interRAI Implementation: Health System Considerations

Abstract

This article focuses on the implementation of interRAI instruments at a national health system level. It is based on a narrative review undertaken by the authors from several interRAI member countries. Implementation experiences from several countries and searches of PubMed and other databases, grey literature sources, policy reports, and the interRAI repository, identified practical insights and recommendations relevant for health system implementation. Key considerations are outlined. These include policy and legal considerations, resourcing considerations, training and education considerations, and data considerations.

Introduction

At a high level, the WHO defines health systems as all organizations, people and actions whose primary intent is to promote, restore, or maintain health. ¹ For any health system to address this primary intent, the first step is to measure and quantify health and care needs to address and measure if this goal can be met. There are many care needs assessment tools—both domain specific and comprehensive, but few have evolved in similar ways as the suite of interRAI instruments which now constitute a digital needs assessment system spanning both the life span and the care continuum.

When planning health and social care services, decisions need to be based on reliable, valid data. interRAI assessment systems have been rigorously tested for reliability and validity and provide governments with comprehensive data on population characteristics. These data assist the delivery, monitoring, and evaluation of interventions and services. Several countries (e.g., Belgium, Switzerland, Finland, Singapore, and New Zealand) have had successful national implementations of interRAI systems. ⁴ While the advantages and benefits of using interRAI assessments systems are clear, several key factors require consideration to ensure successful implementation at a health system level.

This narrative review can support decision-makers (e.g., Ministers, CIOs, clinical, and policy leaders) with national implementations of interRAI systems by providing a checklist of key considerations, methods of evaluation for successful implementation, and decision points for structuring and funding.

Methods

For this narrative review, databases such as PubMed were searched for articles that discussed strategies employed in the national implementation of interRAI systems. In addition, government and policy reports and reports on the interRAI repository that focused on pilot or full implementations of interRAI systems and highlighted recommendations around health system implementations were referenced in this narrative review.

The objective of this narrative review was to synthesize practical insights and recommendations relevant for health system implementation from an international perspective to provide the key considerations decision-makers are to take into consideration when implementation interRAI systems.

Policy and Legislation

The implementation of an interRAI system should ideally align with existing national health and social care policies, strategies, and priorities. This includes understanding the health and social care system’s overarching goals, such as improving accessibility, equity, and efficiency. Initially, implementation may focus on one policy or strategic priority (e.g., community mental health, inpatient services, long-term care for older people, and children’s mental health) and then expand into other policy areas. Alternatively, a life span approach may be preferred, with multiple interRAI instruments being implemented as a health information system across multiple care settings following across the life span; from children with physical, developmental, or mental health problems, through to primary care, mental healthcare, rehabilitation, hospital care, to long-term home care, residential care, and palliative care. Building such a system however requires an integrated and agreed upon policy and legislative foundation.

To assist policy-makers, several structured and methodical approaches to implementation have been developed to ensure effectiveness and sustainability. The United Kingdom Medical Research Council (MRC) framework provides a systematic, evidence-based approach to developing, implementing, and evaluating complex interventions, ensuring feasibility and effectiveness before full-scale implementation. ² An earlier version of this framework provided guidance for the implementation of the interRAI Palliative Care instrument in Belgium, as displayed in Figure 1. ³

Figure 1.

Application of the MRC Framework for interRAI

Based upon experiences across several health systems facing potential challenges to the implementation of an interRAI instrument (e.g., competing policy requirements), it may be necessary to consider mandatory implementation from a policy perspective. Mandatory implementation can provide policy assurances, remove barriers and drive implementation to ensure consistency, create uniformity in care assessments, and prevent fragmentation in care delivery.

By mandating the use of an interRAI system, governments can help secure the integration of interRAI outputs into daily practice across health and social care systems through stakeholder engagement. Furthermore, mandating an interRAI system should consider the importance of eliminating the often paper-based instruments currently in use, thus limiting the duplication of documentation across care settings, thus allowing clinicians to focus on using the information for person-centred care planning. Integration of interRAI assessment systems into electronic health records can further reduce assessment duplication and better support continuity of care across health and social care sectors, including longitudinal follow-up of individuals (e.g., from paediatrics to palliative care; see Figure 2).

Figure 2.

interRAI Suite of Instruments Across the Life Span

Resourcing

While a mandated approach reduces some barriers to implementation, financial investment is always required from the initial implementation phases to ongoing investment in training and education. Initially funding will be needed to address procurement to obtain a high-quality assessment and analytic software platform. This investment is critical as the software solution is one of the foundations for successful implementation along with Training and Education. The amount of Procurement funding will be influenced by the agreed policy directives and requirements. It should include both financial and workforce investment to successfully negotiate and deliver the procurement process.

Funding for software solutions should focus on a one that enhances the clinical decision-support and system analytics, not just software to digitalize assessment forms and algorithms. Investment in software solutions to assist both clinical and administrative professionals in their daily work is optimal and investment should also address interfacing with other systems. Detailed consideration of the requirements and regulations for software also needs to be considered, alongside potential hardware requirements.

Integrating assessment tools into existing health information systems like Electronic Healthcare Records can streamline the care processes, support continuity of care, and reduce administrative burden. However, this requires consideration and investment in digital infrastructure and technical capacity. Policy-makers should prioritize national or regional interoperability standards to ensure successful integration of interRAI instruments into healthcare organizations, fostering continuity of care and effectiveness of the tools. ⁴ Each country must also meet data security requirements and national and international regulations (e.g., General Data Protection Regulation (GDPR ⁵ )).

Training and Education

Another core fundamental investment requirement is for interRAI Training and Education. High-quality training permits healthcare professionals to use interRAI instruments successfully and helps to maintain data quality, enhance care planning, and support outcome measurement. ⁶

Notably, training must include different aspects based on stakeholder needs to ensure that the clinical information, and its related outputs, can be utilized most effectively at the individual, group, and country level. This training needs to include:

• a. Assessor training to complete the assessment based on all available information (e.g., understanding response sets and coding; use of data to support evidence-based clinical decision-making; care planning; and algorithms to identify risk utilizing case finding methodologies);

• b. Team training (both clinical and administrative teams) around the use of interRAI information (e.g., use of assessment outputs to determine prioritization and triaging; to conduct program evaluations); and

• c. Training administration and policy leaders on the use of quality indicators and case mix to support improved outcomes and resource allocation (e.g., applications to support accreditation, quality standards, and benchmarking) at the local, national, and international levels to champion best practice and innovation.

It is also important to support skill development in the use of the software, its applications, and how it can support data-driven care for smoother implementation. High-quality training is essential for multiple aspects of client care so the data collected through interRAI instruments is accurate, which is essential for clinical decision-making, while also supporting the development of personalized care plans based on comprehensive, multi-informant data.^4,7 As part of this process, creating a training plan for organizations that incorporates qualified trainers can serve as both the foundation for initial training and ongoing training needs. To foster sustainability, a “train the trainer” model can be utilized, where highly skilled interRAI trainers within the organization or a specific region can provide the needed knowledge to other care professional who perform assessments within the organization to support sustainability.

As part of this process, dedicated resources need to be allocated to support the development, delivery, and ongoing evaluation of training programs.^7,8 Additionally, providing regular check-ins and booster sessions for training professionals can prevent assessor “drift” while continuing to develop and enhance their skills over time.^9-11

Training programs must be informed and updated by those responsible for policy decisions. When training is not tailored to the specific roles and responsibilities of each group, it can result in misalignment of expectations, underutilization of data, or misinterpretation of assessment outcomes. Research indicates that the benefits of an interRAI instrument are most fully realized when technology solutions are integrated into a larger framework of organizational learning, teamwork, and cultural transformation as opposed to being handled as stand-alone technical fixes.^12,13

Therefore, training should be role-specific: frontline clinicians need practical skills to ensure accurate and consistent assessment and data collection, while also understanding how to utilize instrument outputs to support clinical decision-making and care planning. Decision-makers require training on data interpretation, applications for planning care pathway, and how to use the data for system-level policy decision-making.^14,15 Introducing interRAI instruments within standardized curricula could be embedded within colleges and universities for future health and social care providers to enhance knowledge in the field around the importance of strong standardized assessments and use of data-driven decision-making in the care of vulnerable populations.

Data

A successful implementation must be sustainable. The ultimate goal of implementing interRAI instruments is to improve health outcomes. The development and provision of interRAI data provide mechanisms to track how well the assessment results translate into actual improvements in patient care, resource allocation, and public health.

interRAI uses a “collect once-use many times” approach. A core set of data can be used across multiple assessment types, meaning data collection does not need to be duplicated for different assessments and a range of tools are available to providers, organizations, governments, and nations to support service planning, provision, and quality assessment. In addition, the interRAI system allows for greater interoperability, as data are moved across the care system.^11,16,17

The data can be linked to other routinely collected national data to better understand population health and targeted interventions for policy and program planning, as well as research purposes. For example, in Canada, interRAI assessments have been linked to the National Ambulatory Care Reporting System (NACRs) and the Discharge Abstract Databases (DAD), and in New Zealand, interRAI assessment data were linked to the Integrated Data Infrastructure (IDI).^18,19

Since interRAI instruments use standardized data items within instruments and across care settings, longitudinal analysis of health outcomes over time throughout the care trajectory can be conducted.^6,16,18

From a research perspective, data can be analyzed at a local, national, or international level to improve health services. For example, at a local level, studies in New Zealand focused on the user experience as part of their national implementation. ²⁰ In Canada, local data also provided opportunities to examine the impact of the recent COVID-19 pandemic on child and youth mental health.^21,22 At a national level, data can be utilized to examine specific policy changes (e.g., legalization of cannabis) ²³ and other related substance use issues in youth. ²⁴ Additionally, other studies examined the functional decline in long-term care homes across five Canadian provinces during the first wave of the COVID-19 pandemic. ²⁵ Internationally, for example, the Aged in Home Care project (AdHOC) assessed persons 65 and older receiving home care services across 11 European countries using the interRAI Home care assessment (formerly known as the Minimum Data Set-Home Care) to compare different models of community care. ²⁶

Aggregated interRAI data support evidence-based decision-making for resource allocation, quality monitoring, and system planning. However, this requires clear policies for how interRAI data will be used at clinical, managerial, and policy levels. It may be necessary to develop reporting mechanisms such as Key Performance Indicators and dashboards that provide actionable insights/reports targeted to different stakeholders (e.g., clinical and administrative divisions). National repositories are becoming a common method employed for data storage to ensure greater accessibility of assessment data amongst various healthcare providers. National repositories, such as the Canadian Institute of Health Information (CIHI), provide centralized data storage that allows data to be accessible for care improvement, quality assurance, policy development, service planning, and research purposes.^16,27 Examples such as CIHI require considerable regional or national investment but ultimately demonstrates the importance of integrating and using interRAI-based clinical data for continuous quality improvement and policy development at a health and social system level.

Conclusion

The implementation of an interRAI clinical information system provides consistent, equitable, and high-quality data for use across health and social care systems. Integration of assessment systems such as interRAI into existing health information systems enhances continuity of care and facilitates efficiency and coordination enabling data-driven decisions. InterRAI data move beyond individual care to shape evidence-based policies that can allocate resources efficiently and equitably, monitor and improve quality and safety, plan for future health and social care needs, and promote integration and reduce health disparities. The interRAI system provides a structured approach to evaluating individual needs across the life span and care continuum, guiding care planning, resource allocation, and policy development. While interRAI systems offer significant potential benefits, as outlined in this article, their implementation requires strong policy/managerial and clinical leadership and investment, robust software infrastructure and integration with IT systems, comprehensive training and education programs, and the integration of data for widespread stakeholders. With a mandated comprehensive, coordinated well-resourced policy approach, implementation of the interRAI suite can facilitate triaging, early identification and intervention, and facilitate improved outcomes for vulnerable individuals across the continuum of care.

ORCID iDs

N. Vereker https://orcid.org/0009-0007-9285-4538

J. De Almeida Mello https://orcid.org/0000-0002-1262-318X

K. Hermans https://orcid.org/0000-0002-6126-2907

A. Declercq https://orcid.org/0000-0003-3136-124X

K. Mathias https://orcid.org/0009-0009-0917-1926

G. Heckman https://orcid.org/0000-0003-3847-3287

Ethical Approval

Institutional review board approval was not required.