Achieving a common language: Assessment and decision-making for vulnerable populations

A leader in the fields of healthcare policy and assessment methodology, Dr. Brant Fries has devoted his career to developing assessment measures to improve the care of vulnerable populations across a broad spectrum of healthcare settings. He applies science-driven methods to implement these data in decision-making from the clinical realm to policymaking arenas to improve the care of millions of individuals.

Dr. Fries’ work focuses on assuring quality, designing effective payment systems and regulation, improving operational efficiency, and enabling effective financing and policy decisions. The assessment systems he has developed with collaborators over the past three decades have achieved widespread use in Michigan, across the U.S., and worldwide. His work has significantly changed long-term care practice and regulation in the U.S. and around the world, leading to improved outcomes for older adults and other vulnerable groups. 

Local, nationwide, and global impact of Dr. Fries’ work

  • Developed the U.S. National Nursing Home Resident Assessment Instrument/Minimum Data Set (MDS), a landmark national implementation credited with changing nursing home practice and improving care.
  • Lead developer of the system for measuring the burden of care among nursing home residents in the U.S., used nationwide to determine payment to nursing homes.
  • Founder and President of interRAI, an international research collaborative of 100+ researchers across 35+ nations, whose goal is to improve the quality of life for vulnerable populations through a seamless and comprehensive clinical assessment system. His organization has developed more than 30 assessment systems covering virtually all healthcare sectors.
  • Leads projects with individual U.S. states to improve access to care and understand their institutional and home-care populations.

Changing the mix

For healthcare providers to deliver the right care, at the right time, in the right place requires a comprehensive understanding of individual patients’ needs. Additionally, health system managers and planners must consider the appropriate allocation of resources required for effective patient care. All of these decisions can be supported through “case-mix” methodology, which provides a consistent way to classify individuals into groups based on their clinical characteristics and the cost of their care.

Nearly 30 years ago as an early career faculty member at Yale University, Dr. Fries was part of the team developing a new methodology for classifying inpatient stays into groups for the purposes of Medicare reimbursement, now known as the Diagnosis-Related Group (DRG) classification system. The DRGs have since evolved to become the foundation for classifying hospital stays worldwide.

Dr. Fries was the team member assigned to develop a parallel system for nursing homes. He became the lead developer of the Resource Utilization Groups (RUG) case-mix system, which has become the world’s best-known classification system for nursing homes. The RUG system uses assessment information about nursing home patients to determine the relative cost of their care. Initially created in the 1980s, this system was revolutionary from the very beginning because it was the first to utilize actual, measured per diem costs. 

I’m interested in using data to answer real-life questions. For me, it all comes down to how do you measure, and then how do you use that to solve problems?

Under Dr. Fries’ leadership and federal funding, the RUG system has been revised several times over the last three decades. It has been used since 1998 to pay U.S. nursing homes $33 billion annually under Medicare’s Prospective Payment System, and has been adopted by more than half of U.S. states to pay nursing homes under state-run Medicaid systems. The RUG system has also been validated in more than nine different countries with diverse healthcare systems, and several utilize it to structure payments for funding their long-term care systems. Information produced by this system has also provided a powerful means to compare long-term care delivery between facilities, regions, and countries.

A passion for measurement comes full circle

Measurement of case mix begins with accurate description of the characteristics of the person receiving services. With a background in pure and theoretical mathematics, measurement, and operations research, Dr. Fries collaborated on the development of the U.S. National Nursing Home Resident Assessment Instrument (RAI)/Minimum Data Set (MDS), which became a federally mandated system as part of a comprehensive set of nursing home reforms passed by the U.S. Congress in the 1980s, as well as the basis for RUGs. The MDS is used to plan care for residents in virtually all U.S. long-term care facilities. Its core set of screening, clinical and functional status elements provides a standardized language for facility staff, management, and outside agencies to communicate about issues and address problems, and to reliably and comprehensively evaluate residents’ strengths and needs to help them achieve the highest possible levels of functioning and quality of life.  

Although the initial purpose of the MDS was to facilitate long-term and post-acute care planning, over the years its utility has expanded to inform Medicare and Medicaid reimbursement policies, and to support quality monitoring and improvement efforts. It is credited with changing nursing home practice and improving care in the U.S. 

Broadening reach through global collaboration

In the early 1990s, Dr. Fries established an international collaborative of researchers known as interRAI, whose goal is to improve the quality of life of vulnerable populations through the development and dissemination of comprehensive assessment systems that can be integrated across health and social services settings. The most important application of these assessments is clinical: to help identify an individual’s most critical problems that could be addressed in a care plan, and then to provide internationally validated best practice guidelines for quality care.

The whole concept of measurement relies on everyone speaking a universal language. Having common measures lets providers across different settings improve continuity of care, and it also empowers families, advocates, and payers to monitor how individuals are doing across healthcare settings.

interRAI has developed assessment systems that cover virtually every healthcare sector, including home care, assisted living, nursing homes, palliative care, well elderly, inpatient and community mental health, correctional facilities, acute care hospitals, post-acute rehabilitation, intellectual disability, children and youth mental health, and many more, most recently a caregiver assessment for home care clients.

Canada provides one example of the impact of interRAI’s work, having widely adopted its assessments across its inpatient mental health, long-term home care, and nursing home settings, impacting millions of Canadians who receive care in these sectors each year. Canada Health Infoway, the organization charged with managing the nation’s electronic health record system, has selected interRAI to be the national standard for home care, long-term care, and mental health assessment. Clinicians can use the data collected with these assessments at the bedside to inform care planning and delivery, while researchers, policymakers, system planners, and healthcare facility managers can also use the data in their decision-making.

interRAI licenses its assessment systems free of charge to any caregiver or government in exchange for data to be used to continue to fuel interRAI research efforts. Nearly 200 million assessments based on interRAI instruments have been completed worldwide, generating more than 800 peer-reviewed articles, and they are becoming the international standard as a “language for high-quality care.” 

Looking toward the future

Dr. Fries continues to support assessment implementation through outreach across the U.S. and around the world, by providing training on the use of assessments, facilitating seminars for senior government officials to understand the value of assessment data, and developing applications. In the U.S., for example, Fries has led efforts to develop “level of care” determinations of who is eligible for long-term care supports and services in four states, and to design Michigan’s Medicaid nursing home payment system, both based on interRAI assessments.

Dr. Fries is also leading a team of gerontology researchers studying the health effects of lead exposure on elderly persons receiving home care services in the Flint area. The project, funded through a seed grant from the U-M President’s Office, will use already available, longitudinal, standardized assessment data to examine the epidemiological effects of lead exposure, derived in part from Fries’ previous work.

In October 2016, Dr. Fries earned a Doctor of Laws degree in honorus causa from the University of Waterloo for his pioneering work in long-term care.

About the researcher

Brant Fries

Brant Fries, Ph.D., L.L.D. (h.c.) is a professor of health management and policy at the U-M School of Public Health; a research professor at the Institute of Gerontology, U-M Medical School; Chief, Health Systems Research, Veterans Affairs Ann Arbor Healthcare System, Geriatric Research, Education, and Clinical Center; and President and Founder of interRAI, an international collaborative that develops assessment instruments across health and social services settings.

Acknowledgments

The work of Dr. Fries described here is funded in part through support from the Centers for Medicare and Medicaid Services, multiple individual U.S. states, the Robert Wood Johnson Foundation, the U-M Office of the Provost, the Irish Healthcare Executive, the World Health Organization, Blue Cross/Blue Shield Foundation of Michigan, and the Department of Veterans Affairs.

Dr. Fries’ team members include, at U-M: Mary L. James, M.A., Pil Park, Ph.D., Angela Schmorrow, M.S.W., and Melanie Thomasson, M.A.; within interRAI: John N. Morris, Ph.D. (US), John Hirdes, Ph.D. (Canada), Anja Declercq (Belgium), Harriet Finne-Soveri (Finland), Pálmi Jónsson (Iceland), and Len Gray (Australia).