www.interrai.org

interRAI Assessment System for Mental Health:

An integrated suite of instruments

John P. Hirdes, PhDProfessor

School of Public Health and Health Systems

University 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

Twitter: @interRAI_Hirdes

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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 2005-2008

Forensic(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

0

10

20

30

40

50

60

High Risk (6)

Moder-ate Risk (2-5)

Not Triggere

d

%

www.interrai.orgHirdes Ottawa 2011

Self Care CAP in Various Settings

0

10

20

30

40

50

60

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

iss

ue

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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

mu

ltip

le a

dm

issi

on

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

arg

ed

to

sett

ing

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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

Depress

ion

Aggress

ive B

ehaviour

Disruptiv

e Behavio

ur

Viole

nce

Positive

Sym

ptom

s

Cognition

ADL

Financia

l Managem

ent

Medica

tion M

anagment

Pain

Acute

Contro

l Rx

Physica

l Rest

rain

t

Inte

rpers

onal Conflic

t0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1

Med

ian

Rat

e (I

nte

rqu

arti

le R

ang

e)

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

Ra

te o

f Im

pro

ve

me

nt

in C

og

nit

ion

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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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