The guidelines for the Department of Health (DoH) Single Assessment Process (SAP) specify four levels of assessment: initial contact assessment, overview assessment, in-depth assessment, and comprehensive geriatric assessment. This summary describes how the MDS HC was developed, and outlines the relationship of the MDS HC assessments to the SAP assessments (as well as to the Registered Nursing Contribution to Care (RNCC)).

Development of the MDS HC

The MDS HC was developed on a rigorous systematic basis by interRAI, an international research and development collaboration (www.interrai.org). It was designed to be used by health or social care professionals who had been trained in its use.
In the first stage of development, the domains important for managing people at home were identified, then panels of professionals with expertise in these areas designed the client assessment protocols (CAPs) that give guidance on best practice for care planning for each domain. The following CAPs were designed for the MDS HC:

In the second stage, using evidence from research literature, each CAP was constructed according to a standard framework.  The framework consisted of objectives, triggers (assessment items that identify the presence or risk of a problem or potential for improvement), background information, and care-planning guidelines.  The guidelines are in the form of a check list that, together with professional input, ensure relevant information is considered in ensuring best practice for care planning (see Figure 1 .below). 

In the final stage, the trigger items and other items considered essential to ensure adequate assessment of a domain were compiled into the assessment instrument. Detailed information for completing the assessment and all the CAP information is included in a manual that accompanies the assessment instrument. The manual can also be used for training or reference.

How the MDS HC supports the SAP

When performing the assessments as defined in the DoH SAP consultation papers, different sections of the MDS HC can be completed. The logical links between these sections are illustrated in Figure 2 and are described below. Links between assessment and further action, including information to support best practice in care planning, are provided by the CAPs of the MDS HC.

Note: MDS HC coverage of the domains required by the National Service Framework (NSF) for Older People and the DoH SAP consultation papers is shown in Table 1 on page 8.

The MDS assessment instruments include:

• Valid, reliable, comparable items that accurately record a person's abilities.
  
  

• Free text areas for assessors to fully record important person-centred aspects of assessment such as "What do you want to achieve but cannot at present?" and "What do you feel would be most helpful to you in order to make this possible?"
  
  

• Reliable scales that can be used to inform clinical practice as well as outcome monitoring and planning for management and policy purposes (see the attached paper Outcome Measurement with MDS).

Figure 2: MDS Assessment Logic compared with SAP
Note: At any time the assessor may go directly to a Comprehensive Old Age Assessment if professional judgment so indicates.

Contact assessment

DoH statement of purpose

Contact assessment refers to a first contact between an older person and health and social services, during which basic personal information is collected, the nature of the presenting problem is established, and the potential presence of wider health and social care problems is explored.

The evidence base

There is currently no evidence base for determining which questions at an initial contact assessment best determine the presence of wider health and social care problems beyond a presenting complaint. The questions for which there is evidence come from the screening research literature.

The seven-item self-reliance algorithm in the MDS HC provides a reasonable set of items to be added to the discussion of the presenting problem at contact. Of the people who are identified as self reliant, only a very small proportion (< 5%) will be in need of basic support services such as Home Help as predicted by the MDS Level of Care algorithm (see Outcome Measurement with MDS).

MDS HC at contact assessment

During a contact assessment, the assessor completes the seven self-reliance items of the MDS HC.

• If the person is self-reliant, the presenting problem is addressed and no further assessments are performed.
  
  

• If the person is not self-reliant, the assessor continues with the MDS HC screener (see below).

The self-reliance algorithm could be completed as a coarse screening assessment by, for example, a trained receptionist in a GP practice or by telephone.

Overview assessment

DoH statement of purpose

Professionals carry out an overview assessment if, in their judgement, the individual's problems are such that a more rounded assessment should be undertaken. At overview assessment, all or some of the domains of the single assessment process, such as "personal care and physical well-being", "senses", and "mental health" are explored. The need for an overview assessment may be immediately apparent, and should be commenced once basic personal information has been collected. At other times, a contact assessment may have been carried out. In some situations, an in-depth assessment of a specific problem may have been undertaken first, with the overview assessment providing subsequent contextual assessment information.

MDS HC at overview assessment

The 68 item MDS HC screener covers 18 of the required domains listed in the NSF for Older People. The 62 item screener supplement contains a further 14 domains, five of which are preventive health items, three of which are personal safety, and one of which is accommodation. The remaining items are vision and hearing, dressing, oral care, and foot care (see Table 1 on page 8). interRAI UK recommends that the screener plus the supplement are completed for overview assessment, since the DoH guidance requires that all domains in the NSF are covered in the overview assessment (Guidance for local implementation, page 6 section 8).
There is perhaps a case, however, for excluding the preventive health items if they have been assessed in the past 6-12 months. The personal safety items may be considered unnecessary in a large number of people who are well known to the service that is undertaking the overview assessment. Accommodation would likely be covered in the contact assessment as part of the individual demographic information.

Where the overview assessment questions trigger an MDS HC CAP, in-depth assessment of that domain is indicated. Where several CAPs have been triggered, in-depth assessment is indicated. This may be at the discretion of the assessor, or may be subject to local policy agreement until more research evidence is available.

In-depth assessment

DoH statement of purpose

In-depth assessment offers a way of exploring specific problems in detail and may be indicated by a contact or overview assessment. As a result of an in-depth assessment, professionals should be able to confirm the presence, extent, cause, and likely development of a health condition or problem, and establish links to other conditions and problems.

MDS HC at in-depth assessment

The in-depth assessment should include, as a minimum, the MDS HC screener and screener supplement items. Where a CAP is triggered in an assessment domain during an overview assessment, the remaining MDS HC items in that domain should be completed and the triggered CAPs examined for further guidance on assessment and care planning.

When CAPs are triggered in several domains, then the professional will determine whether a full MDS-HC assessment should be completed. People who fall into the MI-CHOICE level of care "Nursing care at home" (see the attached paper Outcome Measurement with MDS) will likely require a complex care package. These people and those in the level of care "Nursing home" or who are considered likely to need admission to institutional care should have a comprehensive old age assessment.

Comprehensive old age assessment

DoH statement of purpose

Comprehensive old age assessments should be completed for people where the level of support and treatment likely to be offered is intensive or complex, including permanent admission to a care home, intermediate care services, or intensive packages of care at home. No decisions on where people are best supported should be made before all information from a comprehensive old age assessment information has been evaluated, including information from medical assessments and a thorough exploration of rehabilitation potential.

MDS HC in Comprehensive Old Age Assessment

The full MDS HC with all triggered CAPs explored provides a sound base for a comprehensive old age assessment. Once all indicated assessments by health and social care professionals have been completed, the assessments equate with a comprehensive old age assessment.

Eligibility criteria for long-term care should reflect assessment information. These criteria can be checked against MDS HC assessment items. This process provides objective assessment information to support decisions based on eligibility criteria. Professional opinion, based on the objective assessment data and taking into consideration the client's and carer's views, will lead to a decision whether or not to go into a nursing or residential home.

The Registered Nursing Contribution to Care can be determined using the RUG algorithm, which can be completed as a stand alone assessment or derived directly from a full MDS HC assessment (see the attached paper Outcome Measurement with MDS).

Admission to residential long term care

On admission to a nursing or residential home, the MDS RAI provides a reliable, valid comparable assessment with the same structure as the MDS HC and with identical items where these are common to both instruments. The paper Assessment in Long Term Care: The National Care Standards Commission and the MDS RAI provides information on the MDS RAI measured by the standards laid down in the Department of Health guidance: Care Homes for Older People: National Minimum Standards.

SAP domains

Table 1 below shows how the SAP domains and sub-domains are covered by MDS HC assessments.

* Access to formal services recorded; access to public services (e.g., shops, GP surgery) adapted to local requirements.

S = MDS HC Self-reliance algorithm
I = interRAI predictor of decline

SAP information requirements

All the information requirements of the SAP guidance can be aggregated from MDS HC assessments. High quality computer software to support the MDS assessment instruments is available from www.aissystems.com.

The MDS HC has a number of reliable, validated outcome scales for use with individuals or wider group monitoring individuals (see the attached paper Outcome Measurement with MDS).

Copyright

The intellectual property rights and copyright of the MDS instruments are owned by interRAI international and sub-licensed to interRAI UK in the United Kingdom.

Use for care purposes: A license to use the MDS RAI and the MDS HC for care purposes in the UK is obtained by purchasing the relevant instrument manual (cost £50).

Use for research purposes: The use of interRAI MDS instruments for research purposes is encouraged. In order to maintain the integrity of the instruments, research users must register their research use of the copyrighted interRAI MDS assessment instruments with interRAI UK.

Contact

For further information contact:
Dr Iain Carpenter
Associate Director and Reader in Health Care of Older People
Centre for Health Service Studies
George Allen Wing
University of Kent
Canterbury CT2 7NF
E-mail: G.I.Carpenter@ukc.ac.uk