Skip to main content

Mapping a comprehensive assessment tool to a holistic definition of health for person-centred care planning in home care: a modified eDelphi study



Researchers in the Netherlands proposed the Pillars for Positive Health (PPH) as a broadly encompassing health definition to support more realistic and meaningful care planning for people living with chronic disease and other life-long health conditions. The PPH was subsequently converted to the My Positive Health (MPH) spider web visualization tool. This study sought to identify opportunities for more person-centred care planning at the point of care in home care, using the MPH tool as a framework to link comprehensive assessment and dialogue-based goal-setting.


A modified eDelphi method was used to conduct domain mapping with a purposively sampled expert panel (n = 25). The panel consisted of researchers, health care providers, older adults and caregivers. A two-stage eDelphi process was conducted, with each stage consisting of three survey rounds. In the first stage, participants were asked to map 201 elements of the interRAI Home Care (interRAI HC) comprehensive assessment tool to the six MPH domains or “No pillar of best fit”. The second stage focused on identifying opportunities to adapt or expand comprehensive assessment as it relates to the MPH domains.


In Stage 1, 189 of 201 elements reached consensus in domain mapping. These included: 80 elements for Bodily Functions, 32 for Daily Functioning, 32 for Mental Wellbeing, 24 for Quality of Life, 10 for Participation, and 1 for Meaningfulness. Ten elements were identified to have no pillar of best fit. The 12 elements that did not reach consensus in Stage 1 formed the basis for Stage 2, where expert panel participants proposed four new assessment elements in Meaningfulness and Participation and 11 additional descriptors across the six MPH domains. Of these, two elements and nine of the 11 descriptors reached consensus.


Findings show that elements of the interRAI HC are oriented toward the physical, functional, and mental health domains. Consequently, complementary assessment elements and/or tools may be needed to support comprehensive assessment of ‘Meaningfulness’ and ‘Participation’ in person-centred home and community care. Additional descriptors may also be needed to aid communication regarding the understanding and application of MPH domains.

Peer Review reports


How we define health has significant ramifications for care delivery across different settings [1]. The World Health Organization’s (WHO) definition of health as a state of complete physical, and social wellbeing, and not merely the absence of disease [2], is one of the most commonly referenced definitions [3]. Promulgated at the founding of the WHO in 1948 [2], its decision to include mental and social dimensions as integral components to healthy functioning, thus broadening the lens through which health was viewed, was at the time considered pioneering [4]. At present, however, the definition’s focus on completeness appears incongruous with current epidemiological realities related to chronic disease [5, 6]. For individuals managing chronic health conditions, the WHO’s definition does not provide a person-centred goal on which their health needs could be assessed. For the purposes of this study, being person-centred is defined as an approach to health and healthcare that seeks to promote dignity and respect, information sharing, participation in decision making and collaboration with healthcare stakeholders in the development, implementation and evaluation of healthcare delivery [7]. For health systems to plan and deliver services tailored to the unique needs of individuals, a person- and goal-centred definition of health is needed [6].

Recognizing the limitations of the WHO’s health definition, a multidisciplinary group of international healthcare experts attending a two-day conference in the Netherlands explicated a new vision of health that acknowledges its dynamic nature and underscores the individual’s ability to adapt to changing health states [8]. Health was subsequently conceptualized as “the ability to adapt and to self-manage” at the two-day conference [4]. This definition was later operationalized into six measurable dimensions – Bodily Functions (i.e., concepts relating to the physiological systems of the body e.g., physical functioning, pain, health symptoms etc.), Daily Functioning (i.e., concepts relating to an individual’s ability to perform basic and instrumental activities of daily living), Societal Participation (i.e., an individual’s involvement or connectedness to community or society), Quality of Life (i.e., concepts relating to an individual’s overall perception of and satisfaction with how things are in their life), Meaningfulness (i.e., concepts relating to an individual’s quest to find purpose or seek meaningful connections) and Mental Wellbeing (i.e., concepts relating to an individual’s mental and emotional wellbeing) – with 32 sub-dimensions [8]. This broad operational categorization was termed the Pillars for Positive Health (PPH) framework [8]. While the PPH framework is widely known and has been used in home and community care practice in the Netherlands, to the best of our knowledge, it has not been previously used in peer-reviewed home and community care research.

Home and community-based care provides an optimal backdrop for the implementation of a broader conceptualization of health. Persons receiving home care services have complex needs, often having multiple chronic medical conditions complicated by functional impairments and social frailty [9, 10]. Available evidence demonstrates that most older adults prefer to live, age, and receive care at home [11, 12], however a range of medical, functional and social factors can influence the need to transition to facility-based care [9, 13, 14]. Furthermore, goals of home-based care focus on promoting, maintaining, or restoring health while maximizing independence and minimizing the effects of disability and illness [15], thus necessitating a more comprehensive understanding of preferences, strengths and needs. The PPH framework, given its robustness, practicality, and ability to reflect current epidemiological realities, may be particularly well-suited to guiding the point-of-care assessment approach in home and community care.

Comprehensive assessment of client needs has been demonstrated to be an integral part of the care planning process in home care, as it supports the collation of health information which is used to develop individualized, person-centred plan aimed at improving overall health outcomes [16]. A recent scoping review identified that several comprehensive assessment tools have been developed to support holistic care planning in home care, including the interRAI HC [17]. However, findings from a recent survey showed that point-of care use of the interRAI HC may not align with intended use, including supporting care planning efforts within the home care sector in Ontario, Canada [18]. Reasons for this are not well understood, but it is plausible that the robustness of the interRAI HC from an assessment and documentation perspective, could make the process challenging for both the assessor and the client [18]. When utilized as designed as a tool to support care planning, client-level outcomes have been shown to improve [19].

An evidence-based approach to the successful integration of comprehensive assessment tools in the care planning process in home care is through the process of dialogue-based goal setting [20,21,22]. In a recent participatory research study on integrated care planning in home care, the PPH framework was recommended as a tool to guide the implementation of a person-centred, dialogue-based goal setting approach to care planning [23]. These findings guided leaders at a large Canadian home care organization to adopt the PPH framework as a definition of ‘life care’ – a person-centred principle of care that recognizes that the needs of people in community health care settings extend beyond physical and functional domains [23]. The PPH’s dimensions and sub-dimensions were subsequently converted to the My Positive Health (MPH) tool to support use in practice [24]. The MPH tool has the potential to support meaningful dialogue between point-of-care providers, older adults and caregivers and support the integration of life goals into the plan of care in community settings [23].

The overall goal of this study was to identify opportunities to facilitate more person-centred care planning at the point-of-care using the MPH tool as a framework to link comprehensive assessment and dialogue-based goal setting in home care. Specifically, the study aimed to: (1) map the elements of a standardized comprehensive assessment tool mandated for use in Ontario home care onto the six domains of the MPH tool, (2) identify opportunities to adapt or expand the MPH tool based on unmapped items from the comprehensive assessment, and (3) identify opportunities to adapt or expand comprehensive assessment to support life care, as defined by the MPH domains.


Study design

We used a modified eDelphi method for this study. The Delphi method was developed by the Rand Corporation and first described in a paper by Dalkey and Helmer (1963) [25]. The method adopts a systematic approach to consensus building by means of iteration with controlled feedback of the group’s opinion and the aggregation of responses to address differing viewpoints [26, 27]. The Delphi technique employs the use of quantitative and qualitative methods (mixed-methods design) to collect and analyze information from participants. Typically, a Delphi study is conducted through the following processes: (1) Identify an expert panel based on an established eligibility criteria [26, 28, 29]; (2) Develop a questionnaire containing elements that the expert panel are required to vote on or rate [27]; (3) Establish a consensus criteria by which level of agreement will be decided prior to commencement [30,31,32]; (4) Provide participants with anonymized summaries of the findings after each Delphi round, including participant’s own score or ranking, allowing participants to evaluate findings within the context of group responses [27, 29].

Two modifications to the traditional Delphi method were employed for this study. First, due to the geographical spread of the prospective expert panel as well as considerations for social distancing during the pandemic, the survey was conducted online using an eDelphi approach. Additionally, because the initial idea generation phase was replaced with pre-existing information (e.g., interRAI HC elements and MPH domains), this study was considered a modified eDelphi study. We conducted the eDelphi study over two stages. Stage 1 addressed objective 1, and Stage 2 addressed objectives 2 and 3.

Delphi participant recruitment

Non-probability purposive sampling combined with snowball sampling [33] was adopted to recruit international experts who self-identified as fluent in English and familiar with the interRAI suite of assessment tools, comparable comprehensive assessment tools and/or the MPH framework. The process began by identifying names of individuals with the following perspectives: researcher, health and social care provider, older adults with interest or experience in home and community care and/ or caregivers. For those in the researcher, health, and social care provider groups, the study team first compiled a list of individuals within professional networks who met the recruitment criteria described above. These individuals were then sent a recruitment email with detailed information about the study from a member of the study team who had no prior working relationship with them. Those interested in participating in the expert panel were asked to reply to the recruitment email to communicate their interest in participation. For individuals in the client and caregiver groups, representatives of known older adult and caregiver support groups were contacted with detailed information about the study, asking interested parties to contact a member of the study team. Familiarity with the interRAI HC and/or the MPH tool was defined as firsthand experience with the interRAI HC assessment process in their capacity as clients or caregivers. Consent was obtained from participants electronically prior to the start of the first eDelphi survey. Participants who completed all stages of the eDelphi study were offered an optional $50 gift card as an honorarium.

Stage 1

The first stage consisted of three survey rounds and sought to address the first study objective—to map the elements of a standardized comprehensive assessment tool mandated for use in Ontario home care (i.e., the interRAI HC assessment) onto the six domains of the MPH tool. All surveys were conducted online using Qualtrics software (2021; Provo, UT).

InterRAI assessment

interRAI ( is a not-for-profit network of more than 135 researchers, clinicians, and policy experts from over 35 countries focused on the development and application of comprehensive assessment, screening, and care planning systems that identify and respond to the needs of vulnerable persons of all ages across the continuum of care. With over three decades of research experience resulting in over 1400 scientific publications, interRAI has developed assessment systems that have been adopted on a large-scale basis internationally across multiple settings including home and community care, long-term care and both community and in-patient mental health [34, 35]. Across Canada, interRAI tools have been mandated for use in home care and long-term care and, in the Province of Ontario, in in-patient mental health as well as community support services [36,37,38].

The interRAI HC assessment is part of the interRAI suite of assessment tools and is used to evaluate the care needs of home care clients [39]. The reliability and validity of the interRAI HC assessment tool has been established internationally [40,41,42]. The interRAI HC contains more than 300 elements used to assess the needs of home care clients across a range of domains to support care planning and monitoring efforts [39].

It is important to note that the interRAI HC manual recommends the adoption of a dialogue-based approach to the use of the interRAI HC as an assessment tool, thus aligning with the overarching study goals [43]. However, the outlined study goal seeks to provide a clearer, more accessible way to facilitate this, given known barriers to adoption cited previously. After detailed review of the interRAI HC, study investigators flagged 201 assessment items across 19 of 20 assessment categories that sought to directly assess an individual’s health status and excluded elements relating to identifying information, specific medication details or those deemed not directly relevant or tangential to the assessment of individual health status [43]. Assessment elements for expert panel consultation were then defined for ease of interpretation outside of the assessment context (see Table 1 for examples).

Data collection

In the first survey, participants were presented with detailed information about the study, including study objectives, information about the interRAI HC and an image of the MPH tool that included descriptors for each of the six MPH domains (i.e., Bodily Functions, Daily Functioning, Societal Participation, Quality of Life, Meaningfulness, and Mental Wellbeing) [24]. Participants were then asked to match each of the interRAI HC assessment elements with one of the six MPH domains they deemed to be of best fit. A “No Pillar of Best Fit” option was also provided for assessment elements panel members determined to not fit into any of the six MPH domains. Consistent with best practices for Delphi studies, consensus was defined a priori and was set as 70% or greater agreement [31, 44, 45]. In each successive survey round, elements that reached consensus were documented and removed from the survey and participants were invited to respond to the survey again. To facilitate consensus-building, participants were provided with a summary file following each round that contained their individual responses and the summary of the overall expert panel responses from the preceding round (see supplemental file 1 for sample Stage 1 report). Each stage of the study was restricted to three rounds in line with Delphi best practices for consensus determination [46, 47].

Stage 2

The second stage focused on identifying opportunities to adapt or expand the MPH tool based on unmapped items from the comprehensive assessment and identifying opportunities to adapt or expand comprehensive assessment to support life care, as defined by the MPH domains. This stage was also conducted over three survey rounds.

Data collection

In round 1 of the second stage, MPH domains that were considered underrepresented by interRAI HC elements (defined a priori for this study as domains reflecting less than 1/12th of the total interRAI HC element list) and interRAI HC elements that did not reach consensus after stage 1 were considered. Participants were asked to propose suggestions for additional assessment elements and/or domain ideas. Panel responses on proposed new MPH domain ideas and assessment elements were then compiled and in survey round 2 participants were asked to rate their agreement with their inclusion using a 5-point Likert scale (i.e., 1- Strongly Disagree, 2- Disagree, 3- Neutral, 4, Agree, 5- Strongly Agree). As in Stage 1, consensus was defined as proposed MPH domain ideas or assessment elements rated 4 or greater by 70% or more of the Delphi participants. In round 3, after removing elements that reached consensus in round 2, participants were invited to respond to the survey again. To facilitate consensus-building, participants were provided a summary of findings from the previous rounds to inform their decision.

In both stages, the link to the survey was sent individually to each participant by email. Participants had three weeks to complete each survey. A reminder was provided to each participant who had not completed the survey after every seven days (i.e., days 7, 14 and 21). Individuals who did not complete the survey after the three-week period were considered to have opted out of the process and were not invited to participate in subsequent rounds.

Data analysis

Analysis of Stage 1 surveys

Descriptive statistics (i.e., means and standard deviations for continuous variables and percentages and frequencies for categorical variables) were used to describe the demographic characteristics of eDelphi participants. To compare the demographic characteristics of eDelphi starters and completers, independent t-tests for continuous variables and chi-square analyses for categorical variables were conducted.

After each survey round in Stage 1, descriptive statistics (percentages) were used to summarize the distribution of responses for each assessment element matched to the MPH domains, and to identify elements that reached consensus after each survey round. Modes were used to identify the most frequently occurring response option for each interRAI HC assessment element.

Analysis of Stage 2 surveys

Qualitative data from survey 1 of Stage 2 regarding expert panel suggestions for additional assessment elements and additional MPH domain ideas were categorized thematically using Microsoft Excel for Microsoft 365 MSO version 2202. To enhance the reliability of this exercise, this process was conducted by AF and independently verified by all co-authors, first through asynchronous review, and then in a consensus-building meeting.

For surveys 2 and 3 of Stage 2, descriptive statistics (modes and percentages) were used to summarize panel members agreement ratings for additional assessment elements and MPH domain ideas and to identify suggestions that reached consensus after each round.


Forty-seven experts responded to the study recruitment email and were sent the link to survey 1 of the eDelphi study. Of those, 39 expert panel members completed the first survey and provided demographic information. In total, 25 expert panel members completed all six rounds (two stages) of the eDelphi study (Fig. 1). Demographic information describing characteristics of study starters and completers is provided in Table 1. No significant differences in demographic characteristics were observed between expert panel members who started and those who completed the full study (p > 0.05). Expert panel members included 33 females and 6 males representing a broad range of age groups: 31–40 (n = 9), 41–50 (n = 6), 51–60 (n = 6), 61–70 (n = 10), 71–80 (n = 7) and 81–90 (n = 1). A total of 22 experts identified with the researcher/health care provider perspective while 17 identified as caregivers and/or older adults. Geographic distribution of eDelphi participants are included in Table 1.

Fig. 1
figure 1

Flow Diagram Presenting the Steps in the Delphi Consensus Process

Table 1 Characteristics of Delphi Expert Panel

Stage 1 results

Round 1 survey

Thirty-nine out of 47 (83% response rate) individuals who agreed to be part of the expert panel by email completed the first survey. In round 1 there was consensus on 84 (41.8%) of the 201 interRAI HC assessment elements among the expert panel members. Of these, 46 (54.8%) interRAI elements reached consensus in the Bodily Functions domain, 15 (17.9%) in Daily Functioning, 10 (11.9%) in Mental Wellbeing, 7 (8.3%) in Quality of Life, and 6 (7.1%) in Participation. No interRAI HC assessment elements reached consensus in the Meaningfulness domain or in No Pillar of Best Fit.

Round 2 survey

In round 2, expert panel members were presented with 117 non-consensus interRAI HC assessment elements from survey 1. Thirty-six out of 39 (92% response rate) expert panel members completed survey 2. Forty-nine (41.9%) of 117 assessment elements reached consensus across expert panel members. Of these, 18 (36.7%) elements reached consensus in the Bodily Functions domain, 13 (26.5%) in Mental Wellbeing, 6 (12.2%) in Quality of Life, 5 (10.2%) in Daily Functioning, and 2 (4.1%) in Participation. Five (10.2%) elements reached consensus in No Pillar of Best Fit. No assessment elements reached consensus in the Meaningfulness domain.

Round 3 survey

In round 3, the expert panel were presented with the remaining 68 interRAI HC assessment elements which had not yet reached consensus. Twenty-eight of thirty-six (78% response rate) expert panel members completed survey 3. Fifty-three (77.9%) of the 68 assessment elements were found to reach consensus. Of these, 16 (30.2%) reached consensus in Bodily Functions, 12 (22.6%) in Daily Functioning, 11 (20.8%) in Quality of Life, 9 (17.0%) in Mental Wellbeing, 2 (3.8%) in Participation and 1 (1.9%) in Meaningfulness. Five elements (7.4%) reached consensus in No Pillar of Best Fit.

Over the course of the three surveys conducted in Stage 1 of the eDelphi, 189 of 201 assessment elements reached consensus. Of these, 80 (39.8%) reached consensus in the Bodily Functions domain, 32 (15.9%) in Daily Functioning, 32 (15.9%) in Mental Wellbeing, 24 (11.9%) in Quality of Life, 10 (5.0%) in Participation, and 1 in Meaningfulness (Fig. 2; a specific list of assessment elements that reached consensus is provided in Table 2). Ten (5.0%) assessment elements reached consensus in No Pillar of Best Fit, while 12 (6.0%) assessment elements did not reach consensus in Stage 1 and formed the basis for Stage 2 of the eDelphi study (Fig. 2).

Fig. 2
figure 2

List of Assessment Elements that Reached Consensus by Specific My Positive Health Domain

Table 2 List of interRAI HC Assessment Elements that Reached Consensus by Specific Pillar

Stage 2

Round 1 survey

The expert panel members provided a range of suggestions for potential assessment elements for the two MPH domains (i.e., Meaningfulness and Participation) considered underrepresented by interRAI HC elements. After coding, four main themes for each domain were identified from the suggestions provided by the expert panel. For Meaningfulness, the following additional areas for assessment were identified: “person has thriving social support networks or feels included as part of a community”, “person’s ability to volunteer, make positive impact in their communities, or feels part of something bigger”, “person practices mindfulness, is self-aware, or has a spiritual life”, and “person has goals and purpose (i.e., work, career, vocations, occupations)”. For Participation, the following additional areas for assessment were identified: “person’s social and demographic information”, “person has thriving social support networks or feels included as part of a community”, “person’s ability to engage in activities of interest”, and “person’s emotional health and wellbeing”. Notably, one theme, “person has thriving social support networks or feels included as part of a community” was identified in both underrepresented MPH domains. Upon deliberation, the study team agreed to let the expert panel decide through the process of consensus in subsequent surveys, as to which MPH domain the duplicated theme best fit into. Detailed information on suggestions provided by expert panel in each theme is included in Supplemental File 2.

The expert panel also provided a range of suggestions about potential new MPH domain ideas for the interRAI HC elements that did not reach consensus in Stage 1 of the eDelphi study. Upon detailed review and categorization by the study team, the suggestions provided appeared to be additional descriptors (i.e., the highlighted bullet points for each pillar in Fig. 3) for the existing six MPH domains as opposed to entirely new MPH domains. A total of 11 additional descriptors across the six MPH domains were identified: 5 additional descriptors for Bodily Functions, 2 for Daily Functioning, and 1 each for Participation, Quality of Life, Meaningfulness and Mental Wellbeing.

Fig. 3
figure 3

The My Positive Health Spider Web Visualization Tool with Descriptors

Round 2 survey

In round 2 of the second stage of the eDelphi study, a total of three suggested assessment elements reached consensus. The expert panel agreed that “person has goals and purpose (i.e., work, career, vocations, occupations)” fit in Meaningfulness. Additionally, the panel agreed that “person has thriving social support networks or feels included as part of a community” and “person’s ability to engage in activities of interest” fit in Participation.

For the proposed additional descriptors, a total of 9 out of the 11 reached consensus for describing at least one of interRAI HC elements that were the subject of Stage 2.

Round 3 survey

At the end of survey 3, one additional proposed assessment element reached consensus in Meaningfulness, while no assessment elements reached consensus in Participation. The duplicated assessment item, which previously reached consensus in Participation in round 2 (i.e., person has thriving social support networks or feels included as part of a community) also reached consensus in Meaningfulness in round 3.

At the end of round 3, 9 of the 11 proposed additional descriptors in Stage 2 reached consensus. This information was subsequently used to recreate the MPH figure to incorporate the consensus additional descriptors (Fig. 4). A detailed summary of the list of proposed elements and additional descriptors for underrepresented MPH domains and non-consensus assessment elements are included in Supplemental File 3.

Fig. 4
figure 4

Expanded My Positive Health Image to include Phase 2 Findings


This study explored opportunities to improve person-centred goal setting at the point-of-care in home care, using the MPH as a framework to link comprehensive assessment and dialogue-based goal setting. Through a modified eDelphi process, investigators mapped the items from a comprehensive assessment tool mandated for use in Ontario home care to the six domains of the MPH and explored opportunities to adapt or expand comprehensive assessment elements and/or MPH domains. Findings from this study showed that 189 of the 201 interRAI HC elements successfully mapped to the six MPH domains, with Bodily Functions, Daily Functioning and Mental Wellbeing being the most represented of all six domains. A total of 10 elements reached consensus in No Pillar of Best Fit, while the remaining 12 elements did not reach consensus. Similarly, additional assessment elements and MPH descriptors, considered important to health assessment and useful in clarifying the underlying aspect of each MPH domain, were proposed. Taken together, these findings provide valuable insight into the potential for integration of the MPH framework with the interRAI HC comprehensive assessment tool to support more individualized and holistic care planning at the point-of-care in home care.

The expert panel reached agreement on mapping 94% of the assessment elements drawn from the interRAI HC to the six domains of the MPH. Furthermore, the panel did not identify any additional domains which should be added to the framework. This level of agreement highlights the potential use of this framework to help structure comprehensive and person-centred assessment conversations around a broader definition of health, while building on existing international best practices in standardized assessment of home care client needs. Taking advantage of the MPH or comparable frameworks to provide a clear structure to guide a conversational assessment, care planning and goal setting approach, may facilitate the delivery of more individualized care which addresses the range of care needs across population groups. An approach like this is aligned with the intended assessment approach outlined by interRAI in their assessment manuals but is not always seen in practice [18, 43].

There was a disproportionate mapping of assessment elements to the Bodily Functions, Daily Functioning and Mental Wellbeing domains, leaving MPH domains of Meaningfulness and Participation underrepresented. Participants were asked to suggest supplementary assessment elements to address potential gaps in the Meaningfulness and Participation domains. While the expert panel members proposed a range of suggestions, only two additional elements achieved consensus in both these domains. This may suggest that expert panel members found it challenging to propose assessment elements in these domains or that members did not have a unified understanding or definition of Meaningfulness and Participation, making it difficult to come to consensus. This is particularly evident given the duplicative assessment item which was proposed and reached consensus in both domains. These findings may also be reflective of the entrenched nature of the conventional bio-medical model of health across health and social care settings, thus placing limits on one’s ability to visualize health outside of known medically focused health domains [48]. The resulting outcome of interRAI HC assessment elements mapping most heavily to physical and mental health domains may also reflect a bias in participants towards assessment of health needs in areas where health and social care services may be available to address issues identified; however, future research is needed to confirm this.

Our findings are consistent with other comparable studies conducted in the older adult population. In a systematic review that sought to map the domains of 67 commonly used assessment tools to evaluate frailty in older adults, it was observed that while all the tools included assessment elements in the biological domains, only nine tools included elements assessing social connections and social support, despite known links on the importance of these factors towards the conceptualizations of frailty [49]. In another systematic review that used gap map methods to appraise the literature regarding assessment of health and social support services to support functional ability in older adults, it was found that of 528 studies reviewed, only a few studies assessed domains such as social participation, financial security, ability to maintain relationships and communication [50]. However, most of the studies included assessed functional ability within domains related to physical and mental capacity such as mobility, mental function and neuromusculoskeletal function [50]. Consequently, there is a need for the development of new assessment tools, or the augmenting of existing assessment tools to ensure the propagation of a holistic, person-centred model of care planning, particularly for older adults whose health needs tend to be complex and multifaceted.

Clinical implications

This study has implications for comprehensive care planning in home and community care. As demand rises for models of care that support more integrated health and social care service delivery [12], comprehensive and person-centred care practices are necessary to maximize needs-based care opportunities. Findings from this study indicate that the interRAI HC tool supports a full investigation of physical and mental health, but complementary assessment elements and/or tools may be required to support assessment of ‘life care’ according to the MPH; namely Participation and Meaningfulness domains. It is important to note that the MPH was not designed through a clinical assessment lens, which often prioritizes definitive inclusion criteria for each domain that is to be assessed. Results suggest that to support integration of an expanded definition of health into existing care planning practices, additional descriptors for each MPH domain may be needed to enhance understanding, interpretation of and differentiation between the MPH for providers, older adults, caregivers and researchers. For example, one of the suggested assessment elements in Stage 2 of the eDelphi method reached consensus in two MPH domains. Additional research is needed to explore further delineation opportunities among the domains.

Next steps for this research will involve co-designing tools and resources to support dialogue-based comprehensive assessment and goal setting around ‘life care’ needs. The co-design work will be completed in partnership with home care clinicians, leveraging study findings to integrate the interRAI HC, MPH domains, additional descriptors and complementary assessment tools into a person-centred care planning process at the point-of-care in home care.

Strengths and limitations

While the MPH allowed us to categorize the interRAI assessment elements within holistic health domains, it should be noted that the MPH was developed in the Netherlands using the Dutch language and later translated to English. It is possible that aspects of the Dutch language could contain words that cannot be adequately translated into the English language leading to potential biases. While we sought to recruit participants with firsthand experience of the interRAI HC and/or MPH framework, there were no formal inclusion criteria to ensure all participants were starting with the same knowledge base, which may have influenced the study findings. As the majority of our expert panel members were from a single Canadian province, the generalizability of study findings may be limited, given differences in how care is delivered across provinces and across countries. However, as the interRAI HC is used across Canada and in several countries, there is potential to validate this mapping exercise in other jurisdictions using similar methods. The strengths of this study include use of the Delphi method, which allowed for the engagement of a diverse group of experts across a range of perspectives critical to person-centred care planning in home care – older adults and caregiver, health and social care providers, and researchers. Another strength of this study is that the findings can be adopted to potentially expand the clinical utility of the interRAI HC at the point-of-care, building on existing and mandated standardized comprehensive assessment practices in Ontario and elsewhere.


Using an eDelphi approach which included experts with a range of perspectives, we found that most interRAI HC assessment elements mapped onto MPH domains representing physical and mental health, with domains representing social needs like participation and meaningfulness agreed on to be underrepresented by assessment elements. This led to the proposal of new assessment elements and domain descriptors to expand the scope of comprehensive assessment and provide greater clarity between the domains representing ‘life care’ needs through an expanded definition of health. These findings will be used to co-design a dialogue-based approach to comprehensive assessment and goal setting around ‘life care’ needs that has the potential to optimize the care planning process for older adult clients, caregivers and home care providers through a more person-centred lens.

Data Availability

Data used in this study can be made available upon reasonable request from the corresponding author.


  1. Krahn GL, Robinson A, Murray AJ, et al. It’s time to reconsider how we define health: perspective from disability and chronic condition. Disabil Health J. 2021;14(4):101129.

    Article  PubMed  Google Scholar 

  2. World Health Organization. Basic documents: 49th edition (including amendments adopted up to 31 May 2019). 2020. Accessed September 16, 2022.

  3. Larson JS. The conceptualization of health. Med Care Res Rev. 1999;56(2):123–36.

    Article  CAS  PubMed  Google Scholar 

  4. Huber M, André Knottnerus J, Green L, et al. How should we define health? BMJ. 2011;343(7817).

  5. Leonardi F. The definition of Health: towards New perspectives. Int J Heal Serv. 2018;48(4):735–48.

    Article  Google Scholar 

  6. Card AJ. Moving beyond the WHO Definition of Health: a New Perspective for an Aging World and the emerging era of value-based care. World Med Heal Policy. 2017;9(1):127–37.

    Article  Google Scholar 

  7. Institute for Patient and Family Centred Care. Patient- and Family-Centered Care. Accessed October 13., 2013 from

  8. Huber M, Van Vliet M, Giezenberg M, et al. Towards a ‘patient-centred’ operationalisation of the new dynamic concept of health: a mixed methods study. BMJ Open. 2016;6(1):e010091.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  9. Cegri F, Orfila F, Abellana RM, Pastor-Valero M. The impact of frailty on admission to home care services and nursing homes: eight-year follow-up of a community-dwelling, older adult, Spanish cohort. BMC Geriatr. 2020;20(1):1–13.

    Article  Google Scholar 

  10. Giosa J, Saari M, Holyoke P, Hirdes J, Heckman G, Cardoza V. Long-term LIFE care at home: the future of aging-focused care in Canada. SE Research Centre. Published 2022. Accessed February 2, 2023.

  11. Wiles JL, Leibing A, Guberman N, Reeve J, Allen RES. The meaning of aging in place to older people. Gerontologist. 2012;52(3):357–66.

    Article  PubMed  Google Scholar 

  12. Giosa JL, Saari M, Holyoke P, Hirdes JP, Heckman GA. Developing an evidence-informed model of long-term life care at home for older adults with medical, functional and/or social care needs in Ontario, Canada: a mixed methods study protocol. BMJ Open. 2022;12:60339.

    Article  Google Scholar 

  13. Godin J, Theou O, Black K, McNeil SA, Andrew MK. Long-term care admissions following hospitalization: the role of Social Vulnerability. Healthc 2019. 2019;7(3):91.

    Article  Google Scholar 

  14. Aspell N, O’Sullivan M, O’Shea E, et al. Predicting admission to long-term care and mortality among community-based, dependent older people in Ireland. Int J Geriatr Psychiatry. 2019;34(7):999–1007.

    Article  PubMed  PubMed Central  Google Scholar 

  15. Beer JM, McBride SE, Mitzner TL, Rogers WA. Understanding challenges in the front lines of home health care: a human-systems approach. Appl Ergon. 2014;45(6):1687–99.

    Article  PubMed  PubMed Central  Google Scholar 

  16. Aronoff-Spencer E, Asgari P, Finlayson TL, et al. A comprehensive assessment for community-based, person-centered care for older adults. BMC Geriatr. 2020;20(1):1–12.

    Article  Google Scholar 

  17. Stoop A, Lette M, van Gils PF, Nijpels G, Baan CA, de Bruin SR. Comprehensive geriatric assessments in integrated care programs for older people living at home: a scoping review. Heal Soc Care Community. 2019;27(5):e549–66.

    Article  Google Scholar 

  18. Giosa JL, Stolee P, Holyoke P. Development and testing of the Geriatric Care Assessment Practices (G-CAP) survey. BMC Geriatr. 2021;21(1):1–13.

    Article  Google Scholar 

  19. Stolle C, Wolter A, Roth G, Rothgang H. Improving health status and reduction of institutionalization in long-term care–effects of the Resident Assessment Instrument-Home Care by degree of implementation. Int J Nurs Pract. 2015;21(5):612–21.

    Article  PubMed  Google Scholar 

  20. Corbett TK, Cummings A, Lee K, et al. Planning and optimising CHAT&PLAN: a conversation-based intervention to promote person-centred care for older people living with multimorbidity. PLoS ONE. 2020;15(10):e0240516.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  21. Lenzen SA, Daniëls R, Van Bokhoven MA, Van Der Weijden T, Beurskens A. Development of a conversation approach for practice nurses aimed at making shared decisions on goals and action plans with primary care patients. BMC Health Serv Res. 2018;18(1):1–11.

    Article  Google Scholar 

  22. Parsons J, Rouse P, Robinson EM, Sheridan N, Connolly MJ. Goal setting as a feature of homecare services for older people: does it make a difference? Age Ageing. 2012;41(1):24–9.

    Article  PubMed  Google Scholar 

  23. Giosa JL. Developing an integrated geriatric care planning approach in home care. uWaterloo. Published online 2018. Accessed September 16, 2022.

  24. Institute for Positive Health. My Positive Health Dialogue Tool. Accessed January 10., 2023 from

  25. Dalkey N, Helmer O. An experimental application of the DELPHI Method to the Use of experts. Manage Sci. 1963;9(3):458–67.

    Article  Google Scholar 

  26. Barrett D, Heale R. What are Delphi studies? Evid Based Nurs. 2020;23(3):68–9.

    Article  PubMed  Google Scholar 

  27. Geist MR. Using the Delphi method to engage stakeholders: a comparison of two studies. Eval Program Plann. 2010;33(2):147–54.

    Article  PubMed  Google Scholar 

  28. Nasa P, Jain R, Juneja D. Delphi methodology in healthcare research: how to decide its appropriateness. World J Methodol. 2021;11(4):116.

    Article  PubMed  PubMed Central  Google Scholar 

  29. Keeney S, McKenna H, Hasson F. The Delphi Technique in Nursing and Health Research. Oxford: Wiley-Blackwell; 2011.

    Book  Google Scholar 

  30. Mubarak N, Hatah E, Md Aris MA, Shafie AA, Zin CS. Consensus among healthcare stakeholders on a collaborative medication therapy management model for chronic Diseases in Malaysia; a Delphi study. PLoS ONE. 2019;14(5).

  31. Diamond IR, Grant RC, Feldman BM, et al. Defining consensus: a systematic review recommends methodologic criteria for reporting of Delphi studies. J Clin Epidemiol. 2014;67(4):401–9.

    Article  PubMed  Google Scholar 

  32. Keeney S, Hasson F, McKenna H. Consulting the oracle: ten lessons from using the Delphi technique in nursing research. J Adv Nurs. 2006;53(2):205–12.

    Article  PubMed  Google Scholar 

  33. Giannarou L, Zervas E. Using Delphi technique to build consensus in practice. Int J Bus Sci Appl Manag. 2014;9(2):65–82. Accessed September 15, 2022.

    Google Scholar 

  34. Gray LC, Berg K, Fries BE, et al. Sharing clinical information across care settings: the birth of an integrated assessment system. BMC Health Serv Res. 2009;9(1):1–10.

    Article  Google Scholar 

  35. Hirdes JP, Ljunggren G, Morris JN, et al. Reliability of the interRAI suite of assessment instruments: a 12-country study of an integrated health information system. BMC Health Serv Res. 2008;8(1):1–11.

    Article  Google Scholar 

  36. Gallant NL, Peckham A, Marchildon G, Hadjistavropoulos T, Roblin B, Stopyn RJN. Provincial legislative and regulatory standards for pain assessment and management in long-term care homes: a scoping review and in-depth case analysis. BMC Geriatr. 2020;20(458):1–14.

    Article  Google Scholar 

  37. Hirdes JP. Addressing the health needs of frail elderly people: Ontario’s experience with an integrated health information system. Age Ageing. 2006;35(4):329–31.

    Article  PubMed  Google Scholar 

  38. Hirdes JP, Mitchell L, Maxwell CJ, White N. Beyond the ‘Iron lungs of Gerontology’: using evidence to shape the future of nursing homes in Canada*. Can J Aging / La Rev Can du Vieil. 2011;30(3):371–90.

    Article  Google Scholar 

  39. Sinn CLJ, Hirdes JP, Poss JW, Boscart VM, Heckman GA. Implementation evaluation of a stepped approach to home care assessment using interRAI systems in Ontario, Canada. Health Soc Care Community. Published online 2022.

  40. Hogeveen SE, Chen J, Hirdes JP. Evaluation of data quality of interRAI assessments in home and community care. BMC Med Inform Decis Mak. 2017;17(1).

  41. Morris JN, Fries BE, Steel K, et al. Comprehensive clinical assessment in community setting: Applicability of the MDS-HC. J Am Geriatr Soc. 1997;45(8):1017–24.

    Article  CAS  PubMed  Google Scholar 

  42. Landi F, Tua E, Onder G, et al. Minimum data set for home care: a valid instrument to assess frail older people living in the community. Med Care. 2000;38(12):1184–90.

    Article  CAS  PubMed  Google Scholar 

  43. Morris JN FB, Bernabei R, Steel K, Ikegami N, Carpenter I, Gilgen R, et al. interRAI Home Care (HC) assessment form and user’s manual, Canadian Edition. Version 9.1.3 ed. Washington, DC: interRAI; 2019.

  44. Thompson L, Hill M, Lecky F, Shaw G. Defining major trauma: a Delphi study. Scand J Trauma Resusc Emerg Med. 2021;29(1).

  45. Vogel C, Zwolinsky S, Griffiths C, Hobbs M, Henderson E, Wilkins E. A Delphi study to build consensus on the definition and use of big data in obesity research. Int J Obes 2019 4312. 2019;43(12):2573–86.

    Article  Google Scholar 

  46. Niederberger M, Spranger J. Delphi Technique in Health Sciences: a map. Front Public Heal. 2020;8:457.

    Article  Google Scholar 

  47. Iqbal S, Pipon-Young L. The Delphi method. Psychologist. 2009;22:598–600.

    Google Scholar 

  48. Rocca E, Anjum RL. Complexity, reductionism and the biomedical model. Rethinking causality, complexity and evidence for the Unique patient: a CauseHealth Resource for Healthcare Professionals and the clinical encounter. Springer International Publishing; 2020:75–94. doi:

  49. van Damme JK, Lemmon K, Oremus M, Neiterman E, Stolee P. Understanding Frailty Screening: a Domain Mapping Exercise. Can Geriatr J. 2021;24(2):154–61.

    Article  PubMed  PubMed Central  Google Scholar 

  50. Welch V, Mathew CM, Babelmorad P, et al. Health, social care and technological interventions to improve functional ability of older adults living at home: an evidence and gap map. Campbell Syst Rev. 2021;17(3):e1175.

    Article  PubMed  PubMed Central  Google Scholar 

Download references


The authors acknowledge the contribution of the Delphi expert panel for their contribution to the study. The authors gratefully acknowledge the efforts of Tammy Kim who was instrumental in survey design and study implementation. We would also like to thank Dr. Machteld Huber for taking the time to meet with us during the conceptual phase of this study.


The study was funded by SE Health, a Canadian not-for-profit social enterprise.

Author information

Authors and Affiliations



AF contributed to study design and implementation, drafted the manuscript, and approved the final version. JLG and MS contributed to study design and implementation, assisted with drafting of the manuscript, and approved the final version. PH contributed to study design and implementation, critically reviewed the manuscript, and approved the final version.

Corresponding author

Correspondence to J.L. Giosa.

Ethics declarations

Consent for publication

Not Applicable.

Competing interests

The authors declare no competing interests.

Ethics approval and consent to participate

This study was conducted under a research ethics exemption by the Southlake Regional Health Centre Research Ethics Board. The study complied with all the ethical considerations outlined in the Declaration of Helsinki. All participants provided informed consent for study participation.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Supplemental File 1: Sample Stage 1 Report


Supplemental File 2: Summary of Proposed Assessment Elements for Underrepresented My (i.e., Meaningfulness and Participation) Positive Health Pillars *note top bolded row is summary statement of all similar grouped suggestions below


Supplemental File 3: List of Proposed Assessment Elements and Proposed Additional Descriptors for Underrepresented My Positive Health domains and non-consensus assessment elements, respectively

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit The Creative Commons Public Domain Dedication waiver ( applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Fowokan, A., Giosa, J., Saari, M. et al. Mapping a comprehensive assessment tool to a holistic definition of health for person-centred care planning in home care: a modified eDelphi study. BMC Health Serv Res 23, 1268 (2023).

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: