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Technology and health care for the elderly medical research studies

Focus on strategic priorities that have significant social impact.

FRA 2015-B-07

Modeling changes in assessments to predict needs and guide care planning in home care

This study developed a predictive frailty measure for seniors receiving home care by applying advanced analytic methods to data from the Resident Assessment Instrument - Homecare (RAI-HC). Because the new frailty measure was based on the RAI-HC, it can be used in multiple Canadian jurisdictions as well as other countries.

Possible Research Results

Findings: A wide variety of measurements are available in the RAI-HC for predicting risk for residential care or mortality (e.g., health conditions, physical/cognitive impairment, health instability). Although recent measures are valuable, our approach identifies changes occurring in the older adult over time that allows prediction of future care needs.

Impact of findingsArmed with better information, clinicians will be able to identify seniors at highest risk for transitions and direct care resources where they can most effectively make a difference. In additions, some aspects of how we make predictions are more important than others and identifying these factors will be helpful at informing clinical practice and forming policy. Ultimately, this work improves the ability to predict a senior’s home care needs and also identifies what aspects of their health is most important in that regard. With greater attention to the care needs that most predict moving from home to residential care, the senior will have an opportunity to stay at home longer with appropriate support and at a lower cost to government.

Publications, presentations and webinars

About the Project

Although RAI-HC data for tracking change in client status over time is readily available, the predictive value has been largely untapped. RAI-HC application has generally been limited to evaluating outcomes at one point in time.

This project mathematically modeled an individual’s changes in RAI-HC assessments to predict likely changes in the level of care required for an individual. Further, it translated this model into a measure, derived from RAI-HC assessments, for use by home care clinicians, physicians and other care providers. The measure was piloted by working with case managers in Island Health to identify relevant cases and providing results from the new predictive frailty measure to help guide decisions.

Once validated, this new frailty measure will provide a new level of guidance for key decisions, especially the timing of transition from the home to alternative living arrangements. The intent of this eHome (electronic Home Monitoring to Empower)-iCare (inform Caregivers And Robotic Effectors) project was to reduce unnecessary or premature transitions.

For more details on the project rationale, hypothesis, objectives and research plan, click here.

Project Team

Principal Investigators:

Debra Sheets, PhD, MSN, RN, FAAN -- University of Victoria

Stuart MacDonald, PhD -- University of Victoria


Carl Asche, PhD -- University of Illinois, College of Medicine at Peoria

Cheryl Beach, PhD -- Vancouver Island Health Authority

Paul Brewster, PhD -- University of Victoria

Sandra Hundza, PhD -- University of Victoria

Andrew Mitz, PhD -- National Institutes of Health

Jeff Poss, PhD -- University of Waterloo

Knowledge Users and Partners:

Marilyn Malone, MD, FRCPC -- Vancouver Island Health Authority

Office of Seniors Advocate, B.C. Ministry of Health

University of Victoria - Faculty of Human and Social Development

University of Waterloo - School of Public Health and Health Systems 

Project Contact: Debra Sheets --

FRA 2015-B-07