Improving the assessment of people with care needs - The RAI system (RAI SPAIN)

Why was this example implemented?

The RAI is a powerful tool to carry out inter-disciplinary assessment of the needs of people who require LTC by analysing the data collected in the system from health care services. It allows professionals to set out the existing problems and to give initial protocols to help guide health care services to establish interventions and care pathways.

In Spain approximately 1.1 million people need LTC provided by different health care professionals and consequently these health care services need to be coordinated with common pathways in order to reduce costs and increase the efficiency and quality of care. The main potential impact of this action is improvement in the resource allocation of people with LTC needs between hospitals for the chronically ill, nursing homes and hospital at home services. In addition, a further impact is to define more effectively health and social care pathways.

This project is concerned with addressing the lack of individualised and integrated care plans. This gap means that people in need of LTC have different assessments which makes it difficult for them to negotiate the system, reduces the quality of care, and increases costs and expenditures. The project takes into account and merges the social and health care needs of each patient through a standardised assessment pathway.

The main target groups are older people who need institutional health and social care as well as informal carers, and professionals in need of support in their management tasks to improve the operation and provision of care. Through creating individual care plans with specific needs and tasks, the activity of caregivers is supported. The use of RAI assessments allows professionals to have more structured information about patients to define the care plans.

Description

Two research projects have been funded by both national (from 2009 to 2011) and regional (from 2009 to 2013) governments. The objectives of both projects are the same but the geographic focus is different, one of them having been focused in the Valencian Autonomous Region, and the other with a broader focus in several regions.

The project aims to improve continuity of care between hospitals for the chronically ill, nursing homes and hospital at home services, in order to obtain a common protocol based on the RAI system. RAI system provides a comprehensive standardised assessment of patients and will group patients according to their degree of dependency and the burden its care generates. The Resource Utilisation Groups (RUGIII) is used for this purpose. RUGIII is a patient classification of functional profile and the care provided. It helps to optimise the management of long-term care services by establishing criteria for resource allocation, so that the dependent person receives the care required, in the best setting and according to needs. The Michigan Choice algorithm is used as support to decide the first health or social option that derives from an older person’s assessment.  Moreover, the use of the Clinical Assessment Protocols (CAPs) offers a guide for the identification and assessment of problems for individualised planning of care.

The project methodology has been divided in two main steps. The first one is to implement the RAI system and create the institutional web database (with limited access to health care professionals). Thus, a pilot is being developed in several participating centres. In order to have a correct use of the RAI tool,  ERI-Polibienestar researchers have trained  professionals (social and health care professionals and managers) in how to use this instrument. The training consists of both a basic course of 20 hours complemented by monitoring sessions, and other  advanced training depending on the specific needs of the professionals. The training process includes learning five basic steps:

• assessment
• care planning
• leadership and management
• quality improvement
• statistical database in SPSS.

To gather the data, a multidisciplinary team belonging to the centres involved in the project is using SV NURSING HOME.NET (MDS2 for institutional care) and SV HOME CARE.NET (MDS2 for home care) tools. Data collection (as a functional capacity, cognitive status, skin condition or diagnosis) is made daily through a web-based platform and the data is linked through the patient’s evaluation. For this purpose a web-based software tool has been developed in Spain.

For the second step, ERI-Polibienestar together with planning departments will analysis the compiled data in order to: give feedback to the organisations (the global reports are updated every 6 months and are only available to service managers); define efficient health and social care pathways; develop individual care plans; develop quality indicators and to calculate costs associated with care burden. Finally, social and health care pathways will be validated by health care professionals (doctors, nurses, physiotherapists, nutritionists and psychologists).

RAI software licenses, training material, adaptation of the existing systems to specific contexts, maintenance of services and support for the elaboration of technical protocols was necessary to  implement the system, with an estimated cost of €70,000 per year.  The professional time for training and using RAI is not included.

What are/were the effects?

It is expected that, at the end of the project, the system will provide new data about the ease of the implementation of the RAI system in several Spanish hospitals for the chronically ill, nursing homes and hospital at home services. Also, this tool will: identify potential weak points related to nursing skills, leadership and management processes; quantify the extent of any improvement in the quality of the services produced; and create new protocols and health care pathways.

The RAI system has been implemented in a pilot in hospitals for chronically ill, Dr. Moliner and Pare Jofre (Valencia), San Vicente del Raspeig (Alicante) and Magdalena (Castellón); nursing homes, Residencia Alacant (Alicante); and Hospital Home Care Unit Arnau de Vilanova (Valencia). At the moment, its use in several hospitals has been stopped. This is due to political decisions as there is no agreement about the tools that have to be used. The system and the data remain in the hospital unused. In order to solve this problem, a new hospital has been included in the project. The new hospital (Hospital de la Vega Lorenzo Guirao) is located in  Murcia, another Autonomous Region next to the Valencian Autonomous Region.

The potential impacts of these actions are:

• Improvement in the resource allocation of people with LTC needs between hospitals for the chronically ill, nursing homes and hospital at home services.
• Definition of efficient and effective health and social care pathways.
• Better coordination between Regional health and social care services through using a common professional language and the design of efficient care pathways.
• In the long term, economically efficient health and social care systems and improved management of resources for the care of dependent people. However it takes a long time to build a benchmarking system upon which to compare results from different organisation and to learn from the best practice.
• Improved quantification of costs of health and social care.

As these projects are being pioneered in Spain and are still in progress, the actual impacts are not yet known.

What are the strengths and limitations?

The demographic and epidemiological changes that Spain is facing have increased hospital expansion in chronic and degenerative illnesses that require LTC. The recent creation of the Spanish System for the Autonomy and Care to the Dependence (SAAD) ruled by the Spanish Law of Dependence (Law 39/2006) can be supported by the use of this type of management system. This is an opportunity to implement tools such as RAI. RAI helps to build a good management system that enables cooperation of interfaces between different professionals and different management levels.

In this sense, the use of the RAI system in health and social care resources would simplify their coordination, making the care route of people in need of LTC easier. The creation of individual care plans will provide important benefits such as the costs savings and the improvement of quality, efficiency and efficacy of health care and social services.

However, one of the main threats is how to motivate staff and managers to use the RAI system and instruments correctly.

The main weakness of the system is the difficulty found in implementing this in the whole Spanish LTC system. Its implementation has to be slow and progressive due to the fact that it needs an initial economic investment. Besides, the motivation and involvement of stakeholders (policy-makers, professionals and managers) is low. One of the biggest challenges is motivating and training the staff and managers to requisition the RAI-system, to use the RAI instrument correctly (gathered data is valid) and to utilise the knowledge for care planning and management.

These two limitations are even intensified by the current economic situation and the difficulties encountered in the implementation of the Spanish Dependency Law due to lack of economic resources. These facts make scarce the available economic provisions for the implementation of these systems within the Spanish context.

Credits

Author: Francisco Ródenas, University of Valencia (Spain) – Polibienestar Research Institute
Reviewer 1: Gunnar Ljunggren
Reviewer 2: Teija Hammar
Verified by:

Links to other INTERLINKS practice examples

• Joint Strategic Needs Assessment (JSNA)
• RAI-benchmarking: An instrument for leadership and development
• Single Assessment Process

External Links and References

• www.polibienestar.org
• http://www.interrai.org
• http://www.interrai-es.org
• http://www.e-valoras.com/sv_web/portal/portada_dir/portada.aspx
• Ariño, S. (2001) 'La Tecnología RAI, Herramienta para gestión de calidad total en atención sociosanitaria' in: Revista de la Sociedad Española de Geriatría y Gerontología, 36 (3): 135-139.
• Carrillo, E., Garcia-Altes, A.,Peiro, S., Portella, E., Mediano, C., Fries, B.E., Martinez, F., Burgueño, A., Valles, E., Estrem, M. & J.L. Martinez Zahonero (1996). 'Sistema de clasificación de pacientes en centros de media y larga estancia: los Resource Utilization Groups Version III. Validación en España' in: Revista de Gerontología, Vol. 6(4): 276-284.
• Gómez, I. (2000). ‘CMBD-SS, Estudio Descriptivo en Centros de Personas Mayores. Año 1999’. Galicia: Junta de Galicia.
• Garcés, J., Rodenas, F. and V. San José (2003). “Empirical Cost-Profit analysis of Long-Term Care System from Social Sustainability Principle”. XIII Conference of the International Association of Health Policy “Social and economic destabilisation in Europe: implications for health”, Stockholm.
• Garcés, J., Rodenas, F. and V. San José (2004). 'Care needs among the dependent population in Spain: an empirical approach' in: Health and Social Care in the Community, Vol. 12 (6): 466-474.
• Garcés, J., Rodenas, F. and V. San José (2006). 'Suitability of the health and social care resources for persons requiring long-term care in Spain: an empirical approach' in: Health Policy, Vol. 76: 121-130.
• Garcés, J., Rodenas, F. and V. San José (2007). 'El futuro de la atención a la dependencia: Sostenibilidad y Prospectiva' in: Sociedad y Utopía, No 30: 323-344.
• Garcés, J., Rodenas, F., San José, V. and S. Carretero (2004). “An efficient alternative care scenario for long term care based on the Principles of Social Sustainability and Quality of life in Spain”. III International Conference on Health Economics, Management and Policy. Athens Institute for Education and Research. Athens, 3-5 June 2004.
• Garcés, J., Rodenas, F., Sanjosé, V., Zafra, E. & Mª J. Megia (2004). Encuesta de necesidades en población atenida en servicios sociosanitarios de la Comunidad Valenciana, 2001. Valencia: Generalitat Valenciana.
• Garcés, J., Rodenas, F., Sanjosé, V. & M.J. Megia (2002). Estudio sobre demanda y necesidades de asistencia sociosanitaria en la Comunidad Valenciana. Valencia: Generalitat Valenciana.
• Garcés, J., Rodenas, F., San José, V. & M.J. Megia (2002). Estudio sobre demanda y necesidades de asistencia sociosanitaria en la Comunidad Valenciana. Valencia: EVES, Generalitat Valenciana.
• Rodenas, F., Garcés, J., Carretero, S. & M.J. Megia (2008). 'Case management method applied to older adults in the primary care centres in Burjassot (Valencian Region, Spain)' in: European Journal of Ageing, 5: 57–66.