After the introduction of Medicare's Diagnostic Related Groupings (DRGs) as a method of prospective payment for hospitalization, the average length of hospital stays decreased for most DRGs, and thus there was a need for more effective discharge planning. In fact, Congress received many complaints about discharging patients from hospitals too quickly without adequate support at home. Therefore, in the 1986 Omnibus Budget Reconciliation Act (OBRA '87, Public Law No. 100-203), the Health Care Financing Administration (HCFA) was mandated to develop a needs assessment instrument to be used for discharge planning with older adults. As a result, the Uniform Needs Assessment Instrument (UNAI) was developed by a national multidisciplinary panel of experts to systematically assess the continuing care needs of high-risk older adults as part of the discharge planning process (HCFA, 1992). The original UNAI included eight domains with 162 items. Definitions were developed for only the overall domains. Before using the UNAI in a clinical setting, the panel recommended that definitions be developed for all items in the UNAI, consistent with other federally mandated instruments. The panel also recommended further testing of the validity, reliability, and feasibility of using the instrument. After the UNAI is tested, it may be required to determine who receives home care and other formal services after hospital discharge and whether that care is reimbursed (HCFA, 1992).
As a first step in testing the UNAI, a study using two rounds of mailed surveys was conducted to obtain additional content and face validity for the UNAI. Definitions for the 162 UNAI items were created based on existing nationally recognized definitions, research instruments, or textbooks. A multidisciplinary panel of 30 experts from three states responded to two mailed surveys. In the first survey, the relevance of each domain and item in the UNAI was rated. The panel also reviewed the definitions for comprehension. After the research team reached consensus on the recommendations, the UNAI was revised to a total of 200 items in eight domains (Table 1). In the second survey, the panel of experts was asked to review for face validity and rate the relevance of each domain for determining continuing care needs. All domains were rated as quite to very relevant on a five-point scale.
A second study was conducted to determine the reliability, effectiveness, and feasibility of using the revised UNAI in a clinical setting. The three overall goals in this study were to:
* Assess the reliability of the form when used for discharge planning.
* Determine if the form was more effective in needs identification compared with usual hospital discharge planning for older adults.
* Determine the feasibility of using the UNAI in a clinical setting.
A sequential selection using a random start was used to obtain subjects from the daily admissions listings of two hospitals in 1995. The number of patients identified from the daily hospital census sheets who potentially could meet the study criteria ranged from 2 to 23 patients per day. The investigators used a random numbers table to identify the day's starting potential subject. Patients who met criteria for the study were identified and, if available, invited to enroll in the study. If a patient was unavailable, the next patient on the listing was identified and invited. From 2 to 4 subjects a day were enrolled in the study. Each subject met the following criteria:
* Age 65 or older.
* Hospitalized longer than 24 hours in one of two hospitals.
* Resided in Olmsted County.
* Gave verbal consent or had a family member present who gave consent and was able to answer the questions.
Individuals admitted to or transferred to psychiatric services were excluded.
The 103 enrolled subjects were divided into two groups. The first 57 subjects enrolled in the study, Group 1, represented patients who received usual discharge planning at the two hospitals. The next 46 subjects, Group 2, represented patients whose data were made available to those responsible for their discharge planning. The unequal sample sizes reflect oversampling in the first group.
Selection of subjects was limited to Olmsted County, where most residents are of European ancestry, in anticipation of a follow-up study using the Olmsted County Healthcare Expenditures and Utilization database, a 20-year-old database of health care use.
The instruments used in the study were the revised UNAI, an Encounter Form, and a Discharge Planning Needs/Plans Form. An Encounter Form was developed to record the time required to collect data and document any problems or issues encountered when using the UNAI. The Discharge Planning Needs/Plans Form was used with Group 1 to record the perception of continuing care needs assessed by the staff nurse responsible for discharge planning during the usual assessment process.
The study was a two-group comparison design. A comparison was made between needs identified on the UNAI and needs identified through usual discharge planning. For Group 1, results from the UNAI were not shared with those responsible for discharge planning. For Group 2, the results of the UNAI were shared with the staff. At the two hospitals involved in this study, usual discharge planning was done by an assigned primary nurse delivering bedside care. Discharge planning assessment began on admission and was reassessed twice daily. The primary nurse involved specialists such as discharge planning coordinators or social workers only when a need for their involvement was identified, such as for complex home care or placement issues.
Approval for the protection of human subjects was obtained from the Institutional Review Board before the study began. Prior to data collection, a training manual and videotape were developed. Each investigator attended two 4hour training sessions. Data were collected within 24 to 48 hours of admission and again within 24 to 48 hours prior to discharge. Admission data collection was essential because there is a mandate that hospitals' discharge planning évaluations be made on a timely basis to ensure that appropriate arrangements for post-hospital care will be made before discharge and to avoid unnecessary delays in discharge. Data collection at discharge also was essential because continuing care needs change during hospitalization. The investigators also recorded the length of time it took to complete data collection and made journal entries at these times.
When Group 1 subjects were discharged, the RNs responsible for discharge planning were asked by an investigator to indicate the discharge needs and plans for patients identified through usual procedures. For Group 2, the data collected on admission and just prior to discharge were made available to the nurse caring for the patient to incorporate into the usual discharge planning procedure. Within 10 to 14 days after both groups were discharged from the hospital, a data collector telephoned patients and collected data on actual needs and how they were met during the 2 weeks after discharge.
Interrater reliability was obtained with the first 19 subjects by having two data collectors simultaneously collecting data. One investigator interviewed the subject while a second investigator observed. Both investigators independently reviewed the medical record and completed the UNAI.
Of the 316 patients meeting eligibility criteria for the study, 213 (67%) were not admitted for various reasons (Table 2). The 103 subjects who were admitted into the study had a median age of 76 years (range 65 to 94 years). Of these subjects, 38% were male, and 62% were female. Prior to this hospitalization, 40% lived alone, while 60% lived with others such as spouse, other family members, or nursing home residents. At discharge, 72.5% returned home, with 20.5% requiring formal services; 20% went to a nursing home; and 7.8% had "other" as the discharge disposition. The primary medical diagnoses were clustered by major diagnostic categories. The four most frequent categories, representing 66% of the subjects, were circulatory, respiratory, musculoskeletal system/connective tissue, and nervous system. Subjects varied in the number of comorbid conditions: 7% had 0 to 1, 26% had 2 to 3, 24% had 4 to 5, 21 % had 6 to 7, and 16% had more than 8 comorbid conditions.
Reliability of the UNAI
Interrater reliability was determined by examining the percentage of agreement on each item and averaging the agreement for all items in a category. Percentage agreement was greater than .85 in all categories except Assistive Devices and three Skilled Care Requirement subcategories (Integument, Nutrition/Hydration, and Neuromusculoskeletal).
Effectiveness of the UNAI
Effectiveness was measured in two ways. The first was to determine the sensitivity and specificity for all 103 subjects. Sensitivity was determined by calculating the percentage agreement of needs, which the subjects reported as existing after discharge, compared with those identified by using the form just prior to discharge. Specificity was determined by calculating the percentage agreement of needs which did not exist during the 2 weeks after hospitalization compared with those not expected to exist by the discharge data collection. The subjects' reported needs after discharge represented the "gold standard" for comparison. The overall sensitivity and specificity of the UNAI for detecting continuing care needs was high (> 85%).
The second method of measuring effectiveness was to determine if the UNAI was more sensitive and specific in needs identification than usual discharge planning done at the two hospitals. Discharge planning with the UNAI was consistently more sensitive in detecting continuing care needs than usual discharge planning (except for one Skilled Care Requirement subcategory, Counseling). In the majority of categories, the specificity was higher for discharge planning with the UNAI. The consistent trend in both sensitivities and specificities indicated that the UNAI allows more accurate identification of the subjects' needs.
Feasibility of the UNAI
Feasibility was addressed by examining the amount of time required to complete the UNAI and examination of the problems encountered. Most often (63.8% of subjects) it took 45 to 75 minutes to complete the UNAI, with a median of 70 minutes (range of 45 to 130 minutes).
Content analysis of the investigators' journal comments showed clustering into five categories: information access, timing of the interview, information reliability, issues with specific items, and the length of the interview.
Some of the specific problems encountered in relation to information access included the following: medical record was not available, subjects were not available, RN caregiver was too busy, problems accessing information on the computer, and investigators were unable to reach the subject or family on the follow-up evaluation call.
Problems encountered regarding timing of the interview comments included early unplanned discharges and uncertainty about the discharge date. Information reliability issues included: uncertainty about the subject's mental status, difficulty using consistent definitions for some items, concern that some questions seemed to lead the subject's response, and differences between what subjects reported compared with data in the medical record. Specific UNAI items were difficult to ask because some definitions were unclear to the investigator and the nursing staff. Examples include: unsteadiness/dizziness, prognosis, instrumental activities of daily living (IADLs), and abuse/neglect.
The purpose of this study was to determine the reliability, effectiveness, and feasibility of the UNAI for assessment of continuing care needs of hospitalized elderly. High interrater reliability was obtained in completing the UNAI. For all subjects, the UNAI had high (> 85%) sensitivity and specificity when comparing needs identification using the form with subjects' reported needs the first 2 weeks after discharge (the gold standard). In one instance, for Cognitive Status, the UNAI may not be effective for detecting needs because it is likely that a subject's self-report of cognitive deficits may not be accurate at follow up. Overall, the UNAI was more effective (sensitive and specific) in identification of continuing care needs than the usual discharge planning assessment. However, in some instances, the UNAI overdetected needs (lower specificity).
The feasibility of using the UNAI may be controversial, depending on how it is implemented. The UNAI usually required 45 to 75 minutes to complete. For 36.2% of the subjects, the time to complete all information was more than 75 minutes. If the UNAI were incorporated into current processes of care and replaced some of the initial admission assessment and discharge planning data collection, it would be unlikely that workload would increase. In a subsequent study where the form was completed on 375 hospitalized patients by staff RNs, completion time after 13 weeks was reduced to 16 minutes (20 minutes for patients on medical units, 13.5 minutes for patients on a surgical unit).
The timing of the assessments could be problematic with the many tests performed during hospitalization. The HCFA (1992) recommended that the UNAI be completed by specially trained staff. For some models of discharge planning, this could require additional work, training, and personnel. Work schedules would have to correspond to when most patients and family would be available to complete the assessments.
The HCFA (1992) also recommended that results of the UNAI assessment be shared across settings. This would require the information to be completed on a separate form rather than integrated into interdisciplinary documentation. If a hospital had computerized charting, however, information could be integrated into routine processes of care and networked to configure a form useful in sharing results with the next provider of care.
Problems were encountered with completing a few items in the UNAI regardless of the fact that all investigators received training and a manual with item definitions. For example, it was difficult to assess abuse or neglect from a one-item prompt. Some investigators reported discomfort with asking questions about abuse and neglect. Further information and training would be needed for users to assess abuse or neglect accurately.
Questions related to IADLs were difficult to assess in certain situations. For example, it was difficult to be consistent in documenting a need for household chores such as cooking if a male subject usually did not perform the activity but was able to do so if his wife were not available.
When subjects were admitted from a nursing home, certain items were irrelevant. The IADL items do not seem to apply to nursing home residents because the environment restricts their performance of these activities. Some questions related to environmental barriers also are not applicable for facility residents because state regulations require grab bars and barrier-free entrances for all residents.
A number of limitations in the study affect the conclusions. First, the sample size was small. While the setting in which the UNAI was tested provides tertiary care to a world-wide population, only subjects from the surrounding county were included. The UNAI needs to be tested with diverse racial and ethnic groups, as well as those with various economic, education, and employment backgrounds. There were a number of potential subjects who were not included in the study because they were too ill or were not available. No attempts were made to enroll these patients later. It is unknown how they would differ compared with those who participated in the study. The UNAI was tested in only one setting, but it is intended to be used not only in hospitals for discharge planning but also in nursing homes and home care. A national demonstration project is underway to test the UNAI in all three settings in multiple states (Research Triangle Institute, 1995). Lastly, there are multiple models of discharge planning. This study compared the UNAI against only one model.
The intent of the UNAI is to provide a uniform assessment of continuing care needs for high-risk older adults. However, there is no definition for high risk. The current study purposely was not limited to high-risk subjects because the investigators plan to examine which items or domains in the UNAI are associated with poor outcomes (hospital re-admissions within 30 days or emergency department visits within 7 days after discharge) and high resource use within 6 months after discharge in the next phase of the study. There are items on the form found in the literature which might be predictive of highrisk populations: difficulties with functional status, multiple previous admissions, severely disabling chronic conditions, noncompliance, lack of knowledge about managing health problems and treatments, lack of social support, and discharge location (home versus nursing home) (Bull, 1992, 1994; Naylor et al., 1994).
The UNAI provides an opportunity to improve the quality and decrease the cost of health care through systematic analysis of continuing care needs. Unless needs are adequately identified, patient outcomes may be adversely affected, and health care resources will be increased (Boyle, Nance, & PassauBuck, 1992; Bull, 1994; Mamon et al., 1992; Rockwood, 1990). Development and use of instruments such as the UNAI is consistent with other efforts of the HCFA to standardize data collection and benchmark quality care (Hawes et al., 1995; Shaughnessy & Crisler, 1995).
Because it is anticipated that the UNAI may become mandatory in the future for discharge planning in hospitals, nursing homes, and home care, research is needed to determine the usefulness of the UNAI in all of these settings. Also, additional research is needed to determine the criteria for identifying high-risk populations for whom the UNAI needs to be conducted and those who do not need an extensive assessment.
- Boyle, K., Nance, J., & Passau-Buck, S. (1992). Post-hospitalization concerns of medical-surgical patients. Applied Nursing Research, 5, 122-126.
- Bull, MJ. (1992). Managing the transition from hospital to home. Qualitative Health Research, 2(1), 27-41.
- Bull, M.J. (1994). Elders' and family members* perspectives in planning for hospital discharge. Applied Nursing Research, 7, 190-192.
- Hawes, C, Morris, J.N., Phillips, CD., Mor, V., Fries, B.E., & Nonemaker, S. (1995). Reliability estimates for the Minimum Data Set for nursing home resident assessment and care screening (MDS). The Gerontologist, JS, 172-178.
- Health Care Financing Administration. (1992). Report to Congress. Report of the Secretary's advisory panel on the development of the UNAI. Washington, DC: U.S. Government Printing Office.
- Mamon, J., Steinwachs, D.M., Fahey, M., Bone, L.R., Oktay, J., & Klein, L. (1992). Impact of hospital discharge planning on meeting patient needs after returning home. HSR: Health Services Research, 27, 155175.
- Naylor, M., Brooten, D., Jones, R., Lavizo-Mourey, R., Mezey, M., & Pauly, M. (1 994). Comprehensive discharge planning for the hospitalized elderly: A randomized clinical trial. Annals of Internal Medicine, 120, 999-1006.
- Research Triangle Institute. (1995). Health Care Financing Administration (HCFA) field testing of the UNAI (Uniform Needs Assessment Instrument) small scale trial: Data collection manual. Research Triangle Park, NC: Author.
- Rockwood, K. (1990). Delays in the discharge of elderly patients. Journal of Clinical Epidemiology, 43, 971-975.
- Shaughnessy, P. W., & Crisler, K.S. (1995). Outcome-base quality improvement: A manual for home care agencies on how to use outcomes. Washington, DC: National Association for Home Care.