Table 1.

Main aspects of the implementation of the interRAI Suite in seven countries.

ASPECTS OF THE IMPLEMENTATION	BELGIUM	SWITZERLAND	FRANCE	IRELAND	ICELAND	FINLAND	NEW ZEALAND
Settings	Home care and residential care. Rehabilitation and mental health care: under testing.	Home care, residential long-term care, short-stay, day care, assisted living, mental health facilities and acute care	Home care and residential care	Home care and acute care settings	Home care, residential care, acute care, post- acute care and mental health care	Home care, residential care, (MDS pilots in acute care, post- acute care and mental health	Home care, residential care, palliative care and acute care
Territory	First locally in the whole province of Flanders and then nationwide	A mix between nationwide and locally	Locally first and nationwide after	Nationwide	Nationwide (MDS 2.0/LTCF and HC) and at the National University Hospital (AC, PAC, MH)	Nationwide	Nationwide
Types of interRAI Suite instruments to be implemented or already implemented:	Being implemented: interRAI HC, interRAI LTCF, BelRAI Screener, the BelRAI Social Supplement. Under consideration: interRAI PC, interRAI MH, interRAI CMH, supplements of MH, interRAI Rehabilitation Services, Screener for Children and Adolescents	Already implemented: MDS-NH, MDS-HC, interRAI HC and CMH Locally in 1 region: interRAI CU (assessor version), interRAI Screener (Assessment Urgency Algorithm), CPS and ADLH scales integrated in transfer documentation between hospitals and community/residential care To be implemented: Upgrade to interRAI LTCF Under consideration: interRAI Pediatrics and interRAI MH interRAI Check-Up (CU) assessment (self-reported version) interRAI Palliative Care	Already implemented: InterRAI HC for case managers and InterRAI CA for single entry point in integrated model of care To be implemented: interRAI LTCF, PC and AC	Already implemented: interRAI HC and interRAI HC for AC To be implemented: A five-district pilot of the interRAI AC is currently underway in 2022. A pilot of the self- report version of the interRAI CU assessment is in development.	Already implemented: MDS 2.0 to be switched to interRAI LTCF. InterRAI HC partially and increasingly nationwide. Being implemented: ED screener, ED contact Assessment, AC and PAC and MH are all in different stages	Being implemented: HC, LTCF, MDS pilots in acute care, post- acute care, Mental Health Nationwide implementation of the interRAI LTCF and interRAI HC (latest April 2023) Transition from MDS: ongoing	Already implemented: The interRAI Contact, Community Health or interRAI HC,. LTCF, PC in the community or aged residential care (ARC). To be implemented: A five-district pilot of the AC assessment is underway with a national rollout planned for 2022. A pilot of the self-report version of the CU assessment is in development.
Pre-implementation strategy: period and type (top-down, bottom-up, push-pull, etc.)	2006–2016: Feasibility and evaluation studies: firstly top-down, then a bottom-up strategy was put in place.	From 2015: Small scale bottom-up pilots with strong policy support locally	1995–2009: feasibility studies in residential care and nursing home 2009–2015: an experimental integrated care site using the interRAI HC for case management	2012: Pre-Pilot study across Community Care, Long Term Care and Acute care recommending interRAI as most for purpose for implementation in Ireland 2016: National Pilot in 3 locations leading to recommendation for national implementation	1997 to current date: MOH implemented the MDS 2.0 nationwide after some pilot studies in previous five years. The interRAI HC instrument was encouraged by the MOH but not mandated and has taken longer time. The University Hospital assessments are being pushed within different departments.	Pre-implementation strategy MDS voluntary, bottom up from the year 2000 to 2019.	2002: Ministry of Health (MOH) signals the intent to improve assessment systems 2003: an independent Tools Review identified interRAI as best meeting New Zealand’s needs. 2004–2007: Pilot of the interRAI HC in five District Health Boards (DHBs), led by DHBs. 2008–2012: project to implement home and community assessments led by MOH and DHBs 2011–2014: MOH and Aged Care Association pilotted the interRAI LTCF
Implementation design: period and type (top-down, bottom-up, push-pull, etc.)	From 2017 on: Top-down, stepwise implementation	2010–2020: MDS-versions – Top-down with focus on administrative use For nationwide MDS-update: top-down decision and coordination 2020: Push-pull: Larger interest from the field of all sorts of structures and populations hence some applications/conditions demand top-down regulations, development, coordination	From 2017 on: Top down, stepwise implementation of the interRAI HC for the 1,000 case managers in the entire territory	2017: Top down, cross national phased implementation	MDS 2.0 top down and interRAI HC suggested top down. The Hospital systems have been more bottom-up.	When more than one third of all facilities and home care were using MDS, a new legislation about mandatory implementation of the interRAI suite came into force (top-down)	Bottom up initially, then top-down managed implementation in collaboration with relevant stakeholders. 2015: Assessments mandated. Permanent interRAI Service established and funded by MOH includes support for governance, education and support services, software services and data services.
Methods for identifying needs	Feasibility studies, testing of the instruments in real practice, focus groups and intervisions.	Several pilot studies, context analyses, national committees and interregional working groups.	Case studies and focus group with case managers	Pilot study identified challenges which needed to be addressed in order to ensure successful implementation	Needs demonstrated with pilot studies, including cross national studies	Needs of clients, residents, nurses and organisations were collected in pilot studies and in context of cross national studies.	Engagement with key stakeholders. Iterative pilots and projects.
Methods for identifying barriers	SWOT analysis (Strengths, Weaknesses, Opportunities and Threats) and UTAUT analysis (Unified Theory of Acceptance and Use of Technology [51]) during pilot tests	Context analysis Mixed methods evaluations Case studies Structured observations	SWOT analysis	Pilot analysis – SWOT conducted which were categorized into the following categories: ICT, Implementation processes and Training	Not systematically studied and to a variable degree depending on the system	By interviews and discussions with participating nurses and their head nurses, in semi-annual benchmarking meetings. Also by annual board meetings: participating organisations, THL and software companies)	Project management methodology. Strong engagement with key stakeholders. Establishment of a group of highly respected representatives from key government and non- government organisations who had the ability to influence change during implementation.
Main advantages of the interRAI instruments perceived by users	Clinicians and care organisations: Common language across settings., Continuity of care, Improvement and standardization of observations, Involvement of several disciplines in the assessment (multidisciplinary). One single platform to exchange information.	Clinicians and care organisations: Common language across settings Holistic approach: Identifying early decline and domains that are not strictly “medical” Useful in interdisciplinary discussions Facilitates coordination of care by shared information, especially in situations of co-management i.e.	Clinicians and care organisations: Better and comprehensive assessment of resident’s needs Participation of residents and caregivers in their assessment Reinforcement of the multidisciplinary approach Improvement of gerontology knowledge	Clinicians and care organisations: Real time production of decision support information which can be shared by personnel. supports clinical decision-making/corporate decision-making facilitates individualised care planning and integrated care provides case-mix classification at management and systems level	Clinicians and care organisations: Common language across settings, Resource Utilisation Quality indicators Research	Clinicians and care organisations: Makes the demands of the work in older people’s care visible Helps to identify clients’ needs (how and what to observe) and create the individual care plan Helps to monitor client level outcomes Shows the quality of the performed work Helps the workers to discuss with relatives, and informal carers	Clinicians and care organisations: Common language across settings Decision support properties for assessors to inform care Transparent and objective review of assessment quality Supports prioritisation and eligibility processes One single platform (assessment record) to exchange information.
	Policy makers: Benchmarking across organisations. Resource planning. Evidence based decision making	multiple agencies care for the same person simultaneously (e.g. home care and day care service) policy makers: Decision support based on valid and comparable data Potential to support and monitor public health programs across the care continuum (quality, care trajectories, care expenses, alternative care structures, community-enhancing initiatives, comparisons) Interoperability for electronic health records and integration in data warehouse Focus from acute problems to prevention and identifying early decline The 2-step use of interRAI CU and the interRAI HC to differentiate length of assessment according to the care complexity is more efficient The change to broaden the assessors’ job to non-nursing disciplines is greatly appreciated (e.g. social workers, occupational therapist, nutritionist) Difficult to change existing practice and to change routine processes	having a unique assessment with series of applications quality indicators produced by the assessment For case managers using the interRAI HC: making the link between the comprehensive assessment and the care planning Legitimation of their role as case managers Police makers and care managers were not involved in the evaluation	enables quality monitoring, benchmarking, and service improvement informs eligibility criteria for access to services supports prioritisation of services access based on assessed need targets priority groups or identifies groups that are at relative risk of adverse outcomes Policy Makers: Enhances knowledge of client care populations Identifies service need/service improvements Informs allocation of resources and prioritisation of services based on real-time assessed needs Can determine eligibility for services Prioritises service users who are most in need Provision of data for performance monitoring and quality assurance Allows managers to track and compare their organisations’ responses to quality of care issues Better management of services/resources Demonstration of effective care/value for money		Nursing leaders: Helps in dividing tasks between distinct professions, in units Shows gaps in staff knowledge/strengths in expertise and helps planning of further education of the existing staff, and recruiting new type workers Organisational leaders: tool for regulative procedures setting strategic/tactical goals for the organisation protects from false accusations (from media, individuals) Regional leaders case-mix and quality comparisons of public and outsourced care providers Though benchmarking follow-up of performed policies issues of integrated care can be solved in the future Payment systems piloted National leaders/Policy makers: Creating new policies and follow-up of the outcomes (safety and quality of care, gate-keeping criteria, staffing ratio etc.) Identifying need for new legislations/guidelines	Policy makers and researchers: Collection of information once in a live national database that can be used for many purposes, such as understanding the needs of the assessed population, making evidence based decisions, understanding of health outcomes (equity), allowing case mix funding and resource planning
Main disadvantages or barriers perceived by users	Electronic records and IT infrastructure is not always available. Overlap with other instruments already used in the care practice. Low involvement of GPs. Time consuming at first but time saved after first assessment is filled out. Fear that clinical judgement will become redundant.	Difficult to learn Needs specific coaching to integrate it into team processes on the field Overlap with existing assessments in use Fears of administrative charge (MDS-NH was purely used for funding) Software is often non-attractive as some vendors do not use the full potential and are not focused on user-friendliness Low involvement of GPs The locally-made derived versions in the Swiss context are different from the original internationally validated system and therefore confusing (Swiss version of RUGs, QIs, item content, development of RAI-like instruments…) Data literacy is often low Quality of trainings varies Technical software support for longitudinal data visualisations across settings is not developed yet in Switzerland No integration in national electronic health record yet For inter-institutional use, guidelines and communication structures are needed	Fears of the standardisation practices Identification of work-organisation problems in nursing home Lack of connection between research purpose and a routine clinical utilization Lack of appropriation of other applications	Length of assessment – time consuming ICT connectivity/offline use Software/hardware issues	Perceived to be time consuming tardy integration into the Electronic Medical Record and the Nurses Records limited support to utilise the information to change practice.	Need for education in how to assess the client needs interRAI-tools assessment process is time consuming bedside education of new workers is time consuming need for education how to lead and manage with help of interRAI-tools cautiousness among staff and leaders about how to use the tools (human makes the decisions) incompatibility or only partial compatibility of interRAI systems with patient/client records within jurisdictions incompatible software solutions have been a barrier for integrated care between jurisdictions	Conceptual and terminology challenges for assessors changing from a subjective and narrative questionnaire type of assessment to a software supported and transparent assessment system with decision support properties. Trust and confidence in a new assessment process. Potential loss of clinical autonomy. Trust and confidence in the software system. Interoperability barriers if the software does not connect with other systems in use. Trust and confidence in the data. Resources or knowledge to analise or use the data. Time consuming during the learning period.