Abstract: Introduction: The International Resident Assessment Instrument (InterRAI) is a service and needs assessment tool that the Ministry of Health (MoH) was recommended to use by a report “Assessment Processes for Older People” in 2003, authored by the New Zealand Guidelines Group (NZGG). The MoH has implemented a New Zealand wide pilot in order to test the feasibility of InterRAI’s use in the elderly population in New Zealand. Aim: The aim of the dissertation is to provide a descriptive analysis of data from the Canterbury District Health Board (CDHB) Pilot Trial of an InterRAI Homecare Assessment form as a means of assessing the care requirements of the elderly. The data had been collected from 264 people on one, two or three different occasions/assessments. Elderly in the CDHB’s population catchment’s area were assessed between 2005 and 2006, with participants throughout Christchurch and surrounding localities, e.g. Rangiora and Kaiapoi. At the time of assessment approximately 80% were community dwelling and about 20% were inpatients. The data were collected from 264 people on one, two or three different assessment occasions. Methods: The CDHB pilot study data was present in two databases, which was transferred and reformatted from an Excel Spreadsheet format to a statistical programme format for analysis, SAS-9 (2004). The elderly were assessed initially once (called Time One) but some were assessed multiple times, i.e. all participants 264 were assessed once (Time One), 147 (56.7 %) were assessed twice, 65 (24.6%) three times and ten (3.6%) four times. The results presented here are mainly of the first assessment only, as this is the total sample. Results and Discussion: There are 178 females and 86 males, ranging in age from 64 - 95, all English speaking and mainly, New Zealanders, of which most are married or are widowed. The mean and median ages are around 80 years of age. Overall, the reason for movement of elderly, i.e. change in Residential Type was ADL Decline. There was also some correlation with elderly person’s home environment. Possibly the only reason for a non-routine visit to hospital for an elderly person was that the person was alone i.e. no other means of help was available to them. The lack of secondary helpers for the elderly was also important in both elderly person’s movement and non-routine visits to hospital. Conclusions: The results have provided new information for the CDHB. However, more work is required, such as the ethnicity, age–gender range and service use. The CDHB are planning to implement the InterRAI assessment process, into the CDHB’s service delivery, for the elderly population, in Canterbury. Recommendations: Some more time dependent data needs to be analysed i.e. trend analysis across assessments. Further research could focus on two categories, disease coding and medicine usage.

Abstract: Introduction: The International Resident Assessment Instrument (InterRAI) is a service and needs assessment tool that the Ministry of Health (MoH) was recommended to use by a report “Assessment Processes for Older People” in 2003, authored by the New Zealand Guidelines Group (NZGG). The MoH has implemented a New Zealand wide pilot in order to test the feasibility of InterRAI’s use in the elderly population in New Zealand. Aim: The aim of the dissertation is to provide a descriptive analysis of data from the Canterbury District Health Board (CDHB) Pilot Trial of an InterRAI Homecare Assessment form as a means of assessing the care requirements of the elderly. The data had been collected from 264 people on one, two or three different occasions/assessments. Elderly in the CDHB’s population catchment’s area were assessed between 2005 and 2006, with participants throughout Christchurch and surrounding localities, e.g. Rangiora and Kaiapoi. At the time of assessment approximately 80% were community dwelling and about 20% were inpatients. The data were collected from 264 people on one, two or three different assessment occasions. Methods: The CDHB pilot study data was present in two databases, which was transferred and reformatted from an Excel Spreadsheet format to a statistical programme format for analysis, SAS-9 (2004). The elderly were assessed initially once (called Time One) but some were assessed multiple times, i.e. all participants 264 were assessed once (Time One), 147 (56.7 %) were assessed twice, 65 (24.6%) three times and ten (3.6%) four times. The results presented here are mainly of the first assessment only, as this is the total sample. Results and Discussion: There are 178 females and 86 males, ranging in age from 64 - 95, all English speaking and mainly, New Zealanders, of which most are married or are widowed. The mean and median ages are around 80 years of age. Overall, the reason for movement of elderly, i.e. change in Residential Type was ADL Decline. There was also some correlation with elderly person’s home environment. Possibly the only reason for a non-routine visit to hospital for an elderly person was that the person was alone i.e. no other means of help was available to them. The lack of secondary helpers for the elderly was also important in both elderly person’s movement and non-routine visits to hospital. Conclusions: The results have provided new information for the CDHB. However, more work is required, such as the ethnicity, age–gender range and service use. The CDHB are planning to implement the InterRAI assessment process, into the CDHB’s service delivery, for the elderly population, in Canterbury. Recommendations: Some more time dependent data needs to be analysed i.e. trend analysis across assessments. Further research could focus on two categories, disease coding and medicine usage.

Background: The rehabilitation of older persons is often complicated by increased frailty and medical complexity – these in turn present challenges for the development of health information systems. Objective investigation and comparison of the effectiveness of geriatric rehabilitation services requires information systems that are comprehensive, reliable, valid, and sensitive to clinically relevant changes in older persons. The Functional Independence Measure is widely used in rehabilitation settings – in Canada this is used as the central component of the National Rehabilitation Reporting System of the Canadian Institute of Health Information. An alternative system has been developed by the interRAI consortium. We conducted a literature review to compare the development and measurement properties of these two systems and performed a direct empirical comparison of the operating characteristics and validity of the FIM motor and the ADL items on the PAC in a sample of older adults receiving rehabilitation. Methods: For the first objective english language literature published between 1983 (initial development of the FIM) and 2008 was searched using Medline and CINAHL databases, and the reference lists of retrieved articles. Additionally, attention was paid to the ability of the two systems to address issues particularly relevant to older rehabilitation clients, such as medical complexity, comorbidity, and responsiveness to small but clinically meaningful improvements. For the second objective we used Rasch analysis and responsiveness statistics to investigate and compare the instruments dimensionality, item difficulty, item fit, differential item function, number of response options and ability to detect clinically relevant change. Results: The majority of FIM articles studied inpatient rehabilitation settings; while the majority of interRAI/MDS articles focused on nursing home settings. There is evidence supporting the reliability of both instruments. There were few articles that investigated the construct validity of the interRAI/MDS. The analysis showed that the FIM may be slightly more responsive than the PAC, especially in the MSK patients. However, both scales had similar limitations with regards the large ceiling effect and many unnecessary response options. Conclusions: Additional psychometric research is needed on both the FIM and MDS, especially with regard to their use in different settings and ability to discriminate between subjects with functional higher ability.

Background: The rehabilitation of older persons is often complicated by increased frailty and medical complexity – these in turn present challenges for the development of health information systems. Objective investigation and comparison of the effectiveness of geriatric rehabilitation services requires information systems that are comprehensive, reliable, valid, and sensitive to clinically relevant changes in older persons. The Functional Independence Measure is widely used in rehabilitation settings – in Canada this is used as the central component of the National Rehabilitation Reporting System of the Canadian Institute of Health Information. An alternative system has been developed by the interRAI consortium. We conducted a literature review to compare the development and measurement properties of these two systems and performed a direct empirical comparison of the operating characteristics and validity of the FIM motor and the ADL items on the PAC in a sample of older adults receiving rehabilitation. Methods: For the first objective english language literature published between 1983 (initial development of the FIM) and 2008 was searched using Medline and CINAHL databases, and the reference lists of retrieved articles. Additionally, attention was paid to the ability of the two systems to address issues particularly relevant to older rehabilitation clients, such as medical complexity, comorbidity, and responsiveness to small but clinically meaningful improvements. For the second objective we used Rasch analysis and responsiveness statistics to investigate and compare the instruments dimensionality, item difficulty, item fit, differential item function, number of response options and ability to detect clinically relevant change. Results: The majority of FIM articles studied inpatient rehabilitation settings; while the majority of interRAI/MDS articles focused on nursing home settings. There is evidence supporting the reliability of both instruments. There were few articles that investigated the construct validity of the interRAI/MDS. The analysis showed that the FIM may be slightly more responsive than the PAC, especially in the MSK patients. However, both scales had similar limitations with regards the large ceiling effect and many unnecessary response options. Conclusions: Additional psychometric research is needed on both the FIM and MDS, especially with regard to their use in different settings and ability to discriminate between subjects with functional higher ability.

Relief from pain and distressing symptoms associated with a life limiting illness is an issue relevant to all Canadians. Provision of high quality care for persons nearing the end of life may improve the health and quality of life of the person and affects the health and well-being of members of their informal support network including family, friends, and caregivers. Palliative care, a person-centered approach to care for persons faced with a life limiting illness and their informal support network, focuses on the ‘total person’ or ‘whole self’ addressing the multifaceted complex needs of each person on an individualized basis. Palliative care is recognized by the World Health Organization (WHO) to be “achieved through prevention and relief of suffering by means of early identification, comprehensive assessment, and treatment of pain and physical, psychosocial, or spiritual problems” (World Health Organization [WHO], 2010). The palliative care philosophy prioritizes self-determination of the person and supports their engagement in the care planning and decision making process across the illness trajectory. Approximately one fifth of persons who die annually experience unrelieved suffering (Doyle & Woodruff, 2013). Persons nearing the end-of-life face can face a wide range of challenges that may include: uncontrollable pain and physical symptoms, unresolved and emotionally distressing psycho-social issues, and fear of one’s own mortality and of an unknown future. Nearly two thirds of Canadians who die each year may benefit from palliative care (Canadian Hospice Palliative Care Association [CHPCA], 2010), however only approximately one in eight of those persons are able to access palliative care services (Carstairs & Beaudoin, 2000). Comprehensive clinical assessment supports clinicians to make evidence-informed decisions and promotes a person-centered approach to care planning. The interRAI Palliative Care assessment instrument (interRAI PC) is a comprehensive standardized assessment instrument, designed for use by facility and community based palliative care services, with applications that include care planning, outcome measurement, quality monitoring, and resource allocation (Hirdes et al., 1999; Steel, et al., 2003; Gray, et al., 2009; Hirdes et al., 2008). Using pilot data gathered from the interRAI PC, this thesis examines the potential use of interRAI PC assessment data, and in particular how evidence from the interRAI PC Clinical Assessment Protocols (CAPs) has the potential to inform individualized care plan development for persons with a life limiting illness. This thesis begins with a scoping literature search that describes palliative care in a Canadian context and explores care planning with the interRAI PC. This is followed by three research based chapters (Chapters 6, 7, and 8) that include analysis based on pilot data gathered between 2006 and 2011 using the interRAI PC assessment instrument. Community dwelling persons with a life limiting illness receiving palliative home care services in six geographic locations across Ontario, Canada, were included in these analyses. Persons with a life limiting illness residing in institutional or hospice facilities, or in jurisdictions outside of Ontario, were excluded. Analyses were performed using SAS Version 9.2 with an alpha level of p< 0.05 for all statistical tests unless otherwise stated. The University of Waterloo’s Office of Research Ethics granted ethics clearance for this research (ORE# 19424) November 29th, 2013. The first research chapter (Chapter 6) describes how clinicians may use the interRAI PC Clinical Assessment Protocols (CAPs) to inform care planning. It includes an overview of the suite of eight CAPs and provides a background description of the CAP development process. Discussion addresses the unique distributional characteristics of each CAP and describes a hierarchical triggering structure. Following, chapter six which provides an overview of the interRAI PC CAPs from a broad perspective; chapter seven (the second research chapter) takes a more in-depth focus investigating the Dyspnea CAP. Dyspnea was selected as the symptom of focus because it is the one of the most commonly triggered CAPs affecting nearly half of the sample palliative home care population used in this thesis and is reported to be one of the most distressing symptoms affecting both the person faced with a life limiting illness and their informal caregivers (Ng &von Gunten, 1998; Potter, Hami, Bryan, & Quigley, 2003; Dellon et al., 2010; Kroenke, Johns, Theobald, Wu, & Tu 2013). Chapter seven examines the Dyspnea CAP and describes the prevalence of dyspnea. This chapter demonstrates the relationship between dyspnea and prognosis as well as other clinical factors. Moreover, how the presence of dyspnea changes over time is examined and person-level characteristics, some of which are potentially amenable to change, that affect the risk for dyspnea over time are identified. In addition, risk and protective factors for persons who over time developed new dyspnea symptoms and for those who recovered from dyspnea are examined. Recognizing that a hallmark of the palliative care philosophy is its aim to provide the highest quality of care and support for both the person nearing the end of life and members of their care network including their informal caregivers, the third research chapter (Chapter 8) examines distress experienced by both the caregiver and the care recipient as a unit of care. As quality palliative care may increase satisfaction with care, improve global quality of life for client and their caregiver, reduce physical symptoms like dyspnea, decrease signs of depression or anxiety, and improve access to health care resources (Kane, Bernstein, Wales, Leibowitz, & Kaplan, 1984; Melin-Johansson, Axelsson, Gaston-Johansson, & Danielson, 2010) the association between the presence of dyspnea and distress experienced by members of the caregiver-client unit of care is examined to illustrate how dyspnea relates to distress, a major problem affecting over half of the caregiver-client units of care. Together, findings from this thesis show that if one or more interRAI PC CAPs are triggered then the clinician should take notice. Data from the interRAI PC and more specifically from the interRAI PC CAPs examined in this thesis provide evidence on their potential to inform greater understanding of the complex needs of palliative home care clients. Better understanding of the interRAI PC CAPs and identification of patterns in CAP triggering structure suggest symptoms where clinicians may focus increased attention. To address the accumulative complex needs of persons who are faced with a life-limiting illness and the needs of their caregivers, resource allocation focused on evidence gathered from a comprehensive standardized assessment instrument should be prioritized.

Magister Curationis - MCur / Worldwide concerns have been raised about the presence and association of depressive symptoms, cognitive impairment, and dementia in older adults (60 years and older), which are often unrecognised and untreated in long-term care facilities (LTCF’s). The progression of cognitive impairment to dementia reduces quality of life with negative consequences of physical, mental, and psychosocial health. In many LTCF’s internationally, the standardised interRAI system is used to capture depressive symptoms and cognitive impairment. However, there is a fragmentation of systems for making evidence-based decisions to plan and manage care for residents with depressive symptoms, cognitive impairment, and dementia. This study, being the first of its kind in South Africa, addressed this gap, by describing a profile of depressive symptoms and cognitive impairment in residents, and analysing their coexistence, using the interRAI-LTCF in a LTCF in the Cape Metropole in South Africa. A quantitative, descriptive, and analytical cross-sectional secondary data analysis was conducted using the records of all 173 resident’s medical records of residents with a last interRAI-LTCF assessment from 2014 and 2016. The objectives were to determine the levels of depressive symptoms and cognitive impairment, and to assess variously associated demographics and clinical variables between depressive symptoms and cognitive impairment of the interRAI-LTCF in residents in a LTCF. Secondary data were analysed, using the IBM Statistical Package for Social Sciences (SPSS) software, version 25, to test any statistically significant relationship between the extracted variables (Significance was set as p˂0.05).

Abstract Objectives: This research project was undertaken to review two commonly used screening instruments for the elderly who attend at hospital emergency departments in Ontario. These instruments were then contrasted with a new potential screening instrument made up of items drawn from the Minimum Data Set-Acute Care instrument (MDS-AC Version 1_CAN). The hypothesized outcome was better specificity and sensitivity utilizing the newly prepared instrument in predicting at an earlier point if an elderly emergency department patient would become an alternate level of care (ALC) patient. The ability of the screener to predict negative outcomes (delirium, longer length of stay) was also analyzed. Methods: One dataset from a previous International Resident Assessment Instrument (interRAI) organization study in southern Ontario completed in 2000 was utilized to inform this research. Each of the commonly used screening instruments was crosswalked to the MDS-AC items, then both univariate and bivariate analyses were completed. Three research questions were then posed. By testing various logistic regression models, the research looked to establish whether the newly developed instrument would be able to perform comparably to the other two currently-used instruments, and whether it would be more effective in predicting ALC status and particular adverse patient outcomes. Results: The newly-developed instrument was found to perform more accurately. While several variables were tested, a core number were found to be more strongly predictive of future need for ALC status. Conclusions: Future research in this area is recommended.

Abstract Objectives: This research project was undertaken to review two commonly used screening instruments for the elderly who attend at hospital emergency departments in Ontario. These instruments were then contrasted with a new potential screening instrument made up of items drawn from the Minimum Data Set-Acute Care instrument (MDS-AC Version 1_CAN). The hypothesized outcome was better specificity and sensitivity utilizing the newly prepared instrument in predicting at an earlier point if an elderly emergency department patient would become an alternate level of care (ALC) patient. The ability of the screener to predict negative outcomes (delirium, longer length of stay) was also analyzed. Methods: One dataset from a previous International Resident Assessment Instrument (interRAI) organization study in southern Ontario completed in 2000 was utilized to inform this research. Each of the commonly used screening instruments was crosswalked to the MDS-AC items, then both univariate and bivariate analyses were completed. Three research questions were then posed. By testing various logistic regression models, the research looked to establish whether the newly developed instrument would be able to perform comparably to the other two currently-used instruments, and whether it would be more effective in predicting ALC status and particular adverse patient outcomes. Results: The newly-developed instrument was found to perform more accurately. While several variables were tested, a core number were found to be more strongly predictive of future need for ALC status. Conclusions: Future research in this area is recommended.

By the year 2024, one in four adults in Canada will be over the age of 65. In Ontario alone, 100,000 residents live in long-term care (LTC). Residents sometimes experience poor quality-of-life (QOL). Culture change has been proposed as an approach to improve residents’ QOL in LTC. One large LTC organization, Schlegel Villages, has developed and implemented an organizational culture change called Neighbourhood Team Development (NTD). This approach focuses on building cross-functional teams to enhance resident-centredness and promote QOL through optimizing residents’ autonomy and dignity. Implementation of NTD started in 2013 in six LTC homes. The aim of this secondary analysis was to evaluate if NTD has an impact on residents’ QOL in LTC. Using a quantitative repeated-measures design, residents from six LTC homes completed QOL assessments. Quantitative data were collected through the Resident Assessment Instrument-Minimum Data Set 2.0 (RAI-MDS) and the interRAI QOL Survey Short Form. QOL data were analyzed using a paired t-test to assess change scores between time point 1 (data collected between August 2011 and December 2012) and time point 2 (data collected between January 2014 and November 2015) for 232 residents. Study results demonstrate that NTD increased residents’ QOL (p = .003). Organizational culture change such as NTD can lead to innovative approaches to improve the QOL of residents in LTC. This study contributes to literature examining culture change in LTC, and helps inform LTC care models, and interventions to increase residents’ QOL in LTC. / Thesis / Master of Science (MSc)

InterRAI is an internationally validated assessment tool used in many different contexts to assist different groups of people and patients to live fuller, safer and more productive lives. In 2008, the New Zealand Ministry of Health, after the completion a trial of the interRAI – Home Care assessment tool in the District Health Board, rolled out implementation of the interRAI – Home Care tool throughout New Zealand’s 21 District Health Boards. The Quality of Life survey itself is currently being assessed and trialled throughout the world as a follow-up to the Home Care assessment. It will enable researchers and assessors to enable for a comprehensive perspective by bringing together the views of both service providers and recipients of care service. The assessments will be completed by the person directly, as a self assessment, or through interview The overall research aim of the study itself is to evaluate the adequacy of the interRAI Quality of Life survey in assessing the Quality of Life issues and needs of the elderly living in their own homes in the community with some sort of publicly funded health care, social or community support such as meals on wheels, personal care, etc., for the purpose of demonstrating the importance of it as a useful tool within New Zealand. The objectives of the research are as follows: • Objective 1 - To review the management and application of quality of life indicators for the elderly. • Objective 2 – To understand the pressures which an ageing population places on public policy. • Objective 3 - To consider how quality of life measures can best be applied alongside interRAI in New Zealand. The research itself focused on the Quality of Life of thirty participants. Each participant was first assessed through an interRAI – HC assessment at their own home by an assessor from the Canterbury District Health Board. Upon completion of the assessment, they were given the option of being contacted by the researcher about participation in the interRAI Quality of Life Survey. Contact by the researcher by telephone ensued, which was then followed up by a face to face information session at the home of the participant. At this time, thirty out of thirty one potential participants decided to sign the informed consent form for participation. As the Quality of Life Survey itself is self reported, each participant was free to read through the survey and answer for themselves questions regarding their thoughts about their own quality of life. Participants responded to forty six statements from nine different domains on the Quality of Life Survey. Overall results showed a majority of responses of ‘Always’, which were positive. Areas of concern which emerged from the data were of possible issues of social isolation and unresolved emotional health. Limitations of the research included factors such as the small sample size of thirty, the geography of the study which was limited to Christchurch, and the fact that there was no follow up visit to the first and only interview. In conclusion, it is apparent that a larger trial throughout the District Health Board is required to overcome the aforementioned limitations of sample size and geography. Also, it is imperative that a follow-up visit is scheduled after the initial visit to allow for intervention into quality of life issues which emerge from the participant’s self-assessment.