Throughout the world people are living longer and the birth rate is falling. The population of persons over the age of 65 is rapidly growing, both in raw numbers and as a proportion of the whole. For example, for the first time in Italy’s history, there are more persons over age 65 than under age 20. In most developed countries the increase is particularly striking for those aged 80 and older. Improving the ability of the health care delivery system to respond to the needs of those requiring community-based care in a fiscally responsible manner is one of the greatest challenges of our times.
interRAI Home Care Assessment System
The interRAI HC has been designed to be a user-friendly, reliable person-centered assessment system that informs and guides comprehensive care and service planning in community-based settings around the world. It focuses on the person’s functioning and quality of life by assessing needs, strengths, and preferences. It also facilitates referrals when appropriate. When used on multiple occasions, it provides the basis for an outcome-based assessment of the person’s response to care or services. The interRAI HC can be used to assess persons with chronic needs for care, as well as with post-acute care needs (e.g., after hospitalization or in a hospital at home situation). The interRAI HC has been designed to be compatible with the suite of interRAI assessment and problem identification tools. Such compatibility advances continuity of care through a “seamless” assessment system across multiple health care settings, and promotes a person-centered evaluation rather than fragmented site-specific assessments.
The interRAI HC consists of the interRAI HC Assessment and the Clinical Assessment Protocols (CAPs):
The interRAI HC Assessment Form is a Minimum Data Set (MDS) screening tool that enables a home care provider to assess multiple key domains of function, health, social support, and service use. Particular interRAI HC items also identify persons who can benefit from further evaluation of specific problems or risks for functional decline. These items, known as “triggers”, link the interRAI HC to a series of problem-oriented CAPs.
The Clinical Assessment Protocols (CAPs) contain general guidelines for further assessment and individualized care and services. There are 30 CAPs in multiple domains (e.g., clinical, mental health, psychosocial, physical function). On average, a person receiving home care services triggers about 10 of the 30 CAPs. Your goal is to use this information to arrive at an appropriate plan of care, and where possible and required, provide the service or make a referral. At the same time, we also recognize that home care professionals may be operating within a program where reimbursement systems or eligibility requirements limit their care options. You may not be able to offer home care services to address all problem areas. Nevertheless, a comprehensive assessment that includes the strengths and needs of the person can be useful as you schedule services and assess program outcomes.
Governmental or private agency adoption of the interRAI HC. Government agencies from around the world have adopted the interRAI HC, either in its entirety (with or without country-specific supplemental items) or with slight local modifications. A number of private organizations are also using the interRAI HC.