Who are the guidelines for?
This guideline is intended for you, a social and health care professional who carries out RAI assessments as part of your work. You are trained to conduct RAI assessments and work, for example, in services for older people in client or service counselling, in home care, or long-term care facilities. You may also work in family care or informal care. The guidance supports you in making use of multiprofessional collaboration to ensure high-quality RAI assessments.
This guidance is recommendatory in nature.
RAI assessments provides a comprehensive understanding of the client’s needs
RAI assessment provides you with an up to date and multifaceted picture of the client’s functional ability, strengths, need for support, and factors influencing these.
In a RAI assessment you consider functional, medical, and social aspects that affect the client’s quality of life.
Familiarize yourself with the instructions in the RAI manual before conducting a RAI assessment. Follow the instructions shown on the assessment form and check any additional guidance in the RAI manual. RAI assessment forms and manuals are available to RAI users in THL’s RAI Extranet.
THL’s RAI Extranet (in Finnish, Yhteistyötilat)
Client and family member's participation in the RAI Assessment
Conduct the RAI assessment together with the client, so that the client's views, wishes and goals are considered in the assessment and in the planning of care and services. The client’s participation strengthens the sense of involvement, increases satisfaction, and promotes safety and trust in the care relationship.
A family member can provide valuable information about the client’s habits, routines and changes in functional ability. Discuss with the client the role of family members in their daily life and clarify the client's view on their participation in the assessment. As a professional, ensure that the client understands the importance of family members participation.
The client has the right to refuse participation of family members or to choose which family members may participate. Participation can also be arranged remotely (e.g. by telephone) if physical presence is not possible.
The five phases of the assessment process
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1
Start by gathering information through interview and observation
Carry out the RAI assessment in daily work together with the client. Observe the client and assess functional ability.
The primary source of information is the client. You will also obtain essential information from family members. Gather information about the client by observing the client and by reviewing the client's records. Collect information from all professionals involved in the client’s care or service delivery.
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2
Conduct the RAI assessment
Answer the RAI assessment questions based on the information gathered in the first phase and record the answers carefully in the software.
The RAI manual is your most important tool. Understand the purpose and definitions of each question and how each question is to be answered.
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3
Identify the client’s needs based on the assessment information
Responses across domains generate scales and clinical assessment triggers that reflect the client’s strengths and needs. When you have entered the data into the software, the scales and triggers are generated automatically.
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4
Use RAI assessment information in the client plan
Prepare the client plan using the information obtained from the RAI assessment. Consider the care, services and rehabilitation that meet the client’s needs.
Even if the RAI assessment indicates that the client does not require regular services, the assessment information may help you guide the client to other supportive activities such as physical activity services.
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5
Follow up implementation and follow up of care, services and rehabilitation
Implement the client plan together with the client and other professionals. This ensures follow-up of the client’s situation and the adherence of the plan.
Carry out a new RAI assessment every six months or earlier if the client’s situation changes significantly.
Multiprofessional collaboration in conducting the RAI assessment
Ensure multiprofessional collaboration when conducting RAI assessments. A multifaceted assessment of functional ability requires using the competencies of various professions. Such situations include, for example, evaluating rehabilitation potential or identifying the severity of memory disorders.
Multiprofessional collaboration may include:
- Physiotherapist assesses functional ability and recommends measures to support physical functioning.
- Occupational therapist highlights strengths and challenges in daily activities and suggests ways to facilitate everyday functioning.
- Care assistant provides valuable information about daily activities, e.g. how outdoor mobility is working.
- Registered nurse reports observations related to wound care, health status and medication management.
- Practical nurse assesses the implementation of exercises that support everyday life and their effects on functional ability.
- Physician complements the assessment as needed with diagnoses and medical background information.
Collaboration between professionals ensures that the RAI assessment is based on reliable and diverse information about the client’s functional ability and need for support. This promotes the client’s well being and supports preparation of the client plan.
Ensuring the RAI-competence in client work (in Finnish)
Courses related to the RAI-competence (in Finnish)
THL's role
THL maintains the Resident Assessment Instruments (RAI) for evaluating functional capacity and service needs in Finland. These instruments support the implementation of the Act on Care Services for Older Persons and are intended for comprehensive assessments. Under the Act on Care Services for Older Persons, THL ensures that the RAI instruments and training for its use are available to the wellbeing services counties. As part of its statutory duties, THL also collects data from RAI assessments and produces benchmarking data from them to support the management and development of services.
