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
Twitter: @interRAI_Hirdes
www.interrai.org
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
Twitter: @interRAI_Hirdes
www.interrai.org
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
Twitter: @interRAI_Hirdes
www.interrai.org
4
interRAI Countries
North America
Canada
US
Mexico
Europe
Iceland, Norway, Sweden, Denmark, Finland,
Netherlands, France, Germany, Switzerland,
UK, Italy, Spain, Czech Republic, Poland,
Estonia, Belgium, Lithuania, Russia
Portugal, Austria
Central/
South America
Brazil, Chile
Peru
South Asia, Middle East
& Africa
India, Israel, Lebanon
Ghana
Twitter: @interRAI_Hirdes
Pacific Rim
Japan, China, Taiwan,
Hong Kong, South Korea,
Australia, New Zealand
Singapore
www.interrai.org
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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
Twitter: @interRAI_Hirdes
www.interrai.org
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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
Twitter: @interRAI_Hirdes
•
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
www.interrai.org
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Implementation & Testing of interRAI Instruments in Canada
DB
RAI 2.0
RAI-HC
RAI-MH
interRAI
interRAI
interRAI
interRAI
interRAI
interRAI
interRAI
interRAI
interRAI
Solid symbols – mandated or recommended by govt;
Hollow symbols – research/evaluation underway
Twitter: @interRAI_Hirdes
www.interrai.org
CMH
ESP
PC
ID
ED/AC
CA
CHA
AL
SQoL
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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!!
Twitter: @interRAI_Hirdes
www.interrai.org
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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
Twitter: @interRAI_Hirdes
www.interrai.org
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Integrated Mental Health Information System
Twitter: @interRAI_Hirdes
www.interrai.org
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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
@interRAI_Hirdes
% HistoryTwitter:
of Sexual
Violence
14.8
5.1
www.interrai.org
4.2
3.4
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Applications of interRAI’s Assessment Instruments:
One assessment … multiple applications
Case-mix
Single Point Entry
Care Plan
Evaluation
Best Practices
Risk Management
Resource Allocation
Assessment
Outcome Measures
Balance incentives
Quality Indicators
Patient Safety
Quality Improvement
Public Accountability
Accreditation
Twitter: @interRAI_Hirdes
www.interrai.org
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interRAI Mental Health
Clinical Assessment Protocols
(CAPs)
Twitter: @interRAI_Hirdes
www.interrai.org
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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
Twitter: @interRAI_Hirdes
www.interrai.org
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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
Twitter: @interRAI_Hirdes
www.interrai.org
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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
* Also available in ESP
Twitter: @interRAI_Hirdes
www.interrai.org
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Emergency Screener for Psychiatry
Self Care Index (SCI)
Cognitive skills
for decision
making
0
1+
Positive
Symptoms
Scale - Short
Insight to
mental health
Full - limited
Abnormal
thought
process
Making self
understood
0
0-2
None
1+
0
Decreased
energy
Poor hygiene
2
Full-Limited
4
2
ESP Mania
Scale
Positive
Symptoms
Scale - Short
0
0
4
2
7+
Anhedonia
0-1
1+
1+
0
0-6
Insight to
mental health
1+
0
3
2
2+
1
1+
Twitter: @interRAI_Hirdes
1
3+
www.interrai.org
5
None
6
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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
Twitter: @interRAI_Hirdes
www.interrai.org
Self Care CAP in Various Settings
60
50
40
%
30
20
10
0
Not Triggered
Moderate Risk (2-5)
High Risk (6)
Hirdes Ottawa 2011
www.interrai.org
Self Care CAP in Various Settings
60
50
40
%
30
20
10
0
Not Triggered
Moderate Risk (2-5)
High Risk (6)
Hirdes Ottawa 2011
www.interrai.org
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Medication Issues by Self Care CAP Trigger
Levels and Care Setting
% with issue
100
80
Community
Mental Health
In-Patient
Emergency
60
40
20
0
Med
Adherence
Med
Refusal
Not Triggered
Twitter: @interRAI_Hirdes
Med
Adherence
Med Risk
Med
Refusal
MedMgt
IADL
High Risk
www.interrai.org
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% with multiple admissions
Multiple Psychiatric Hospital Admissions
(Last 2 years) by Self Care CAP Trigger
Levels and Care Setting
40
Community
Mental Health
In-Patient
Emergency
30
20
10
0
Multiple
Admissions
Multiple
Admissions
Not Triggered
Twitter: @interRAI_Hirdes
Med Risk
Multiple
Admissions
High Risk
www.interrai.org
23
Health Service Use at Follow-up/Discharge by Self
Care CAP Trigger Levels and Care Setting
% discharged to setting
50
In-Patient
Community Mental Health
40
30
20
10
0
Acute hospital
admission
ED visit
Not Triggered
Twitter: @interRAI_Hirdes
Psychiatric
hospital admission
Med Risk
High Risk
Discharged to
Congregate
Setting (e.g., LTC)
www.interrai.org
24
Development of Mental
Health Quality
Indicators based on
interRAI Assessments
Twitter: @interRAI_Hirdes
www.interrai.org
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Mental Health Quality Indicators
(MHQIs)
1) Patterns of Change:
a) Improvement & b) Incidence/ Failure to Improve
•
•
•
•
•
•
2)
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
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)
Twitter: @interRAI_Hirdes
www.interrai.org
Median Rate (Interquartile Range)
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Median Adjusted MHQI Rates among Ontario
1
Hospitals/Units Green = Improvement/time 1
0.9
prevalence
0.8
Red = Time 2 prevalence
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0
Twitter: @interRAI_Hirdes
www.interrai.org
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Case-mix adjusted QI Rates between
Hospitals
Rate of Improvement in Cognition
100%
Unadjusted
Adjusted
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Twitter: @interRAI_Hirdes
OMHRS Hospital
www.interrai.org
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Clinical Example Forensic Psychiatry
Twitter: @interRAI_Hirdes
www.interrai.org
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Too often in forensic psychiatry we
consider only the risk indicators …
Twitter: @interRAI_Hirdes
www.interrai.org
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… when we should really be looking at the
whole person
Social isolation
Bad posture
resulting in
pain in butt
Twitter: @interRAI_Hirdes
Poverty
Addictions
www.interrai.org
31
Clinical Example
Who Gets an
Unaccompanied Leave in Ontario?
Twitter: @interRAI_Hirdes
www.interrai.org
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Authorized leaves outside of facility or locked unit, by
day of stay and type of assessment, forensic patients
70
60
50
40
30
20
10
0
For <4 yrs ReAx
For <4 yrs Disch
For 4+yrs ReAx
Axis Title
Any days out
Twitter: @interRAI_Hirdes
For 4+yrs Disch
Unaccompanied Days Out
www.interrai.org
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Authorized leaves outside of facility or locked
unit, forensic patients (2+yrs only)
90
80
70
60
50
40
30
20
10
0
A
B
H
G
C
D
F
Facility
No days out
Twitter: @interRAI_Hirdes
Unaccompanied Only
www.interrai.org
E
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Multivariate Logistic Regression Models for Unaccompanied Leaves
from Hospital Among Ontario Forensic Mental Health Patients
Independent Variable
Day of Stay and Assessment Type
(ref=<4 yrs & reassessment)
<4 yrs & discharge assessment
4+ yrs & reassessment
4+ yrs & discharge assessment
Approximate age (years)
Aggressive Behaviour Scale
Cognitive Performance Scale
ADL Hierarchy Scale
Depression Rating Scale
Threatened Violence/Intimidation
Impaired Capacity Transportation IADL
Multiple Life Time Hospitalizations
Has confidant
Staff Frustrated
Others concerned re: self-harm
Family Overwhelmed
c statistic
Twitter: @interRAI_Hirdes
Model A
Odds Ratio (95% CL)
Model B
Odds Ratio (95% CL)
0.58 ( 0.47-0.70)
1.23 ( 0.82-1.86)
1.87 (0.90-3.87)
1.01 (1.01-1.02)
0.83 (0.79-0.87)
0.80 (0.73-0.87)
0.81 (0.70-0.93)
0.90 (0.87-0.94)
0.72 (0.61-0.84)
0.48 (0.39- 0.58)
2.17 (1.85-2.55)
1.73 (1.39-2.15)
1.34 (1.09-1.63)
0.78 (0.60-1.01)
0.58 ( 0.48-0.70)
1.23 ( 0.82-1.86)
1.86 (0.94-4.08)
1.01 (1.01-1.02)
0.83 (0.79-0.87)
0.80 (0.73-0.87)
0.81 (0.70-0.93)
0.90 (0.87-0.94)
0.73 (0.62-0.85)
0.48 (0.40- 0.58)
2.16 (1.84-2.54)
1.66 (1.33-2.07
1.42 (1.16-1.74)
0.70
0.79 (0.69-0.91)
0.71
www.interrai.org
35
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
Twitter: @interRAI_Hirdes
www.interrai.org
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Join in on the interRAI-EFP-TBS
partnership!!
Thank you
Twitter: @interRAI_Hirdes
www.interrai.org