Then I went on to do some work for the NHS National Casemix Office, looking at a way of identifying the clinical problems associated with costs of care in older people. This lead me to read about a system developed in the United States that dealt with the problems that older people face. I thought it made very good sense. We ran a validation project in the early 1990s which again was remarkably successful, as it showed that you could clearly identify people with similar conditions who had similar costs of care. In the course of that work I met a group of people in Italy who had an interest in this thing called the ‘Minimum Data Set Resident Assessment Instrument’. They were so enthusiastic about it that we decided to see if there would be any value in having an international collaborative project based upon it.

What’s the philosophy behind MDS?

It’s unique. Professionals base an older person’s care plans on their assessment of the care need. The principle behind MDS is that you do it in a structured way. Expanding on that, the information in an MDS assessment is put into a structured format. This enables all the benefits of aggregated information - on outcome, quality of care, cost of care and so on – to be based solely on a comprehensive assessment carried out for the purposes of caring for the person who is in front of you.

So how was the MDS originally developed?

The Minimum Data Set Resident Assessment Instrument – that’s the MDS for Nursing Home Care - was originally developed in the United States to improve the quality of care in their nursing homes. * As evidence showed that good assessment could drive up the quality of care, a research group within the United States set about developing a rigorous system that would not only thoroughly assess need, but would also assist care planning and improve all round skills. That took place at the end of the 1980s and it was introduced in 1992.

The international initiative you mentioned earlier: was that interRAI?

That’s right. interRAI was formed in 1992, and we immediately recognised that community care was crucially important in care of older people. We therefore set about developing the MDS for Home Care. By now interRAI spanned 20 countries and represented extremely able scientists and professionals in leading organisations.

We set about the process of identifying those areas that were important for maintaining older people as independently as possible in their own homes. This came to a list of about 36, which we reduced to 30, and shared out into groups with expertise in specific domains.

We researched the literature and constructed separate protocols for each domain. These protocols all have a similar structure: they define the problem, they give information about the nature of the problem - why it is important and how common it is, and then offer more detailed guidance on how to deal with it, either by more detailed assessment or referral to a specific expert or specialist advice. We then sent the protocols out for consultation and review by panels with expertise in those areas and revised them.

From that process we succeeded in specifying the minimum set of questions that could identify whether or not a person had a particular problem, or was at risk of developing a problem. * Those questions became the items in the assessment instrument, hence the name ‘Minimum Data Set’.

The assessment instrument was compiled in this way, and then rigorously tested for reliability and validity. To test for reliability, we had different people assessing the same person to ensure they come up with the same answer.

To test for validity, we made sure that what people thought they were assessing was what they actually were assessing. So now we are confident that there is a highly systematic scientific basis for these assessment instruments.

What can you tell us about the use of MDS internationally?

InterRAI now encompasses 29 countries around the world and the MDS instruments are used widely. Not only are there instruments for Nursing Home and Community Care, they also exist for Mental Health, Community Mental Health, Palliative Care, Post Acute Care and what the North Americans call Assisted Living.

The Nursing Home assessment is used in every nursing home in the United States, the majority of the chronic care hospitals and nursing homes in many of the territories and provinces in Canada, and every nursing home in Iceland. Its use is rapidly expanding in Germany, Finland, Italy, Switzerland and it is being actively evaluated in several other countries.

The Minimum Data Set for Homecare is used in most of the territories and provinces in Canada. It has been adopted voluntarily (as opposed to mandated) in 16 States in the USA, and it is the commonest of 4 recommended instruments in use in Japan. It is also in use in Hong Kong, South Korea, Italy, Switzerland and many Scandinavian and European countries. It is currently being investigated in Australia and New Zealand for widespread implementation. The Nursing Home instrument first came into place in 1992 and in the past 2-3 years has really taken off.

Why is it that the quality of data gathered using MDS is so good?

Principally because it’s completely relevant to the task in hand. The information you collect in the MDS is the only information that you need for the care of that person. You don’t ask questions just to complete scales or for administrative purposes.

Also, it is very precise. When people first see the instrument they are often frightened by the structure, but very soon they come to recognise how beneficial it is. It works very well as a basis for discussion between professionals.

Our research in the United Kingdom shows if Care Managers use the MDS for Homecare, 95% of all the items in all the people assessed are completed compared with 40-60% in the current use of assessment instruments. Another reason is that it is enormously effective for determining the resident nurse contribution to care for people admitted to nursing homes, and identifying people who are eligible for NHS continuing care. We’ve identified these areas as a common source of conflict between health and social services and a common source of concern for older people themselves.

MDS is a very objective measure, so it is a very reliable and fair indicator of these eligibility levels. On the basis of this information, the professionals and people for whom they are caring find they can resolve disagreement and come to a conclusion on appropriate funding levels with which they are both very happy.

Given the overall context of the single assessment process, where do you see these assessment forms being used?

The nice thing about the MDS assessment instruments is that they really do cover all the important domains. Because we have a lot of research evidence, we have also been able to produce evidence-based components of the MDS for use at different levels of assessment.

This means that the contact assessment contains the basic information that one would ask about the person in any case, but only a very small number of questions that indicate what we call self-reliance. People who are self-reliant really do not need any further assessment, while people who are not self-reliant can be referred on for an overview assessment.

The overview assessment is a very effective way of gathering the appropriate information that one would gather in an overview screening process. It also works very well as an admission assessment, for example: into intermediate care services. In intermediate care, we found that the use of the MDS has helped identify the sorts of people for whom the different forms of intermediate care service are most appropriate.

We have been able to use them for evaluating intermediate care and even for determining what affects hospital bed requirements. In this way the MDS is useful for the person doing the assessment because it gathers the information they need, in their discussion with their patient or client, in order to develop a best care plan for them. The information from the assessment can then be aggregated and used to look at outcomes, quality of care indicators, costs of care and, of course, eligibility for different levels of care.

The MDS also has a use in working out the underlying causes for delayed discharges. If people whose discharges are delayed are assessed using an MDS assessment, it is possible to identify what sorts or services are the ones that are consistently causing the delay.

To sum up, the MDS provides an extremely sound evidence base for identifying who needs specialist or comprehensive assessment, for the provision and valuation of services, and for determining the cost effectiveness of services. All this can be generated from the routine practice of health and social care practitioners focussing solely on planning the care of their client. .