Abstract
Standardized assessments are crucial in effective care planning, ensuring that clients receive appropriate services. However, a gap exists in the availability of such tools for complex and comorbid populations—particularly those discharged from hospital settings and living in the community with behavioural deficits or fluctuating functional presentations. In public health systems like Canada’s, where the focus is on keeping individuals out of hospitals to support sustainability, the need for a standardized assessment tool that can capture the unique care requirements of these populations has become increasingly urgent. For individuals living with permanent conditions, such as acquired brain injury (ABI), behavioural challenges, or other fluctuating health conditions, fragmented communication and lack of consistent assessment can result in poor care coordination, leading to suboptimal outcomes.
Recognizing this gap, Head Injury Rehabilitation Ontario (HIRO) initiated a project to develop an assessment tool tailored to the ABI population. However, as the project progressed, it became evident that the tool's potential applications extended beyond ABI, with broader relevance for individuals with multiple conditions. HIRO, along with health and social service providers, collaborated with researchers from interRAI, an international not-for-profit scientific organization responsible for an internationally recognized suite of assessment tools. We embarked to design a tool to allow different sectors to "speak the same language" when assessing care needs for individuals with fluctuating presentations.
An international scoping review and local survey to Ontario-based ABI service providers identified current use of between 20-45 distinct assessment tools. The sheer number of assessments highlighted two key issues: first, the inconsistency of tools across providers, and second, the hypothesis that existing tools were not adequately capturing the full scope of needs within this population. These findings underscored the urgent need for a standardized tool capable of addressing the unique complexities of ABI and other chronic conditions in the community setting.
In April 2024, a two-year research project was launched in collaboration with interRAI and community providers. We are developing and testing a tool that accurately predicts levels of care required in a community setting for ABI clients. After a crosswalk was developed, ""domain"" items that empirically correlate functional presentations with levels of care. Initial results from stakeholder engagement indicate that while these domain items originate from various sectors (including pediatrics, mental health, and dementia care) their combination in a single tool offers a unique framework for addressing the behavioral and fluctuating presentations often seen in individuals with ABI and other permanent conditions.
The development of this tool, focused on functional presentation rather than diagnostics, offers profound implications for care systems. Clients with complex conditions frequently cycle through multiple health and social care systems, requiring acute care at times, and remaining stable at others. A standardized tool that can capture these fluctuations, and provide a communal language for health and social service providers, will enhance care coordination, ensuring that individuals receive the right level of care at the right time. Ultimately, this project aims to improve continuity of care as individuals with complex needs transition between care settings, fostering optimal outcomes.