The Government’s decision to accelerate the time frame for the roll-out of interRAI to all residential aged care facilities has met with mixed reactions. JUDE BARBACK looks at why there is such a strong drive for the clinical assessment tool and what it is hoped to achieve.

Earlier this year, Associate Health Minister Jo Goodhew laid two new deadlines on the table for the residential aged care sector: by June 2014, all facilities will be participating in the roll-out of interRAI, and by June 2015, it will be mandatory in residential aged care. The decision has provoked some concern from the New Zealand Aged Care Association (NZACA). The association feels there is not enough time and funding allowed for the effective implementation of interRAI.

The interRAI story so far

InterRAI stands for ‘international Resident Assessment Instrument’. It is an electronic clinical assessment tool that is being used by the Needs Assessment Service throughout New Zealand.

Basically, it is a tool that provides a comprehensive clinical assessment of needs, which is then fed into the development of tailor-made care plans. The tool is expected to help provide, for the first time in

New Zealand, detailed objective statistical information about older people in care; the hope is for this information to better support policy development and implementation.

The need for a validated assessment process dates back to the introduction of needs coordination in 1994, which was reinforced a decade later by the Guideline for Specialist Health Services for Older People. The guideline, which suggested assessment of older people needed to be comprehensive, multidimensional, and standardised across New Zealand, led to an evaluation of assessment tools used throughout the world. The interRAI Home Care assessment was thought to be the best tool available that met the criteria of the guideline.

InterRAI was developed by a collaborative network of researchers in over 30 countries, and the result is an internationally recognised assessment tool that is designed to assist nurses in aged care facilities to provide quality care for residents.

The roll-out of interRAI for assessing needs for home-based support services was completed in June this year, with all DHBs now using interRAI for their community clients.

Following the success of a pilot programme using interRAI in residential aged care in Canterbury and the Bay of Plenty, the Ministry of Health and the district health boards (DHBs), with the involvement of the NZACA, started to roll out interRAI in residential aged care last year.

“This is a positive move to build on the good work being done by aged care providers and ensure people in aged care facilities across the country are getting a consistently high standard of care,” says Minister Goodhew.

Why make it mandatory?

Ministry of Health, Deputy Director-General Policy, Don Gray says the mandatory nature of the programme from June 2015 will ensure each aged care resident in New Zealand receives a Comprehensive Clinical Assessment at least twice a year or when their health status changes. The Ministry believes this will help ensure continuity of care across the sector and create a level playing field for all providers.

“The Ministry recognises that most rest home providers already provide a high standard of care for residents. However, one of the biggest advantages of making interRAI mandatory is that all of the approximately 700 residential aged care providers nationwide will be using just one standardised assessment tool.

“This will mean standards of care can be benchmarked with data collected nationally and used to give an indication of the quality of care in facilities across New Zealand,” says Gray.

Why sooner?

Gray says the Government is asking providers to get engaged in the roll-out of interRAI a year in advance of its June 2015 deadline because, as with any new system, interRAI brings with it some challenges.

“It is hoped this shorter time frame will help place providers in a better position to train staff earlier and learn the new assessment in a systemised way together, which is important in an area as challenging and critical as clinical change,” says Gray.

However, the NZACA has criticised the Ministry’s decision.

“It is no longer a partnership,” says chief executive Martin Taylor.

While the NZACA remains supportive of the interRAI project – Taylor is a co-sponsor on the project’s steering group – the association believes the sector is not ready for the tool to be made mandatory on the terms laid out by the Ministry.

“It is disappointing that something so positive has now become a regulatory compliance burden as a result of being made mandatory and having the time allocated to roll out this initiative shortened substantially,” says Taylor. >>

What does interRAI training involve?

The NZACA’s concerns are justified: the roll-out entails training around 2000 Registered Nurses to understand the assessment tool and how to use the web-based assessment software. All facilities need to be participating in training in approximately 18 months’ time. Given that only a small percentage of these nurses have received training so far, it is a big task ahead of the sector.

However, the Ministry has put in place a number of training approaches to help meet the varying requirements of providers. The interRAI project team will ensure that a nurse in each facility is trained to become the lead practitioner, who will then be supported by interRAI trainers to roll out the training to other nurses in the facility via “classroom days”. The lead practitioner supervises assessments. If a facility would rather not have a lead practitioner, interRAI trainers will provide the training directly to the facility. Training can also be rolled out to groups of facilities.

Following this approach to training, the Ministry expects training to take on average one day a week during the six to eight week process, outside of three classroom days.

InterRAI competency, which includes classroom learning, supervised experience completing assessments, and a competency evaluation, takes between 50 to 55 hours for staff to achieve. In return, providers are expected to play their part in terms of making their staff available for training.

“We encourage providers to contact their local trainer through DHB Shared Services as early as possible so they can discuss what is required,” says Gray.

There are currently seven dedicated interRAI trainers spread around the country. However, Gray says this will increase significantly in the coming months.

The Ministry says there will also be ongoing support provided for aged care facilities as they introduce interRAI. Such initiatives include a phone-in support desk, access to online self-paced learning, a ‘buddy system’, and the quality review of assessments so nurses get feedback to support learning.

“Feedback from facilities who have already adopted interRAI has been positive and we believe it will provide better assurance about the standards of patient care and safety in aged care facilities,” says Gray.

Facilities that haven’t yet received interRAI training appear to be keen to get on board, too.

Sharon Owen, manager of Carter House in Te Puke, says her staff are looking forward to receiving their interRAI training and are awaiting more information.

Jenny Crawford, manager of Oakdale Rest Home in Cambridge, is supportive of interRAI, as it is a nationally driven initiative. Like Carter House, the staff at Oakdale are waiting in anticipation of hearing more.

Costs of training

Taylor points out that the training costs associated with getting the sector interRAI-ready in time for the deadline are likely to be problematic for many providers.

“Before [providers] could decide whether and when they wanted to accept these costs – now they have no choice,” he says.

According to the Ministry, the Government has invested more than $10 million over four years (2011-2014), which will support the roll-out into residential aged care. The Ministry will cover the cost of the interRAI software, a laptop to use the programme and initial interRAI training.

However, Taylor is critical of the funding allocation.

“When DHBs rolled out this initiative, they trained only about 700 Registered Nurses on a budget of $12.5 million over four years. In comparison, we are being expected to train almost three times that number for $10.8 million dollars and complete that training in less time.”

Hopes for interRAI

Despite concerns over costs and timing, Taylor says NZACA “is committed to making this quality initiative a success for elderly New Zealanders”.

To be a “success”, the assessment scores produced by interRAI need to be used effectively to produce fair and optimal outcomes for older people. Given that the tool will now be mandatory across the board, encompassing DHBs and the residential aged care sector, in theory interRAI should result in a consistent approach to care placements across the country. So if an older person assessed by the tool under one DHB receives the same interRAI score as another person under a different DHB, both should receive the same level of care or have the same access to residential care.

Providing a robust, standardised approach to a continuum of care is what interRAI is all about. Dr Brigette Meehan, interRAI project leader, describes it as a “very satisfying assessment process to be involved with” as it looks beyond a person’s current status to his or her future, presenting opportunities to modify any risks he or she may face.

She also praises the holistic nature of the assessment yielded by interRAI.

“Sometimes, there’s an assumption that because you have one health condition it somehow protects you from getting another. But what happens if you have arthritis and then have a stroke?

InterRAI is designed to look less at a person’s conditions and is much more about how they manage in their daily life.”

There is certainly much enthusiasm for interRAI, from the Ministry to the nurses. Assuming the Ministry, DHBs and facilities can work within the tight time frames and budget – which shouldn’t be understated – the initiative stands a real chance of success.

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