The Resident Assessment Instrument: Unambiguous needs assessment in home care.

Introduction: Unwarranted practice variation in needs assessment by home care nurses is a recognizable problem in the Netherlands. The care needs of clients with comparable characteristics are assessed differently bij different nurses. As a result, clients do not always receive proper care, there is risk for either undertreatment or overtreatment. The aim of this care trajectory design project was to improve quality and unambiguity of needs assessment by home care nurses. Research question: in what way can an intervention to reduce unwarranted practice variation in needs assessment be designed and implemented in practice?

Methods: In addition to literature research, a qualitative field study was conducted among home care nurses and a manager of a large home care organization in the Netherlands, using a focus group interview (n = 8), two semi-structured interviews (both n = 1) and two online surveys (n = 12 and n = 34). Results were analyzed using inductive content analysis. In April 2021 a pilot project was started to test the proposed intervention in practice among 12 home care nurses. In August a survey (n=12) was used tot evaluate this pilot.

Results: An intervention that combines a number of strategies to reduce unwarranted practice variation found from literature and field research, is the Resident Assessment Instrument (RAI). Although developed for residential care, RAI could reduce unwarranted practice variation in home care needs assessment. This validated assessment tool provides computerized decision support in determining care needs of clients in different care settings. Status and outcome scales, care planning and resource allocation tools, and quality indicators are embedded in the instrument.

For a successful implementation, reaching and educating home care nurses is pivotal. In addition, peer review should support implementation of RAI, because peer review is an effective strategy to reduces unwarranted practice variation.

With the support of a government grant, implementation of RAI is financially feasible for most home care facilities. This is especially true if health insurers see the added value of this instrument because of its social benefits.

The results of the survey used to evaluate the pilot are promising. The home care nurses considered the instrument to be user-friendly. RAI helped them to formulate comprehensible goals for the care plan, in consultation with the client. With RAI, they were able to provide an appropriate and evidence based needs assessment in less time. 

Conclusion/ Discussion: With RAI, the quality and unambiguity of the needs assessment can be improved. Without the right knowledge and skills to work with the system, RAI can deliver incorrect output, or it can be misinterpreted. It is important that home care nurses use it as a support, not as a substitute for their own professional view or clinical reasoning. For this reason, it is recommended to support the implementation of RAI with nursing peer review.  This enables home care nurses to evaluate whether the care assessment with RAI meets the professional standards, and to learn from each other.