data holdings • > 350,000 RAI MH from inpatient psychiatry • 2,000 interRAI CMH from Ontario and Newfoundland

  15. Basic Principles for MH CAPs • Evidence-based triggers and assessment guidelines • Incorporate recovery principles • Collaborative decision-making involving person and, where appropriate, informal support network • Not a robotic care planning library • Focus on enhancing person’s quality of life in all domains possible • Multidimensional intervention strategies (person, family, community) • Not a diagnostic system • Support autonomy of person and take into account strengths, preferences, and needs • Calibrate approach to person’s current level of functioning

  16. New interRAI Mental Health CAPs • Safety • Suicidality and Purposeful Self-Harm * • Harm to Others * • Self Care * • Social Life • Social Relationships • Social Support (CMH) • Support Systems for Discharge (MH) • Interpersonal Conflict • Traumatic Life Events • Criminal Activity • Economic Issues • Personal Finances • Education and Employment • Autonomy • Medication Management & Adherence • Rehospitalization • Control Interventions (MH) • Health Promotion • Smoking * • Substance Use • Exercise • Weight Management • Sleep Disturbance • Pain • Falls * Also available in ESP

  17. Staff Ratings of Severity of Risk Related to Ability to Care for Self by Self Care Index (SCI), interRAI ESP Pilot

  18. Self Care CAP in Various Settings

  19. Self Care CAP in Various Settings

  20. Medication Issues by Self Care CAP Trigger Levels and Care Setting CommunityMental Health In-Patient Emergency

  21. Multiple Psychiatric Hospital Admissions (Last 2 years) by Self Care CAP Trigger Levels and Care Setting CommunityMental Health In-Patient Emergency

  22. Health Service Use at Follow-up/Discharge by Self Care CAP Trigger Levels and Care Setting In-Patient Community Mental Health

  23. Development of Mental Health Quality Indicators based on interRAI Assessments

  24. Mental Health Quality Indicators (MHQIs) • Depressive Symptoms • Aggressive Behaviour • Disruptive Behaviour • Inpatient Violence • Positive Symptoms • Cognitive Performance • Activities of Daily Living • Capacity to Manage Finances • Capacity to Manage Medication • Pain • Interpersonal Conflict 2) Prevalence at time of assessment: • Inpatient Violence (violence in 3 days prior to assessment) • Physical Restraints (including manual) • Acute Control Rx Use (not including PRN) • Patterns of Change: a) Improvement & b) Incidence/ Failure to Improve

  25. Median Adjusted MHQI Rates among Ontario Hospitals/Units Green= Improvement/time 1 prevalence Red = Time 2 prevalence

  26. Case-mix adjusted QI Rates between Hospitals

  27. Clinical Example Forensic Psychiatry

  28. Too often in forensic psychiatry we consider only the risk indicators …

  29. … when we should really be looking at the whole person Poverty Social isolation Bad posture resulting in pain in butt Addictions

  30. Clinical Example Who Gets an Unaccompanied Leave in Ontario?

  31. Authorized leaves outside of facility or locked unit, by day of stay and type of assessment, forensic patients

  32. Authorized leaves outside of facility or locked unit, forensic patients (2+yrs only)

  33. Multivariate Logistic Regression Models for Unaccompanied Leaves from Hospital Among Ontario Forensic Mental Health Patients

  34. Future Directions for interRAI Research on Forensic Mental Health Services • Refinement of Forensic Supplement • Link to other risk indicators in forensics • Early evidence to inform clinical management of risk • Development of forensic specific MHQIs • Refinement of case mix classification related to resource use in forensics • Cross national comparative research on outcomes of care in forensic services

  35. Join in on the interRAI-EFP-TBS partnership!! Thank you

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