Using RAI with the clients

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• RAI assessment maps the need for services in a comprehensive way
• RAI assessment will be carried out as the client’s condition change
• The service and management plan are based on a RAI assessment
• Results of RAI indicators as a basis for service criteria
• Five stages of the evaluation process

The client’s needs are the starting point for services and care. The RAI assessment is a systematic and versatile service needs assessment process that is carried out together with the client. A carefully performed RAI assessment provides an up-to-date description of the client, their condition and life situation.

Assessing the clients consistently with RAI provides a basis for goal-oriented, systematic care and services that meet clients’ needs.

RAI assessment maps the need for services in a comprehensive way

An assessment of the need for services identifies the functional, medical and social conditions that affect the quality of life of the client of the services for older people or the disabled, including any individual service needs.

The comprehensive service needs assessment examines the client’s resources and the need for help including the factors that affect them. Based on the assessment, the client manager or service manager prepares, as necessary, a plan for services, care, rehabilitation or other interventions that maintain or improve the client’s situation. 

The RAI assessment should be carried out in a multidisciplinary way. For example, identifying rehabilitation opportunities or the severity of a memory disorder require special expertise. A wide-ranging survey and the participation of several professional groups in the assessment will provide a comprehensive overview of the client’s situation.

The client’s own views, wishes and goals should be taken into account. Therefore, it is essential that the client and their family member(s) participate in the service need assessment of a client and the RAI assessment of a client who is already receiving service. Engaging the client in the planning and implementation of care creates satisfaction, safety and trust. 

RAI assessment will be carried out as the client’s condition change

A client receiving regular services is subject to a comprehensive assessment at the beginning of care, every six months during care, and whenever the client’s condition changes significantly. The starting point of the assessment is always the client and the assessment of their changing needs. 

In addition to an overall assessment, targeted partial assessments can be carried out to monitor the effects of treatment or rehabilitation or an identified problem affecting the client.

Regular and up-to-date assessments enable the organisation to monitor changes in a client’s situation and functional ability. Quick and preventative action can be taken if any problems are identified.

The service and management plan are based on a RAI assessment

An individual service, care or rehabilitation plan is drawn up on the basis of data generated by the RAI assessment. The data can also be used for monitoring the realisation of the plan.

The following items are recorded on the plan: 

• results of the RAI assessment
• goals set in cooperation with the client 
• monitoring of the plan. 

The attainment of the goals is assessed by multidisciplinary cooperation and with the client and their family members. The RAI indicators help monitor the actualisation of care.

Data generated in a RAI assessment

In addition to the answers to the assessment questions, the RAI assessment generates the following data:

• Triggers that describe the client’s resources and risk factors
• RAI indicators that describe the client’s functional ability and health
• Data about the client’s services and his or her social network.

Triggers help in identifying the client’s needs and resources. They help answer questions like:

• What should be addressed?
• Why should it be addressed?
• How should it be followed?

The individual indicators describe, for example, the client’s health, functional ability and resources, as well as the need for care, services and rehabilitation. The indicators also assist in the monitoring of the results of treatment, service or rehabilitation.

Results of RAI indicators as a basis for service criteria

Case management and care planning require common, fair and transparent practices as to what kind of services are used to meet the client’s needs.

One way is to agree on the criteria for inclusion in the service. The criteria must always be based on reliably obtained information about the client’s situation. 

The RAI indicators can be used for creating the criteria, while keeping in mind that no single indicator value indicates the client’s overall situation. Therefore, the result of a single indicator must not be used as the basis for a service.

Five stages of the evaluation process

Carrying out a reliable RAI assessment requires professional expertise and skills in both performing the RAI assessment and recording it in the software. An assessment is reliable when sufficient time is reserved for it and also the client participates in it.

1. Collecting information through interviews and observations. 
   The primary source of information is the client themselves. Important information can also be obtained from the client’s family members and close relatives. Information is also gathered by observing the client and studying documents about him or her. The assessment gathers information from all professionals involved in the client’s care or service implementation.
2. Performing a RAI assessment and recording it with the software. 
   The information gathered in the first stage of the assessment process is used to answer the RAI assessment questions and the answers are carefully recorded with the software.
3. Results of the RAI assessment: indicators and resources. 
   The responses to the different topics of the assessment generate indicators and triggers that describe the client’s resources. The software generates the triggers and indicators automatically after the assessment data has been recorded in the system. 
4. Utilising assessment data in the client’s service, care or rehabilitation plan. 
   The data produced by the RAI evaluation is used in practice. The data is used to prepare a plan for the services, care and rehabilitation that meet the client’s needs. Even if the RAI assessment does not lead to a decision to provide a regular service, the assessment information will also help to guide the client to other activities that support his or her situation, such as physical exercise services offered by the municipality or other organisations. 
5. Implementation and monitoring of care or service. 
   The client is provided care according to the service and care plan. The RAI assessment is repeated after six months or earlier, or if the client’s situation changes significantly. Regular RAI assessments monitor the client’s situation and the implementation of the plans.