The MDS-RAI (the Minimum Data Set Resident Assessment Instrument) is a standardised assessment system developed by interRAI used internationally to raise standards of care in long-term care homes.

Implementation in the UK has been sparse and currently there are no well-established demonstration sites for use in long-term care (although Cheshire has adopted and successfully implemented the MDS-HC (the Minimum Data Set Home Care) for community care).

Successful implementation of the MDS-RAI requires a methodical approach and commitment: it is a way of developing best practice that goes far beyond just gathering information about care needs. This project aimed to develop an implementation process model for MDS-RAI use in three UK care homes through an iterative and collaborative process.

The report includes:

• development of the MDS/RAI;
• lessons learned from the international community on MDS/RAI best practice;
• the development of MDS/RAI reports in the UK;
• barriers to implementation in the UK;
• recommendations for implementation in a care home;
• future goals and development.

Summary

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The MDS-RAI (Minimum Data Set Resident Assessment Instrument for Long Term Care Facilities) is designed to provide a comprehensive standard assessment of residents' needs for use in nursing and residential homes. This action research project explored how care home staff and management could raise care provision standards through embedding its use in daily practice.

Key points:

• MDS/RAI can produce reports which are useful in care planning and management, quality assurance and resource allocation, and planning a business strategy for the care home.
• Key factors to its success are: teamwork, communication, a dedicated co-ordinator, evaluation, management, human and material resources, and government policy,
• Using MDS/RAI successfully in a typical UK care home requires a shift both in cultural practice and in organisational structure in the long-term care system.
• It also requires the understanding and involvement of social services, PCTs, regulators and other external organisations.
• At an operational level, this research suggested that:
  - One person in each care home should be responsible for overall implementation and day to day running of the MDS/RAI.
  - Managers need time to evaluate reports and link the outcomes to care practices.
  - Care staff may specialise in sections of the assessment, but teams need to collate information to complete assessments and produce care plans.
  - Computer software must meet the needs of frontline staff.
  - Comparing the reports of similar care homes could motivate staff to improve provision by fostering competition between them.
• The researchers conclude that care homes will need to work with local agencies to increase awareness of the MDS/RAI – and providers will need to set their own policy, above and beyond the government's minimum standards, if they are to fully realise the potential of the MDS/RAI. A UK-wide network would help to drive development of the MDS/RAI

Background

The Minimum Data Set Resident Assessment Instrument (MDS/RAI) for Long Term Care Facilities is designed to be a comprehensive standardised way of assessing the needs and planning the care of residents in nursing and residential homes. It includes the assessment (MDS), care planning guidance, and can report on changes in resident well-being and resource use.

Its primary purpose is to improve quality of care, through recording needs and strengths and providing evidence-based support for those who care for older people. Because the assessment tool uses standardised information about the care needs of residents, it can be also used for calculating resource use. Users of the MDS/RAI have said that the tool helps them to:

• identify the unmet needs of residents;
• plan the delivery of care;
• evaluate their care provision;
• manage human and material resources.

The aim of this project was to improve the usefulness of the MDS/RAI for long-term care, by exploring its reporting capabilities and embedding its use into the practice of care home staff and management.

Using MDS/RAI for reporting

In the study, reports with facility-wide data were produced every three months. The reports contained information on three levels and tracked changes over time. The types of reports at each level are listed below.

• Resident: cognitive performance, social engagement, depression, frailty, activities of daily living, range of motion, fractures, pain, and cost of care.
• Care home: Quality indicators (e.g. falls, medication use, pressure ulcers etc), resident ages, resource use.
• Management team: Comparisons between all three care homes in the study, aggregated resident scores (listed above), resource use, correlations between: depression and cognitive impairment, falls and wandering, and mood and activities of daily living.

These reports helped care home managers to identify potential problems in their care homes, such as high levels of depression. This led managers to consider what interventions could be put in place to address the issues identified by the quality indicators.

Managing the MDS/RAI

Carrying out assessments, creating care plans and reports, and monitoring care provision using the MDS/RAI requires more time than other assessment tools. In countries where the MDS/RAI has been extensively developed (for example, Canada and the US), a new role – MDS/RAI Co-ordinator – has evolved. This person is responsible for the overall implementation of the MDS/RAI in the care home. Duties include:

• completing assessments, in part or whole;
• training new staff;
• creating and analysing reports;
• creating care plans for issues identified by the MDS assessment;
• creating schedules for completing MDS assessments;
• determining fees and funding levels based on MDS/RAI data;
• developing new uses for the data;
• tracking new developments in the MDS/RAI system.

The care home managers in the study felt that having a co-ordinator is essential for maintaining use of the MDS/RAI at a high standard. The role of the co-ordinator may vary by home, depending on the roles of other members of the care team, but s/he is always responsible for overall use and in leading colleagues in use of the tool.

Comparisons and competition

MDS/RAI reports contain valid and reliable data that can be used to compare standards of care between care homes. In other countries, these comparisons motivate staff to improve their care provision. These countries have a large comparison sample and use benchmarks to rank the quality of care homes. In this project only three care homes could be compared, therefore the element of competition was limited. However, staff found the comparisons interesting and helpful in identifying potential problems or areas of success in their care homes. They believed the reports would be more useful should more homes be compared.

Evaluation

Home managers who had more time to reflect on the reports achieved a better understanding of the MDS/RAI and were better able to use the reports to improve care. For example, using the reports, one manager identified that hiring an activities co-ordinator had a positive impact on the social engagement of residents. This suggests that managers and care staff should be given more time to reflect on the data so that the appropriate changes in care provision can be made.

Communication and teamwork

Completing an MDS assessment and care plan for a resident needs input from many sources (e.g. the resident, care staff, GP, family). This requires care teams to work together and communicate often regarding the status of residents.

The research suggests communication should happen routinely between staff members within the care home, between the care homes, and from the care home to its management team. Monthly meetings with managers can provide a useful forum for sharing information.

Software and technology

Home managers said that a major barrier to using the MDS/RAI was the complexity of their current software package which used to complete assessments and reports. Their software package was not user-friendly and made the MDS/RAI appear more complicated. Also, they believed the assessment process could be sped up by using appropriate technology.

When selecting an MDS/RAI software package managers and frontline care staff who will use it on a daily basis should be consulted. It is important that they feel confident in its use and that it meets their needs.

Policy and working with government agencies

Some home managers found that the lack of joined-up working and understanding within social services about the MDS/RAI hindered their ability to obtain funding for residents. The managers were frustrated that social services would not accept MDS/RAI data as proof of care needs.

There were also discrepancies with how regulators viewed MDS/RAI data. Their understanding of the MDS/RAI varied by location, with some inspectors impressed with it and others not understanding it at all. Government policy does not require that assessment tools are used to as high a level as the MDS/RAI. Therefore care homes that choose to use it will have to set their own policy above the minimum standards set by the government.

Recommendations

The researchers suggest a model (Figure 1) for using the MDS/RAI in a care home setting similar to that trialled in this study.

Sharing information

MDS/RAI use within a care home will change in response to government policy as will developments in the wider MDS/RAI network. The MDS/RAI can produce data that can be used by all levels of staff and management in a care home. Therefore care homes should adopt an organisational structure in which information is circulated throughout and practice and policy decisions are based on the evidence in reports.

Informing policy and practice

Organisational policy should set the direction for MDS/RAI use (e.g. that it will be used for determining staffing levels). The software and technology will produce resident reports and researchers or data analysts can be commissioned to produce more in-depth reports quarterly. Evidence in the reports should inform policy and be used by the care team and co-ordinator to plan care. The MDS/RAI Co-ordinator should facilitate the use of reports and ensure that staff are trained to a high standard.

Managing MDS/RAI

Within care homes, it may be beneficial to share the responsibility of completing assessments and creating care plans between several members of senior staff. Individual staff members would 'specialise' in their own area of the assessment (such as mood and behavioural patterns, psychosocial well-being and activity pursuit patterns) and complete those items. The various sections of the assessment would then be collated by the MDS/RAI Co-ordinator, and the team would work together to create care plans and review reports. The MDS Co-ordinator would also be responsible for keeping the teams to a schedule, ensuring assessment quality and linking to the MDS/RAI network.

Developing MDS/RAI

Currently there is no network of homes using the MDS/RAI in the UK, but users could be linked together to provide mutual support and opportunities for development. Creating an MDS/RAI network could have the following benefits:

• aid development and help to make the assessment tool more specific to UK usage;
• ensure that work to develop the MDS/RAI is not duplicated;
• create excitement in users and reduce isolation and apathy;
• provide support for other users to influence local policy-makers and government.

A first step towards establishing a network is to create or engage in an MDS/RAI user group. The group should include other users of the MDS/RAI and researchers, and potentially health information analysts, health and social care commissioners, and software providers.

About the project

The study took place in three care homes (two residential and one nursing care home) run by the Joseph Rowntree Housing Trust, a Yorkshire-based housing association which shares its trustees, staff and strategic plan with the JRF. The number of residents in each home ranged from 34 to 42. The development project followed an action research design. Knowledge that was gained through interviews with MDS/RAI practitioners in Canada and the US was used to inform the implementation process in the care homes.