interRAI Assessment Information

page description

• Nebraska changed assessments to allow a single tool to serve mulitple purposes. Using one tool for mulitple purposes saves state administrative funding resources and decreases repetitive participant assessment.
  
• Nebraska already used interRAI assessment tools for the Aged and Disabled (AD) and Traumatic Brain Injury (TBI) Waivers. 
  
• Previously, Nebraska determined level of care with a home-grown assessment and determined budgets with an assessment which is no longer being updated. 
  
• interRAI assessments contain results to assist service planning.
  
• interRAI captures existing supports which contribute to the participant's success.​
  

Document review confirming diagnosis of a severe, chronic disability that results in at least one developmental delay likely to continue indefinitely.​

The ChYMH-DD is the interRAI Children and Youth Mental Health and Developmental Disability Assessment. It is used for ages 4 through 21 years. A supplement is also completed for adolescents ages 13-21. ​​

The interRAI ID is the interRAI Intellectual Disability Assessment. It is used for adults over the age of 22 years.

Assessment sections:

• ​Identification Information
• Intake and Initial History
• Community and Social Involvement
  
• Strengths, Relationships, and Supports
  
• Lifestyle
• Environmental Assessment
• Communication and Vision
  
• Cognition
• Health Concerns
• Independence in Everyday Activities
• Oral and Nutritional Status
  
• Mood and Behavior
• Medications
  
• Supports and Services
• Diagnostic Information
• Discharge Information
• Assessment Information
  

The participant will be interviewed, as it is their assessment. They will be asked questions and observed. 

• When the participant has difficulty communicating, they should have access to alternative communication methods and adequate time.
  
• Others can be present at the interview. Members of the participant's support structure are welcome, including caregivers, family, friends, providers, and school supports.  
  
• If a question or request is not understood, the interviewer can be asked to clarify. 
  
• There are a variety of questions asked. Some may be embarrassing or even triggering. The participant will be asked all questions. It is okay for additional conversations to occur outside of the participant interview when someone believes additional information needs to be shared. 
  
• Assessors administering the interRAI assessments are trained to reconcile differences in opinion between different interviewees.
  

• ​In addition to the participant interview, the assessor will review many different sources of information. 
  
• Information may include observation, document review, and interviews with members of the participant's person-centered team. 
• Documents may include medical records, educational documents, and person-centered plans. 
• The assessment is completed based on answers given during interviews, documentation gathered, and observations. 
  
• Assessors are trained to reconcile differences between interviews and documentation.
  

DD waivers have a level of care requirement of an intermediate care facility for individuals with intellectual disabilities (ICF/IID). The Division assesses to determine if you meet ICF/IID Level of Care after you meet other waiver requirements. Level of care is assessed every year.​

The interRAI assessment provides an output for which waiver best provides the services the participant is assessed to need. The DDD assessors use these results to inform waiver enrollment decisions. There are instances in which a manual review involving DDD clinical staff is the recommended output from the interRAI assessment. In these cases, clinical staff will make a waiver recommendation based on the interRAI assessment, additional documentation gathered from a participant's care team, and feedback provided as part of interviews with the participant, guardians, family members, providers, and identified others. 

There are four indicators that a participant may require services unique to the Comprehensive Development Disabilities (CDD) waiver, which include:

• Limited informal supports available.
• Residential instability.
• High supervision needs.
• High respite needs.
  

The Division uses an objective assessment process to determine funding to pay for Medicaid Home and Community-Based Services (HCBS) DD Waiver services. This process is meant to calculate the same funding amount for eligible people with similar skills and abilities. 

For the Adult Day (DDAD) and Comprehensive (CDD) Waivers, results from the objective assessment process are translated into the participant's individual budget amount (IBA). 

• ​The IBA is the maximum funding available each waiver year. 
  
• The IBA is organized in five funding tiers: Basic, Intermediate, High, Advanced, and Behavioral Risk.
  

The IBA is determined before services begin and every year after. When the participant has a change in skills or abilities that is expected to be long-term, their team can request a new assessment. 

The goal of DD waiver services is to help participants live as independently as possible. This is done by identifying and providing the services a person needs. The participant's Service Coordinator (SC) will write and monitor their person-centered plan outlining needs and services to meet those needs.

Collaborative Action Points (CAPs) are created from the results of the interRAI assessment. The participant's team will use these to help with service planning.​

• About the interRAI - who they are and what they do
• Comprehensive Assessment Instruments - assessment tools and their uses
• How Systems Develop​ - development and testing of assessment tools​

• DD Assessment Brochure - Trifold about interRAI use for DD waivers.
  
• interRAI Presentation Slides - June 2024 Myers & Stauffer presentations for families
• Slides 1-31 from Myers and Stauffer about interRAI
  
  
• Slides 32-46 from DDD with update on FSW
• interRAI Presentation Video - watch on YouTube 
• FAQs about interRAI - June 2024 answers about Nebraska's change to use interRAI assessments

The interRAI assessment system is a suite of standardized assessments utilized to evaluate the needs, strengths, and preferences of individuals from different populations. The interRAI tools in use for Nebraska's Developmental Disability (DD) waivers are the interRAI Intellectual Disability (ID) for participants 22 years of age or older, and the interRAI Child and Youth Mental Health and Developmental Disability (ChYMH-DD) for participants aged 4 to 21.

The interRAI ID and the interRAI ChYMH-DD are functional needs assessments owned by the interRAI organization. The organization is a network of researchers and practitioners who are dedicated to improving health and social outcomes for individuals with disabilities, who are aging, or who have a medical complexity.

Like all functional needs assessments owned by the interRAI organization, the interRAI ID and the interRAI ChYMH-DD are validated, standardized assessments. This means the data and results from these assessments are accurate for individuals with intellectual or developmental disabilities across different populations.

Nebraska DDD was using the Developmental Index (DI) and the Inventory for Client and Agency Planning (ICAP) to assess individuals for their DD waivers. Changes to their assessment tool were pursued due to concerns about the ability of the DI and the ICAP to accurately reflect support needs, including behavioral health needs, from year to year when the appropriate supports were in place. The interRAI captures service utilization, including frequency and focus of supports as a part of the assessment. The interRAI offers Collaborative Action Plans (CAPs) and acuity scales that can be utilized to support care planning and measure the intensity of a participant's needs from data gathered during the assessment. 

One of the strengths of the interRAI assessments is a person-centered focus, placing the participant at the center of the process. Whenever possible, the participant provides the information gathered by the assessor. Members of the participant's support structure are also welcome as interviewees. This includes, but is not limited to, caregivers, family, friends, providers, and school supports. Assessors administering the interRAI assessments are trained to reconcile differences in opinion between different interviewees.

Assessors 

Responsible for completing interRAI assessments by gathering evidence and making objective ratings based on review of this evidence. This includes, but is not limited to:  

1. Remain objective throughout the assessment. When possible or required by the specific interRAI item, verify information shared during the assessment interview with available supporting documentation and other evidence.
   
2. Collect, organize, and review all available documentation.
3. Seek additional information and evidence from multiple sources.
4. Leverage professional judgement to synthesize multiple information sources and gauge information source reliability.
5. Assessors are responsible for assessment accuracy. In addition to a thorough evidence review, assessors will need to cultivate good habits to promote reliable and accurate assessments:
1. Base determinations on all available evidence.
2. Reconcile differences in shared evidence from various sources referenced (e.g., participant testimony, caregiver perspectives, case notes, diagnostic reports).
   

Participants

The center of the interRAI process. Whenever possible, participants' self-reporting should be the primary source of information.  We understand that some participants may struggle with sustaining attention for long periods of time or there may be questions regarding the participant's ability to be a reliable reporter of their life. In these cases and others where the participant may not be able to engage fully in the interview process, assessors should prioritize certain items that require the participant's direct feedback.

Participant's Support System (family, caregivers, friends, providers, and identified others)

The Participant's Support System holds valuable information to help the assessor complete the assessment. Before of during the assessment, the Participant's Support System should:

1. Help the participant feel comfortable and reduce nervousness or anxiety.
2. Providers should ensure that documentation is accurate and up to date.
3. Will allow the assessor to follow the interRAI process and standards to ensure an objective, standardized assessment is completed. This may include allowing the assessor to guide the assessment, letting the assessor ask the participant first, and encouraging the participant to answer when and where they can.
   
4. Provide honest information that reflects the true needs of the participant. If information is inaccurate or withheld, the assessment may overlook key needs or misinterpret the person's abilities, resulting in supports that don't truly align with the person's abilities and needs.​

Many of the items on the interRAI utilize a three-day look-back window to quantify a participant's performance over time. A three-day window was selected for most items because it increases the accuracy of the recall of the interviewee. Items related to health and behavior symptoms utilize the three-day window but account for health symptoms or behavioral needs that occurred beyond that three-day window. Other items, such as a history of violence or other service utilization, have longer look-back windows to reflect intensity or frequency of supports. 

One result provided by the interRAI is the identification of the participant's case-mix group. The case-mix groups have been researched and tested for reliability by interRAI. The case-mix groups are comprised of a series of items and functional performance scales that have resulted in similar resource needs. The case-mix group is linked to a case-mix index score that reflects the participant's cost to serve them. The case-mix index score is aligned to the Nebraska budgeting tiers. 

For more detailed information on how case-mix index is utilized to determine a person's budge, see the above section Nebraska's Use of interRAI Assessments, Case Mix Index (CMI) and Budgeting Decisions.  

​The interRAI assessments review a wide range of areas, including but not limited to the sections below: 

Cognition is assessed in its own section, as well as cognitive and physical abilities being assessed functionally within the Independence in Everyday Activities section.​

Yes, the interRAI assessment collects both historical and current information on mood and behavior, such as symptoms of anxiety, depression, physical abuse, verbal abuse, resisting care, inappropriate or disruptive behaviors, and violence. The collected information is used to generate scaled scores, which are developed by the interRAI organization. Scaled scores are a way to indicate a participant's acuity or how the severity of their diagnosis is expressed. Some scaled scores are used to generate outputs specific to waiver enrollment and/or residential habilitation needs. Additionally, the interRAI captures information about utilized behavioral interventions and their recency.  

The interRAI assessment provides an output for which waiver best provides the services the participant is assessed to need. The DDD assessors use these results to inform waiver enrollment decisions. There are instances in which a manual review involving DDD clinical staff is the recommended output from the interRAI assessment. In these cases, clinical staff will make a waiver recommendation based on the interRAI assessment, additional documentation gathered from a participant's care team, and feedback provided as part of interviews with the participant, guardians, family members, providers, and identified others. 

There are four indicators that a participant may require services unique to the Comprehensive Development Disabilities (CDD) waiver, which include:

• Limited informal supports available.
• Residential instability.
• High supervision needs.
• High respite needs.​

More information about the interRAI can be found on their website.