The RAI-PC: an assessment instrument for palliative care in all settings.

Large numbers of persons in most types of healthcare settings have palliative care needs that have considerable impact on their quality of life. Therefore, InterRAI, a multinational consortium of researchers, clinicians, and regulators that uses assessment systems to improve the care of elderly and disabled persons, designed a standardized assessment tool, the Resident Assessment Instrument for Palliative Care (RAI-PC). The RAI-PC can be used for both the design of individual care plans and for case mix and outcomes research. Some elements of this instrument are taken from the resident assessment instrument (RAI) mandated for use in all nursing homes in the United States and widely used throughout the world. The RAI-PC can be used alone or in counjunction with the other assessment tools designed by the InterRAI collaboration: the RAI for homecare (RAI-HC), for acute care (RAI-AC), and for mental health care (RAI-MH). The objective of this study was to field test and carry out reliability studies on the RAI-PC. After appropriate approvals were obtained, the RAI-PC instrument was field tested on 151 persons in three countries in more than five types of settings. Data obtained from 144 of these individuals were analyzed for reliability. The reliability of the instrument was very good, with about 50 percent of the questions having kappa values of 0.8 or higher, and the average kappa value for each of the eight domains ranging from 0.76 to 0.95. The 54 men and 95 women had a mean age of 79 years. Thirty-four percent of individuals suffered pain daily. Eighty percent tired easily; 52 percent were breathless on exertion; and 19 to 53 percent had one or more other symptoms, including change in sleep pattern, dry mouth, nausea and vomiting, anorexia, breathlessness at rest, constipation, and diarrhea. The number of symptoms an individual reported increased as the estimated time until death declined. The "clinician friendly" RAI-PC can be used in multiple sites of care to facilitate both care planning and case mix and outcomes research.

A commitment to change: revision of HCFA's RAI.

OBJECTIVE: To describe the reliability of new assessment items and their clinical utility as judged by experienced nurse assessors, based on the results from the field test of Version 2.0 of the Resident Assessment Instrument (RAI). DESIGN: Independent dual assessment of residents of nursing facilities by staff nurses using a draft of Version 2.0 of the minimum data set (MDS). SETTING AND PARTICIPANTS: A total of 187 randomly selected residents from 21 nursing homes in seven states volunteered to test Version 2.0 of the MDS. MEASUREMENT: The full array of MDS assessment items included measures in the following areas: Background information, cognitive patterns, communication/hearing, vision, mood and behavior, psychosocial well-being, physical functioning and structural problems, continence, disease diagnoses, health condition, oral/nutritional status, dental status, skin condition, activity pursuit patterns, medications, special treatments and procedures, and discharge potential and overall status. RESULTS: Evaluative data address issues of MDS item utility and reliability. For new items, almost all achieved a reasonably high-weighted Kappa interrater reliability; revised items also surpassed earlier items, and with the updated training materials, even the non-changed items had higher average reliability levels. Based on the success of the field test and the positive response of the industry, Version 2.0 of the RAI has been adopted, and HCFA has initiated a more long-range process to update further the RAI when necessary. CONCLUSION: Findings support the reliability and clinical utility of the new and revised assessment items incorporated by HCFA in Version 2.0 of the MDS.

Reliability estimates for the Minimum Data Set for nursing home resident assessment and care screening (MDS).

The MDS is a core set of items, definitions, and response categories used to assess all of the nation's 1.5 million nursing home residents who reside in facilities participating in the Medicare or Medicaid programs. Further, the Health Care Financing Administration (HCFA) has proposed a rule that would require facilities to computerize MDS data and submit it to state and federal agencies, paving the way for a national database. This article describes the process of testing the reliability of the MDS items in 13 nursing homes in five states. The results demonstrate that MDS data gathered in a research effort attain reliabilities that make such data useful. MDS items met a standard for excellent reliability (i.e., intraclass correlation of .7 or higher) in key areas of functional status, such as cognition, ADLs, continence, and diagnoses. Sixty-three percent of the items achieved reliability coefficients of .6 or higher. Eighty-nine percent of the items in the MDS achieved .4 or higher.