Long Term Care in the Information Age The Potential of the MDS

Long-term care is at the dawn of a new era — not the next millennium, but rather the information age. Evidence based decision-making, accountability, patient focused care, and integrated systems rank at the top of the list of the most repeated phrases used by health policy makers and service providers alike. Underlying each of these concepts is the need for health information that allows a variety of audiences to evaluate current circumstances with the aim of setting a path toward a desired endpoint at the patient, agency or societal level. In the absence of sound evidence, progress tends to be undetected, incremental and a function of chance.

The time when long-term care could function adequately in an information vacuum is long gone.

The challenges facing the industry in the immediate future are enormous. Canada’s population is aging rapidly, not only in terms of the percentage of the population that is elderly, but also the absolute numbers. Massive efforts to restructure health care including reductions of lengths of stay in acute hospital settings have meant that new admissions to longterm care facilities are increasingly frail and medically complex. These changes have been accompanied by fiscal restraints that were imposed in times of economic recessions and are unlikely to be removed quickly despite improvements in the Canadian economy.

Canadians themselves are also changing in many ways. They have become much less tolerant of poor quality of care, their preferences to avoid institutional placements have been magnified over time, and new cohorts of older adults are much more likely to challenge the conduct of authority figures including health professionals. Electronic communication in the form of popular media, but perhaps more importantly the Internet, has also raised the level of sophistication of Canadian consumers who can now enjoy almost instantaneous access to a vast range of information on health and health care from around the globe. Even if we wanted to, longterm care could not return to the time where facilities operated in relative isolation and experienced managers and clinicians had to rely only on their gut instincts to determine where to go next.

A quick look at acute care reveals a daily stream of technological breakthroughs. The Human Genome Project has the foreseeable goal of mapping the entire genetic code of humans, with the ultimate potential benefit of creating new treatments and preventive strategies for a plethora of serious health conditions. Computer assisted robotic devices hold the promise of performing major surgery (e.g., coronary bypass) in an unobtrusive, cost effective manner perhaps even at remote distances. Magnetic resonance imaging (MRI) has revolutionalized medical diagnosis in a way that allows for the detection of diseases or injuries well in advance of what was previously possible. So where is the equivalent of an MRI for long-term care? The answer, surprising as it may be, is in comprehensive geriatric assessment.

A helpful starting point is to review the goals of long-term care. Certainly, treatment of acute medical problems like pneumonia is a high priority for any care setting including nursing homes. However, cure is not the only purpose of long-term care. Rehabilitation to reduced disability and the maintenance of existing function are high priorities when one aims to enhance quality of life. Similarly, the principles of palliative care (e.g. alleviation of suffering, supporting autonomy) should apply to all persons at the end of life whether or not they are in a designated palliative care bed. However, we cannot easily see palliation, rehabilitation or maintenance happening through the output of an MRI. The challenge in providing good health care to the elderly is further complicated by the increase in complexity of illness associated with aging. Older people manifest the symptoms of diseases in different ways from younger people. Their health status is affected by interactions of social, psychological, environmental and physical factors, and these interactions can be exacerbated by iatrogenic problems such as adverse drug reactions.

It has been absolutely clear to geriatricians and gerontologists for the last two decades or more, that the only way to address the full range of needs of older persons is to begin with a comprehensive assessment.

A search of the term “assessment” in any electronic health bibliographic database will yield thousands of hits. Countless specialty assessment instruments have been developed to test a host of dimensions related to quality of life and functional ability. We have depression scales, balance scales, dementia scales, disability scales, spirituality scales and so on. The difficulty often faced by clinicians is what set of instruments should be selected to make up the definitive assessment battery. With the possible exception of mental status assessment, it is virtually impossible to get consensus on the components of that battery. In addition, these first generation assessment instruments generally can only be used only for one thing, and it is often not clear what a score on a given scale means.

The Minimum Data Set (MDS) series of assessment instruments for long-term care, home care, mental health, acute care and rehabilitation (see Hirdes et al., in press) represent a second generation of assessment systems for the frail elderly and people with disabilities. These instruments have been developed through exhaustive research efforts involving broad based consultation (see, for example, Morris et al., 1990) and multinational evaluations of reliability, validity and clinical utility (see, for example, Sgadari et al., 1997). The MDS 2.0 is now used for day-to-day clinical practice or in geriatric research in nursing homes around the world. interRAI is a 19 country research network that collaborates in the development, evaluation and application of the MDS series of instruments (www.interrai. org). The main application of the MDS is to support care planning through the use of scientifically derived clinical algorithms known as Resident Assessment Protocols (RAPs). RAPs are used to alert clinicians to the current or imminent presence of problems that posed threats to the resident’s health or independent functioning (e.g., falls, depression, pressure ulcers).

Other applications of the MDS are case-mix based funding (Fries et al., 1994; Hirdes, 1997), quality improvement (Zimmerman et al., 1995) and outcome measurement (see, for example, Morris et al., 1994).

Therefore, the MDS is a new generation of assessment instruments that can serve multiple applications for multiple audiences. Nurses can use the MDS to create care plans and track the status of residents in several domains. Quality managers, accreditation councils and regulatory agencies can use MDS data to support benchmarking and quality improvement. Governments can use MDS data to establish equitable funding formulas that reimburse longterm care facilities on the basis of the needs of residents. Consumers can use quality reports from the MDS to evaluate the performance of the facilities that are providing care to their relatives.

It is reasonable to ask, what is the evidence that the MDS has or can make a difference in long-term care? One example is a study by Bernabei et al. (1998), which showed that about one third of US nursing home residents experiencing daily pain related to cancer received no analgesia by World Health Organization standards. By providing representative data from the MDS linked to prescription drug data these researchers were able to identify an urgent need to modify practice patterns in the US. Across-national comparison of restraint use (Hirdes et al., 1999) showed that the rates of restraining patients in Toronto chronic hospitals far exceed international benchmarks even after adjusting for differences like age, sex, dementia and disability. A report of the Canadian Institute for Health Information (Nenadovic et al., 1999) provided the first provincial overview of regional variations in the quality of chronic care hospitals in Ontario based on the MDS.

A study of Japanese facilities adopting the MDS demonstrated clearly that the quality of care plans with respect to the psychosocial needs of patients improved after the introduction of the instrument (Ikegami et al., 1998). Mor et al. (1997) showed that the mandated use of the MDS in US nursing homes was followed by a reduction in the rate of hospitalizations. As more countries move toward the broad based adoption of the MDS, we can expect an explosion of evidence about what does and does not work in long term care.

In Canada, several provinces have begun to move ahead with the use of the MDS. Ontario mandated the MDS in chronic hospitals in 1996, and hospital funding will be based on the Resource Utilization Groups (RUG-III) system by April 2000. Saskatchewan’s implementation of the MDS in long-term care started at about the same time, initially with a pilot project in Prince Albert, but now widely across the province. Submission of RUG-III scores to the Saskatchewan Department of Health will be mandatory by April 2001. Alberta has conducted a series of pilot studies, and use of the MDS 2.0 and the MDS-Home Care has been recommended for long-term care facilities and home care agencies, respectively. Alberta has also undertaken efforts to develop an eligibility screening system to be compatible with the MDS instruments. Governments in Manitoba and Nova Scotia have recently launched demonstration projects to evaluate the MDS in those provinces. Therefore, the opportunity to conduct inter-provincial comparisons of longterm care practice patterns is at hand.

This is not to say that successful implementation of the MDS in Canada can happen automatically. In fact, many issues remain to be addressed before the full potential of the use of the MDS can be realized. First, long-term care must have the capacity for computer-based implementation of the MDS. It is only possible to fully use all of the applications (i.e., care planning, outcome measurement, quality improvement, case-mix based funding) when hardware and software designed to support each of these applications are in place. That being said, the need to computerize long-term care is obvious even in the absence of the MDS. Second, clinically focused training provided on an on-going basis from a variety of sources is absolutely essential. Front-line staff must be given the opportunity to learn how they can use the MDS to improve the care given to their residents.

Nursing schools need to incorporate the MDS into their curriculum so that new graduates are prepared to use this as their own clinical tool for providing leading edge long-term care. However, there is also a need for expertise in how to use the MDS in other applications on the part of researchers, administrators and policy makers. The development of capacity in health informatics in non-acute care is a pressing need in Canada that is not being addressed adequately in terms of research funding or training of new graduates. By giving high priority to putting the technology in place and developing the expertise needed to thrive in the information age, long-term care can respond to any and all of the challenges it faces at the dawn of this new age.