List of Figures References (by Chapter) Chapter 1 Australian Institute of Health and Welfare. (1997). Australia’s welfare 1997: services and assistance. Retrieved from Commonwealth of Australia 2009. Report on the Operation of the Aged Care Act 1997 1 July 2008 - 30 June 2009.
NA Section O. Treatments and Procedures PREVENTION THERAPY / NURSING SERVICES IN LAST 7 DAYS HOSPITAL AND EMERGENCY ROOM USE PHYSICIAN VISITS PHYSICIAN ORDERS RESTRICTIVE DEVICES No NSAF items were noted. NA Section F. Psychosocial Well-Being Social Relationships Sense of Involvement Unsettled Relationships Major life stressors in last 90 days Strengths CA: Social Client as carer AX Tool: Caregiver Strain Index NA Section D. Communication and Vision Making self-understood (expression) Ability to understand others (comprehension) Hearing Vision CA: Communication needs Preferred language, communication issues, translating service CA: Physical Domain – Health and Lifestyle Sensory section (vision. sight, speech) Table A2.2: Detailed comparison of ACFI, InterRaI and NSAF Domain ACFI InterRAI NSAF Tools overview Non-mandated contemporaneous assessments (ACFI 1-4, ACFI 12) ACFI 12.3, 12.4a/b, 12.10: Evidence-based pain assessment ACFI 12.5: Skin Integrity Assessment ACFI 12.6: Swallowing Section G. Functional Status [timed 4-metre walk] RAS tools Caregiver Strain Index Mini Nutritional Assessment OARS-ADL Barthel index of ADL KICA-ADL Kessler-10
Assessment ACFCI 12.10 Wound Assessment Mandated records (ACFI 5, ACFI 7-9) Mandated assessments ACFI 6: PAS-CIS ACFI 10: Cornell Depression Scale ACATs tools Caregiver Strain Index Kessler-10 Brief Pain Inventory (short) R-VBPI ABBEY AUDIT SA Oral Health Referral Pad OHAT for non-dental professionals Revised Urinary Incontinence Scale Revised Faecal Incontinence Scale Mini Nutritional Assessment OARS-ADL Barthel index of ADL KICA-ADL SMMSE RUDAS IQCODE KICA-COG Geriatric Depression Scale Diagnoses List of Medical diagnoses List of Mental & Behavioural diagnoses Section I. Disease Diagnoses Section J. Health Conditions falls, recent falls, problem frequency (balance, cardiac, psychiatric, neurological, GI status, sleep, other), Dyspnoea (SOB), Fatigue, Pain symptoms, instability of conditions CA: Medical Domain Health Conditions (condition, Dx status, primary) Relevant medical history. Health Checks in past 3 months Hospitalisation in past 3 months Nutrition ACFI 1: Nutrition Currently ACFI 1 does not cover oral hygiene. EBCAT: NSAF preferred over MNA. NSAF misses (1.1=1; 1.1=2; 1.2=1). RNDC misses (1.1=1) 1.1 =1 (no match) P 76: Q1. Ask the person or family about weight changes over the last 30 to 180 days. subjective estimate of weight change from the person or caretaker can be used if no written records are available. Q2. Identifying dehydration can be difficult. Record your clinical judgement based upon signs and symptoms (for example, severe vomiting over a period of time). Alternatively, laboratory results indicating dehydration may be available (i.e., BUN/creatinine ratio of > 25 [note that the standard for this ratio value can be country CA: Medical Domain (not in ACFI) Oral Health, Appetite, weight loss and fluid intake. CA: Physical Domain Function- eating CA: Medical Domain - Appetite, weight loss and fluid intake, How is your appetite?
5 Maximal assistance—Weight-bearing support (including lifting limbs) by 2+ helpers—OR—Weight-bearing support for more than 50 per cent of subtasks 6 Total dependence—Full performance by others during all Episodes 8 Activity did not occur during entire period Will assistance be required- episodic, not episodic, no, yes/unable to determine For items: Dressing Eating Transfers Toilet use Independent, Needs some help, dependent If difficulty, who assists? Will assistance be required? ADL (cont.) ACFI 1-4 Based on evidence from a contemporaneous assessment completed in last 6 months (of the required needs) Must reflect current needs Restricted to specified activities Reflects usual care needs Page 50 The scales in Items G1 are used to record the person’s actual level of involvement in self-care and the type and amount of support received during the last 3 days. DO Engage direct care staff from all shifts who have cared for the resident over the last 3 days in discussions regarding the resident’s ADL functional performance. Remind staff that the focus is on the last 3 days only. To clarify your own understanding and observations about each ADL activity (bed mobility, locomotion, transfer, etc.) ask probing questions, beginning with the general and proceeding to the more specific. DO NOT record your assessment of the resident’s capacity for involvement in self-care — that is, what you believe the resident might be able to do for himself or herself based on demonstrated skills or physical attributes. CA: Physical Domain – Function Eating Transfers Walking Bath or shower Dressing Toilet use Independent, Needs some help, dependent Without help, with some help, completely unable. Functional No items titled function. ACFI 2 Transfers and Locomotion is similar to InterRAI item G2. Requires contemporaneous assessment in last 6 months (note Section G: Functional Status In last 3 days P52: Ask the person and direct care staff about the person’s movement in the unit and outdoors during the last 3 days. Record the farthest distance travelled without a prolonged stop. 2. Locomotion/Walking CA: Physical Domain – Function Can the client walk? Transfers
One-to-one physical assistance is required for: staff to push wheelchair; OR assistance with walking Distance wheeled self Farthest distance wheeled self at one time in the LAST 3 DAYS (includes independent use of motorized wheelchair) 0 Wheeled by others 1 Used motorized wheelchair / scooter 2 Wheeled self less than 5 metres 3 Wheeled self 5–49 metres 4 Wheeled self 50–99 metres 5 Wheeled self 100+ metres Continence ACFI 5 assessments Mandated Records Frequency determines Rating No episodes of urinary incontinence or self manages Incontinent urine < or = 1/day 2-3 episodes daily of urinary incontinence or passed urine during scheduled toileting > 3 episodes daily of urinary incontinence or passed urine during scheduled toileting No episodes of faecal incontinence or self manages Incontinent faeces 1 or = 2/week 3-4 episodes weekly of faecal incontinence or passed faeces during scheduled toileting > 4 episodes per week of faecal incontinence or passed faeces during scheduled toileting Section H: Continence P57- To determine and record the person’s pattern of bladder continence (control) over the last 3 days. Review clinical records and flow/bowel charts, ask the person, validate with care staff, observation where inconsistent information. 1. BLADDER CONTINENCE 0 Continent—Complete control; DOES NOT USE any type of catheter or other urinary collection device 1 Control with any catheter or ostomy over last 3 days 2 Infrequently incontinent—Not incontinent over last 3 days, but does have incontinent episodes 3 Occasionally incontinent—Less than daily 4 Frequently incontinent—Daily, but some control present 5 Incontinent—No control present 8 Did not occur—No urine output from bladder in last 3 days 2. URINARY COLLECTION DEVICE (Exclude pads / briefs) 0 None 1 Condom catheter 2 Indwelling catheter 3 Cystostomy, nephrostomy, ureterostomy 3. BOWEL CONTINENCE 0 Continent—Complete control; DOES NOT USE any type of ostomy device 1 Control with ostomy—Control with ostomy device over last 3 CA: Domain Continence Assessments Revised Urinary Incontinence Scale- not suitable Revised Faecal Incontinence Scale- not suitable
Treatments (cont.) ACFI 12 12.1 Blood Pressure 12.2 BGL 12.5 Skin Integrity 12.6 Management of special feeding undertaken by an RN 12.7 Suppositories & enemas 12.8 Catheter care 12.9 Chronic infectious conditions 12.10 Chronic wounds 12.11 Ongoing IV, syringe drivers, dialysis, hypodermoclysis 12.12a Mgmt of Arthritic joints and oedema related to arthritis with tubular elasticised support bandages. 12.12b Mgmt. of non-arthritic oedema OR DVT with compression garments / bandages. 12.13 Oxygen therapy not 12.14 Palliative care (end of life) 12.15 Ongoing stoma care 12.16 Suctioning airways, tracheostomy care 12.17 Management of ongoing tube feeding 12.18 Technical equipment for continuous monitoring of vital signs including Continuous Positive Airway Pressure Section O: Treatments & Procedures 2. TREATMENTS AND PROGRAMS RECEIVED OR SCHEDULED IN THE LAST 3 DAYS (OR SINCE LAST ASSESSMENT IF LESS THAN 3 DAYS) 0 Not ordered AND did not occur 1 Ordered, not implemented 2 1–2 of last 3 days 3 Daily in last 3 days Treatments Chemotherapy Dialysis Infection control—e.g., isolation, quarantine IV medication Oxygen therapy Radiation Suctioning Tracheostomy care Transfusion Ventilator or respirator Wound care Programs Scheduled toileting program Palliative care program Turning / repositioning program No NSAF items were noted. managed
Rationale for new R-ACFI Mobility Questions The following gives the rationale for modifying the current ACFI Mobility question. Relevant Assessment Tools Review The NSAF collects information about walking and transfers: For walking the person is: rated on a 3-point scale (Without help -except for walking stick or similar; With some help from a person or with the use of a walker or crutches etc.; Completely unable to walk). If there is difficulty, it then asks: who assists, and is the assistance episodic. For transfers the person is: rated on a 4-point scale of (Independent; Minor Help -verbal or physical; Major help or two people, physical, can sit; Unable- no sitting balance); If there is difficulty, it then asks: who assists, and will assistance be needed. Further comments on the physical domain are collected (not mandatory, with prompts) - why does the person need assistance, what is the underlying problem, what activities can they do themselves and what do they have difficulty with, is the person likely to benefit from reablement, in what area, referral to allied health/aids and equipment? The supplementary functional tools are OARS-ADL, Barthel Index of ADL, and KICA-ADL. These supplementary tools primarily record assessment outcomes – they do not explain the reason why the care is needed. The NSAF items do not give a rationale for the ADL assessment outcome, which is both clinically important and would also strengthen the objectivity of the assessment. The interRAI mobility items cover two mobility items in the ADL self-performance section: Walking (how the person walks between locations on same floor indoors) Locomotion (how the person moves between locations on same floor). These two items rate the person on a detailed seven-point scale: Independent Set up help only Supervision-oversight Limited assistance - guiding with no weight bearing Extensive assistance - weight bearing assistance for less than 50 per cent of subtasks Maximal assistance - weight bearing assistance for more than 50 per cent of subtasks or more than two helpers Total dependence - full performance by others.
Standard Care: Independent or staff standing by for occasional assistance or provision of setting up activities. Independent (with or without aids). Standing by for occasional or episodic assistance. Transfer Setting up activities Verbal assistance, prompting, cuing. Moderate Assistance: Always providing physical assistance, on a one-to-one basis, for at least part of the activity, whenever the activity is needed. Full Assistance: Always providing physical assistance, by at least two staff, throughout the entire activity, whenever the activity is needed. Assessors This tool is suitable for external assessment (pre-entry or review) and internal assessment (new resident or re-appraisal). External Assessors could review the claim or complete the ACFI Checklist using evidence from: Diagnoses that support a physical impairment, sensory loss, dementia/ cognitive loss, behavioural issues Documentation by Physical Therapists, Medical Practitioners Informants e.g. Physical Therapist who has recently assessed the person, Medical Practitioner, resident, carer Rationale for new R-ACFI Continence Question The following gives the rationale for modifying the current ACFI Continence question: Relevant Assessment Tools Review The NSAF collects information to identify continence issues: Do you have bladder or bowel issues that affect your lifestyle? Bladder issues; Bowel issues; Have you discussed these problems with anyone (e.g. GP, continence advisor)? Would you like to discuss continence issues with a continence advisory service? The supplementary functional tools are Revised Urinary Incontinence Scale and Revised Faecal Incontinence Scale. These tools rate responses on 5 questions, and then give a mean score for identifying incontinent male/female patients. The relevant interRAI items are (i) Bladder Continence and (ii) Bowel Incontinence. Both items use a rating scale to score frequency over the last 3 days (Continent; Control catheter or ostomy; Infrequent incontinent - none in last 3 days but does have episodes; Occasionally incontinent – less than daily; Frequently incontinent - daily but some control present; Incontinent - no control present).
An External Assessor will rely on informants for collecting disruptiveness over a recent time period (last 7 days). Recalling the most frequently disruptive behaviour in the past week that required an intervention should be easier and less subjective than recalling and estimating numerous frequency events. They should ask if the behaviour occurred less than daily, daily, 2/day or more often (refer to Table A5.2). Disruptiveness is not a new concept, as all current behaviour recordings must receive staff interventions to meet the eligibility criteria. The level of disruptiveness is to be validated by informants and file notes. The Disruptiveness Rating produces an objective outcome of the type of staff intervention. If the disruptiveness was rated mild it is considered to be part of standard care. The behaviours (Wandering, Verbal or Physical) must occur at least daily to be allocated above Rating A (i.e. B, C or D rating). Table A5.2: Frequency and Disruptiveness Matrix for determining the A, B, C, D Ratings for R-ACFI 7 Disruptiveness Ratings Frequency Less than daily Frequency Daily Frequency Twice per day, everyday Frequency More than twice per day, everyday None or mild A A A A Moderately A A B C Severely A B C D Extremely A C D D Determining the A, B, C, D Rating for each of the three Behaviour Groups (Wandering, Verbal and Physical) Steps for the RACF to determine the Behaviour ratings (e.g. A, B, C, D) for Wandering, Verbal Behaviour and Physical Behaviour: Complete the Behaviour Records over 7 days; Record every eligible event, total the daily frequency score. Record a daily disruptiveness level. Complete the Behaviour Assessment Summary; Complete individualised behaviour descriptions for all claimed behaviour groups. Record the frequency scores based on the Behaviour Records. Less than daily is scored 1; daily is scored 2; 2/day everyday is scored 3 and more than 2/day everyday is scored 4; Record the disruptiveness scores based on the most frequently scored (over the 7 days) in the Behaviour Records. None or mildly is scored 1, moderately is scored 2, severely is scored 3, and extremely is scored 4. Complete the Behaviour Checklist; Use the Frequency-Disruptiveness matrix to determine the A, B, C, D rating for each Behaviour Group (Wandering, Verbal Behaviour and Physical Behaviour).
Chapter 8 R-ACFI IRT Analysis A discussion of the benefits of IRT method are described in Chapter 2 Methods. IRT Analysis of ACFI ADL Data There were two modifications made to the ADL domain before application of the IRT analysis was applied. These were: (i) Nutrition item Based on the feedback from the consultations and data analysis the nutrition question was modified into a single checklist. As has been detailed in Chapter 4 the new R-ACFI Nutrition item now has four levels (Table A8.1). The IRT analysis used the recode Nutrition data in the analysis. Table A8.1: R-ACFI Nutrition Checklist R-ACFI Nutrition Checklist Usual daily care needs for Eating and drinking activities Assistance level (Tick one) Standard Care: Independent during the activity, staff standing by for occasional or episodic assistance, provision of modified textured food and drinks and setting up activities e.g. taking lids off, cut up food, specialised plates and cutlery, special diets, placing food in front of resident etc. 0 Monitoring: Needs general monitoring for an assessed nutritional need using the mandated assessment. Includes residents with either ACFI checklist rating of ‘Physical Assistance’ for Readiness to Eat OR ‘Supervision’ for ‘Eating’. 1 Moderate Assistance: Always providing verbal or physical assistance, on a basis, for part of the activity, whenever the activity is needed due to a swallowing issue or other impairment. Includes residents with the ACFI checklist ratings of ‘Physical Assistance’ for ‘Readiness to Eat’ AND the ‘Supervision’ for ‘Eating’. 2 Full assistance: Always providing physical assistance, on a one-to-one basis, throughout the entire activity, whenever the activity is needed. Includes residents with the ACFI checklist rating of ‘Physical Assistance’ for ‘Eating’. 3 (ii) The Personal Hygiene Checklist Item ‘Grooming’ The personal hygiene checklist item ‘grooming’ was removed from the analysis as it was not statistically discriminating and the effort is captured in other checklist items. This served to also simplify the provider claiming requirements. IRT Analysis Steps and Results While the R-ACFI ADL items are good measures of ADL performance, as with any other measures used to capture dependency or need, ability or performance can never be fully