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Expanding Long-term Care Choices for the Elderly

Assessment & Eligibility


Brant E. Fries, Ph.D., Senior Research Scientist, Institute of Gerontology and Professor, School of Public Health, University of Michigan, Ann Arbor, MI.

The Resident Assessment Instrument for Home Care (RAI-HC) Assessment System (the community version of the RAI mandated in U.S. nursing facilities) was developed by a multinational group of clinicians, researchers, and regulators to improve care planning through improved assessment. The RAI-HC consists of three parts:

  • Minimum Data Set for home care (MDS-HC).
  • Triggers.
  • Client assessment protocols (CAPs), which are care planning guidelines. The RAI-NF has 18 guidelines, and the RAI-HC has 30, which have all tested to be both valid and reliable measures covering all relevant domains.

The RAI-HC is currently being used in Michigan and Georgia. Rhode Island, Massachusetts, and North Carolina plan to implement the system. It is also being used in Canada, Hong Kong, Switzerland, and Japan. The RAI-HC is available to any governmental entity, as long as it uses the entire instrument; if modified, the reliability and validity of the instrument is called into question.

The data gained through this assessment can be used by policymakers as well as care planners. It can help:

  • Determine funding.
  • Prevent gaming.
  • Assess quality improvements or facilitate accreditation efforts.
  • Evaluate best practices.

The RAI-HC is one of a family of assessment instruments, developed by interRAI, and available under the same licensing arrangements. All instruments in the family have common items and the shared purpose of improving care directly through improved care planning. Assessment instruments are available for:

  • Nursing facility care.
  • Home care.
  • Palliative care.
  • Assisted living.
  • Acute care.
  • Mental health care.

For many of these settings, case-mix systems, quality indicator measures, and summary scales are also available.

Michigan's Home and Community-Based Waiver Program decided to expand services statewide but also recognized the need to control growth in long-term care (LTC) expenditures. Michigan officials felt they needed to develop a more equitable and rational allocation of LTC resources by creating an integrated data system, consistent eligibility criteria for enrollment, and statewide screening capacity. The integrated data system uses an assessment based on the RAI-HC that:

  • Is implemented with scanning technology.
  • Can follow clients over time to track outcomes.
  • Facilitates implementing and evaluating CAPs.

From this has arisen Michigan's MI Choice Long-term Care Initiative.

One of the goals of the MI Choice screening algorithm is to find the best setting and level of care for which an elderly or disabled person is eligible. Once a level of care has been computed, it is moderated to acknowledge other factors, including informal care services, client preferences, and availability of services.

To develop and test the tool, individuals who were considered the best assessors in the State were trained in using the MDS-HC, the laptop system, and were given vignettes to train them on the consistent definitions of "appropriate level of care." These assessors then used the system to assess approximately 900 people who were at risk of nursing facility placement but who were interested in receiving home and community-based services. These individuals were assessed at intake, with longitudinal followup. The screening algorithm did a much better job of approximating the assessments of the "gold standard" assessors than did other systems, including those based solely on ADLs/IADLs.

The screening algorithm "peels the onion," classifying a client into the first category to which he/she qualifies, in the following order:

  • Eligible for nursing facility level of care: The person exhibits at least seven characteristics from a list that includes severely impaired decisionmaking and never/hardly ever left alone.
  • Eligible for information and referral level of care: The person exhibits at least four characteristics from a list that includes independent decisionmaking and no new skin problem within the last 30 days.
  • Eligible for home care level of care: The person exhibits either of the following: RN monitoring daily/less than daily, or meal preparation by others and dependent in locomotion in home.
  • Eligible for intermittent personal care level of care: The person has difficulties with certain IADLs, has current or prior use of at least two ongoing care providers (e.g., home health aide), feels he/she would be better off somewhere else, or has difficult access to home.
  • Eligible for homemaker level of care: All remaining clients.

This system has now been implemented statewide in Michigan for slightly less than 1 year. The entire system will be evaluated in early 2001. Meanwhile, evaluation of the screening tool is ongoing, as is the development of quality indicators.


Morris JN, Fries BE, Bernabei R. InterRAI-home care (RAI-HC) assessment manual. Boston (MA): InterRAI; 1999 Nov.

Morris JN, Fries BE, Knight S, et al. Comprehensive clinical assessment in community settings: applicability of the MDS-HC. J Am Geriatr Soc 1997;45:1017-24.

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