Trevor Frise Smith

Integrated Health Information Systems Based on the RAI/MDS Series of Instruments

There is a growing need for an integrated health information system to be used in community, institutional and hospital based settings. For example, changes in the structure, process and venues of service delivery mean that individuals with similar needs may be cared for in a variety of different settings. Moreover, as people make transitions from one sector of the healthcare system to another, there is a need for comparable information to ensure continuity of care and reduced assessment burden. The RAI/MDS series of assessment instruments comprise an integrated health information system because they have consistent terminology, common core items, and a common conceptual basis in a clinical approach that emphasizes the identification of functional problems.

The Resident Assessment Instrument-Mental Health (RAI-MH): Inter-Rater Reliability and Convergent Validity

An important challenge facing behavioral health services is the lack of good quality, clinically relevant data at the individual level. The article describes a multinational research effort to develop a comprehensive, multidisciplinary mental health assessment system for use with adults in facilities providing acute, long-stay, forensic, and geriatric services. The Resident Assessment Instrument-Mental Health (RAI-MH) comprehensively assesses psychiatric, social, environmental, and medical issues at intake, emphasizing patient functioning. Data from the RAI-MH are intended to support care planning, quality improvement, outcome measurement, and case mix-based payment systems. The article provides the first set of evidence on the reliability and validity of the RAI-MH.

Use of physical restraints and antipsychotic medications in nursing homes: a cross-national study.

This study compares inter‐ and intra‐country differences in the prevalence of physical restraints and antipsychotic medications in nursing homes, and examines aggregated resident conditions and organizational characteristics correlated with these treatments.

From Theory to Practice: A Determinants Approach to Workplace Health Promotion in Small Businesses

A determinants approach to workplace health promotion focuses on the sources of health and ill health in the workplace itself. Key practice requirements of such an approach include the capacity to shift focus beyond the individual to the work environment, to cross disciplinary and jurisdictional boundaries in identifying problems and solutions, to foster health promotion self-sufficiency within the workplace, to enable worker participation in the process, and to adapt practice strategies to a business setting. This article identifies the challenges of such practice by reference to the experiences of health promoters in a Canadian public health department who attempted a determinants-centered stress reduction program for small-sized businesses. Findings under-score the significance for workplace health promotion of the broader structural context in which the workplace and the intervention are located, of differing perspectives between health professionals and workplace parties, and of conflicting professional accountabilities. Possibilities for addressing these challenges are considered.

Predictors of caregiver distress among palliative home care clients in Ontario: evidence based on the interRAI Palliative Care.

OBJECTIVE This study examines predictors of caregiver distress among community-based palliative care clients. Analyses are based upon interRAI Palliative Care (interRAI PC) assessment data from palliative home care programs in three regions in Ontario, Canada. METHOD The study sample involved all community-based palliative care clients in Ontario who were assessed with the interRAI PC as part of normal clinical practice during pilot implementation of the instrument between 2007 and 2009 (N = 3,929). The assessments were performed by trained case managers and were used as the basis for determining service needs to be addressed through services contracted from provider agencies. The main study outcome of interest was the presence of one or more indicators of caregiver distress: helper(s) unable to continue caring activities; primary informal helper expresses feelings of distress, anger, or depression; family or close friends report feeling overwhelmed by persons illness. RESULTS Caregiver distress was evident among about 22% of palliative home care clients. Multivariate analyses identified included clinical instability (Changes in Health, End Stage disease, Signs and Symptoms [CHESS] scale), depressive symptoms, cognitive impairment, and positive outlook as significant client-level predictors. Significant caregiver characteristics included hours of informal care. Three service use/provider variables were significant predictors of caregiver distress: the specific home care agency, hospitalizations in the last 90 days, and nursing visits. SIGNIFICANCE OF RESULTS Caregiver distress affects approximately one in five palliative care clients in the community. This may lead to a number of adverse outcomes for the caregiver and client. The experience of distress is affected by client, caregiver, and agency characteristics that are readily identified by the interRAI PC assessment instrument. The present results point to the need for a care planning protocol that may be used on a targeted basis for clients experiencing or at elevated risk of caregiver distress.

Depression in patients with advanced illness: an examination of Ontario complex continuing care using the Minimum Data Set 2.0.

OBJECTIVE In this study, we examined the prevalence of depression, its recognition, and its treatment in continuing care patients with advanced illness (AI). METHODS All data were obtained from the Ontario (Canada) provincially-mandated MDS 2.0 form for chronic care. Of 3,801 patients, 524 met our empiric definition of AI, which was predicated on a previously validated algorithm. The MDS-embedded Depression Rating Scale (DRS) was used to measure psychological well-being and a score of 3 or greater indicated potential depression. RESULTS Twenty-nine percent of patients with AI scored greater than 3, making them nearly twice as likely to be potentially depressed as other patients (OR 1.8, 95% CI 1.5-2.2). Despite this patients with AI were less likely to have received antidepressants (28.9% vs. 38.2%), even among those with a diagnosis (45.3% vs. 58.4%). Using logistic regression, correlates of potential depression were identified and surprisingly patients with cancer were substantially less likely to be depressed (AOR 0.37, 95% CI 0.2-0.6). Further investigation revealed that cancer patients were more likely to be treated for depression and to be recognized as being within the terminal phase of illness. SIGNIFICANCE OF RESULTS These findings suggest that a high proportion of terminally ill patients had unmet needs for psychological support. As well, they suggest that cancer patients received better targeted end-of-life care, which resulted in an overall decrease in psychological distress when compared to other patients with similarly advanced illness.

Predicting social isolation among geriatric psychiatry patients.

BACKGROUND This exploratory study examines factors associated with isolation from informal social ties among geriatric psychiatry inpatients. Specifically, it examines the associations of diagnoses, psychiatric history, and measures of current functioning with social isolation. METHODS Analyses rely upon data derived from the Resident Assessment Instrument-Mental Health (RAI-MH), which is a patient focused, multidimensional, comprehensive assessment instrument designed to be a component of a larger, integrated health information system linking mental health with home care, long-term care, acute care, rehabilitation, and palliative care. RESULTS Controlling for age, multivariate results show that being married or widowed was associated with a lower odds of being isolated. Mood disorders were also associated with a lower odds of isolation, while a history of a personality disorder and a personal biography of institutionalization were both clearly associated with an increased odds for isolation. Although significant bivariate predictors in the multivariate model, both schizophrenic and organic diagnoses failed to reach statistical significance. In addition, patients hospitalized at an earlier age and/or predicted to have a longer stay on the current admission were much less likely to have contact with informal supports. Of the study variables indexing functional status, only activities of daily living (ADLs) remained a significant predictor for isolation in the final multivariate model. CONCLUSIONS The analyses demonstrate the detrimental effects of an earlier life experience with mental illness. Having an earlier age of illness onset may lead to a potentially greater impairment in establishing and maintaining informal social ties throughout the life course into older age. These analyses reinforce the need for comprehensive assessment of patients on admission and over time.

Prevalence and risk factors of depressive symptoms in a Canadian palliative home care population: a cross-sectional study

BackgroundDepression in palliative care patients is important because of its intrinsic burden and association with elevated physical symptoms, reduced immunity and increased mortality risk. Identifying risk factors associated with depression can enable clinicians to more readily diagnose it, which is important since depression is treatable. The purpose of this cross-sectional study was to determine the prevalence of depressive symptoms and risk factors associated with them in a large sample of palliative home care patients.MethodsThe data come from interRAI Palliative Care assessments completed between 2006 and 2012. The sample (n = 5144) consists of adults residing in Ontario (Canada), receiving home care services, classified as palliative, and not experiencing significant cognitive impairment. Logistic regression identified the risk factors associated with depressive symptoms. The dependent variable was the Depression Rating Scale (DRS) and the independent variables were functional indicators from the interRAI assessment and other variables identified in the literature. We examined the results of the complete case and multiple imputation analyses, and found them to be similar.ResultsThe prevalence of depressive symptoms was 9.8%. The risk factors associated with depressive symptoms were (pooled estimates, multiple imputation): low life satisfaction (OR = 3.01 [CI = 2.37-3.82]), severe and moderate sleep disorders (2.56 [2.05-3.19] and 1.56 [1.18-2.06]), health instability (2.12 [1.42-3.18]), caregiver distress 2.01 [1.62-2.51]), daily pain (1.73 [1.35-2.22]), cognitive impairment (1.45 [1.13-1.87]), being female (1.37 [1.11-1.68]), and gastrointestinal symptoms (1.27 [1.03-1.55]). Life satisfaction mediated the effect of prognostic awareness on depressive symptoms.ConclusionsThe prevalence of depressive symptoms in our study was close to the median of 10-20% reported in the palliative care literature, suggesting they are present but by no means inevitable in palliative patients. Most of the factors associated with depressive symptoms in our study are amenable to clinical intervention and often targeted in palliative care programs. Designing interventions to address them can be challenging, however, requiring careful attention to patient preferences, the spectrum of comorbid conditions they face, and their social supports. Life satisfaction was one of the strongest factors associated with depressive symptoms in our study, and is likely to be among the most challenging to address.

Confirmatory factor analysis of the burden interview of the caregivers of terminally ill home care clients.

As the population ages and the need for informal care in the home continues to increase, so, too, will the issue of caregiver burden. The Burden Interview was developed by Zarit, Orr, and Zarit (1985) and has become one of the most widely used measures of caregiver burden experienced by family caregivers caring for older adults suffering from cognitive impairment, dementia, or Alzheimer’s disease. Subsequent research has applied this interview to a variety of populations with a high level of success (Helmes, Green and Almeida, 2005; Higginson et al., 2010; Kumamoto and Arai, 2005; Longmire and Knight, 2011; O’Rourke and Tuokko, 2003). Although today it is widely used for burden measurement, the factor structure of this interview has never been tested in palliative home care. The original Burden Interview was comprised of 22 items; it was later abridged to 12 concise questions by Bédard et al., 2001 (see appendix). The latter version, which was created using the highest item-total correlations, is considered a reliable and valid measure of burden. The two-factor structure (personal strain and role strain) retained an acceptable level of internal consistency (a = 0.88 and a = 0.78, respectively) and was found to be highly correlated with the original version, boasting correlations that ranged from 0.92 to 0.97. A later study surveying the carers of institutional and communitydwelling patients suffering dementia found support for the two-factor structure (O‘Rourke and Tuokko, 2003), adding to the validity that the Burden Interview is a robust measure of burden. Though widely accepted, the Burden Interview has never been used to measure burden among informal caregivers of palliative home care clients. Caring for a family member suffering from terminal illness is different from caring for a family member diagnosed with dementia or Alzheimer’s disease (Grunfeld, Glossop, McDowell, and Danbrook, 1997). Providing care to a family member suffering from Alzheimer’s disease is said to be one of the most difficult challenges faced by informal caregivers. Challenges include reduced social skills, disruptive behavior, and personality fluctuations (Chappell, Penning, 1996; Morris, Morris, and Britton, 1988; Schulz, Visintainer, and Williamson, 1990). This may result in chronic stress that will affect the health and well-being of the caregiver. Alternatively, informal carers of terminally ill patients may experience significant psychosocial (Chappell, Penning, 1996), physical, and economic burdens that may reduce the caregivers’ quality of life (McMillan, 1996). Considering these important differences, it is difficult to determine whether the factor structure of the Burden Interview will be maintained in the population. The current study examined the psychometric properties of the Burden Interview. This study postulated that the first nine indicators would load only on the latent construct of personal strain and that the remaining three indicators would load only on role strain. The degree of fit of the hypothesized model was tested using the maximum likelihood chi-square statistic provided in the LISREL output.

Correlates and Predictors of Changes in Dyspnea Symptoms Over Time Among Community-Dwelling Palliative Home Care Clients.

CONTEXT Dyspnea is a frequently reported and highly distressing symptom for persons nearing end of life, affecting the quality of living and dying. OBJECTIVES This study described health and clinical characteristics of persons experiencing dyspnea who receive palliative home care services and identified factors affecting change in dyspnea over time. METHODS Anonymized assessments (N = 6655 baseline; 959 follow-up) from the interRAI palliative care assessment instrument (interRAI PC) were collected during pilot implementation (2006-2011). Triggering of the interRAI PC dyspnea clinical assessment protocol was used to indicate presence of dyspnea. Bivariate and logistic regression analyses described risk and protective factors for developing new dyspnea and for recovery from dyspnea at follow-up. RESULTS At baseline, 44.9% of persons exhibited dyspnea. Dyspnea was more prevalent among older adults, males, persons with shortened prognoses, and persons without cancer. Persons with dyspnea were more likely to experience functional impairment, moderate cognitive impairment, fatigue, weight loss, and urinary incontinence. Among persons with dyspnea at baseline, 31.5% recovered from dyspnea at follow-up. In contrast, 31% of persons without dyspnea at baseline reported new dyspnea at follow-up. Risk factors for developing new dyspnea included smoking, fatigue, and receiving oxygen therapy. CONCLUSION Results highlight that dyspnea is not inevitable as persons progress toward death. Accordingly, dyspnea should be identified and prioritized during the care planning process. Integrated approaches using the interRAI PC dyspnea clinical assessment protocol may assist clinicians to make informed decisions addressing dyspnea at the person-level and thereby improve quality of life at the end of life.