Jiro Okochi. Tatsumasnosato Geriatric Facility

Transcription

1 Geriatric Health Measurement for care-management using the International Classification of Functioning (ICF) Use of the ICF to quantify health information Jiro Okochi Tatsumasnosato Geriatric Facility Special Thanks to Prf. Tai Takahashi International University of Health and Welfare Dr. Kiyoshi Takamuku Association of Geriatric health care facilities

2 My speech today 1. Background 1: lessons from case-mix system for elderly persons used in Japan. 2. Background 2: ICF 3. Development of ICF based geriatric health scales 4. Discussion

3 Background 1 Lessons from developing Japanese long-term care case mix system in Japan

4 Type of Insurance and Care system Medical Insurance by its funding in Japan compulsive, funded by premium Co-payment 30% Long-term care insurance (LTCI) for the elderly people since year 2000 Compulsive, funded by premium(50%) and Tax Co-payment 10%

5 Can she walk? questi onnair e 85 questions Results First step judgment Her level of required care is 3 この人は Decision tree software 要支援 Result Physician s opinion Determining the level of care requirement Second step judgment Home Doctor

6 要介護認定等基準時間の推計 Toileting 1.independent 2. minimum help Care 45 排尿 after 後の後始 toileting 末 3.Partial dependence 4.Total dependence Wearing off socks Special care 1.independent Transfer 3.Not possible 3.No Sholder joint contruction Sitting alone 85> 移乗 63communication 13.7 Specail care incontinence 1.yes Wearing off socks paralysis 14.1 eating =47.4

7 Direct IADL care 12.1 Toileting Eating Total Bathing 2.2 Mobility Total time Indirect Care Rehabilitation min Problem Behavior 11 Medical care Other special care 0 7.8

8 76min. Because her time is between 70 min. and 90 min., her level is min/day 90min/day 70min/day 50min/day 30min/day 20 min/day Degree5 Degree4 Degree3 Degree2 Degree1 Preventive services Not eligible

9 Eligibility Level and Benefit Limit Case-mix classification system according to the elderly ADL and IADL Table 1 The amount of benefit according to the eligibility level (in the case of home care) Eligibility level Assistance required Care required: level 1 Care required: level 2 Care required: level 3 Care required: level 4 Care required: level 5 Eligibility criteria *1 Monthly benefit limit *2 " 25 to 29 minutes " or " S um of indirect ADL care and rehabilitation care 10 \61, to 49 minutes \165, to 69 minutes \194, to 89 minutes \267, to 109 minutes \306, minutes and more \358,300 *1: Level of eligibility is determined according to estimated caregiving time. Detail of calculation is explained yen/month in Figure 3 *2: Benefit is allocated in kind. In principle, Institutional there service, is no cash allowance or at home service 7 day care per week

10 Decision tree model using Time study data Predictive power of the eligibility test in Japanese long-term care Insurance system: predicted vs actual time 1996(n=2896) 2001(n=4478) Predictive power : R R

11 Limitation To many scales (80 items) High management cost Municipality Physicians and other professional costs Can t measure change of functioning Not suitable for rehabilitation services

12 Back ground 2

13 ICF (International Classification of Functioning, Disability and Health) ICF (International Classification of Functioning, Disability and Health) was developed and approved by WHO in 2001 for classifying the functioning, health and disability According to WHO, the ICF has been accepted as the international standard to describe and measure health and disability Application is still underway

14 ICF domains Environmental Factors Body function Activity and Participation Body structures

15 Index of ICF (chapter level) ICF inclusively covers human functions, but there are to many codes. Contents of chapter 4 (Mobility)

16 ICD and ICF ICD(international Classification of Disease) To describe causes of death for health statistics To classify diseases for financing=drg/dpc ICF To describe and measure health and disability Coding Measurement

17 ICD and ICF Coding Measurement By physician By professional coder Dichotomous data Reliability and Validity has improved through revisions By health care staff Polychotomous data 1400 codes Reliability study 2003

18 Weighted kappa (test-retest reliablity) by chapter (Activity and Participation domain) Average Weighted kappa 0.55 Fig 1 Weighted Kappa According by the Chapter of Activity and Participation Weighted Kappa 1.learning* 2.general task and demands 3.communication 4.mobility 5.self care 6.domestic life 7.interpersonal interaction* 8.major life area 9.community life* Test-retest reliability distribution by chapters of ICF AP domain

19 ICF Illustration library The cartoon is from ICF illustration library Japanese English Spanish

20 Development of ICF based geriatric health scales Japanese Association of Geriatric Care facilities decided to develop new ICF based coding/assessment system ICF used as measurement scale Purpose Intermediate facility Measurement of improvement Care-management Standardization of care Improve quality of care

21 Selection of ICF items 134 ICF item sere selected based on Former reliability study Delphi method Used of dichotomous qualifier Dichotomous qualifier were more reliable than polytomous qualifier

22 Method: samples and sample institution measurement 15 Geriatric health facility. sample selection Elderly person over 65 years old was selected from each facility elderly persons were eligible for this study Man 19.8% Women 80.2% Average age 84

23 Flow of the ICF scale development Grouping of ICF codes according to its content Rasch analysis of each item within a group Rasch analysis of a group Test of Item fit and location Construction of Gutman model Contents and detail design that fit to the elderly care setting

24 About Rasch methodology An statistical method to evaluate and forecast response pattern using relationship between item difficulty and person ability based on item responsive theory The only available statistical method to construct meaningful scale (probability of answering correctly) Βn: ability of person n δi: difficulty of item I (item location) IF β=δ Probability of correct answer = 0.5

25 Jump trial Tai ouch Giro success failure When two person tries an Jump, or answering a question item. The higher the ability, the higher the possibility to jump successfully (correct response) β: person ability >δ:item difficulty(height of a bar)

26 If the item are very easy, both of them jump Tai Giro D465walking safely success success Two person responding ICFd465 walking safely

27 Result 1 Initial Rasch analysis using 21 mobility related ICF codes items 項目 Location SE FitResid DF C hisq DF Prob 1 walking ICF-50m meters 歩行 on ( 実 a 用 flat 的面 flor 内 with/without 歩行 )-2 assistive devices walking ICF-50m meters 歩行 on ( 面 a 内 flat 歩行 flor )-2 without assistive divices walking ICF-100m meters 歩行 -2(10ヵ月後 ) walking ICF- avoiding 障害物 barriers を避けての歩行 -2(10ヵ月後 ) climbing ICF- up 昇り降りすること( 昇る) climbing ICF- down 昇り降りすること( 降りる) moving ICF- within 施設 a 内 house/institution での移動 -2(10ヵ月後 ) moving ICF- within 入所 a 施 building 設以外 not の建 home 物での屋内移動 -2(10ヵ月後 ) moving ICF- outdoor 屋外での移動 -2(10ヵ月後 ) walking ICF- using 杖のみを cane 用いた歩行 walking ICF- using 杖と both 装具 cane の双方 and を用 brace いた歩行 use T of 字 Tcane 杖の利用 (10ヵ月後 ) using 4 点 four 杖ロフトランド point cane 杖等の利用 (10ヵ月後 ) moving 歩行 using 器 (ウォーカーシニアカー walker and senior car 等 )の利用 (10ヵ月後 ) walking しがみつき using cicle 歩行 type 器 (サークル walker 歩行 )(10ヵ月後 ) moving 車椅 using 子の利 a wheelchair 用 (10ヵ月後 ) walking 装具 using ( 短下 braces 肢装具等 )(10ヵ月後 ) going 外 out 出状 with 況 -つき assistance 添いがあれば person 近所に外出 going 外 out 出状 neighborhood 況 - 近所に外出 going 外 out 出状 using 況 - 個 private 別的交 trasportation 通手段を利用して外出 going 外 out 出状 using 況 - 公 public 共交通 transporation 機関を利用して外出

28 Flow of ICF scale development Grouping of ICF codes according to its content Rasch analysis of each item within a group Rasch analysis of a group Test of Item fit and location Construction of Gutman model Contents and detail design that fit to the elderly care setting

29 Result 2 Item fit and location analysis ICF item Item selection criteria fitness of good χsquare <10 項目 Location SE FitResid DF C hisq DF Prob 7 moving ICF- within 施 a 設 house/institution 内での移動 -2(10ヵ月後 ) walking ICF- 50 meters 杖と装 on 具の a flat 双方 flor を用 with/without いた歩行 -2 assistive devices moving ICF- outdoor 屋外での移動 -2(10ヵ月後 ) climbing ICF- up 昇り降りすること( 昇る) going out 外出 using 状況 public - 公共交 transporation 通機関を利用して外出 Proxy threshold location 7 moving within a house/institution 1 walking 50 meters on a flat flor with/without assistive devices 9 moving outdoor 5 climbing up 21 going out using public transporation

30 Our product : Gutman type scale ICF code tytle explanation state classification d4702 d4551 Going out using public transpor tation Climbing up Going out using public transportatio n(regardless of using assistive devises) Climbing more than 5 stares yes no yes no 5 Going out of home using pulic and/or private transportation 4 can not going out, but can climb stairs. Without limitation 3 walking around safely d465 d450a walking Moving around within an instituti on Walking safely (regardless of using cane and/or brace) Moving around within an building (regardless of using assistive devises such as wheelchair) yes no yes no 2 can not walk, but move around within a building 1 can not walk around with in a building

31 Then we know the level of the person ICF code tytle explanation state classification Tai GIRO d4702 d4551 Going out using public transpor tation Climbing up Going out using public transportatio n(regardless of using assistive devises) Climbing more than 5 stares yes no yes no 5 Going out of home using pulic and/or private transportation 4 can not going out, but can climb stairs. Without limitation X Giro level X X d465 d450a walking Moving around within an instituti on Walking safely (regardless of using cane and/or brace) Moving around within an building (regardless of using assistive devises such as wheelchair) yes no yes no 3 walking around safely 2 can not walk, but move around within a building 1 can not walk around with in a building Tai Level

32 Merit of knowing level of a person By using Gutman type scale A single result using multiple question item Require same level of health resource Standardization of care-plan and interventions

33 Basic Movement 1. 基本動作 ICF code title explanation choic e Status d4154a d4200 d4155a d429 Maintain Standing position Transfer while sitting Maintain Sitting position Change lying position Maintain standing position without help for 3minutes As transferring from sitting to bed,transferri ng oneself from and to different level of surface Maintain sitting position without assistance Change lying position (with/withou t holding assistive device) Yes no yes no yes no yes No 5 maintain standing position 4 can not maintain standing position but can transfer from sitting position to lying position 3 Can not transfer while sitting, but maintain sitting without assistance 2 can not maintain sitting without assistance, but change lying position 1 can not change lying position

34 Walking/Mobility ICF code tytle explanation state classification d4702 d4551 Going out using public transportati on Climbing up Going out using public transportation (regardless of using assistive devises) Climbing more than 5 stares yes no yes no 5 Going out of home using pulic and/or private transportation 4 can not going out, but can climb stairs. Without limitation 3 walking around safely d465 d450a walking Moving around within an institution Walking safely (regardless of using cane and/or brace) Moving around within an building (regardless of using assistive devises such as wheelchair) yes no yes no 2 can not walk, but move around within a building 1 can not walk around with in a building

35 Eating maneuver ICF コードタイトル説明選択肢状態の判定 d550a Eating Eating cleanly by himself using chopstick or knife and folk yes no 5 eat cleanly using knife or fork or chpstick 4 eat somehow using hand yes d550b Eating maneuver Eating without help no 3 require setting when eating d550c Setting on eating Require setting arrangement when eating yes no 2 require direct help on eating yes d550d Direct help on eating Require direct help when eating no 1 can not eat even with direct help

36 Toileting ICF コードタイトル説明選択肢状態の判定 d53001 d5401 Use of toilet Potting on and Takeing of f clothes Coordinating and managing urination,and do it properly on toilet Carrying out the coordinated actions and tasks of putting on and taking off clothes Yes No Yes No 5 Use toilet clean and properly 4 taking off and putting on clothes while toileting 2 transfer to toilet by himself d420a Transferi ng oneself on and off toilet Moving from one surface to another, such as sliding along a bench or moving from a bed to a chair, without changing body position. Yes No Yes Require assistive device for toileting d5308a Toileting otherwise specified Can not transfer to toilet, and using assisitive device No

37 Functional monitoring Re-evaluation (every 3 month) 1 月 2 月 3 月 4 月 5 月 6 月 mobility mmnicati eating toileting

38 Predictive Validity Total Time Prediction R-square=0.688 Four scales and intensity of medical service were used to estimate the total care-staff time required in geriatric care facilities. Predict time 100 This is not ICF based scale, but TAI scale with similar constructs we have developed using the ICF codes Real (Recorded) Time TAI 高齡者照護計劃之制定中華民國長期照護專業協會, ,

39 ICF based Gutman type scale By fitting to the Rasch model and then by re-constructing a Gutman type scale, we successfully decreased the number of geriatric scales. 4 ICF items are remodeled in one scale, measuring same constructs, but with different difficulty; We constructed 13 scales, that contain 13x4=52 ICF codes Use of international valid language

40 Conclusion With this simple scale, the users can share image of the elderly persons monitor change in functioning standardization of care