TY - JOUR
AU - C. Schumacher
AU - M. Saari
AU - M. Northwood
AU - F. Mowbray
AU - C. Mensink
AU - M. Heyer
AU - K. Bail
AU - G. Pyatt
A1 - 
AB - Older adults living with frailty and multimorbidity interact with multiple care providers and health settings, resulting in fragmented care and information discontinuity. Standardized assessments potentiate integrated care by communicating consistent measures of health information between sectors and providers. We use a pragmatic case example of a theoretical medically complex older adult to illustrate use of interRAI standardized assessments throughout the health journey. The case example represents the assessment findings of a patient accessing care through primary care, the emergency department, home/community care and long-term care. A suite of assessment instruments embedded with decision support algorithms guides nursing care decisions, while a common language and standardized assessment items support effective communication and collaboration among the health team. Successful adoption of integrated and comprehensive assessment tools requires training, engagement, and time to embed processes into practice. interRAI assessments enable integration through a common language, aligning successive assessments across the care continuum.
AD - Brock University, St. Catharines, Ontario, Canada. RINGGOLD: 7497; SE Health, Markham, Ontario, Canada.; University of Toronto, Ontario, Canada. RINGGOLD: 70379; McMaster University, Hamilton, Ontario, Canada. RINGGOLD: 3710; Michigan State University, East Lansing, Michigan, United States of America. RINGGOLD: 3078; New Vision Family Health Team, Kitchener, Ontario, Canada.; Conestoga College, Kitchener, Ontario, Canada. RINGGOLD: 59129; University of Canberra and ACT Health Directorate, ACT, Australia. RINGGOLD: 110446
AN - 41017160
BT - Healthc Manage Forum
C5 - Healthcare Disparities; Measures
DA - Sep 28
DO - 10.1177/08404704251370371
DP - NLM
ET - 20250928
JF - Healthc Manage Forum
LA - eng
N2 - Older adults living with frailty and multimorbidity interact with multiple care providers and health settings, resulting in fragmented care and information discontinuity. Standardized assessments potentiate integrated care by communicating consistent measures of health information between sectors and providers. We use a pragmatic case example of a theoretical medically complex older adult to illustrate use of interRAI standardized assessments throughout the health journey. The case example represents the assessment findings of a patient accessing care through primary care, the emergency department, home/community care and long-term care. A suite of assessment instruments embedded with decision support algorithms guides nursing care decisions, while a common language and standardized assessment items support effective communication and collaboration among the health team. Successful adoption of integrated and comprehensive assessment tools requires training, engagement, and time to embed processes into practice. interRAI assessments enable integration through a common language, aligning successive assessments across the care continuum.
PY - 2025
SN - 0840-4704 (Print); 0840-4704
SP - 8404704251370371
ST - Care Planning Across the Health System: Intersectoral Application of the interRAI Assessment System
T1 - Care Planning Across the Health System: Intersectoral Application of the interRAI Assessment System
T2 - Healthc Manage Forum
TI - Care Planning Across the Health System: Intersectoral Application of the interRAI Assessment System
U1 - Healthcare Disparities; Measures
U3 - 10.1177/08404704251370371
VO - 0840-4704 (Print); 0840-4704
Y1 - 2025
ER -