www.interrai.org
interRAI Assessment System for Mental Health:
An integrated suite of instruments
John P. Hirdes, PhDProfessor
School of Public Health and Health SystemsUniversity of Waterloo
Twitter: @interRAI_Hirdes
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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
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www.interrai.org
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
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North AmericaCanada
USMexico
EuropeIceland, Norway, Sweden, Denmark, Finland, Netherlands, France, Germany, Switzerland, UK, Italy, Spain, Czech Republic, Poland,
Estonia, Belgium, Lithuania, RussiaPortugal, Austria
Pacific RimJapan, China, Taiwan,
Hong Kong, South Korea, Australia, New Zealand
Singapore
South Asia, Middle East & Africa
India, Israel, LebanonGhana
interRAI Countries
Central/ South America
Brazil, ChilePeru
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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
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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
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Implementation & Testing of interRAI Instruments in Canada
Solid symbols – mandated or recommended by govt; Hollow symbols – research/evaluation underway
RAI 2.0RAI-HCRAI-MHinterRAI CMHinterRAI ESPinterRAI PCinterRAI IDinterRAI ED/ACinterRAI CAinterRAI CHAinterRAI ALinterRAI SQoL
DB
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• 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!!
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Canadian Institute for Health Information Data Holdings based on interRAI Assessments
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What Makes the interRAI Instruments an Integrated System?
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• 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
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ChYM
AdolYJQoL
ID CMH
FSQoL
MH
FSQoL
CF CHA
MHQoL
HC
QoL
LTCF
QoL
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4-17
18+
Mainly elderly
CA
ESP
BMHS
CF Screen
Integrated Mental Health Information System
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New Admissions by Patient Type, Ontario 2005-2008Forensic(n=1,895)
Acute(n=44,918)
Long Stay(n=5,778)
Geriatric(n=2,122)
Mean Age 38.5 42.9 44.1 76.0
% Male 85.9 48.6 55.2 46.4
% Never Married 78.1 49.7 47.1 16.2
% Age of 1st Admission <25 56.5 39.3 34.8 9.3
% 4+ Lifetime Admissions 41.5 36.6 25.1 22.9
% Admitted Homeless 6.7 3.6 2.2 0.8
% Police Intervention 82.5 15.0 14.1 4.1
% Cognitive Performance Scale 2+ 18.7 16.3 16.9 66.1
% Depressive Severity Index 3+ 24.3 56.5 54.1 47.0
% Positive Symptoms Scale 1+ 51.4 49.1 31.4 46.1
% ADL Hierarchy 1+ 16.1 14.5 17.3 64.2
% History of Sexual Violence 14.8 5.1 4.2 3.4Twitter: @interRAI_Hirdes
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Applications of interRAI’s Assessment Instruments:One assessment … multiple applications
Assessment
Care Plan
Outcome Measures Quality Indicators
Resource Allocation
Balance incentivesEvaluation
Best PracticesRisk Management
Case-mixSingle Point Entry
Patient SafetyQuality ImprovementPublic Accountability
Accreditation
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interRAI Mental Health Clinical Assessment Protocols (CAPs)
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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
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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
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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
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* Also available in ESP
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Emergency Screener for PsychiatrySelf Care Index (SCI)
Cognitive skills for decision
making
Positive Symptoms
Scale - Short
Insight to mental health
1+
3+
65
NoneFull-Limited
Decreased energy
1+0
0-2
Insight to mental health
0
Abnormal thought process
Making self understood
ESP Mania Scale
Poor hygiene
NoneFull - limited
0
0
1
0
3
2
4
1+0
4
2
2Anhedonia
Positive Symptoms
Scale - Short
0-6
0-1
1+
1+
7+
2+
1
1+0
2
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Staff Ratings of Severity of Risk Related to Ability to Care for Self by Self Care Index (SCI),
interRAI ESP Pilot
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www.interrai.orgHirdes Ottawa 2011
Self Care CAP in Various Settings
0102030405060
High Risk (6)
Moder-ate Risk (2-5)
Not Triggere
d
%
www.interrai.orgHirdes Ottawa 2011
Self Care CAP in Various Settings
0102030405060
High Risk (6)
Moder-ate Risk (2-5)
Not Triggere
d
%
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Medication Issues by Self Care CAP Trigger Levels and Care Setting
Med Adher-ence
Med Re-fusal
Med Adher-ence
Med Re-fusal
MedMgt IADL
0
20
40
60
80
100
Not Triggered Med Risk High Risk
% w
ith is
sue
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CommunityMental Health In-Patient Emergency
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Multiple Psychiatric Hospital Admissions (Last 2 years) by Self Care CAP Trigger
Levels and Care Setting
Multiple Ad-missions
Multiple Ad-missions
Multiple Ad-missions
0
10
20
30
40
Not Triggered Med Risk High Risk
% w
ith m
ultip
le a
dmis
sion
s
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CommunityMental Health In-Patient Emergency
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Health Service Use at Follow-up/Discharge by Self Care CAP Trigger Levels and Care Setting
0
10
20
30
40
50
Not Triggered Med Risk High Risk
% d
isch
arge
d to
set
ting
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Community Mental Health In-Patient
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Development of Mental Health Quality Indicators based on interRAI Assessments
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Mental Health Quality Indicators (MHQIs)
1) Patterns of Change: a) Improvement & b) Incidence/ Failure to Improve
• 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)
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Median Adjusted MHQI Rates among Ontario Hospitals/Units
Depre
ssion
Aggress
ive B
ehavio
ur
Disrup
tive B
ehav
iour
Violence
Positive
Sym
ptoms
Cognit
ion ADL
Financ
ial Mana
gemen
t
Medicati
on M
anagm
entPain
Acute C
ontrol
Rx
Physica
l Res
traint
Interperso
nal Con
flict
00.10.20.30.40.50.60.70.80.9
1
Med
ian
Rat
e (In
terq
uart
ile R
ange
)
Green = Improvement/time 1 prevalence
Red = Time 2 prevalence
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Case-mix adjusted QI Rates between Hospitals
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%Unadjusted Adjusted
OMHRS Hospital
Rate
of I
mpr
ovem
ent i
n C
ogni
tion
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Clinical Example Forensic Psychiatry
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Too often in forensic psychiatry we consider only the risk indicators …
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… when we should really be looking at the whole person
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Social isolation
Addictions
Poverty
Bad posture resulting in pain in butt
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Clinical ExampleWho Gets an Unaccompanied Leave in Ontario?
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Authorized leaves outside of facility or locked unit, by day of stay and type of assessment, forensic patients
For <4 yrs ReAx For <4 yrs Disch For 4+yrs ReAx For 4+yrs Disch0
10
20
30
40
50
60
70
Any days out Unaccompanied Days Out
Axis Title
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Authorized leaves outside of facility or locked unit, forensic patients (2+yrs only)
A B H G C D F E0
102030405060708090
No days out Unaccompanied Only
Facility
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Multivariate Logistic Regression Models for Unaccompanied Leaves from Hospital Among Ontario Forensic Mental Health Patients
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Independent Variable Model AOdds Ratio (95% CL)
Model BOdds Ratio (95% CL)
Day of Stay and Assessment Type (ref=<4 yrs & reassessment) <4 yrs & discharge assessment 4+ yrs & reassessment 4+ yrs & discharge assessment
0.58 ( 0.47-0.70)1.23 ( 0.82-1.86)1.87 (0.90-3.87)
0.58 ( 0.48-0.70)1.23 ( 0.82-1.86)1.86 (0.94-4.08)
Approximate age (years) 1.01 (1.01-1.02) 1.01 (1.01-1.02)Aggressive Behaviour Scale 0.83 (0.79-0.87) 0.83 (0.79-0.87)Cognitive Performance Scale 0.80 (0.73-0.87) 0.80 (0.73-0.87)ADL Hierarchy Scale 0.81 (0.70-0.93) 0.81 (0.70-0.93)Depression Rating Scale 0.90 (0.87-0.94) 0.90 (0.87-0.94)Threatened Violence/Intimidation 0.72 (0.61-0.84) 0.73 (0.62-0.85)Impaired Capacity Transportation IADL 0.48 (0.39- 0.58) 0.48 (0.40- 0.58)Multiple Life Time Hospitalizations 2.17 (1.85-2.55) 2.16 (1.84-2.54)Has confidant 1.73 (1.39-2.15) 1.66 (1.33-2.07Staff Frustrated 1.34 (1.09-1.63) 1.42 (1.16-1.74)Others concerned re: self-harm 0.78 (0.60-1.01) Family Overwhelmed 0.79 (0.69-0.91)c statistic 0.70 0.71
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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
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Join in on the interRAI-EFP-TBS partnership!!
Thank you
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