Learning from Leas Cross – time for a unified approach

One of the saddest aspects of the Leas Cross scandal of a decade ago was the exposure of a lack of focus and drive among government agencies towards meeting the complex needs of older people, the key adult demographic for health and social care services.

While gaps still remain (such as the impoverished 2009 position paper of the Nursing and Midwifery Board on nursing for older people and the utilitarian design of some new nursing homes), it is encouraging to report on new horizons, as evidenced by two major conferences in Dublin this week.

The first is a joint conference of the National Clinical Programme for Older People, a joint initiative of the HSE and the Royal College of Physicians in Ireland, and the Integrated Care Programme of the HSE. This brings together the many elements of the care systems dealing with older people, and has developed helpful care blueprints for pathways for more appropriate care of older people in hospitals and the community to be implemented in a number of pilot sites across the country.

An element uniting this conference with one later in the week, is a focus on a new single assessment tool. Arising from the Leas Cross review, it had become clear that the Irish service needed a unified system for assessing disability and vulnerability among older people accessing services, whether in the community, hospital or nursing home.

Common language

The HSE and

Department of Health

instituted a working group to choose an assessment tool that provided a common language for assessing loss of function and disability, ideally one used in other countries so that we can benchmark quality of care, service developments, the degree to which services are “older-friendly”, and generate high-quality, comparable data for research.

The international collaborative, interRAI, was the final choice. It has the longest pedigree and its assessment instruments comprise an integrated health information system with a consistent terminology, common core items, and a common conceptual basis in a clinical approach that emphasises the identification of functional problems such as mobility, continence and memory.

There is vast experience with this instrument, in part arising out of the mandatory requirement in the US that all nursing home residents have the instrument administered on admission and quarterly thereafter.

There are also versions of the assessment for older people in the community and in hospitals, as well as a mobile phone app for screening in the emergency department.

As well as significant engagement by health systems in Europe and North America, with a large number of research papers, the interRAI is kept up to date through an international not-for-profit consortium of researchers and clinicians, and has expanded to cover not only care of older people but also other areas of care, such as mental health.

This consortium is meeting in Ireland this week, and some of the originators will be speaking at a conference in Dublin on Friday organised by the Irish Gerontological Society.

It will include an overview from Belgium, which has implemented interRAI assessment of older people across all sectors of care, an experience which should help inform Ireland in the wider roll-out of more accurate assessments of older people.

Funding

The early development in Ireland was part-funded by Atlantic Philanthropies, and is currently an implementation for the assessment of needs for home care packages and nursing home care. It will be rolled out more widely in coming years, a point of note for Irish nursing homes as they invest in information technology systems.

From the perspective of Hiqa, the interRAI is ideally placed to gauge care and support standards.

Ireland has also contributed to the international project with a carer needs module for the interRAI.

It can also prompt care pathways, an ideal basis for staff in nursing homes to use in conjunction with telemedicine consultations with off-site specialists: I had a very helpful experience of this when visiting Brisbane a number of years ago.

Life is a zero-sum game, and if we were not carving out time and energy to systematically assess older people in our health service up to now, then there will need to be a significant change in our practice.

Ireland should welcome this opportunity to provide better care of our older citizens and ensure allocation of appropriate resources to staff training and IT resources for interRAI to ensure its success.

More details on the research symposium on the interRAI are available online: iti.ms/25bcglq Prof Des O’Neill is a consultant geriatrician at Tallaght Hospital and an honorary staff member of Trinity College Dublin.