Valuing Quality in Aged Care: A Cost-Benefit Framework for interRAI Implementation

Abstract

Improving aged care quality is a global priority. Effective monitoring and evaluation systems are the mechanism through which this priority can be realized. The interRAI consortium offers an integrated clinical information system that spans multiple care settings to support quality improvement in clinical care, meeting policy, industry, and recipient needs. However, the economic value of implementing these systems remains unknown, complicated by challenges in monetizing relevant costs and benefits. Using Campbell and Brown’s cost-benefit methodology, we present a flexible framework to evaluate the cost-benefit of implementing interRAI as a minimum dataset for aged care, focused on the cost-benefit domain of care quality. Our framework provides a comprehensive foundation for cost-benefit analysis of interRAI implementation. It presents an informative starting-point for high-level decision-makers to reliably estimate the value of implementing integrated clinical information systems at multiple levels.

Background

Quality improvement remains a central priority in aged care programs worldwide.^1-4 National inquiries including the Royal Commission into Aged Care Quality and Safety in Australia (the Royal Commission), ¹ the Belgian Federal Health Ministry, ² and Ireland’s Health Service Executive ³ underscore the imperative to collect reliable, consistent data to inform quality improvement in aged care. ⁵ Increasingly, experts advocate for a mandated National Minimum Data Set (NMDS) to inform and support comprehensive care planning, quality monitoring, and funding decisions. ⁶ Without such mandates, the collection and reporting of clinical assessment data risks becoming a combination of legacy and standalone assessments that are fragmented, opaque, and inconsistent.

System-wide adoption of clinical information systems can mitigate some of this risk. These digital platforms support multiple functions, including local planning and delivery of care, system-wide monitoring and evaluation of health outcomes, and the provision of reliable data that gives transparency and accountability to stakeholders.^5-8 The interRAI suite is an example of a robust clinical information system supported by a collection of standardized, internationally validated instruments that collect clinical and functional data that can be centrally collated, reported, and linked across care settings. ⁹ Internationally, there are over 32 countries using interRAI assessment instruments, with nine having officially mandated use of interRAI systems at either a regional or national level across different settings.^10,11 While each jurisdiction requires adjustments to suit the local context, the collection of minimum data and standardization of items across instruments ensures that the interRAI system retains transparency and comparability across all countries and regions.

Evaluating healthcare for quality improvement is complex and multi-faceted, evidenced by the variety of assessment instruments, data items and software systems developed for this purpose. Presently, the monitoring and evaluation of healthcare at national levels ranges from negligible to fully integrated and is frequently categorized by complex and complicated instruments, duplicate data collection, inconsistencies in interpretation of reporting requirements, and incomplete understanding of the clinical and functional care needs of care recipients. ¹¹ Compounding the data collection burden, data are frequently collected through disparate systems and not able to be linked or communicated across care settings, leading to further duplication of effort, increased administrative burden, reductions in quality and reliability of collected data, and limited interoperability. ⁵ There are arguments for and against integrated clinical information systems and current quality improvement programs, further complicated by variations in the extent and purpose of implementation for each, and limited consensus or reporting of the costs and benefits associated with either.^12,13

Cost-Benefit Analysis (CBA) is a widely recognized tool for evaluating investment projects for governments and the private sector.^14,15 CBA involves identifying, measuring, and comparing the tangible and intangible inputs and outcomes associated with a project. By defining clear project boundaries and engaging stakeholders, CBA allows for a systematic examination of whether the project’s implementation will yield greater benefits compared to maintaining the current situation. CBA can be a powerful tool in a decision-making context where there are competing objectives and interests among stakeholders as it describes benefits and costs accruing to each stakeholder in a logical framework.

The purpose of this article is to develop a cost-benefit framework for assessing the value of implementing an interRAI system as an NMDS, partially or fully, at a national or state level. The framework identifies the broader systemic benefits of interRAI—such as improved care quality and continuity, data interoperability, administrative efficiency, and policy alignment—that are essential considerations for decision-makers to fully understand the long-term implications of investing in interRAI or pursuing alternative approaches.

Methods

The process for developing this CBA framework was based on the Campbell and Brown methodology ¹⁴ used previously by the authors in evaluating the implementation of electronic health records. ¹⁶ The Campbell and Brown methodology was selected for its recency and pragmatic, intuitive application in health. The framework development process follows three interrelated steps: a literature review, stakeholder engagement, and framework development. Steps are iterative and overlapping, allowing for continuous refinement as new insights emerge. This dynamic approach ensured that the framework evolved to reflect a comprehensive and contextually grounded analysis that is flexible and responsive to different contexts across diverse jurisdictions.

Literature Review

The literature review underpinning this framework was informed by the comprehensive systematic review conducted alongside the initial development of this framework by Dendere et al., ¹⁷ which assessed international Comprehensive Geriatric Assessment (CGA) systems for residential and community aged care. This review identified interRAI Home Care and Long Term Care Facilities assessments as the most robust and suitable systems, based on criteria including psychometric validity, international uptake, and software support.

To complement this evidence base, we incorporated findings from the Digital Health Cooperative Research Centre’s (DHCRC) interRAI Implementation Feasibility Analysis, ⁵ which provided detailed insights into the practical, technical, and policy considerations for implementing interRAI in Australia. This report included stakeholder consultations with aged care providers, software vendors, and government representatives. This facilitated rapid mapping of the existing evidence base and identified key themes relevant to the implementation of geriatric assessment systems in different international contexts.

Stakeholder Engagement

Stakeholder engagement facilitates a practical, context-specific approach to cost-benefit analysis, ensuring precision and relevance of included parameters. ¹⁸ Identified stakeholders included care recipients, care workers, care organizations, software vendors and developers, government representatives, independent institutes of health data, and research institutes. We undertook two formal engagement activities to determine relevant inputs based on experience of interRAI implementation in 2024 a 2-day workshop held in March 2024 with stakeholders from interRAI NZ, and an international reference group forum held in September 2024 at the annual interRAI network meeting. We also undertook informal ad-hoc consultations with researchers and practitioners with experience using interRAI in aged care contexts across jurisdictions.

Framework Development

The identification of specific cost and benefit items within the framework was informed by both deductive and inductive processes, combining literature review and stakeholder consultation outcomes. Initially, domains and items were derived deductively from the literature and international implementation experiences. This was complemented by inductive input from stakeholders, including targeted consultation with interRAI New Zealand representatives, who shared their experiences of national interRAI implementation.

The framework was further validated with iterative stakeholder validation involving confirmation, rejection, or supplementation of the proposed items. This grounded the framework in both evidence and practical relevance, capturing the diverse perspectives of aged care providers, software vendors, and policy stakeholders. The final framework parameters were drawn from the continual iteration between literature and stakeholder consultation. Operationalization of the framework will require consideration of the context in which the analysis is being conducted. This will include the timeframe for the analysis, the discount rate, and the relevant perspective that will drive the final selection of the items to be used.

Results

Literature Review

Multiple international and national studies consistently identify interRAI as the most robust and person-centred assessment system for aged care.^7,10,13,17 These reviews endorse interRAI as a standardized, evidence-based system capturing medical, functional, emotional, and social needs. It is repeatedly selected for its ability to support care planning, quality monitoring, and system-level evaluation through a unified, validated assessment suite. Its versatile format enables the same assessment to be administered and linked across different settings over time, enhancing continuity of care across all levels of health and aged care systems while avoiding redundancy and duplication. The literature review also identified the challenges faced in assigning value to the benefits of improved care quality.^16,19 While the benefits can readily be identified in a cost-benefit framework, identifying a monetary benefit to offset monetary costs is challenging and strongly impacted by the model of care.

Stakeholder Engagement

Seven key stakeholder groups (care recipients, care workers, care organizations, software vendors, government and regulators, independent institutes of health data, and research institutions) potentially impacted by implementation of interRAI in aged care settings were identified. Representatives of each stakeholder group were engaged to develop and validate the interRAI implementation cost-benefit framework. Five key considerations emerged from these engagement activities (Table 1).

Table 1.

Stakeholder Perspectives on CBA Considerations

Consideration	Key factors	Example
Implementation strategy	Scope: number of instruments and services mandated; broader scope yields synergistic benefits.	New Zealand implemented interRAI over 15+ years via phased rollout: 3 years infrastructure development, 4-8 years pilot/refinement, followed by national scale-up. Used single provider (Momentum/Invica) on Azure cloud with national health identifiers for data linkage.
	Implementation Horizon: time allocated affects resource needs and benefit accrual.
	Approach: phased vs. simultaneous rollout.
	Software Solutions: single mandated platform vs. vendor choice for workflow integration.
Governance and government investment	Stakeholder Engagement: inclusion of stakeholders in design vs. government-led implementation.	NZ government fully funded interRAI: software, training, district-level support staff, and national data infrastructure for monitoring aged care provider performance.
	Policy Support: legislation enabling use of individual health identifiers for longitudinal analysis.
	Government Investment: full/partial funding vs. unfunded mandates.
Training and workforce development	Training Model: centralized government-funded vs. competitive private providers.	NZ created a central training authority with 25 trainers for ∼600 services. Training included theory and practice, starting with nurses, then allied health and managers. Developed culturally appropriate materials. Canada’s CIHI designed training; some provinces use independent providers. eLearning and train-the-trainer models vary by jurisdiction but align with CIHI standards.
	Training Scope: limited to nurses vs. extended to allied health, managers.
Data infrastructure and use	Interoperability: transferability of assessments across settings.	NZ’s centralized infrastructure includes a secure Azure-hosted data warehouse, national health identifiers, and APIs (SOAP, RESTful, FHIR). Supports monitoring, planning, and research. Used in >50 legal/regulatory cases to support care quality claims.
	Accessibility: staff access to assessments.
	Technical Infrastructure: point-of-care data capture vs. retrospective entry.
	Software Functionality: advanced features supporting workflows and planning.
	Data Sharing: availability of data for benchmarking and public use.
Research and communities of practice	Research Access: availability of deidentified data for research.	Canada’s interRAI research network has published 2,300+ peer-reviewed articles, influencing aged care policy. Regional communities of practice support peer learning and quality improvement.
	Networks: existence of interdisciplinary communities to analyze and apply data insights.

Notes: NZ—New Zealand; CIHI—Canadian Institute for Health Informatics; API—Application Programming Interface; SOAP—Simple Object Access Protocol; RESTful—Representational State Transfer; FIHR—Fast Healthcare Interoperability Resources; RAI—Resident Assessment Instrument

The relevance and importance of elements in each consideration varies across jurisdictions and will alter framework inputs. For completeness, all stakeholder groups and considerations are identified in the framework, though may be removed or augmented to meet unique contextual environments. The framework can incorporate multiple options, which is useful when comparing levels of implementation. For example, comparing three levels of mandatory reporting where (1) reports items from standalone instruments, (2) describes a mandated national minimum data set for reporting only, and (3) a fully integrated clinical information system with additional care planning and quality improvement functions.

Framework Development

Data from the literature review and stakeholder engagement, combined with continued stakeholder discussions, were summarized into a cost-benefit framework (Figure 1). The interRAI implementation CBA framework for aged care is developed around four domains identified by literature review and iterative stakeholder engagement for broader system-wide impacts of interRAI and health-systems evaluation programs, namely (1) care quality and continuity, (2) data and software, (3) administrative efficiency, and (4) policy alignment. ¹³ The framework is designed to capture the advantages of a comprehensive cost-benefit analysis by enabling comparisons and estimated opportunity costs of different implementation options, while also providing flexibility to adjust to changing contexts, where items irrelevant to a particular jurisdiction can be omitted from cost-benefit calculations.

Figure 1.

The interRAI Implementation Cost-Benefit Framework Describes Domains and Cost-Benefit Parameters for Consideration by Stakeholder Groups When Deliberating interRAI Implementation

CBA frameworks have adjustable parameters that illustrate the net benefit or net cost of a policy or program over different analysis periods, levels of certainty, stakeholder groups, and implementation options. Monetary value is assigned to each relevant cost and benefit to derive benefit-cost ratios over specified time horizons. Discount rates relevant to the local context are applied and sensitivity analysis conducted to evaluate and compare the options under consideration. Table 2 includes a description of the possible valuation methods and rationale for a sample of the identified interRAI costs and benefits.

Table 2.

Rationale and Possible Valuation Methods for interRAI Implementation Cost-Benefit Framework

Item	Description	Rationale	Possible valuation method	Stakeholder	interRAI instrument	Unit
Benefits
Case management	Costs of administrating, co-ordinating, and planning care delivery for care recipients, including time spent collating information from multiple sources.	Costs of maintaining administrative records for care recipients varies with approaches to care planning and level of integration between clinical care and care records.	Time × wage	Providers	Check Up, Home Care, Long Term Care Facilities	$
Transfer of records across settings	Avoided costs of disruptions to care, duplicate assessments, staff time, and non-compliance with care plans.	Integration and documented clinical history improves reliability of historical data, reducing time and stress spent on administrative processes which can then be used for providing clinical care.	Direct cost	Providers, care recipients, care workers, government, vendors, health data institutes, researchers	Check Up, Home Care, Long Term Care Facilities	$ per duplicate assessment
Adverse events	Case Management and Care planning informed by clinical protocols and CAPs, Care that meets client and clinical needs.	Savings from inappropriate care and savings from deterioration leading to adverse events.	Savings from inappropriate care and savings from deterioration leading to adverse events	Care recipients, providers	Check Up, Home Care, Long Term Care Facilities	$ per adverse event
Preventable hospitalizations	Benefit derived from early identification of people using risk screeners at risk of deterioration to support earlier intervention.	Accessibility and responsiveness of system when care needs change improves quality by moving towards right care at the right time.	preventable hospitalization, reduction in adverse events	Care recipients, providers	Check Up, Home Care, Long Term Care Facilities	$ per hospitalization
						$ per adverse event
Staying in own home	Benefit derived from lower costs of care associated with in-home vs. residential aged care.	Each day in a home care program reduces costs of residential aged care.	Length of stay/ savings from delay	Person, government (if funder)	Check Up, Home Care, Long Term Care Facilities	$ Avg per person/day saved
Workforce stability	Avoided costs of disruptions to care, improve workplace culture and increase staff well-being, improve staff retention.	Standardization of assessment instruments reduces training requirements, cognitive load and stress on clinical care staff, increasing retention and stabilizing service delivery which improves continuity of care for residents and improves their satisfaction.	Direct cost	Provider, care workers	Check Up, Home Care, Long Term Care Facilities	$
Costs
Training and instrument development	Anticipated budget expenditure associated with training and upskilling workforce to accommodate reforms.	Costs of developing, validating, and training staff in policy implementation is central to justifying investment and demonstrating overall project value.	Direct cost	Provider	Check Up, Home Care, Long Term Care Facilities	$
Costs of data reporting	Administration time associated with preparing reports and error detection.	Preparation of data for reporting varies with respect to level of automation and relevance of reports to clinical care.	Time × wage	Provider	Check Up, Home Care, Long Term Care Facilities	$
Data sharing	Administration time for communication across settings, collaboration, benchmarking, care planning continuity.	Standardization of items across settings and facilities allows for seamless transfer of information across a care recipient’s trajectory.	Time × wage	Provider	Check Up, Home Care, Long Term Care Facilities	$ per hour
Design and implementation	Resources for designing and establishing monitoring and evaluation frameworks, including stakeholder engagement, feasibility testing, and retraining of care staff to use new systems and frameworks.	System change has associated costs that should be captured.	Direct cost	Government	Check Up, Home Care, Long Term Care Facilities	$
Software development costs	Resources required for incorporating assessment instruments with software vendor’s product offering.	Vendors incur costs for accessing instruments and for integrating instrument functionality into product offering.	Direct cost	Vendors	Check Up, Home Care, Long Term Care Facilities	$

Discussion

We present a framework for determining a comprehensive set of costs and benefits associated with interRAI implementation that is adaptable to meet the needs and context of the jurisdiction considering interRAI implementation. We include an overview of four cost-benefit domains; (1) care quality and continuity, (2) data and software, (3) administrative efficiency, and (4) policy alignment. Specific inputs and values vary across contexts, with flexibility inbuilt into the framework to adjust to changing time horizons, discount rates, and sensitivity parameters, as well as the perspective of the analysis in relation to cost-benefit inputs and the degree of stakeholder involvement.

Costs associated with implementation of integrated clinical support systems across these domains include resource direct costs such as equipment costs, especially data infrastructure and software integration. While any system incurs some level of ongoing maintenance costs, the larger proportion of expenditure for such systems is incurred upfront during implementation. The main advantage of implementing a “tried-and-tested” system like interRAI is that implementation costs in their entirety will only be incurred once, whereas cyclical replacement “from scratch” necessitates associated implementation costs on each occasion of change, outweighing costs for ongoing maintenance. The interRAI systems are designed to be adjustable, generating capacity to update in-line with recent and relevant evidence-based practices without necessitating a full overhaul. ²⁰ This cost feature has flow-on effects in consultancy and consumer consultation, both expensive but necessary processes to governments when implementing a new system. Overall government expenditures for programs are unlikely to change; however, the benefits of improved efficiency will be realized in improved outcomes and cost savings in other areas such as hospitalization.

Benefits in healthcare are difficult to calculate due to their inherent intangibility. ¹⁴ Our framework can be adjusted to reflect differences in aspects of healthcare evaluation. For example, quality reporting is often achieved by governments through monitoring and reporting of Quality Indicators (QIs), where countries like Australia mandate the reporting of 11 QIs, contrasted with interRAI Canada’s generation of over 80 clinical indicators.^13,21 Neither program offers a method to evaluate the monetary benefit associated with quality indicators so the value difference between the two programs cannot be ascertained, nor is there definitive evidence of the extent that QI reporting leads to overall improvement in quality of care. ²² Benchmarking has known benefits but is dependent on the underlying data quality, which is poor in situations where data collection is not standardized, yet the economic impacts of differences in data quality have not yet been defined.^5,8,23 It is also difficult to quantify, in monetary terms, the benefit of improved efficiency in a situation where the item does not exist, for example, when quantifying the value of public facing information, it is unknown whether providing information in the format of star ratings (Australia) is superior to the QI library generated from interRAI data (Canada).

Our framework has some limitations and requires continued efforts to refine estimates. The main challenge for a cost-benefit framework in healthcare is dealing with the complexity of health systems in general. ²⁴ There are many component parts that interact in different ways, which is difficult to capture in a single framework that retains flexibility to adjust to different contexts and jurisdictions. Adding to this complexity is the valuation of aspects of health using traditional cost-benefit methodology. Health and healthcare is associated with substantial intangible costs and benefits, and quantifying the unquantifiable is a limitation of all cost-benefit analyses in health. ¹⁹ The uncertainty surrounding these estimates is well-provided for in this framework, but this evaluative work has not historically been performed and will evolve over time. Finally, there is the issue of willingness to pay in health. Willingness to pay is often used as an indicator of project viability, however, health markets are welfare markets, not traditional markets, and so stated willingness to pay is often disparate from observed willingness to pay. ¹⁶

Regardless of limitations, our framework provides a solid foundation for decision-makers to be informed of costs and benefits associated with monitoring and evaluation of health systems in the interests of quality improvements. ¹⁴ It encourages global, holistic thinking at a systems level to improve outcomes and meet the triple legislative obligations to support policy-makers, industry, and citizens to make the best decisions for health programs. The framework is flexible and adaptable to diverse contexts and jurisdictions as a useful tool to compare quality monitoring and evaluation activities. Countries seeking to enhance quality in healthcare can use the framework as a basis for valuing quality.

Conclusion

This article is part of a response to the global growing imperative for robust, well-informed quality improvement in health, especially aged care. interRAI presents a successful suite of assessment instruments, but the costs and benefits of implementation have not previously been systematically calculated. We present a cost-benefit framework that is comprehensive and adaptable to local contexts, stakeholder interests, and jurisdictions. This framework allows rigorous assessment of the costs and benefits of implementing interRAI and provides for comparative assessment to the next best alternative. The framework acknowledges and encourages further work on quantifying unknown values and reducing uncertainty estimates around inputs but remains robust to accommodate the dynamic nature of implementation inputs. It remains crucial that future research efforts review inputs and adjust to changing technologies, ensuring continued relevance and appropriate valuation of those inputs.

ORCID iD

Danelle Kenny https://orcid.org/0000-0001-7396-9742

Ethical Approval

Institutional review board approval was not required.