Andrew Downes HIQ Ltd New Zealand & Canterbury District Health Board (Thursday, 2.30, Innovation in Practice 1) In the days and weeks after the Canterbury earthquake, emergency response teams needed to be able to identify and support people who were at risk of adverse outcomes from a health perspective. These people were not acutely injured during the earthquake itself. They were a potentially sizeable population of frail elderly living in the community in their own homes. They often have multiple co-morbidities and due to their low resilience could have ‘tipped over’ into needing acute care services very rapidly. The implementation of interRAI, a national assessment tool being used by all District Health Boards allowed Canterbury DHB to receive prioritised lists from the national interRAI data warehouse, of ‘at risk’ elderly to assist the response teams to target their services. In addition, subsequent to the earthquake a number of elderly people were moved from their homes and residential care facilities to other parts of the country. The national interRAI system was able to seamlessly move assessment and care plan records to the receiving District Health Board so that the receiving services could continue care appropriately.

1. A novel use of a clinical assessment system to assist
emergency teams to support the frail and vulnerable
elderly after the Canterbury earthquake
Health Informatics New Zealand
23rd November 2011
1

2.  Describe the system
 interRAI
 How it is used today in New Zealand
 How interRAI information was used
post earthquake

3. interRAI - clinical assessment and care
planning methodology
 interRAI (www.interRAI.org) is a not for
profit collaborative network of 60
researchers and health/social service
professionals in over 30 countries
 Their goal is to promote evidence-based
clinical practice and policy decisions
through the collection and interpretation
of high quality data about the
characteristics and outcomes of persons
served across a variety of health and
social services settings.

4. Single assessment framework – many areas of
health care
At least 80% of items common across the suite:
 Contact Assessment (screener assessment)
 Home Care
 Long Term Care Facility
 Assisted Living
 Acute Care
 Post Acute Care
 Mental Health Care
 Community Mental Health
 Palliative Care
 Quality of life

5. If you are going to assess somebody make sure
you cover at least these domains...

6. ...and enquire further for each domain
around specific items....and code consistently

7. interRAI outputs – CAPs, outcomes, quality
indicators

8. 2002 Health of Older People Strategy
Gap between
current and best
practice
Need Evidence
based approach
Assessment Process
for Older People
(2003) NZGG

9. National interRAI platform business model „today‟
DHBs contracted Ministry of Health Residential care
to implement
interRAI
‘SaaS ‘SaaS
Contract’ Contract’
Service
Management Single national
contract SLA (DHBs)

10. The national interRAI platform technical model „today‟
Assessor
Connected health networks
National Health
Index Internet External cliniical
PAS systems
Single host
National
Northern/Southern regions PROD Central/Midland regions PROD
TRAINING data warehouse TEST/Wiki/data warehouse

11. At risk population (s) post earthquake
 Frail elderly...
 Frailtyencompasses many dimensions including but
not limited to; functional capability, physiological
reserve, cognitive performance, disease
progression and disease instability.
 .....who are also vulnerable
 Vulnerability encompasses dimensions such as
whether someone lives alone, the strength of their
support networks both formal and informal,
loneliness and the persons cognitive performance
(especially in relation to decision making).

12. interRAI fellows - on the ground in NZ (and in Canada)
 Brigette Meehan, PhD – in charge of national
interRAI Implementation
 Nigel Millar, MD – Chief Medical Officer, Canterbury
District Health Board
 Vincent Mor, PhD – Visiting Professor from Brown
University, on sabbatical in NZ
 Professor John Hirdes - Chair, Department of
Health Studies and Gerontology, University of
Waterloo

13. An email timeline
Feb 21/11 9:15 pm (Hirdes)
“Just saw the footage of the Feb 22/11 1:33 am (Millar)
terrible earthquake in “Jan and I plus family ok - but its
Christchurch. I hope you guys are not good here.”
ok.”
Feb 22/11 2:09 am (Mor)
Feb 21/11 10:10 pm (Meehan) “Take care of yourself and good
“I haven't heard from Nigel, but luck as you struggle to help your city
expect he will be very busy given and its people recover.”
his role. My family are all ok but
quite distressed.” Feb 22/11 4:30 am (Millar)
“Sorry to miss you …
Feb 22/11 1:20 am (Mor) Planning an interRAI earthquake
“we are fine; not in assessment.”
Christchurch yet so I'm not going.
I've not heard from Nigel but will
soon.” @interRAI_Hirdes
Twitter:

14. email timeline (cont‟d)
Feb 22/11 7:05 am (Hirdes) Feb 22/11 6:18 pm
“if the RAI-HC is fully rolled Hirdes sends draft algorithm
out in Christchurch and you are code to NZ group
able to obtain person-level
outputs, you should be able to
get a list of vulnerable seniors
who may be in need of extra
help at this point”.
Feb 22/11 5:20 pm (Meehan)
“great idea … [it] will be
helpful I'm sure. I have spoken
to Andrew [our] software
manager and he is going to pull
data this morning to send to
Canterbury.”
Twitter: @interRAI_Hirdes

15. Initial NZ Earthquake Algorithm (Principles)
(Source: Back of Napkin)
 Identify those with immediate (emergent) risk
with limited caregiver support
a) Isolated or distressed caregiver
b) Vulnerable (and frail)
Twitter: @interRAI_Hirdes

16. The risk profile (Source: Back of Napkin)
 Lives alone, no primary helper, any signs of caregiver
distress, poor vision, difficulty with meal
preparation, difficulty with managing medications
 Had Cognitive Performance Score (CPS) of >2.
 the CPS score is an interRAI outcome measure scored from 1-6 where 1= no
cognitive impairment and 3-6 = moderate to severe cognitive impairment.
Elements that make up the CPS score include decision making ability, memory
loss, ability to make self understood and ability to manage eating. A score of >2
indicates early onset of cognitive issues eg memory loss.
 Had CHESS score > 2
 the CHESS score is an interRAI ‘frailty/stability’ measure scored 1-5 where 1=
person is stable and 5= highly unstable. Elements that make up the CHESS score
include presence of vomiting, oedema, shortness of breath, weight loss, decrease
in food or fluid, insufficient fluid intake, decline in ADLs, decline in decision
making and any end stage disease.
 Had ADL score >2
 The ADL score is scored from 1 – 6 where 1= no problems with ADL and 6 = fully
dependent in washing and dressing, toileting , eating and locomotion.

17. Clinical prioritisation (Source: Back of Napkin)
 Many items common across most clients, the data was
grouped based on the outcome scores to support quicker
prioritisation
 Group 1 (most likely highest priority)
 all those WHERE CPS > 2 AND CHESS >2 AND ADL >2 –
approximately 100 people
 Group 2 (most likely next priority)
 all those WHERE score >2 in ANY two of: CPS OR ADL
OR CHESS - approximately 250 people
 Group 3 (most likely next priority)
 All those WHERE score >2 in ANY one of: CPS OR ADL
OR CHESS – approximately 400 people

18. email timeline (cont‟d)
Feb 22/11 8:56 pm (Mor)
“Add diabetes and ver[y] advanced age. Great idea. I suggested this
for Katrina but no one listened”
Feb 23/11 3:26 am (Downes)
“Nigel & the Canterbury response teams have now had a copy of
the list of vulnerable seniors.What a great international effort and one
based on real life up to date accurate person level data”
Within 24 hours a great set of data for use
Twitter: @interRAI_Hirdes

19. Supporting evacuations out of Canterbury
interRAI Assessments also Used to Manage Transfer of
300 Seniors out of Earthquake Zone
Twitter: @interRAI_Hirdes

20. Acknowledgements
 Dr Nigel Millar - Chief Medical Officer of Canterbury DHB and interRAI
fellow for New Zealand.
 Professor Vince Mor - Chair of the Department of Community Health at the
Brown University School of Medicine, Providence, Rhode Island and interRAI
fellow.
 Professor John Hirdes - Professor and Ontario Home Care Research and
Knowledge Exchange Chair, Department of Health Studies and Gerontology,
University of Waterloo & Scientific Director, Homewood Research Institute
and interRAI fellow. (For use of some slides also)
 Stella Ward - Executive Director Allied Health Canterbury DHB & West Coast
DHB
 Rebecca Rippon – information analyst at Capital and Coast District Health
Board. Rebecca completed the data extraction and analysis for Canterbury
DHB
 Doug Braun – Database administrator at Momentum Healthware Inc for
additional technical support and assistance with data extraction.
 The interRAI lead practitioners and system clinicians that supported the
transfer process.