1. www.interrai.org 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 1

2. www.interrai.org 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 2

3. www.interrai.org 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 3

4. www.interrai.org 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 Pacific Rim Japan, China, Taiwan, Hong Kong, South Korea, Australia, New Zealand Singapore South Asia, Middle East & Africa India, Israel, Lebanon Ghana interRAI Countries Central/ South America Brazil, Chile Peru Twitter: @interRAI_Hirdes 4

5. www.interrai.org 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 5

6. www.interrai.org 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 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 Twitter: @interRAI_Hirdes 6

7. www.interrai.org Implementation & Testing of interRAI Instruments in Canada Solid symbols – mandated or recommended by govt; Hollow symbols – research/evaluation underway RAI 2.0 RAI-HC RAI-MH interRAI CMH interRAI ESP interRAI PC interRAI ID interRAI ED/AC interRAI CA interRAI CHA interRAI AL interRAI SQoL DB Twitter: @interRAI_Hirdes 7

8. www.interrai.org 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 8 Canadian Institute for Health Information Data Holdings based on interRAI Assessments

9. www.interrai.org What Makes the interRAI Instruments an Integrated System? Twitter: @interRAI_Hirdes 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 9

10. www.interrai.org Twitter: @interRAI_Hirdes 10 4-17 18+ Mainly elderly CA ESP BMHS CF Screen Integrated Mental Health Information System

11. www.interrai.org 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 Age38.542.944.176.0 % Male85.948.655.246.4 % Never Married78.149.747.116.2 % Age of 1 st Admission <2556.539.334.89.3 % 4+ Lifetime Admissions41.536.625.122.9 % Admitted Homeless6.73.62.20.8 % Police Intervention82.515.014.14.1 % Cognitive Performance Scale 2+18.716.316.966.1 % Depressive Severity Index 3+24.356.554.147.0 % Positive Symptoms Scale 1+51.449.131.446.1 % ADL Hierarchy 1+16.114.517.364.2 % History of Sexual Violence14.85.14.23.4 Twitter: @interRAI_Hirdes 11

12. www.interrai.org Twitter: @interRAI_Hirdes Applications of interRAI’s Assessment Instruments: One assessment … multiple applications Assessment Care Plan Outcome Measures Quality Indicators Resource Allocation Balance incentives Evaluation Best Practices Risk Management Case-mix Single Point Entry Patient Safety Quality Improvement Public Accountability Accreditation 12

13. www.interrai.org interRAI Mental Health Clinical Assessment Protocols (CAPs) Twitter: @interRAI_Hirdes 13

14. www.interrai.org Twitter: @interRAI_Hirdes 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 14

15. www.interrai.org Twitter: @interRAI_Hirdes 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 15

16. www.interrai.org 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 Twitter: @interRAI_Hirdes * Also available in ESP 16

17. www.interrai.org Twitter: @interRAI_Hirdes 17

18. www.interrai.org Twitter: @interRAI_Hirdes Staff Ratings of Severity of Risk Related to Ability to Care for Self by Self Care Index (SCI), interRAI ESP Pilot 18

19. www.interrai.org Hirdes Ottawa 2011 Self Care CAP in Various Settings

20. www.interrai.org Hirdes Ottawa 2011 Self Care CAP in Various Settings

21. www.interrai.org Medication Issues by Self Care CAP Trigger Levels and Care Setting Twitter: @interRAI_Hirdes Community Mental Health In-Patient Emergency 21

22. www.interrai.org Multiple Psychiatric Hospital Admissions (Last 2 years) by Self Care CAP Trigger Levels and Care Setting Twitter: @interRAI_Hirdes Community Mental Health In-Patient Emergency 22

23. www.interrai.org Health Service Use at Follow-up/Discharge by Self Care CAP Trigger Levels and Care Setting Twitter: @interRAI_Hirdes Community Mental Health In-Patient 23

24. www.interrai.org Development of Mental Health Quality Indicators based on interRAI Assessments Twitter: @interRAI_Hirdes 24

25. www.interrai.org Mental Health Quality Indicators (MHQIs) 1)Patterns of Change: a) Improvement & b) Incidence/ Failure to Improve 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 2) 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 25

26. www.interrai.org Median Adjusted MHQI Rates among Ontario Hospitals/Units Green = Improvement/time 1 prevalence Red = Time 2 prevalence Twitter: @interRAI_Hirdes 26

27. www.interrai.org Case-mix adjusted QI Rates between Hospitals Twitter: @interRAI_Hirdes 27

28. www.interrai.org Clinical Example Forensic Psychiatry Twitter: @interRAI_Hirdes 28

29. www.interrai.org Too often in forensic psychiatry we consider only the risk indicators … Twitter: @interRAI_Hirdes 29

30. www.interrai.org … when we should really be looking at the whole person Twitter: @interRAI_Hirdes 30 Social isolation Addictions Poverty Bad posture resulting in pain in butt

31. www.interrai.org Clinical Example Who Gets an Unaccompanied Leave in Ontario? Twitter: @interRAI_Hirdes 31

32. www.interrai.org Authorized leaves outside of facility or locked unit, by day of stay and type of assessment, forensic patients Twitter: @interRAI_Hirdes 32

33. www.interrai.org Authorized leaves outside of facility or locked unit, forensic patients (2+yrs only) Twitter: @interRAI_Hirdes 33

34. www.interrai.org Multivariate Logistic Regression Models for Unaccompanied Leaves from Hospital Among Ontario Forensic Mental Health Patients Twitter: @interRAI_Hirdes 34 Independent Variable Model A Odds Ratio (95% CL) Model B Odds Ratio (95% CL) Day of Stay and Assessment Type (ref=<4 yrs & reassessment) <4 yrs & discharge assessment 4+ yrs & reassessment 4+ yrs & discharge assessment 0.58 ( 0.47-0.70) 1.23 ( 0.82-1.86) 1.87 (0.90-3.87) 0.58 ( 0.48-0.70) 1.23 ( 0.82-1.86) 1.86 (0.94-4.08) Approximate age (years)1.01 (1.01-1.02) Aggressive Behaviour Scale0.83 (0.79-0.87) Cognitive Performance Scale0.80 (0.73-0.87) ADL Hierarchy Scale0.81 (0.70-0.93) Depression Rating Scale0.90 (0.87-0.94) Threatened Violence/Intimidation0.72 (0.61-0.84)0.73 (0.62-0.85) Impaired Capacity Transportation IADL0.48 (0.39- 0.58)0.48 (0.40- 0.58) Multiple Life Time Hospitalizations2.17 (1.85-2.55)2.16 (1.84-2.54) Has confidant1.73 (1.39-2.15)1.66 (1.33-2.07 Staff Frustrated1.34 (1.09-1.63)1.42 (1.16-1.74) Others concerned re: self-harm0.78 (0.60-1.01) Family Overwhelmed 0.79 (0.69-0.91) c statistic0.700.71

35. www.interrai.org 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 35

36. www.interrai.org Join in on the interRAI-EFP-TBS partnership!! Thank you Twitter: @interRAI_Hirdes 36