Rethinking the Resident Assessment Protocols.

To the Editor: We are writing on behalf of interRAI, a 26country research network whose members developed the Nursing Home Resident Assessment Instrument and the 18 Resident Assessment Protocols (RAPs) for the Minimum Data Set, Version 2.0 (MDS V2.0). The recent article by Dosa et al. raises some interesting issues related to the RAPs, but it would be useful to take a somewhat broader view than was presented in the article. The authors point to some valid and useful criteria by which RAPs can be considered. Without impugning their credentials, it is important to recognize that this study simply represents the ratings and opinions of two selfselected individuals, rather than a sample of independent raters who are representative of any population. Thus, the conclusions need to be considered with care. In developing the MDS V2.0 RAPs, many of the criteria suggested by Dosa et al. were considered. Nevertheless, several of their criteria may be inappropriately applied. Four specific examples illustrate this point. First, it is not clear that there is a singular, appropriate level of detail that would apply uniformly to the care planning activities of all potential users, ranging from sophisticated physicians and registered nurses to other staff with less training, fewer resources, and substantial time limitations. Thus, ‘‘clarity’’ is a subjective consideration that needs to be evaluated from the perspectives of multiple users. Second, in designing the triggersFthe algorithms involving MDS items that indicate which of the 18 care planning areas should be consideredFthere was an explicit government-requested criterion that lead to overtriggering. The emphasis was on triggers that were sufficiently sensitive to provide a broad ‘‘safety net’’ to capture all the potential needs of nursing home residents. Experience has shown that this is not as effective as a more-targeted approach that emphasizes specificity. Although RAPs are being used around the world in care planning, these efforts are often overwhelmed with too many triggered RAPs. Third, when these initial RAPs were developed, there was no sufficient evidence base and too much variability in resident situations to provide a highly structured set of recommendations (e.g., a checklist or flowchart, as suggested by Dosa et al.). Thus, RAPs were designed to provide suggestions of how to ‘‘think about the problem’’ rather than narrow practice guidelines that would lead to a criticism of ‘‘cookie-cutter care-planning’’ or, eventually, reliance on outdated protocols. International experience has shown that the RAP approach provides motivation for care staff to provide better care. Finally, authors were acknowledged for all RAPs in early versions, but the U.S. government omitted them as standard policy. The authors are correct that the set of RAPs they evaluated was the most recent set adopted by the U.S. government, but these are not the only RAPs available. The U.S. federal requirements stipulate that the care planning process has to be at least as thorough as that represented by the approved 18 RAPs, but clinicians are allowed to substitute replacements that improve upon them. InterRAI is engaged in a multinational effort to develop and promulgate updated RAPs that incorporate new clinical insights into the domain areas addressed and a new approach to care planning based on a more-targeted triggering methodology. This development is part of the design of a more-sophisticated ‘‘suite’’ of assessment instruments that span a much broader set of care environments that include not just nursing homes, but also postacute care, assisted living, home care, palliative care, inpatient mental health, community mental health, intellectual disability, and acute care. In addition, these instruments are designed to be used around the world, in different cultures. The suite has ‘‘titrated’’ items from the RAI and other earlier interRAI instruments so that any item used in multiple assessment systems will be identical and thus provide the ability to compare populations in all care settings and follow individuals across these settings. As part of the suite development, all of the RAPs are being reconsidered. The extensive databases that are accumulating from international adoption of the interRAI instruments provide a strong scientific basis for the new triggers. The care planning protocols are now called Clinical Assessment Protocols (CAPs), in recognition of their applicability to more populations than nursing home residents alone. In this redevelopment, interRAI has considered many of the same criteria as those that Dosa et al. suggest. In particular, our triggering approach now seeks to identify two types of persons. First are those who have a higher-thanexpected likelihood of decliningFa typical scenario for longstay nursing home residents. Second are persons who have a high likelihood of improving, including those declining because of a recent acute problem (e.g., delirium, psychosis, fall, pneumonia) and whose symptoms would be alleviated when the problem was addressed. Using this approach, it was possible to cut the proportion of CAPs triggered for followup by more than half for the 18 areas represented by the current RAPs. Finally, interRAI is updating the approach to care instructions provided in each of these problem areas, focusing where possible on clinical concerns and strategies that have been empirically demonstrated to lead to positive outcomes. We see this as a continuing effort to refine the guidelines as knowledgeFours and othersFimproves.