All of the participants we spoke with used some form of the interRAI assessment data for quality improvement in their organization. Participants discussed overseeing the implementation of RAI tools, providing structure and support for home care projects, understanding the data reports generated, and supervising quality improvement initiatives. Several participants provided powerful examples of how interRAI data have been used to guide patient safety and quality improvement initiatives; however, all participants recognized the challenges inherent in using these data.
Utilizing interRAI data in home care
Participants explained how they presently use RAI data to guide and assess the performance of their home care organizations. In particular, the RAI data that are reported back to organizations give them a clear picture of how their organization is doing compared to others in their region:
The information that we get from interRAI Canada is that they give us our [organization’s] data but they also compare it, other home care providers, generic of course, as a whole … And so it allows us to really look at, are we on par with other providers? And so that really helps us to identify as well the learning needs of our, of our assessors … You know are they on target, are we falling short, you know where can we improve sort of piece. So that’s been beneficial. (Interview 2)
Other participants explained how RAI data helped them to see the “bigger picture” of their organization, as the provision of home care is rapidly changing and evolving. Having this big picture allows them to make crucial and timely business decisions:
… there’s some really important business decisions that need to be made, and home care is something that is growing at a quicker rate funding-wise and the clients that we take care of than other areas within the healthcare system and understanding how our business is serving clients … . So there’s a whole bunch of different pieces around data that’s so important to us that really helps guide our zones and guide us provincially around where new money needs to be invested to continue to grow home care. (Focus Group 2)
Finally, participants shared specific examples of how RAI data have helped them to identify, implement, and track several quality and safety improvement initiatives:
We’re using the quality indicators that come out of the RAI-HC, running those on an annual basis to take a look at what are some of the quality issues that we could be tackling as a program. So using that kind of information, so for example, our pain management, having that clinical information and evidence to support that, we really could be doing better as a program in terms of pain management for our clients because that was something that was notable that came out of quality indicators. Or issues around incontinence, you know, various things like that, all prevention [We] just finished collaborating with CPSI on a virtual falls collaborative, and the RAI data was fundamental in that as well, it’s a key component of what we can monitor, prevalence of certain indicators in the program. (Focus Group 1)
This participant went on to share another example:
They give us extracts of the RAI assessment every quarter, the regions supply that to us and it’s de-identified. So once a quarter, we actually get our home care data that we can look at … One of the quality improvements is antipsychotic use without a diagnosis of psychosis. So now what we have done is we’re pulling that information of who is on an antipsychotic in home care. Then we can get home care looking at it and finding out, okay does this person really need, how did they get on meds and do they really need it?
In spite of these strengths, however, the resounding theme in our interviews and focus groups was that most jurisdictions are experiencing limitations to their use of interRAI home care data.
Challenging factors in the home care context
All participants discussed challenges that they face when utilizing interRAI data in the home care context, including: the general “newness” of these data in many jurisdictions; the sheer volume of data; limited capacity and resources to “make sense” of the data; and connectivity issues in rural areas. The overarching theme was that they simply were not, and did not know how to best interpret and utilize the data.
“Newness”
Participants noted that data use in home care is a newer concept, and one that is still evolving:
Home care data is a newer thing. The home care environment is a more complex environment. There’s lots of provincial nuance from province to province … the environment and the models of care are continuing to evolve and change. So we don’t necessarily have what I would call a very stable service delivery and policy environment right now around … home care services in particular creates some challenges and a bit of a dynamic element to the data. What kind of data should we be collecting, the continuing of the updating of the RAI assessment tools and that. So, so there is still lots I think that fall in the place of that but we’re hoping over the next they say 5 to 10 years, we may have an improved and more efficient way of capturing some of the data off the front end. (Focus Group 3)
Volume & capacity
With these new tools and datasets, participants are still figuring out how to utilize this information. One focus group participant noted, “it’s a rich dataset and it can be a bit overwhelming.” Home care providers are confronted with both issues of volume, and insufficient capacity to work with large datasets:
I think you know, just the volume of data, especially on the service data, it’s just unbelievably massive, right? So were looking at, I think it’s about, I want to say a million records a week on the service side. So having the capacity to really look at that’s such a large dataset, is challenging. (Focus Group 2)
Several participants noted that they have collected large amounts of data, but do not necessarily have the personnel or skills to use the data in a meaningful way:
I think the other thing is you know we’ve amassed large databases, we have multiple different databases, we’ve got our clinical database, we have a lot of data at our fingertips and sometimes it is that overload with our clinicians, you know, we do still have a generation of, some generation of our workers and staff that don’t really see anything in numbers, and, I don’t want to say the touchy-feely type [laughs] but I’m a number person, I can see in the numbers quite a lot about a person, so it’s very hard to get some folks to see that as well. (Focus Group 1)
I think the core is the challenge for a lot of the providers is building the knowledge of what is available and then the capacity and the skills to use it, right? And to somehow embed it in quality improvement processes, etc. So it’s lots of tools but can also be a flood of data out there that, that doesn’t necessarily bring the value add. (Focus Group 3)
Highly-trained personnel
The agencies that were able to use the data in ways that add value were the ones with highly trained personnel, individuals with PhD and or/extensive previous experience working with large clinical datasets, including interRAI data in other sectors. An example of a dedicated, highly-trained position is outlined below:
So, one of the reasons that my position as a researcher was created here … in the home care program specifically was so that the program could mine that data more so than it had done previously. So as the data accumulated after bringing in the RAI-HC into the region, it became more and more clear to how important and useful that information was and that to really be able to leverage it for program planning and evaluation, policy development, decision-making, that they really needed someone who could work with the data and have that expertise that they didn’t currently have in the program. So that’s why my job was created, specifically because of my interRAI background.
Agency size and location
The agencies most able to work with interRAI data were those with qualified, dedicated staff. Smaller agencies and those in rural areas had greater challenges working with these larger datasets:
I also think that that bigger agencies have really fulsome quality departments and program evaluation and that kind of stuff. I don’t think that the smaller agencies or some of the smaller community support service agencies … I don’t think that they’ve got the kind, the quality staff or data collection … They report the number of clients served kind of thing. (Interview 3)
Participants with clients in rural areas also experienced issues related to internet connectivity, which prevented their staff from completing interRAI assessments. Data were not being captured consistently:
However, what is happening is, is because of spotty connectivity issues, our clinical staff are going in doing [RAI assessments] in hardcopy, returning to the office, then generating it, uh data entering it electronically … then returning back to the client’s home, to inform the care planning and at times are not returning back to the client home, just because of the, the increase to the work load … So that’s where we’re falling short.
… the connectivity challenges I know were, were definitely an issue across the board with all the providers that were involved in the collaborative and I think there was five other providers and they were all finding the same issue, so it’s not isolated to [our organization]. (Interview 2)
Opportunities for education and capacity-building
Participants see the value and potential in the interRAI tools, but recognize that in most jurisdictions, in particular those without dedicated and highly-trained personnel, they are not able to optimally utilize the data. Participants are unfamiliar and insufficiently equipped to work with large data sets, feel overwhelmed by the volume of data, and do not have the right personnel to analyse the data in meaningful ways. Participants are using interRAI data, but feel that they are not using it to its fullest capacity. As one participant explained:
I think we could do a much better job, absolutely. I do think what we’re doing is the bare minimum. I think that if there could be offered some regular lunch-and learns, or webinars, or conference calls, things of that nature. (Interview 2)
When asked if she was confident in her ability to use the datasets, another participant explained:
I would say we’re still in the learning process... but we’re starting to use the data. I would really like to see more push on, you know, now we’ve got the home care data, what do we do with it?
In order to bolster their ability to utilize interRAI data, several participants noted that they are presently working with researchers at the Universities of Waterloo, Calgary and Alberta to examine particular outcome scales and other areas of interest. In addition to university partnerships, participants enthusiastically supported and appreciated the training modules provided by CIHI. For example, one participant commented:
We have a good relationship with CIHI and so all of our case coordinators go through the CIHI education before, because that’s how they’re trained on doing the clinical assessments. We have our in-house specialists as well, but every new case coordinator does have to have the CIHI education and then that also imprints upon them the appropriate coding so that we have good quality data … . I really do believe CIHI has done an excellent job of doing those, providing those materials, having quick reference sheets about the outcome scores so that uh it is quick referral for them. (Focus Group 1)
When probed, all participants requested additional data usage/health informatics training in online, webinar formats. One interviewee explained:
Because home care is so spread out and, really, we hardly have enough time to breathe, I think webinars are the best … and webinars at times that are not work times. So doing it from noon to 1 doesn’t really help because, we don’t, nobody takes lunches. (Interview 3)