Pan-African Utilization of Lay Assessment Systems (PAULAS)

Problem statement

Demographic transitions mean that Africa is about to experience an accelerated rate of population aging such that the population of older Africans will triple in size within 30 years. Older adults play important roles in African societies, but almost all nations in the continent are inadequately prepared to deal with their health needs. Those health needs are further complicated by social, environmental, and economic considerations unique to Africa combined with severely under-resourced health care systems that have little to no expertise in care and support of older persons.

Global Aging

 Increased life expectancy at birth and population aging (1) have been regarded as among the most important public health achievements of the 20th century (2, 3). In her 1998 address to the 102nd session of the Executive Board of the World Health Organization, Secretary General Gro Harlem Brundtland stated “We have another transition, the transition from the communicable to the non-communicable diseases.” She went on to state that attention to acute infectious disease and to chronic conditions associated with aging “cannot be seen as competing tasks. They are complementary. We need to fight both.”

For most high resource nations, population aging is now viewed as a major economic challenge and some consider it as a threat to the viability of publicly funded health care systems (4). Policy initiatives to adapt to such changes have been a major focus in these countries (3). However, scant attention has been paid to population aging in low and middle resource nations (5).

Faced with major health concerns for younger populations, low and middle resource nations have placed little to no emphasis on efforts to address the health needs of older persons. This has been particularly true in Africa (6). One of the leading authorities on aging in Africa stated that the 1992 First World Assembly on Ageing in Vienna “had a remarkably good vision on aging in the 21st century, [but] much of Africa at that time viewed aging issues as unimportant for policy dialogue and planning” (5). However, as African nations make the demographic transition to lower fertility and reduced mortality rates, they are ill-equipped for the rapid growth of the older population. By 2050, the population of older adults in Africa will triple (7). Over two-thirds of African nations will have over 1 million citizens aged 60 years or more. On-going economic challenges, changing social dynamics, and under-resourced health care systems with little expertise in geriatrics leave most African nations seriously unprepared for the dramatic increase in population aging in the next three decades (8).

Even before the onset of the COVID-19 pandemic, it would not be reasonable to assume that approaches used to support health needs of older adults in high resource nations could be easily transferred to address aging in Africa (9). According to Apt, the “43 countries in sub-Saharan Africa [SSA] … are far more diverse than Europe, for example, with respect to language, social organisation, and social environment.” (5) The diversity is even more pronounced when comparing Northern Africa with SSA. Cultural considerations limit the acceptability of some models of care of older persons. In addition, African nations simply do not have the economic resources to replicate existing approaches to health care delivery for older adults in high resource nations.

The societal importance of older adults in Africa – As is the case elsewhere, respect for the elderly has been a traditional value in African nations. The growing emphasis on human rights and civic consciousness in these countries includes recognition that responding to the needs of older adults should be part of any societal transformation to improve the well-being of its citizens (5, 9).

However, there are also more pragmatic, functional considerations for why the health of older adults is of central importance to African nations. These include:

• Social cohesion – in many African nations, older adults (particularly grandmothers) play important roles in family decision-making and maintenance of family stability and integration (9);
• Economic considerations – poverty is a pervasive problem in Africa, and it disproportionately affects older adults. However, in some countries, the pension incomes of older adults may be a primary economic resource for the broader family. On the other hand, in countries without adequate pension systems older adults must remain in the paid labour force to survive. In SSA, over half of adults aged 65 or more remain in the paid labour force, which is a higher proportion than any other region in the world (7);
• Informal economic contributions – childcare within multigeneration families is a common form of support that older adults provide globally. However, in Africa the HIV/AIDs epidemic and the Rwandan genocide have left many families without a middle generation, leaving grandparents to care for grandchildren. The percentage of older adults living in such “skipped generation” households ranges from 2.4% in South Africa to 11.7% in Ghana (7).

Health needs of older adults in Africa – health related declines associated with aging are universal, but pathological changes can be accelerated by a variety of social, environmental, lifestyle, and iatrogenic factors. In addition, the needs of older adults are usually multidimensional in nature, including both physical and mental health aspects. Frailty combined with impairments in both cognition and functional status are major concerns requiring sophisticated medical care combined informal support from family members (10). In addition, aging is rarely associated with a single medical condition. Instead, multimorbidity characterized by the concurrent manifestation of multiple diseases further increases the complexity of medical care for older adults (11). All these considerations are true for older adults anywhere in the world. The health of older adults in Africa is further complicated by:

• Double burden of disease – As is the case elsewhere, heart disease is the leading cause of death for older adults in Africa. However, infectious disease including HIV/AIDs, tuberculosis, and malaria pose both acute and chronic health concerns that further exacerbate health problems associated with non-communicable diseases (NCDs) (12). Infectious disease remains a major cause of mortality but is also an important cause of disability. For example, about 26.3 million people in Africa are blind or have low vision due to age-related changes (e.g., cataracts) and/or infectious diseases like trachoma and onchocerciasis (river blindness) (13);
• Changes in life expectancy – Improvements in life expectancy at birth and at age 60 have been evident in many African nations (5, 7). These are clearly positive changes; however, this also means that more older adults will survive to ages where non-communicable diseases occur including neurodegenerative conditions and chronic cardiorespiratory illnesses. In addition, there have been notable increases in survival of persons with HIV/AIDs, but the greater complexity of the health needs of those who live to advanced ages pose further challenges (14, 15);
• Crime and conflict – Many older persons in Africa are exposed to high crime environments or live in regions of violent conflict. An extreme example is the genocide of Rwanda that left lasting consequences among survivors including social upheaval, disability, and severe mental health concerns (16, 17). Similar events occurred in the Darfur region of Sudan (18). For those current living in such settings, access to necessary medical care may be severely constrained;
• Poverty – The pervasive poverty experienced by many persons over their life course can result in accelerated rates of age-related illness due to inadequate nutrition, limited access to necessary medications, environmental problems (e.g., poor sanitation), and elevated levels of stress (19).  In addition, many African nations have inadequate publicly-funded health care coverage making income a major barrier to necessary medical care;
• Neglect and abuse – older persons are often more vulnerable to abuse and neglect than younger persons due to their physical and cognitive limitations. In some African nations, a relative lack of attention to the needs of older adults has led to elevated mental health concerns, loneliness, and suicide-related behaviour (20-22).

Societal changes in Africa relevant to population aging – Several African nations are in the intermediate stages of demographic transition where fertility rates and mortality decline, but this change has been at a slower rate than in other parts of the world. That said, there is considerable diversity within African regions. For example, the projected rate for fertility in 2050 for southern Africa is 1.9 compared to 3.6 in middle Africa (7). Life expectancy at 60 varied from a high of 21.9 years in Algeria to a low of 13.3 in Sierra Leone in 2016 (7). This means that there will also be great heterogeneity in Africa with respect to the percentage of the population aged 60 or more. For example, Tunisia has 13.5% of its population over 60 compared to Uganda, which has only 3.6% in that age range. However, that equates to 1.6 million older Ugandans and that number will grow to 6.2 million within 30 years (23).

Aside from the demographic transitions affecting Africa, some important social changes are also underway. These include:

• Urbanization and migration - There is great diversity in the degree of urbanization between African nations. For example, 41% of older South Africans live in rural settings compared with 90% of Rwandans aged 60 and over (7). There are two factors that are increase the concentration of older adults in rural settings in many nations: i) movement of younger persons from rural to urban settings, mainly for economic reasons; and ii) emigration of younger persons from the country itself. These are important phenomena because they can lead to social isolation of older adults as family members leave, and they can reduce access to informal care that has been a traditional resource to meet the health needs of older adults;
• Changing family structures ­– As occurred elsewhere in the world, the reductions in family size may also sometimes translate to fewer informal supports in later life. The severe health and social impact of factors like HIV/AIDs may magnify this vulnerability;
• Changing social norms – A common feature of modernization in many societies is a change in the emphasis on filial responsibility for care of older persons. While many African nations would have had social norms dictating family responsibilities in caring for elders, some of these norms may be less ingrained for future generations (5, 9, 24). Even in high resource nations, the majority of home and community-based care is provided to older adults by family members (25, 26). The viability of community-based services is therefore dependent on access to support from family or friends.
• Gender differences – Women have longer life expectancies at all ages than men in most countries of the world and this is also true in Africa (7). This means that women are more like to survive to widowhood and are more likely to experience disabilities and multimorbid health conditions associated with aging. In addition, women in Africa often experience systematic disadvantages including greater poverty, lower education, lower literacy, and unequal access to and control of capital (5).

Health care in Africa – In high resource nations the per capita use of primary care and other forms of health care are substantially higher among older adults due to their higher needs for all types of care. However, in African nations, basic access to primary care is often severely limited for numerous reasons. Moreover, specific expertise in health care for older adults in primary care (as well as specialization in geriatric medicine and geriatric psychiatry) is almost completely absent. As with other points noted above, there is considerable heterogeneity in health care services between African nations. While the degree of their severity may vary, most African nations share the following key health care challenges:

• Severe lack of health human resources – SSA has about 11% of the global population and about one quarter of the world’s disease burden, but it has only 3% of the world’s health workforce. (27) More than three quarters of African nations faced critical physician shortages in 2006 compared with about 14% of countries in the rest of the world (27). In the 1980’s the differential between SSA and high resource nations was stark with respect to health human resources. For example, each physician served 10,800 persons compared with 300 in high resource nations (28). The corresponding numbers per nurse were 2,100 persons in Africa compared with 170 in high resource nations. This situation has improved over time, but most African nations still face health human resource limitations. For example, based on World Health Organization workforce estimates between 2017-19 South Africa, Nigeria, and Rwanda had 7.9, 3.8 and 1.2 physicians per 10,000 persons, respectively, compared with 24.4 and 26.1/10,000 in Canada and the United States, respectively (29). In the same time period, the availability of nurses in Rwanda (9.5 per 10,000 persons) was about 1.5 times greater in Nigeria, five times greater in South Africa, 11 times greater in Canada and almost 16 times greater in the United States (29);
• Inadequate expertise in geriatrics - Only 4% of SSA medical programs included mandatory training in geriatrics (30). This is a major problem for two reasons. First, the complexity of geriatric patients requires careful attention to the interactions of multiple biomedical, psychosocial, functional, sensory, and environmental factors that can result in atypical manifestations of physical and mental health problems. These are made worse when misdiagnosis and avoidable errors in prescribing or medical treatment make older adults’ exacerbate underlying conditions (31). Second, most of the major geriatric syndromes and health problems affecting older adults cannot be tested with simple diagnostic procedures based on laboratory tests or diagnostic imaging. Cognitive impairment, disability, frailty, depression, pain, incontinence, falls, and caregiver distress require evaluation based on standardized, scientifically validated comprehensive geriatric assessments. Africa does not have the health human resources to conduct this type of testing using regulated health professionals in primary care;
• Affordability of available care – Where health care is available in Africa, it is often unaffordable to large portions of the population. High out-of-pocket expenses and sparsely available universal health coverage pose major financial barriers for impoverished individuals (32, 33).
• Non-person-centred approach to older adults – The lack of training in geriatric medicine/nursing means that care for older adults is often only disease-centred without attention to geriatric syndromes, frailty, functional status, or mental health. In addition, older adults are often not regarded as priority cases within African health care settings (34). Consequently, this narrow approach to care is often ineffective in addressing underlying factors affecting older adults’ health.
• Inadequate health information systems and failures in health system integration – It is a fair criticism of most health care systems in high resource nations that electronic medical records in primary care are rudimentary and that health care providers across the continuum of care fail to function as a system (35). Given the vast lack of resources in most African nation’s health systems, these problems are dramatically worse in most countries in that continent. Care is provided in silos and longitudinal follow-up with patients is inadequate (36). 
• Geographic isolation and transportation costs – All the abovementioned concerns are more pronounced in less urbanized African nations and in rural regions of those countries with higher levels of urbanization. This means that persons in rural settings must either cope without health care services or they must travel substantial distances to receive necessary care. The costs and physical demands of distant travel may be prohibitive for many older adults (37, 38).

References

 1.            Kinsella, K, He, W. An Aging World: 2008. Washington, DC: US Government Printing Office; 2009. US Census Bureau. International Population Reports, PS95/09 2009;1.

2.            Centers for Disease, C, Prevention. Ten great public health achievements--United States, 1900-1999. MMWR Morbidity and mortality weekly report 1999;48(12):241-243.

3.            Dobriansky, PJ, Suzman, RM, Hodes, RJ. Why population aging matters: A global perspective. National Institute on Aging, National Institutes of Health, US Department of Health and Human Services, US Department of State 2007:1-32.

4.            Ogura, S, Jakovljevic, MM. Global population aging-health care, social and economic consequences. 6. Frontiers Media SA; 2018:335.

5.            Apt, NA. Aging in Africa: Past experiences and strategic directions. Ageing International 2012;37(1):93-103.

6.            Aboderin, IAG, Beard, JR. Older people's health in sub-Saharan Africa. The Lancet 2015;385(9968):e9-e11.

7.            He, W, Aboderin, I, Adjaye-Gbewonyo, D. Africa aging: 2020. US Government Printing Office; 2020.

8.            World Health, O. World report on ageing and health. World Health Organization, 2015.

9.            Makoni, S. Aging in Africa: A critical review. Journal of Cross-Cultural Gerontology 2008;23(2):199-209.

10.          Sutorius, FL, Hoogendijk, EO, Prins, BA, et al. Comparison of 10 single and stepped methods to identify frail older persons in primary care: diagnostic and prognostic accuracy. BMC Fam Pract 2016;17:102.

11.          Nunes, BP, Flores, TR, Mielke, GI, et al. Multimorbidity and mortality in older adults: A systematic review and meta-analysis. Arch Gerontol Geriatr 2016;67:130-138.

12.          Boutayeb, A. The double burden of communicable and non-communicable diseases in developing countries. Transactions of the Royal society of Tropical Medicine and Hygiene 2006;100(3):191-199.

13.          Boutayeb, A. The burden of communicable and non-communicable diseases in developing countries. Handbook of disease burdens and quality of life measures 2010:531.

14.          Bigna, JJ, Ndoadoumgue, AL, Nansseu, JR, et al. Global burden of hypertension among people living with HIV in the era of increased life expectancy: a systematic review and meta-analysis. Journal of Hypertension 2020;38(9):1659-1668.

15.          Moraes, RPd, Casseb, J. Depression and adherence to antiretroviral treatment in HIV-positive men in São Paulo, the largest city in South America: Social and psychological implications. Clinics 2017;72:743-749.

16.          Munyandamutsa, N, Mahoro Nkubamugisha, P, Gex-Fabry, M, et al. Mental and physical health in Rwanda 14 years after the genocide. Social psychiatry and psychiatric epidemiology 2012;47(11):1753-1761.

17.          Rieder, H, Elbert, T. Rwanda–lasting imprints of a genocide: trauma, mental health and psychosocial conditions in survivors, former prisoners and their children. Conflict and health 2013;7(1):1-13.

18.          Hagan, J, Schoenfeld, H, Palloni, A. The science of human rights, war crimes, and humanitarian emergencies. Annual Review of Sociology 2006:329-349.

19.          Ogwumike, FO, Aboderin, I. Exploring the links between old age and poverty in anglophone West Africa: evidence from Nigeria and Ghana. Generations Review 2005;15(2):7-15.

20.          Bigala, P, Ayiga, N. Prevalence and predictors of elder abuse in Mafikeng Local Municipality in South Africa. African Population Studies 2014:463-474.

21.          Chane, S, Adamek, ME. Factors contributing to elder abuse in Ethiopia. The Journal of Adult Protection 2015;17(2):99-110.

22.          Gyasi, RM. COVID-19 and mental health of older Africans: an urgency for public health policy and response strategy. International Psychogeriatrics 2020;32(10):1187-1192.

23.          Molsd, U. The State of Older Persons in Uganda. Situational analysis report Ministry of Labour and Social Development Uganda 2020.

24.          Essuman, A, Agyemang, FA, Mate-Kole, CC. Long-term care for older adults in Africa: Whither now? Journal of the American Medical Directors Association 2018;19(9):728-730.

25.          Health Council of, C. Seniors in need, caregivers in distress: What are the home care priorities for seniors in Canada? : Health Council of Canada Toronto; 2012.

26.          World Health, O. Towards long-term care systems in sub-Saharan Africa. World Health Organization, 2017.

27.          Elkhalifa, GO. The current crisis in human resources for health in Africa. South Sudan Medical Journal 2014;7(1):7-8.

28.          Huddart, J, Picazo, O, Duale, S. The health sector human resource crisis in Africa: an issues paper. United States Agency for International Development, Bureau for Africa, Office of Sustainable Development Washington, DC 2003.

29.          Organization, WH. Global Health Workforce Statistics Database; 2022. https://www.who.int/data/gho/data/themes/topics/health-workforce. Accessed 2022-08-05 2022.

30.          Frost, L, Liddie Navarro, A, Lynch, M, et al. Care of the elderly: Survey of teaching in an aging sub-Saharan Africa. Gerontology & geriatrics education 2015;36(1):14-29.

31.          Onder, G, Vetrano, DL. The complexity of the geriatric patient. In: Learning Geriatric Medicine. Springer, 2018.

32.          Enabulele, O. Achieving universal health coverage in Nigeria: moving beyond annual celebrations to concrete address of the challenges. World Medical & Health Policy 2020;12(1):47-59.

33.          Wagstaff, A, Neelsen, S. A comprehensive assessment of universal health coverage in 111 countries: a retrospective observational study. The Lancet Global Health 2020;8(1):e39-e49.

34.          Kelly, G, Mrengqwa, L, Geffen, L. “They don’t care about us”: older people’s experiences of primary healthcare in Cape Town, South Africa. BMC geriatrics 2019;19(1):1-14.

35.          Knebel, E, Greiner, AC. Health professions education: A bridge to quality. 2003.

36.          Oni, T, Mogo, E, Ahmed, A, et al. Breaking down the silos of Universal Health Coverage: towards systems for the primary prevention of non-communicable diseases in Africa. BMJ Global Health 2019;4(4):e001717.

37.          Adamek, ME, Gebremariam Kotecho, M, Chane, S, et al. Challenges and assets of older adults in Sub-Saharan Africa: Perspectives of gerontology scholars. Journal of Aging & Social Policy 2022;34(1):108-126.

38.          Stefanoni, S, Bukuluki, P, Williamson, C, et al. SOCIAL PROTECTION AND ACCESS TO HEALTH SERVICES.

Our solution

Our solution sets the foundation for a novel primary care performance measurement system focussed on the complex health needs of older adults in 10+ African nations. We will work with community-based organizations using lay health assessors to deploy self-reported comprehensive geriatric assessments. This will provide essential clinical information about older persons combined with evidence-based person-centred care planning protocols and performance measurement systems for benchmarking quality of care at the organizational, regional, and cross-national levels.

Lay health assessors

The reality of the current health human resource crisis in Africa is that it would take several decades to expand and train enough nurses and physicians to meet the current and future primary care needs of older adults. The low priority allocated to care of older adults to date means that such an initiative is unlikely to keep pace with the accelerated rate of population aging in the continent.

The solution is to draw from the large existing base of older lay persons in Africa who wish to remain in the paid labour force. We will train those with the appropriate background to become lay health assessors using standardized assessment tools developed by the interRAI research network (www.interRAI.org). The major considerations in this strategy are:

• Role – The lay health assessors will work with primary care organizations to conduct in-person interviews with older patients as a first level of screening and geriatric assessment. They will obtain actionable health information that will be used by primary care health professionals as part of their clinical decision-making;
• Background – Assessors will not be required to have any prior training as a regulated health professional. Instead, they must have strengths in the following areas: literacy levels, interpersonal interaction, and verbal communication. The assessors should be regarded as having good standing in the community and have a capacity to establish trust with older adults and their family members. As examples, the current lay assessors involved in South African projects include retirees with the following backgrounds: librarian, accountant, factory floor supervisor;
• Gender – Assessors will work in teams of two – one male and one female. This allows flexibility for dealing with the full patient population and also provides some security for assessors as they reach out to communities with varying economic circumstances;
• Cultural considerations and language – Assessors will reflect the cultural communities in which they function. The training will include basic guidelines on cultural competency as part of interviewing skills; however, the expectation is that in most cases the cultural backgrounds of assessors and patients will match. In addition, while the interviewers will have appropriate literacy levels, ability to read will not be expected of patients. Instead, the assessors will conduct interviews in the language of the person being assessed;
• Training – All assessors will be trained in the following key areas: i) basic interviewing skills; ii) cultural competence; iii) protocols for administering, recording, and transmitting assessment results; iv) safety protocols; v) consent procedures; vi) patient confidentiality; and vii) response to cases where there are medical or psychiatric emergencies or instances of abuse and neglect;
• Oversight – All assessors will work with and report to a primary health care organization with appropriate access to regulated health professionals. A team coordinator will provide oversight of all assessors to ensure that assessment protocols are adhered to, data quality and completeness are ensured, and that assessments are completed in a timely and appropriate manner. In addition, the assessments will be shared within the patient’s circle of care with their primary care team and assessors will be available to the primary care team should they require clarification on any observations noted in the assessments.

Target population

The PAULAS project will be undertaken in at least 10 African nations as a starting point. We have already completed successful pilots in South Africa (more than 6,000 assessments), Nigeria (300 assessments), and Uganda (120) assessments. Our team members have already confirmed the intent to participate in the initiative by sites in the following regions of Africa:

• Northern Africa – Egypt, Sudan
• Eastern Africa – Ethiopia, Kenya, Rwanda, Tanzania, Uganda
• Southern Africa – Namibia, South Africa
• Western Africa – Benin, Nigeria

As a general guideline, we will focus on community-based adults aged 60 years and older who are receiving primary care services. We will be flexible to allow cases where it might be appropriate to use the assessment strategy with somewhat younger individuals where it is clinically justifiable (e.g., aged 50+ with physical or cognitive disabilities). In addition, given that there is not a singular model of primary care in Africa, we will target a diverse range of settings where such services might be provided. Examples include primary care clinics, older adult community settings, outreach programs, HIV/AIDS clinics, and hospital outpatient services.

Comprehensive assessment

The interRAI Check Up  Self-report (CUSR) system (39) will be used by all lay health assessors completing assessments as part of the PAULAS project. interRAI is an international not-for-profit research network focused on the development and application of assessment and screening systems to improve the quality of care and quality of life of vulnerable persons of all ages across care settings (40, 41). interRAI has developed a suite of clinician-led assessments that are widely used in high resource nations for nursing home, home care, mental health, and palliative care settings (42-47). For example, in Canada over 20 million interRAI assessments have been completed on over 6 million unique Canadians as part of the Pan-Canadian implementation of these instruments with the support of the Canadian Institute for Health Information (CIHI) (48).

While most of interRAI’s assessment systems are designed for use by health professionals, the CUSR is designed to be either self-administered or completed through interviews with a lay interviewer or family member. Some of the important features of the CUSR are as follows:

• Self-report vs clinician-led assessment – Although clinicians can use the CUSR as part of their practice, there is no requirement for the interviewer to be a regulated health profession. The interviewer does not apply clinical judgement to evaluate the person’s health status. Instead, the instrument relies on a fixed narrative of standardized questions and response sets (akin to a survey questionnaire) and the interviewer records only the person’s response. In cases where the person is unable to respond (e.g., due to cognitive impairment) answers from family members can be acceptable;
• Clinical issues addressed – The CUSR is designed to detect medical, functional and mental health problems most likely to be encountered in primary care settings. Therefore, it does not cover the full range of clinical measures covered in the 350-item interRAI Home Care assessment, which can take about an hour for a clinician to complete. The CUSR includes about 90 items and takes about half an hour to complete on average (49). The CUSR measures the following issues to address the double burden of infectious and chronic disease:
  • Sociodemographics (e.g., marital status, living arrangements);
  • Cognitive function (e.g., memory, decision-making);
  • Communication and sensory perception (e.g., making self understood, vision, hearing);
  • Mental health (e.g., depression, anxiety, loneliness);
  • Social relationships (e.g., confidante, informal support system, community engagement);
  • Functional status (e.g., dressing, bathing, locomotion, continence, meal preparation, managing medications, transportation use);
  • Acute and chronic health indicators and medical symptoms (e.g., falls, fatigue, shortness of breath, pain, infection, gastrointestinal symptoms);
  • Diagnoses and treatment (e.g., tuberculosis, hypertension, heart failure);
  • Nutritional status (e.g., weight loss, loss of appetite);
  • Poverty and psychosocial stressors;
• Scientific rigor – interRAI has over 30 years of experience in developing geriatric assessment instruments for a wide range of settings. These instruments have been subject to extensive testing for reliability and validity (50-63). These instruments are designed to form an integrated health information system providing a longitudinal clinical record that follows the person across care settings (41, 45, 54, 64-66). The CUSR differs from those instruments in that it relies on self-report only, whereas the clinician-led assessments use all sources of information, including but not limited to self-report. Therefore, it is important that studies in both South Africa and Canada established the reliability and validity of the CUSR in community settings as well as its compatibility with other interRAI systems (39, 49). Recent not-yet-published research in Uganda has replicated these findings. As part of the PAULAS project, we will continue efforts to evaluate the reliability and validity of the CUSR in all participating African nations where this has not yet been done;
• Data collection strategy and IT requirements – Although it is possible for persons to self-administer the CUSR on a mobile or laptop device, the PAULAS project will utilize lay assessors mainly because of literacy concerns and need for data completeness. We will use tablets or smartphones as the data collection devices. The commercial grade software we will deploy (provided by industry partner RAISoft) will allow offline completion of the assessment where cellular or internet access is not available. When assessors return to their home organization, assessments that were completed off-site will automatically download to the organization’s secure health record system. We have already deployed this approach successfully with organizations in Cape Town and surrounding towns;
• More than a survey – The interRAI CUSR differs from a conventional health survey in several ways. First, it is designed to provide clinically actionable information not just summarize health status. Second, it has much greater precision in its measures than more simplistic tools such as the EQ-5D (https://euroqol.org/), which only provides a crude measure  of health-related quality of life. For example, the CUSR includes standardized time frames, inclusion/exclusion criteria, definitions of concepts, conceptual anchor points for responses, and examples to illustrate what is being asked. In contrast, measures that simply rely on undefined gradations of severity ratings lack the necessary validity for clinical use. That said, the previously mentioned studies also demonstrated the feasibility and lay acceptability of the more sophisticated CUSR survey for both Canadian and South African older adults (39, 49). Third, the CUSR system includes numerous decision-support algorithms that can be used to trigger actions and can inform clinician and management decision-making. In other words, unlike conventional health surveys, the CUSR makes you do something in response to the assessment (see CAPs described below);
• Translations and cultural adaptations – interRAI instruments have been translated into numerous languages as part of their development. In addition to the existing English version, we have already completed full translations of the CUSR with independent back translations to confirm validity in the following languages: Arabic, Afrikaans, Dendi, French, Hausa, Igbo, IsiXhosa, IsiZulu, Kiswahili, Luganda, Nago, and Yoruba (Benin and Nigerian variants). Amharic and Kinyarwanda translations are in process. An important feature of the software to be used in the PAULAS project is the ease with which reports from the CUSR can be switched between languages. This provides flexibility for use in multilingual regions. In addition to the translations of the standard items, we will allow for cultural adaptations in item content and examples for country-specific requirements. This may include addition of a limited set of new items and deletion or modification of up to 5% of items that are not appropriate within a country. Also, as part of the project we will carry out qualitative interviews with the lay health assessors to further examine feasibility and acceptability issues on a country-by-country basis;
• Timing of assessments – The CUSR will initially be completed prior to the person’s next primary care visit (if one is scheduled). The purpose will be to provide clinically relevant information that can inform the discussion with the primary care provider’s interaction with the patient and development of a care plan (see below). In addition, we will complete at least one follow-up assessment with random assignments to follow-up times of six months, one year, and 18 months to determine optimal reassessment time frames. However, we will also allow for unscheduled reassessments if there has been clinically significant change in the person’s health that must be considered by the primary care team. This work will be relevant because it sets the stage for practice standards for use of the CUSR as a patient-reported outcome measure (PROM) as part of routine clinical follow-up and for outcome indicators in a primary care performance measurement system. Related to this, our project will include the establishment of tracking protocols to allow longitudinal follow-up of individual cases and record linkage of follow-up assessments. This is particularly important for the African context where patients may be geographically dispersed, have unstable housing, or may be in transit to other regions.

Clinical applications: Primary care interventions after assessment

Our solution is not limited to simply gathering data. Comprehensive assessment is the first step in geriatric medicine (67); however, it is not a sufficient step to fully realize improvements in the quality of care. The next step is to enact person-centred interventions as part of a shared decision-making approach that builds on the person’s strengths, preferences, and needs. The aim of interRAI systems is to support early intervention to prevent avoidable decline, support recovery from acute problems, and mitigate impact of frailty and disability of subsequent health outcomes. As with other interRAI assessments, the CUSR includes a series of care planning tools, known as Clinical Assessment Protocols (CAPs) (68-70), that utilize the assessment results and scientifically validated triggering algorithms to identify care planning needs in the following domain areas:

• Activities of daily living (basic physical functioning)
• Cardiorespiratory health
• Cognition
• Communication
• Dehydration
• Falls
• Instrumental activities of daily living (e.g., meal preparation)
• Mood
• Pain
• Physical activity
• Smoking
• Social Function
• Urinary incontinence

Each CAP includes the following components: background information about the problem triggered; goals of care; triggering rules to identify persons who are at moderate or high risk of adverse outcomes; list of more detailed clinical issues to address beyond those covered in initial assessment, guidelines of interventions and treatments that may be considered in response to problem, reference materials from current literature. In that regard, one can also regard the PAULAS project as one where primary care clinicians receive tools and training to enhance their ability to assess and respond to key geriatric syndromes and conditions. An important finding from our recent Ugandan pilots was that the CUSR raised awareness among clinicians of a broad range of previously unaddressed health concerns faced by their older patients.

In addition to the CAPs, the CUSR includes measurement scales and algorithms for decision-support related to health system management. For example, it includes clinical severity scales for frailty, cognitive impairment, health related quality of life, physical disability, pain, depression, and medical complexity than can be used for referrals or for service eligibility determination (71-74). In addition, it includes risk scales to predict hospitalization, emergency department visits, and mortality (75-79). At the organization level, these measures can be used for population need analysis.

Telehealth applications

interRAI’s clinician-led assessments have been shown to have great utility in supporting telemedicine services for older persons requiring specialized geriatric care (58, 80, 81). The CUSR has the same potential for use in telemedicine because it provides comprehensive clinical summaries that can be used by specialized health professionals and clinicians in primary care. In addition, interRAI has collaborated with health informatics experts to ensure interoperability of interRAI systems with international standards such as Health Level-7 (HL-7©) and Fast Healthcare Interoperability Resources (FHIR©). This will permit effective exchange between interRAI CUSR assessments done by lay assessors and the electronic medical record in primary care. This type of functionality may not yet be available in all African nations, but the PAULAS project will help lay the foundation for information standards to support this function in the future.

An essential principle underlying this work is that the clinical assessment information will follow the person. Information stored in secure data repositories can be shared within the circle of care irrespective of where the person’s primary care services are provided over time. In addition, the use of electronic records rather than paper-based charts ensures that the assessment data are usable longitudinally and that access to the data is feasible in the context of emergencies.

Management and policy applications: Performance measurement system

The WHO has stated that all nations of the world should establish metrics for older person’s health. Our aim is to create a system that goes beyond simple description of crude health indicators like life expectancy to having scientifically sound measures of the quality of primary care received by older persons. Mortality is a convenient and necessary measure of health system performance, but it is not sufficient to describe quality of care of older adults.

interRAI has almost three decades of experience in developing performance measurement systems based on the point-of-care data gathered through assessments completed by front-line health care staff. This approach is cost-effective because it allows for data to be gathered once but used for multiple purposes by multiple audiences. Patients and clinicians benefit from the data because they can inform care planning decisions. Service providers, managers and policy makers benefit because their secondary use of the data can be used to identify needs, monitor quality of care, allocate resources, and establish equitable funding methods (40, 48, 65, 82-86). In addition, data that are used for many purposes by different stakeholders can improve data quality. This is because alternative uses create disincentives to manipulate data for a given application (e.g., funding) and their shared use increases expectations from all parties for data accuracy.

The PAULAS project will begin with implementation of the CUSR as a clinical assessment system that will be used in normal clinical practice. However, those data will also be pooled at the organization-level to form the basis for a preliminary primary care performance measurement system for older adults in Africa. Some specific considerations include:

• Pan-African scope – Participation of diverse care settings in multiple African nations is an essential feature of the PAULAS project. First, there is tremendous heterogeneity within Africa in terms of culture, language, health system development, population aging, health human resources, and models of primary care service delivery. Success or failure in one country may not apply to the rest of Africa. Second, the capacity to benchmark health system performance with other countries is essential for progress because it provides a “natural policy experiment”. When only local comparisons are made, ingrained practice patterns may result in little or no variance in performance and a consequent inability to detect promising (or problematic) approaches to care.  Third, quality comparisons between high resource and low resource nations may be of limited use. The overwhelming differential in resources may feel “unfair” to the extent that motivation to improve quality is lost when poor nations are benchmarked against wealthy countries. Instead, benchmarking with other African nations can point to what is possible in peer nations where approaches to care may differ but resources are comparable;
• Data warehouses and reporting systems – For this stage of research we will establish two data centres to manage deidentified data arising from implementation of the CUSR in Africa. The Samson Institute for Aging Research in Cape Town will serve as the main African data centre. The interRAI Canada team at the University of Waterloo currently manage one of two international data centres for interRAI, and they will house the second secure server for PAULAS at that site. Teams from both centres will collaborate establish secure data transfer and reporting protocols. In addition, they will provide secure access to the PAULAS data for approved analysts from the various teams of collaborators in Africa. Given the more than two decades of experience working with CIHI on national performance measurement systems for home care, long-term care and mental health, the University of Waterloo will take a leadership role in establishing the quality benchmarking and performance standards for data arising from the CUSR. It should be noted that all primary care teams will have access to the data for their own patients and all African teams will have access to the deidentified data gathered in their own countries. The pooled multinational data repository will be subject to oversight by the lead investigators for the PAULAS project;
• Types of indicators - An effective performance measurement system must include different types of indicators to inform policy, practice, and service delivery. Quality indicators typically include structure and process measures, but rarely include outcome-based measures. The CUSR will provide the data needed to support a wide range of risk-adjusted outcome measures for benchmarking quality. interRAI has already developed such indicators for home care (87, 88), nursing homes (89), post-acute care (90), mental health (91), and palliative care (92). In addition, other indicators can be used for population level needs analysis and for describing resource intensity of clients with complex care needs (93). A further management application of these data is their use as part of an emergency management strategy for vulnerable persons at risk of adverse outcomes during disasters (94);
• International scalability and applicability – interRAI already has a robust history of cross-national comparisons in high resource nations (40, 95-102) but this will be the first multinational benchmarking effort for older adults in low and middle resource nations. If the PAULAS initiative succeeds, it may set the stage for scale and application to other nations with limited resources in South and Central American and in Asia. 

References (continued from previous section)

39.          Kelly, G, Geffen, LN, Morris, JN, et al. Establishing the criterion validity of the interRAI Check-Up Self-Report instrument. 2020.

40.          Carpenter, GI, Hirdes, JP. Using interRAI assessment systems to measure and maintain quality of long-term care. In: A good life in old age? Monitoring and improving quality in long-term care. Vol 28. Paris: OECD Publishing, 2013.

41.          Heckman, GA, Gray, LC, Hirdes, JP. Addressing health care needs for frail seniors in Canada: the role of interRAI instruments. 2013.

42.          Gray, LC, Berg, K, Fries, BE, et al. Sharing clinical information across care settings: the birth of an integrated assessment system. BMC Health Serv Res 2009;9:71.

43.          Hirdes, JP, Ljunggren, G, Morris, JN, et al. Reliability of the interRAI suite of assessment instruments: a 12-country study of an integrated health information system. BMC Health Serv Res 2008;8:277.

44.          Hirdes, JP, van Everdingen, C, Ferris, J, et al. The interRAI Suite of Mental Health Assessment Instruments: An Integrated System for the Continuum of Care. Front Psychiatry 2019;10:926.

45.          Morris, JN, Berg, K, Fries, BE, et al. Scaling functional status within the interRAI suite of assessment instruments. BMC Geriatr 2013;13:128.

46.          Rolfson, DB, Heckman, GA, Bagshaw, SM, et al. Implementing Frailty Measures in the Canadian Healthcare System. J Frailty Aging 2018;7(4):208-216.

47.          Stewart, SL, Celebre, A, Semovski, V, et al. The interRAI Child and Youth Suite of Mental Health Assessment Instruments: An Integrated Approach to Mental Health Service Delivery. Frontiers in Psychiatry 2022;13.

48.          Hirdes, JP, Mitchell, L, Maxwell, CJ, et al. Beyond the 'iron lungs of gerontology': using evidence to shape the future of nursing homes in Canada. Can J Aging 2011;30(3):371-390.

49.          Iheme, L, Hirdes, JP, Geffen, L, et al. Psychometric Properties, Feasibility, and Acceptability of the Self-Reported interRAI Check-Up Assessment. Journal of the American Medical Directors Association 2021.

50.          Betini, RSD, Hirdes, JP, Curtin-Telegdi, N, et al. Development and validation of a screener based on interRAI assessments to measure informal caregiver wellbeing in the community. BMC Geriatr 2018;18(1):310.

51.          Gambassi, G, Landi, F, Peng, L, et al. Validity of diagnostic and drug data in standardized nursing home resident assessments: potential for geriatric pharmacoepidemiology. SAGE Study Group. Systematic Assessment of Geriatric drug use via Epidemiology. Med Care 1998;36(2):167-179.

52.          Gray, LC, Beattie, E, Boscart, VM, et al. Development and Testing of the interRAI Acute Care: A Standardized Assessment Administered by Nurses for Patients Admitted to Acute Care. Health Serv Insights 2018;11:1178632918818836.

53.          Hawes, C, Morris, JN, Phillips, CD, et al. Reliability estimates for the Minimum Data Set for nursing home resident assessment and care screening (MDS). Gerontologist 1995;35(2):172-178.

54.          Hirdes, JP, Ljunggren, G, Morris, JN, et al. Reliability of the interRAI suite of assessment instruments: a 12-country study of an integrated health information system. BMC health services research 2008;8(1):277.

55.          Hirdes, JP, Poss, JW, Caldarelli, H, et al. An evaluation of data quality in Canada's Continuing Care Reporting System (CCRS): secondary analyses of Ontario data submitted between 1996 and 2011. BMC Med Inform Decis Mak 2013;13:27.

56.          Hogeveen, SE, Chen, J, Hirdes, JP. Evaluation of data quality of interRAI assessments in home and community care. BMC Med Inform Decis Mak 2017;17(1):150.

57.          Martin, L, Hirdes, JP, Fries, BE, et al. Development and Psychometric Properties of an Assessment for Persons With Intellectual Disability—The interRAI ID. Journal of Policy and Practice in Intellectual Disabilities 2007;4(1):23-29.

58.          Martin-Khan, MG, Edwards, H, Wootton, R, et al. Reliability of an Online Geriatric Assessment Procedure Using the interRAI Acute Care Assessment System. J Am Geriatr Soc 2017;65(9):2029-2036.

59.          Poss, JW, Jutan, NM, Hirdes, JP, et al. A review of evidence on the reliability and validity of Minimum Data Set data. Healthcare Management Forum 2008;21:33-39.

60.          Morris, JN, Fries, BE, Steel, K, et al. Comprehensive clinical assessment in community setting: applicability of the MDS‐HC. Journal of the American Geriatrics Society 1997;45(8):1017-1024.

61.          Morris, JN, Howard, EP, Steel, K, et al. Updating the Cognitive Performance Scale. Journal of Geriatric Psychiatry and Neurology 2016;29(1):47-55.

62.          Sgadari, A, Morris, JN, Fries, BE, et al. Efforts to establish the reliability of the Resident Assessment Instrument. Age Ageing 1997;26 Suppl 2:27-30.

63.          Kim, H, Jung, YI, Sung, M, et al. Reliability of the interRAI Long Term Care Facilities (LTCF) and interRAI Home Care (HC). Geriatr Gerontol Int 2015;15(2):220-228.

64.          Gray, LC, Berg, K, Fries, BE, et al. Sharing clinical information across care settings: the birth of an integrated assessment system. BMC Health Services Research 2009;9(1):1-10.

65.          Hirdes, JP, Fries, BE, Morris, JN, et al. Integrated health information systems based on the RAI/MDS series of instruments. Healthcare Management Forum 1999;12(4):30-40.

66.          Hirdes, JP, Kehyayan, V. Long-term care for the elderly in Canada: progress towards an integrated system. In: Mor, V, Leone, T, Maresso, A, eds. Regulating long-term care quality: An international comparison. Cambridge: Cambridge University Press, 2014.

67.          Stuck, AE, Iliffe, S. Comprehensive geriatric assessment for older adults. 343. British Medical Journal Publishing Group; 2011.

68.          Fries, BE, Morris, JN, Bernabei, R, et al. Rethinking the Resident Assessment Protocols. J Am Geriatr Soc 2007;55(7):1139-1140.

69.          Martin, L, Hirdes, JP, Morris, JN, et al. Validating the Mental Health Assessment Protocols (MHAPs) in the Resident Assessment Instrument Mental Health (RAI-MH). J Psychiatr Ment Health Nurs 2009;16(7):646-653.

70.          Mathias, K, Hirdes, JP, Pittman, D. A care planning strategy for traumatic life events in community mental health and inpatient psychiatry based on the InterRAI assessment instruments. Community Ment Health J 2010;46(6):621-627.

71.          Morris, JN, Carpenter, I, Berg, K, et al. Outcome measures for use with home care clients. Canadian Journal on Aging/La Revue canadienne du vieillissement 2000;19(S2):87-105.

72.          Sinn, CJ, Betini, RSD, Wright, J, et al. Adverse Events in Home Care: Identifying and Responding with interRAI Scales and Clinical Assessment Protocols. Can J Aging 2018;37(1):60-69.

73.          Sinn, CJ, Jones, A, McMullan, JL, et al. Derivation and validation of the Personal Support Algorithm: an evidence-based framework to inform allocation of personal support services in home and community care. BMC Health Serv Res 2017;17(1):775.

74.          Sinn, C-LJ, Heckman, G, Poss, JW, et al. A comparison of 3 frailty measures and adverse outcomes in the intake home care population: a retrospective cohort study. Canadian Medical Association Open Access Journal 2020;8(4):E796-E809.

75.          Costa, AP, Hirdes, JP, Heckman, GA, et al. Geriatric syndromes predict postdischarge outcomes among older emergency department patients: findings from the interRAI Multinational Emergency Department Study. Acad Emerg Med 2014;21(4):422-433.

76.          Costa, AP, Hirdes, JP, Bell, CM, et al. Derivation and validation of the detection of indicators and vulnerabilities for emergency room trips scale for classifying the risk of emergency department use in frail community‐dwelling older adults. Journal of the American Geriatrics Society 2015;63(4):763-769.

77.          Gray, LC, Peel, NM, Costa, AP, et al. Profiles of older patients in the emergency department: findings from the interRAI Multinational Emergency Department Study. Ann Emerg Med 2013;62(5):467-474.

78.          Hirdes, JP, Frijters, DH, Teare, GF. The MDS-CHESS scale: a new measure to predict mortality in institutionalized older people. J Am Geriatr Soc 2003;51(1):96-100.

79.          Hirdes, JP, Poss, JW, Mitchell, L, et al. Use of the interRAI CHESS scale to predict mortality among persons with neurological conditions in three care settings. PLoS One 2014;9(6):e99066.

80.          Gray, L, Wootton, R. Comprehensive geriatric assessment 'online'. Australas J Ageing 2008;27(4):205-208.

81.          Gray, LC, Fatehi, F, Martin-Khan, M, et al. Telemedicine for Specialist Geriatric Care in Small Rural Hospitals: Preliminary Data. J Am Geriatr Soc 2016;64(6):1347-1351.

82.          Hirdes, JP, Poss, JW, Curtin-Telegdi, N. The Method for Assigning Priority Levels (MAPLe): a new decision-support system for allocating home care resources. BMC medicine 2008;6(1):9.

83.          Björkgren, MA, Fries, BE, Shugarman, LR. A RUG-III case-mix system for home care. Canadian Journal on Aging/La Revue Canadienne du Vieillissement 2000;19(S2):106-125.

84.          Fries, BE, Schneider, DP, Foley, WJ, et al. Refining a case-mix measure for nursing homes: Resource Utilization Groups (RUG-III). Med Care 1994;32(7):668-685.

85.          Fries, BE, Schroll, M, Hawes, C, et al. Approaching cross-national comparisons of nursing home residents. Age and Ageing 1997;26(suppl_2):13-18.

86.          Morris, JN, Berg, K, Topinkova, E, et al. Developing quality indicators for in-patient post-acute care. BMC Geriatr 2018;18(1):161.

87.          Hirdes, JP, Fries, BE, Morris, JN, et al. Home care quality indicators (HCQIs) based on the MDS-HC. The Gerontologist 2004;44(5):665-679.

88.          Morris, JN, Fries, BE, Frijters, D, et al. interRAI home care quality indicators. BMC Geriatr 2013;13:127.

89.          Jones, RN, Hirdes, JP, Poss, JW, et al. Adjustment of nursing home quality indicators. BMC Health Serv Res 2010;10:96.

90.          Fries, BE, Morris, JN, Aliaga, P, et al. Risk adjusting outcome measures for post-acute care. Am J Med Qual 2003;18(2):66-72.

91.          Perlman, CM, Hirdes, JP, Barbaree, H, et al. Development of mental health quality indicators (MHQIs) for inpatient psychiatry based on the interRAI mental health assessment. BMC Health Serv Res 2013;13:15.

92.          Guthrie, DM, Harman, LE, Barbera, L, et al. Quality Indicator Rates for Seriously Ill Home Care Clients: Analysis of Resident Assessment Instrument for Home Care Data in Six Canadian Provinces. J Palliat Med 2019.

93.          Turcotte, LA, Poss, J, Fries, B, et al. An Overview of International Staff Time Measurement Validation Studies of the RUG-III Case-mix System. Health services insights 2019;12:1178632919827926.

94.          van Solm, AIT, Hirdes, JP, Eckel, LA, et al. Using standard clinical assessments for home care to identify vulnerable populations before, during, and after disasters. J Emerg Manag 2017;15(6):355-366.

95.          Foebel, AD, van Hout, HP, van der Roest, HG, et al. Quality of care in European home care programs using the second generation interRAI Home Care Quality Indicators (HCQIs). BMC Geriatr 2015;15:148.

96.          van Lier, LI, van der Roest, HG, Oosten, BS, et al. Predictors of Societal Costs of Older Care-Dependent Adults Living in the Community in 11 European Countries. Health Serv Insights 2019;12:1178632918820947.

97.          Foebel, AD, Liperoti, R, Onder, G, et al. Use of Antipsychotic Drugs Among Residents With Dementia in European Long-Term Care Facilities: Results From the SHELTER Study. Journal of the American Medical Directors Association 2014;15(12):911-917.

98.          Frijters, DH, van der Roest, HG, Carpenter, IG, et al. The calculation of quality indicators for long term care facilities in 8 countries (SHELTER project). BMC Health Serv Res 2013;13:138.

99.          Onder, G, Carpenter, I, Finne-Soveri, H, et al. Assessment of nursing home residents in Europe: the Services and Health for Elderly in Long TERm care (SHELTER) study. BMC Health Serv Res 2012;12:5.

100.        Garms-Homolova, V, Notthoff, N, Declercq, A, et al. Social and functional health of home care clients with different levels of cognitive impairments. Aging Ment Health 2017;21(1):18-23.

101.        van Lier, LI, van der Roest, HG, van Hout, HP, et al. Convergent validity of the interRAI-HC for societal costs estimates in comparison with the RUD Lite instrument in community dwelling older adults. BMC Health Serv Res 2016;16:440.

102.        Guthrie, DM, Declercq, A, Finne-Soveri, H, et al. The Health and Well-Being of Older Adults with Dual Sensory Impairment (DSI) in Four Countries. PLoS One 2016;11(5):e0155073.

A detailed description of the primary target population for the interRAI CUSR is provided in our response to previous sections for the problem statement and the description of the solution.

Our solution will yield a variety of positive effects for different stakeholders in the participating African nations:

• Older adults – The most important populations to benefit from this solution are older adults receiving primary care in the participating organizations in at least 10 African countries. Older persons are dramatically under-served in Africa because little attention has been paid to their health care needs historically, the health human resource crisis in Africa results in most of the very limited resources being directed at younger populations, there is scant training and expertise in care of older persons or geriatric medicine in African medical and nursing schools, and models of care have been largely ineffective in addressing the complex needs of geriatric patients in primary care. This solution will have a direct impact on the quality of care for older patients in primary care because it will lead to better identification of their needs through a comprehensive assessment and will trigger evidence-based interventions that are person-centred and designed to address their strengths, preferences and needs;  
• Family members – The traditional emphasis on family responsibility for care for older adults must be adapted in recognition of trends of urbanization and migration, changing family structures, and changing responsibilities related to care of older adults. The interRAI CUSR and its associated care planning protocols will support the mobilization of supports that are able to address the needs of older adults in a more cost effective manner than historic approaches to care that fail to consider the broader range of issues affecting geriatric patients and that sometimes worsen rather than alleviate the health problems of older adults. Family members will still need to be heavily involved in the care of older adults, but the use of this approach can reduce avoidable health declines, facilitate improvement in areas where interventions can be effective, and maintain function where possible. The care planning approach associated with interRAI systems engages family members as important partners in the shared decision-making process to ensure effective collaboration between health care providers and the informal support network;
• Primary care clinicians – Africa’s severe health human resource crisis has made it difficult to meet the health needs of the general population let alone older adults with complex health needs. Primary care clinicians typically do not have the time, resources or skill set to complete comprehensive geriatric assessments of their older patients. This solution will provide a scientifically validated approach to completing those assessments without the need for additional regulated health professional resources. Instead, lay assessors can complete high quality assessments that will yield clinically actionable information to the primary care team prior to the patient’s visit and as a follow-up to track outcomes over time. In addition, the training materials associated with interRAI systems will provide a rapid mechanism for enhancing the knowledge base of primary care clinicians in key principles of geriatric medicine and care of older adults;
• Health system managers­ – African nations have rudimentary health information systems dealing with the needs of older adults. Mortality rates and life expectancy are meaningful for health care planners, but they provide little information that is relevant to the day-to-day lives of older adults. They do not address quality of life, disability, mental health, functioning, community engagement, frailty, or functional status. All these measures are highly relevant to the patients who are alive and seeking care from primary care providers. The interRAI CUSR includes assessment and care planning protocols for each of these areas of need and provides evidence-based guidance to inform treatment and health management strategies. In addition, these data can be used for population level need determination to help managers seek appropriate resources for the population they serve and to evaluate the quality of care they are providing using scientifically sound outcome-based indicators;
• Policymakers and planners - WHO has put forth an expectation that all nations will put in place indicators to measure the health of older adults (103). The PAULAS project will support the development of advanced performance measurement tools that are comparable to those used in high resource nations, but at a dramatically lower cost using lay health assessors. The performance measurement systems based on indicators derived from the interRAI CUSR will include direct measures of clinical quality of care based on risk-adjusted outcome measures. In addition, these data can be aggregated in a manner to describe resource needs of populations served and they can be a basis for establishing standardized, needs-based eligibility criteria for new program serving older adults. All health policy makers are faced with the need to make complex choices about the health care provided to their population. This initiative will help provide a more effective, scientifically sound evidence-base to inform those decisions;
• Lay assessors - In many African nations, older adults must remain in the paid labour force because of the inadequacy or absence of pension systems. In high resource nations where the service sector plays a major role in the economy, health care is an important employer. For example, in Canada about 13% of GDP is spent on health care, with the bulk of expenditures allocated to health professionals. For African nations, the health human resource crisis cannot be readily solved by a massive influx of newly trained regulated health professionals. This project makes use of a valuable asset in the form of older adults with appropriate literacy and interpersonal skills to quickly add new capabilities in the health system. At the same time, the older adults gain an opportunity to obtain employment that allows them to make a meaningful, positive contribution to their community. This is consistent with the philosophy of initiatives promoted by renowned African gerontologist Nana Apt. She established a program in which older women in Ghana formed a benevolent community network to support elderly widows and divorced women to live in dignity and have their health needs met (5);
• Clinical and health services researchers – High resource nations can typically draw from extensive scientific communities with a diverse range of expertise to address complex health system challenges. In African nations, available scientific resources are sparser, and there are few experts with training in geriatrics, gerontology, or health services research. This project will bring together a multidisciplinary Pan-African network of young, highly qualified personnel to play leadership roles in this work in their respective home nations. In addition, they will have the opportunity to become actively involved in the interRAI network internationally. In other words, the PAULAS project includes the potential to dramatically boost the scientific resources of African nations with young researchers who will be supported by a well-established network of international researchers. The capacity built through this network will come at a time when African nations must urgently prepare for the rapid aging of their population that will occur within the next few decades.

interRAI has a proven track record of over 30 years of research on the development, implementation, and application of sophisticated geriatric assessment systems that are now widely implemented in North America, Europe, Asia, and Oceania. These systems have contributed to dramatic improvements in the quality of care in nursing home and home care settings in multiple nations. They have supported cross-national comparisons that have been essential sources of evidence to motive quality improvement initiatives in different countries. For example, in Canada, interRAI data were used to guide interventions to reduce the rate of physical restraint use in long term care homes. Those rates dropped from over 40% in the mid 1990s to below 5% today.

The PAULAS project builds on successful initial pilots of the interRAI CUSR in South Africa, Nigeria, and Uganda with the aim of transforming primary care for older adults using low-cost but scientifically sound assessment and care planning systems to drive improvements in care. Our team is co-led by senior interRAI researchers from Canada and Africa, including experts in geriatric medicine and primary care, health services research, quantitative research methods, epidemiology, and performance measurement. The team leaders include African researchers and clinicians with backgrounds in primary care and community medicine, nursing, psychology, gerontology, palliative care, mental health, and health communication. In each participating country, there is a country lead investigator who will plan an active role as part of the full PAULAS team. In addition, those individuals will be charged with recruiting sites within the participating countries and building a national subnetwork of collaborators to form the emerging Pan-African network. Our aim is not to conduct this work on a remote basis. Rather the aim is to build capacity within Africa of young African leaders who will bolster the scientific and clinical resources of the participating nations. We already have established team leads in South Africa, Namibia, Benin, Nigeria, Sudan, Kenya, Rwanda, and Uganda. Our African team members are in the final stages of discussion with likely partners in Ethiopia, Tanzania, and Egypt.

Our African team members are taking the lead in identifying the partner primary care organizations we will collaborate with in each country. They have provided oversight to the translation process for the interRAI CUSR and they will collaborate in the development of appropriate training materials for their country. In addition, they will give feedback to interRAI on any country-specific adaptations that must be made to the CUSR. They will also oversee qualitative evaluations with lay health assessors to make needed refinements to that instrument over time. In addition, they will collaborate with the full research team in development of the structure, process, and outcome indicators for the primary care to be used as part of the performance measurement system. They will participate fully in scientific report writing and knowledge translation to health care professionals including clinicians, managers, and policymakers.

This initiative will also greatly enhance interRAI’s capacity to conduct research in low and middle resource nations. It is expected that many of the African PAULAS collaborators will be appointed to the interRAI networks as Fellows of that collaborative. In turn, they would work with peers in other low and middle resource nations to translate their experiences to other countries. In that sense, this work will develop a network of young African researchers who will be equal partners in global health initiatives. This will provide them opportunities to take leadership roles in contributing to the international enhancement of health care for older adults. 

We are applying to the Novel Measurement for Performance Improvement Challenge for a variety of reasons. These include:

• Fit with expertise – Our research team includes a mixture of clinicians, health services researchers, and policy experts with direct experience in the development and use of performance measurement systems. The interRAI research network had been engaged in this type of research for almost 30 years and has seen successful adoption of its performance measurement tools in several high resource nations;
• Fit with organizational priorities – interRAI has had great success in obtaining funding for research and implementation of its systems in high resource nations in North America, Europe, Asia, and Oceania. However, the opportunity to support innovations in quality of care in low and middle resource nations is a very high priority for future work by our network;
• Unrecognized challenge of population aging – As noted in our statement of the problem, there has been a belief that population aging is primarily a concern for high resource nations. That has meant that governments and granting agencies have given little to no priority to efforts to prepare for this demographic change in regions like Africa. However, within a few decades the size of the older population in Africa will triple. The need to prepare for this imminent change is urgent. Based on the information session for applicants to this competition, innovations related to primary care for older persons is in scope for this challenge;
• Limited focus of national funding agencies – The COVID-19 pandemic and the relative lack of interest by national funding agencies of high resource nations in supporting international research means that funding for an under-recognized problem will not be readily obtained through traditional research granting agencies. The secondary impact of COVID-19 on the health system (e.g., staff shortages) is creating new health care crises that will become a priority for these agencies;
• Stage of work - In most cases, national research funding agencies require a track record of prior success, and their focus is often on clinical trials or pragmatic trials. The “chicken-or-egg” problem is that foundational work must occur before such trials can be attempted, but those national agencies generally do not wish to fund this early stage of work;
• Build on existing funding – The University of Waterloo provided $20,000 CAD in seed funding for the first steps of the PAULAS project through its Waterloo International office. In response, the interRAI Board of Directors approved up to $80,000 CAD in matching funding to support establishment of the PAULAS team, travel costs for planning meetings, and preliminary small-scale cross-sectional pilots in African sites. Our initial plan was to recruit sites in at least six countries, but interest in the project has rapidly exceeded that target. Therefore, our application to this challenge represents the next step in scaling our work to the point that it will yield adequate longitudinal data for benchmarking performance. 

Our solution is based on more than 30 years of international scientific collaboration, including pilot research in three African nations. It can have a dramatic, fast-moving impact on the quality of primary care for older adults in Africa at a relatively low cost because it involves:

• using lay health assessors as an inexpensive approach to the first point of assessment rather than regulated health professionals;
• comprehensive, person-centred geriatric assessment of the individual’s strengths, preferences, and needs;
• established care planning guidelines drawn from international best practices for geriatric care;
• big data analytics allowing cost-effective re-use of point-of-care data for multiple applications by multiple audience ranging from front-line clinical decision-making to population-level measurement of primary health care performance;
• straightforward training that makes the system easy to use and rapidly scalable;
• rigorous health information framework that allows assessments done by lay persons to articulate with electronic medical records as part of a longitudinal, clinical management strategy;
• simple, ready to use information technology that has already been deployed successfully in South Africa;
• partnerships with over 140 health researchers, clinicians, and policy experts from over 30 countries;
• opportunity to scale African findings to other low and middle resource nations in South America and Asia.

Within the first year we will achieve the following:

• Recruit at least one primary care organization per country in about 10 countries covering all the major geographic regions of Africa;
• Train teams of at least 8 lay health assessors per organization in the use of the interRAI CUSR;
• Train participating primary care clinicians in the interpretation of CUSR assessment findings and approaches to shared decision-making using the interRAI Clinical Assessment Protocols (CAPs);
• Launch data collection as part of routine practice in the primary care programs with the aim of completing 500 baseline CUSR assessments;
  • Complete 165 repeat assessments within 6 months of the baseline assessment and 165 within 12 months of baseline (remaining 170 assessments will be completed within 18 months of baseline);
• Produce a summary report of baseline and 6-month follow-up assessment results for all participating sites and host a web-based forum to discuss the findings and their implications for practice.

In years 2 and 3 we will:

• Continue with on-going use of the interRAI CUSR in the initial pilot sites to further embed its use in routine practice;
• Expand the number of sites participating in the initiative within each country;
• Engage up to five additional African nations in the collaborative network;
• Develop quality indicators and other metrics as the basis for the primary care performance measurement system using interRAI CUSR data;
• Refine the interRAI CUSR and associated CAPs to make country-specific modifications as needed;
• Publish scientific articles as well as lay language publications to support knowledge translation to stakeholder audiences;

In years 4 and 5 we will:

• Establish communities of practice within and between countries linking organizations using the CUSR to work together in collaborative networks that use the data to inform quality improvement initiative using benchmarked indicators to guide decision-making;
• Work with government, health care, and scientific organizations in African nations to support the establishment of national reporting systems that will assume on-going responsibility for performance measurement and reporting of CUSR within countries and on a Pan-African basis;
• Reach out to other low and middle resource nations outside of Africa to build on the experience of the PAULAS project sites. 

We will measure the progress toward our implementation goals based on the number of countries participating, the number of sites that we have involved, the number of lay assessors and primary care clinicians we have trained and engaged, and the number of baseline and follow-up CUSR assessments that have been completed.  We will also examine the quality of data from the assessment, the use of data in primary care settings (by primary health care providers), perceptions of older persons and their family regarding key processes and tools, policies and systems developed because of evidence from the intervention, and overall quality of life for older persons in participating communities. Gathering those indicators will be a relatively routine task as part of overall project management.

However, our overall goal is not simply to implement a new data system in African health care settings. Instead, we aim to change the primary care of older adults in a manner that improves their lives in a broad-based holistic manner.

To that end, we will evaluate the impact of the initiative using qualitative methods to evaluate the feasibility, acceptability, and appropriateness of the lay health assessor methodology with the interRAI CUSR. We will interview the lay assessors and primary health care clinicians directly to obtain their perspectives. We have employed this protocol successfully with our Ugandan and South African pilots and will replicate it in other nations.

We will use the CUSR data themselves to evaluate the impact of the solution using quantitative indicators to describe the types of persons being served in the primary care organizations over time. More importantly, we will use the new risk-adjusted outcome measures developed in this work to evaluate changes in health outcomes over time as the solution becomes more fully implemented and the participating sites begin to function as communities of practice. We will employ a mix of indicators covering different domains to evaluate the extent to which we achieve our aim of having a broader impact on the well-being of older adults than is achieve with conventional, single disease focused approaches to primary care. Examples of the longitudinal indicators we expect to use in these comparisons include separate measures for improvement and for worsening of the following:

• Pain severity;
• Dyspnea;
• Gastrointestinal symptoms;
• Fatigue;
• Functional ability to meet daily needs, including
  • Performance of activities of daily living;
  • Capacity related to instrumental activities of daily living;
• Cognition;
• Frailty;
• Mood disturbance;
• Loneliness;
• Hospitalization;
• Mortality.

Ultimately, what we would hope to see in these indicators are two types of change: i) lower rates of decline and higher rates of improvement in indicators within participating organizations over time; and ii) reduced heterogeneity between participating organizations over time. Such idealized changes are difficult to realize in such a short period of time, but they would be indicative that care is improving within organizations over time and that quality is becoming more consistent between organizations. 

The PAULAS theory of change is based on a contextual analysis obtained through robust engagement with collaborating countries and supported by existing literature on challenges to healthy aging in Africa.

Evidence shows that a lack of healthcare workers with expertise in the care for older adults in primary care and specialized care settings, is a major impediment to the delivery of optimal care for aging adults for two important reasons. First, the complexity of geriatric patients requires careful attention to the interaction of multiple biomedical, psychosocial, and environmental factors that can result in atypical manifestations of physical and mental health problems. These are often incorrectly attributed to aging itself and their reversibility is not recognized. Secondly, such misdiagnoses are exacerbated by prescribing practices and procedures that fail to account for the needs and vulnerabilities of older adults, and which lead to further disability, functional decline, caregiver burden, and costs.

Insufficient expertise in geriatric care is compounded by a lack of contextually appropriate data and evidence to support care planning. Such information is usually generated during routine care delivery, then aggregated and analyzed to characterize population needs, identify gaps and problems, and develop plans to address these. In most African nations, healthcare systems are greatly limited in their ability to generate such information, lacking resources and technical skills. Frontline healthcare workers are not resourced to conduct the comprehensive assessments required to understand the needs of older adults, and therefore healthcare systems cannot have information on the health needs of the older persons that they support.

The PAULAS project has collaborated with numerous community actors and health facility administrators to implement a novel performance measurement system focused on the complex health needs of older persons in 10+ African nations. The PAULAS project will work with partners in each of the participating countries to improve the quality and availability of information to manage older adults, with a focus on communities and primary care settings.

The foundation of the PAULAS project is the identification and training of community members as lay assessors. The PAULAS project will work with participating sites to develop pools of competent community members (lay assessors) who will routinely conduct comprehensive geriatric assessments of older persons in their households within the communities of interest using a validated assessment instrument, the interRAI “Check-Up Self Report” (CUSR). InterRAI is a well-established non-for profit international scientific organization with a proven track record for developing assessment systems for vulnerable groups of patients. Previous pilot projects of the CUSR in South Africa and Uganda showed that when communities are motivated and buy into this approach, there is good uptake among community members. Thus, we are confident that the project’s assumption that community members will be highly motivated to avail themselves of such a lay assessor-delivered service is well-founded.

In addition to building competency among community members to assess older adults, the PAULAS project will partner with participating health facilities to train care providers on the interpretation and utilization of the CUSR assessment to make care decisions. The CUSR provides outputs and a summary narrative about older adults, including frailty, cognition, mood, disabilities and function, pain, health instability, falls, socio-economic risk, and other health conditions. Data from the participating countries will also be pooled and made available to researchers and planners within Africa to develop contextually appropriate evidence to support care planning for older adults. Health care providers’ acceptance of this approach is critical for the success of the intervention. Our previous pilot work strongly suggests that there will be sufficient interest among healthcare providers to support the PAULAS project.

Assessments conducted by lay assessors will need to be shared with frontline healthcare workers and consultants to be most useful. The PAULAS project will create a cloud-based infrastructure to house assessment data, and which will link participating sites and healthcare workers. Our goal is to have the CUSR assessment embedded into routine healthcare for patient and system care planning. For this to happen, the PAULAS project will vigorously pursue advocacy with health facility administrators and policymakers to make the case for the intervention’s wider implementation. Policymaker and stakeholder engagement will be facilitated by the development of knowledge translation materials from initial pilot projects of the CUSR and with data emerging from the PAULAS project. These materials will include population-level information describing the needs and characteristics of older adults in regions served. Our assumption is that policymakers will be interested in such information, and motivated to develop evidence-informed interventions to improve their health outcomes.

Over the long-term, PAULAS project will seek the widescale adoption and utilization of the CUSR and outputs to support the care of older adults in African nations. We strongly believe that the community-wide implementation in African countries of a geriatric assessment system anchored by lay assessors and based on the CUSR, whose outputs are used routinely for individual care planning by clinicians and by healthcare system planners, will contribute to improved health outcomes for older adults in community settings.

PAULAS Project Logic Model

There are three distinct types of technology that are used in the PAULAS project.

• Comprehensive geriatric assessment systems linked with decision support algorithms for care planning and risk management. As mentioned previously, the interRAI Check Up Self-report is not simply a survey questionnaire. It is a comprehensive assessment system built through three decades of research using millions of assessment records from over 35 countries. These measures are standardized, precise and designed to be highly predictive of a variety of health outcomes pertinent to older adults. The decision-support algorithms were developed using advanced statistical methods and machine learning techniques with scientific and clinical oversight by the lead scientific committee of interRAI (Instrument and System Development (ISD) Committee). Our research has adapted these systems to be used with lay health assessors who do not have specialized health training, but we have shown we are able to obtain valid and reliable evidence that is clinically actionable;
• Mobile computing technology – We will deploy relatively simple smart phone or tablet-based systems to gather interRAI CUSR data in the community using already available commercial grade clinical software provided by a licensed interRAI vendor as an industry partner. That software has already been used successfully in South African pilots. It will have data quality checks in place to ensure that assessments are complete and fully coded with within-range values. In addition, the software will produce health summary reports that can be shared with the patient and will their primary care providers as the basis for a longitudinal health record for the person. The technology will include use of HL7 and FHIR standards to ensure interoperability and connectivity with the electronic health record;
• Big data analytics – we will employ advanced statistical methods and machine learning tools to analyze the PAULAS data and to develop novel decision-support applications for primary care in low resource nations. In addition, we will develop risk-adjusted quality indicators that can be used for internal and/or public reporting of primary care performance to stakeholders. It is expected that these indicators will also be of interest in other countries, including high resource nations, that adopt the CUSR for primary care. We will use both the African data from the PAULAS project as well as existing interRAI data holdings with more than 20 million assessment records from other nations in this work. In some cases, one would expect similar associations between clinical indicators in Africa as we see in high resource nations (e.g., pain is likely to be associated with mood disturbances in comparable ways internationally). That means we will be able to leverage millions of assessment records to refine some of the indicators that we will use in the PAULAS reporting system. Of course, we will always confirm the applicability of findings with non-African data to the PAULAS data prior to their deployment in African settings. At least one African PAULAS researcher will be appointed to interRAI’s ISD Committee, which provides scientific oversight of all interRAI research and development efforts internationally. 

We have provided a comprehensive summary of our approach in the description of our solution. In brief terms, the interRAI Check Up Self-report data will be gathered by teams of lay health assessors using the CUSR for a fixed narrative used in face-to-face interviews with older primary care patients. The assessments are completed for clinical use by the primary care team to inform care planning and treatment decisions as part of a shared decision-making approach. In addition, follow-up assessments are completed over time to provide patient reported outcome measures that the clinical teams care use to monitor progress. Also, those longitudinal data will be aggregated at the agency level to provide risk-adjusted quality indicators based on a holistic set of measures of improvements and worsening in health over time. These indicators will be used by primary care teams to monitor their own performance over the course of the project. But they will also collaborate with other primary care organizations as part of collaborative communities of practice using these indicators to drive shared quality improvement initiatives. 

The PAULAS team is well-represented by members of equity-seeking groups particularly with respect to gender identity and members who are Black, Indigenous or persons of colour (BIPOC). The primary basis for recruitment of collaborators, students and staff has always been with respect to skill sets required for admission to academic programs or job performance; however, we have also engaged in strategies to recruit under-represented equity-seeking groups with respect to our team specifically and the broader field of research related to this proposal. Lay health assessors will be specifically recruited to be fully representative of the communities in which they serve.

The broader interRAI network includes 140 other Fellows and their associated students and staff in over 35 countries in 6 continents. However, low and middle resource nations have been under-represented to date. The proposed project will engage many new collaborators in Africa in addition to those already part of the interRAI network. Therefore, while there is already a strong commitment to supporting the principles of equity, diversity, and inclusion (EDI) in situ within the existing research team, the expanded collaboration with other teams in Africa will create novel opportunities for mentoring and training of all team members. Collaboration with international teams is a unique opportunity associated with this proposed research that will expose team members to different perspectives and approaches for how to prioritize diversity and create inclusive team environments. It will expose team members to EDI differences between countries and will provide insights about unique approaches that could be incorporated into other countries.

Our research team will make full use of available resources at our home institutions and internationally to support leadership development, training, and mentorship of our team. We will apply the University of Waterloo’s standards for EDI within the PAULAS research team and will promote their application to external activities with collaborating organizations and the research field more generally.

Team Composition and recruitment process

We will ensure that standardized selection criteria are applied equitably and place priority on additional skills related to SGBA+. Also, we will disseminate inclusive job advertisements broadly to reach under-represented equity seeking groups.

The research team is fully committed to implementing concrete actions to integrate all members of the project team, including members of equity-seeking groups, as active contributing collaborators in the proposed research. The team will pursue opportunities for EDI training (e.g., online courses offered by the University of Waterloo Equity Office). We will advertise broadly to seek out a diverse range of candidates for consideration of HQP positions that may be funded under the proposed research and will aim to address gaps in representation of equity-seeking groups. We will use strategies to reach a broad and diverse applicant pool for team positions.

Outreach to other collaborators and site selection for the project will ultimately be the decision of each African nation’s lead investigator working in consultation with the PAULAS project steering committee.

All team members will be trained in EDI to ensure that participating workplaces are welcoming and inclusive. Also, advanced training in SGBA+ will also be provided. Access to training/development opportunities will be allocated consistently and equitably.

 We will ensure that team members have access to training on the importance of equity, diversity, and inclusion. This will support our efforts to continue fostering an inclusive and welcoming environment for all HQP and research team members by reducing unconscious bias and fostering positive engagement of team members.

We will also ensure that team members receive training in EDI issues related to all aspects of the research process ranging from study design, hypothesis testing, and analytic methods through to knowledge exchange and stakeholder engagement.  For example, in our research there will be substantial opportunity for the examination of sex- and gender- based analyses in this project. All team members will be expected to complete training modules related to SGBA+ and we will seek out additional opportunities for training over the course of the grant period.

As part of our EDI strategy, we will keep a written record of all training and development opportunities leveraged by HQP to identify and address any gaps for HQP who are less likely to come forward and volunteer. We will ensure that we communicate transparently and broadly about available opportunities (for example, through weekly updates to all team members). We will also provide funding for professional development opportunities like conferences to ensure that financial barriers will not pose a barrier to participation.

This project will also help to address EDI gaps in the interRAI network as a whole. Appointments to the international interRAI network will develop new, diverse African HQP who will improve the representation of equity seeking groups in the international network.

PAULAS Project Business Model

 Key Resources

The success of the PAULAS project will depend on our ability to access and collaborate with primary care organizations providing care to older adults in the participating countries. In some countries we have already established those relationships. For example, in South Africa we have partnered with primary care organizations providing community outreach services linked to primary care clinics. In Nigeria, we have established a relationship with a hospital outpatient program. In Uganda, we have been working with an HIV/AIDS community program for older adults. Our team lead for each country will be responsible for establishing these partnerships and maintaining the relationship on an on-going basis.

The key human resources we require are:

• 1) Lay health assessors – These individuals will not be regulated health professionals, but they will be trained to complete the interRAI Check Up Self-Report (CUSR) with older patients under the care of the primary care organization. They will contact patients under the direction of primary care staff in the organization;
• 2) Primary care clinicians – We will provide clinical education to the physicians, nurses and other regulated health professionals associated with the primary care organizations using the CUSR. They will learn how to interpret the outputs from the CUSR assessment, how to engage older patients and their families in shared decision-making, how to use the assessment results to track outcomes over time;
• 3) Project managers – We will require staff to work with each team lead in the participating countries to ensure that the implementation and use of the CUSR is proceeding successfully. These staff members will support the country team lead in liaising with participating sites and will ensure that training is completed in the participating organizations;
• 4) Data management, analysis, and reporting – Data will be managed at two sites (University of Waterloo, Canada and Samson Institute for Aging Research, South Africa), but the bulk of the analytic and reporting work for PAULAS will be done at the University of Waterloo. This will be based on a 0.5 FTE position for an existing staff member;

Partners and Key Stakeholders

There are a variety of partners and key stakeholders that will play an essential role in the success of this project. These include:

• Primary care agencies – We will engage a diverse range of primary care organizations from the participating countries. There is no single model of primary care that is true for all of Africa. Therefore, it will be important to test the use of CUSR in a variety of settings to determine where it will be most successful. We will reach out to these agencies directly and their participation in the PAULAS project will be entirely voluntary;
• Clinicians – It will be critical for clinicians to see the value of the CUSR assessment data as a tool to inform their clinical decisions. In addition, it will be essential to establish clinical trust in and partnership with the lay health assessors. Clinicians will be associated with the participating primary care organizations, but their individual participation will also be voluntary;
• Health system managers and policy makers – Stakeholders who manage primary care services and policy makers in governments will be important partners in this effort because they will be the main users of the performance measurement system that draws from CUSR data. Clinicians will use the CUSR on a patient-by-patient basis to make person-level decisions; however, managers and policy makers will use the aggregated CUSR data for population level need analysis, quality monitoring, resource allocation, and policy development. They will also need to work with the front-line clinicians to function as part of a collaborative community of practice where CUSR data are used to monitor and evaluate the health impact of differences in clinical practice patterns between organizations;
• interRAI – As the organization responsible for the development, refinement, and international licensing of the CUSR, interRAI is a partner critical to the success of this initiative. The current interRAI Fellows in the PAULAS project (Hirdes, Geffen, Heckman, Perlman, Gishoma, Umubyeyi, Bagaragaza) are free to use interRAI’s intellectual property as part of their research. This will also be true for other team members who become interRAI Fellows in the future. However, when organizations or governments adopt interRAI systems into routine use, a user license and data sharing agreement must be put in place between the two parties. Therefore, as the project transitions from pilot demonstration to scaled up routine use it will be necessary to put in place user agreements between interRAI and the implementing entities. interRAI has almost 30 years of experience with establishing these agreements internationally, so this should not be a major point of concern.
  
  interRAI’s role in this project is not simply administrative. Indeed, our aim is to fully integrate the PAULAS research effort into interRAI’s global research efforts. We expect to appoint numerous African collaborators to interRAI to become Fellows of the international network. In addition, interRAI’s Fellows and its committees will provide technical, scientific, and substantive expertise in support of this project. For example, the interRAI Instrument and System Development Committee and the interRAI Network for Integrated Care and Aging will be two major committees where the PAULAS project will be included in the routine meeting agendas. interRAI will work with the PAULAS team to support knowledge exchange efforts with other low and middle resource nations to support application of the PAULAS findings to other countries. interRAI has also provided direct financial support to the early efforts to launch the PAULAS project (in partnership with the University of Waterloo). interRAI will work with the PAULAS team to secure other sources of funding as the scale up of this work continues;
• Commercial partners – As countries transition from the pilot phase to scaled up use of the CUSR, it will be necessary to deploy commercial grade software solutions that can connect the CUSR data with the electronic health record. interRAI has licensed numerous commercial organizations globally. RAISoft (https://www.raisoft.com/en/frontpage/) is one such partner that has played an active role in launching the first phases of the PAULAS project with minimal costs to support the project. We expect RAISoft to continue to collaborate with us as industry partners and we would be open to other commercial organizations joining this partnership on equivalent terms.

Key Activities

There are several key activities in the PAULAS project as it transitions from being a data collection system to a performance measurement system that drives quality improvement in primary care. These include:

• Training lay health assessors - All assessors will be trained in the following key areas: i) basic interviewing skills; ii) cultural competence; iii) protocols for administering, recording, and transmitting assessment results; iv) safety protocols; v) consent procedures; vi) patient confidentiality; and vii) response to cases where there are medical or psychiatric emergencies or instances of abuse and neglect;
• Clinical education – The PAULAS team will also provide clinical education to physicians, nurses and primary care health professions in: i) basic principles of geriatric medicine; ii) interpreting clinical outputs from the CUSR; iii) patient and family engagement in shared decision-making; iv) using interRAI CAPs as part of care plan development; and v) using outcome measures to monitor clinical change. Hence, introduction of the CUSR includes an educational intervention to provide primary care clinicians in Africa with the geriatric training they do not receive as part of their standard education;
• Conducting assessments – Lay health assessors will use the CUSR as part of routine assessment prior to primary care visits and follow-up afterwards to gather actionable clinical data relevant to the health needs of older adults;
• Clinical application of CUSR data – This will not simply be a data collection exercise. Clinicians will receive and review the CUSR findings prior to patient visits. They will use those data to identify areas of strengths and needs for individual patients. They will incorporate those findings into their clinical discussions with patients and family members to discuss their care preferences. They will also use the assessment follow-up data to monitor outcomes over time and to refine approaches to care as needed;
• Data Analytics – Our team will be responsible for the aggregated data analyses and evaluation of implementation of the CUSR in the PAULAS project. This will include provision of comparative and summary reports, preparation of statistical data quality analyses, population level need analyses, and preparation of analyses for scientific publications. University of Waterloo will be the lead analytic site, but all PAULAS researchers will be engaged in report preparation;
• Benchmarking ­– There will be two major activities with respect to the performance measurement applications of the CUSR data. First, we will develop risk adjusted primary care quality indicators dealing with improvements and worsening of health outcomes in a variety of domain areas relevant to older adults. Second, we will produce comparative reports that participating agencies can use to understand their level of performance compared with other PAULAS sites;
• Focus groups – We will use focus groups as a qualitative approach to refinement of the CUSR for use in African primary care settings. We will work with lay health assessors to evaluate the feasibility and acceptability of the CUSR in each country’s context. In addition, we will work with clinicians to examine the content validity of the CUSR as well as the clinical utility of decision support tools like risk algorithms and care planning protocols;
• Collaborative community of practice – As the implementation of the PAULAS project matures we will reach a point where there are adequate data and sufficient experience with the CUSR to allow participating organizations to work together as a collaborative community of practice. They will examine quality indicators for themselves compared with other PAULAS organizations and they will share learnings about implementation and use. In addition, variations in quality performance will provide a starting point for organizations to share ideas about what worked and what did not work in their clinical practice with respect to important health outcomes for older adults. Our successful experience with such communities of practice in high resource nations demonstrates their importance for the on-going sustainability of the CUSR in the participating countries (see, for example, www.seniorsqualityleapinitiative.com). Success will depend on organizational buy-in and leadership, analytic support, commitment to quality improvement, and availability of web-based collaboration tools to permit information sharing over large geographic distances.

Type of Intervention

The PAULAS project is a multidimensional intervention. It includes training for lay health assessors and clinicians in the implementation and use of geriatric assessment tools in routine practice. In addition, it involves data analytic services and mentoring in the use of risk adjusted data for performance measurement, including need analysis, quality monitoring, and resource allocation. It is also a capacity-building effort because it will add to health human resources with a low-cost solution in the form of lay health visitors. It builds capacity to care for and support older adults. In addition, this initiative will build a network of young African researchers who will dramatically enhance the capacity for research on aging in Africa. Finally, it is a product in the form of the CUSR and its associated software. CUSR is a state-of-the-art patient reported outcome measure that is based on three decades of international research. The CUSR is an essential clinical tool that allows primary care clinicians to employ comprehensive geriatric assessment as a critical first step to providing good quality care to older adults.

Segments

As noted earlier, there are multiple stakeholders that will be involved in and find value from the PAULAS initiative. The benefits will range from direct, tangible benefits to those that are more indirect and less tangible. The most important among these are:

• Beneficiaries – There are three major groups that will experience direct benefits from the PAULAS initiative. First, older patients in primary care will have previously undetected needs met and addressed, and they can be expected to have better health outcomes as a result. Second, family members will have reductions in distress and avoidable care burden in areas where patient needs are addressed effectively. Third, lay health assessors will be trained in new roles that can provide novel job opportunities in which they can make important contributions to their community;
• Customers – the three main customers for the CUSR and PAULAS project are clinicians, managers, and policy makers. Each of these stakeholders should see value in this system for it to succeed in scaling up. Clinicians are customers for the CUSR as a tool to improve their clinical practice with older adults. Managers are customers for the emergent performance measurement system that will help them to better identify population needs, monitor quality, and allocate resources. Policy makers are customers of the new evidence-base that will emerge from implementation of the CUSR as a means for refining government policy to better meet the needs of the rapidly aging population.

Value Proposition

The fundamental value proposition underlying the PAULAS initiative is that better data will lead to better health care decisions which will lead to better health outcomes for individuals and populations. That is at the heart of the argument for establishing any performance measurement system. The additional value proposition is that clinicians will be trained to make better decisions because they both have better data and they have received clinical education in geriatric medicine that was not available as part of their usual training.

The specific value propositions to different stakeholder groups are noted above. Patients and family find value in receiving better care that meets the physical and mental health needs of older adults. Clinicians will value new science-based tools that will help them be more effective and patient-centred. Managers will value information that helps them maximize the health benefits incurred based on the limited resources they have available. Policy makers will value the insights they will be able to obtain at the population level as the number of older adults rises dramatically. Governments will find value in the low-cost mechanism to address an important problem in health human resources. The larger society will find value in the improved scientific capacity that will arise from this collaborative network with expertise in health and aging.             

The PAULAS project established a foundation for a major component of the Institute for Healthcare Improvement’s (IHI) Quadruple Aim (https://www.ihi.org/communities/blogs/the-triple-aim-or-the-quadruple-aim-four-points-to-help-set-your-strategy) strategy for improving healthcare. The central building block of that initiative is the use of outcome measures to improve care. The secondary IHI aims of cost-effectiveness, patient experience, and staff satisfaction are not central to the PAULAS project at this time. However, those aims could be more fully addressed in future work. Therefore, our most essential impact measures for this project will be the risk-adjusted outcome indicators that we develop as part of this work.

Channels

We will reach out to users and customers through our existing relationships with African primary care organizations, where possible, and through outreach by PAULAS team members where those relationships do not yet exist. We have already established collaborative projects with the CUSR in South Africa, Nigeria, and Uganda. interRAI has already appointed Fellows in South Africa and Rwanda. We will expand our involvement with those sites as part of this effort. In other countries, our team members have begun recruiting sites for PAULAS as part of the first wave of this research that has been funded by interRAI and University of Waterloo.

The team members responsible for site recruitment and on-going liaison are as follows:

• Leon Geffen, MD – South Africa
• Sylvi Ndeva, MD – Namibia
• Bon Egbujie, MD and Oluwakemi Olanike Aderibigbe, MD PhD – Nigeria
• Moussiliou Paraiso, PhD – Benin
• Reem Mulla, MD – Sudan and Egypt
• Sospeter Gotabu, PhD – Kenya, Tanzania, Ethiopia (note: we are in the process of identifying additional collaborators in Tanzania and Ethiopia)
• George Heckman MD and Brittany Kroetsch – Uganda (note: we have identified a Ugandan geriatrician that we expect will join our effort)
• Benoite Umubyeyi, PhD, Darius Gishoma, PhD, and Emmanuel Bagaragaza, PhD - Rwanda

Cost Structure

There are different costs associated with data collection, analysis and reporting, and on-going use of data. Each has different trajectories when scaled up. Specifically:

• Health human resources – The main cost associated with data collection is the salary that will be paid to lay health assessors. It is not sustainable to make this a voluntary role, so there will be health human resource implications for this work. However, these human resources will come at a dramatically lower cost than regulated health professionals like nurses. In addition, the scale up with such staff can happen at a much faster pace than is imaginable with regulated health professionals. The on-going costs of lay health professionals will rise proportionally with the degree of scale up in the intervention, and these will become costs to the health system itself. That said, it should be recognized that the need for completion of geriatric assessment as part of health care for older adults is inevitable. There is no substitute for this using conventional laboratory tests or diagnostic imaging. A dramatic increase in population aging is in Africa’s imminent future. Geriatric assessment must be part of its plans for the future of a health care system that will have to deal with surging numbers of older persons with complex health needs. There are no additional costs for nurses and physicians to use the CUSR in their practice. The data will be gathered for them, so the only change will be the time they spend interpreting and responding to the CUSR findings. That time will easily be offset by the time savings arising from better health outcomes for their patients;
• Software and user licenses – Our commercial partner RAISoft is donating access to the CUSR software for this project. The only computing costs are the out-of-pocket costs to RAISoft for building in translations of the CUSR into African languages. This cost has already been covered by previous funding from interRAI and University of Waterloo. In addition, the project budget will cover the costs for servers housing the RAISoft clinical data for participating primary care organizations. The future use of clinical software systems for the CUSR will need to be negotiated between governments/primary care providers and licensed commercial organizations such as (but not limited to) RAISoft. This may well become a market opportunity for African based IT providers. interRAI license fees have historically been charged to software vendors who pay a single digit royalty of there software sales to interRAI. interRAI uses those royalties to support research expenses, which was the case for interRAI’s financial support to the first phase of the PAULAS effort. However, interRAI also allows for a population-based or “lives covered” model for governments to pay royalties to interRAI directly rather than as a portion of software fees. This model is heavily discounted for low and middle-income nations. While this model is not yet finalized, we would expect that the license discount for participating countries would make license costs at least 90% lower than those of high resource nations;
• Training materials – As part of this project we will develop CUSR and associated training materials for use in Africa and we will employ a train-the-trainer model for capacity building. interRAI manuals will be made available at a discounted cost, but the majority of training materials will be in the form of e-learning content to support in-person education by trainers based in Africa. With scale up there would be a need for more educators, but the PAULAS project will build local expertise to support that development;
• Analysis and reporting – The costs of analyses of data from the PAULAS project are part of our planned use of funds for this project. The server costs for data analyses and benchmarking are already covered by the existing secure server at the University of Waterloo. The funds from this project will support staff time for data management and analysis. Our approach will be to train African researchers and analysts to develop this capacity so that they can take over this role with scale up.

Surplus

interRAI is a not-for-profit organization registered as a charity in the United States. Its members are typically full-time employees of universities, colleges, and/or health care organizations. The same is true for the PAULAS team members that are currently not interRAI Fellows. As a result, we are not engaging in this effort as a commercial enterprise.

That said, interRAI owns the intellectual property (IP) associated with the CUSR and it licenses the use of that IP to commercial organizations. It can also work directly with governments/health care providers that wish to use the “lives covered” royalty structure instead of the percentage of software sales. The royalties amount to a minor source of funding for interRAI research and are invested in support of interRAI related research.

For example, interRAI uses its royalty funds to offset membership fees to Fellows from low-income nations, to support travel costs for Fellows without sufficient funding from other sources, and to support new research initiatives. interRAI committed to provide $80,000 CAD in support of the first phase of the PAULAS project.

interRAI’s Board is entirely composed of volunteers from six countries providing oversight to the activities of over 140 Fellows in over 35 countries. The Board is solely responsible for decisions about how interRAI funds are allocated and they ensure that such use is made in accordance with interRAI’s scientific aims.

Revenue

The PAULAS project will not generate any revenue to interRAI. As mentioned above, only a small fraction of interRAI revenue comes from commercial revenue. Using the Canadian context as an example, when one compares government research grants to support interRAI research with royalties obtained from commercial vendors, the royalties account for less than 2% of overall research revenue. In African, nations those royalties will be calculated at a dramatically lower rate. 

interRAI is a not-for-profit research network that is already financial stable. It receives funding mainly through research grants to individual Fellows and their affiliated research centres, modest royalties from commercial organizations licensed to use interRAI IP, and limited revenue from manual sales. Hence, the long-term viability of interRAI as a research network does not depend on the scale up of the PAULAS project. However, our capacity to engage African researchers, clinicians, and policy experts in interRAI’s international work will depend on finding future grants to support their work. In addition, our proposed solution supports the initial phase of work toward a fully sustainable system. It is our intent to pursue additional funding from agencies like the National Institutes of Health in the US and the Canadian Institute for Health Research to support future stages of this research.

The part of the PAULAS that has greater financial implications is the sustainability of scaling up use of the CUSR in the African context. That means that governments and health care organizations need to find funds to cover the costs of lay health assessors, software, analytic services and collaborative communities of practice for routine use.

The largest of these costs will be for lay health assessors. One might think of this as an add-on expense to health care; however, it is more appropriate to consider this to be a low-cost mechanism for what will ultimately become an essential service. Inappropriate management of health needs of older adults will ultimately cause African societies to incur avoidable health care expenditures. Future care of older persons will by necessity include use of comprehensive assessments. This approach is sustainable because it yields high quality, actionable data at a fraction of the cost that would be incurred with the use of regulated health professionals.

interRAI’s aim is that the use of the CUSR and the associated performance measurement system is fully incorporated into routine practice by African health care organizations and governments. interRAI will continue to engage these stakeholders as research and knowledge exchange partners, but the routine use of these data to support clinical practice and quality improvement will become an internally managed function of the partner agencies.

The overwhelming majority of funding for interRAI’s research comes from government grants. For example, the team lead (Hirdes) has received over $25 million CAD from Canadian government organizations, granting agencies, and health care foundations. This funding supported a broad range of interRAI research, including development of assessment systems and decision-support tools used in the PAULAS project.

In Canada, interRAI systems are used on a Pan-Canadian basis beginning with the implementation of the nursing home assessment system in the mid-1990s. Since then, all provinces and territories (except Quebec) have implemented (or are implementing now) one or more of interRAI’s assessment. The interRAI instruments in most widespread use in Canada today are the clinician-led home care, nursing home, mental health, palliative care, quality of life, and child/youth assessments. To date, over 20 million interRAI assessments have been completed on over 6 million unique Canadians. The interRAI Brief Mental Health Screener is used by police officers in four Canadian provinces during encounters with persons with serious mental health concerns. This use by police officers represents another successful case example of persons who are not regulated health professionals using interRAI systems.

As a new interRAI system, the use of the interRAI CUSR is in early stages in Canada. We have completed pilots in primary care programs, older adult centres, retirement communities, assisted living, and home care settings. During the pandemic, the CUSR was used to complete home care assessments when in-person visits by clinicians were not possible.

At the national level, the Canadian Institute for Health Information (www.cihi.ca) supports the Pan-Canadian use of interRAI systems (www.cihi.ca/en/the-cihiinterrai-partnership) including through the an innovative public portal to report on risk-adjusted quality indicators in long term care (www.yourhealthsystem.cihi.ca).

There are about 15 different licensed commercial software vendors in Canada providing data collection systems to support interRAI implementations. In addition, the Seniors Quality Leap Initiative is a highly successful collaborative community of practice involving Canadian, US, and South African long term care organizations who use interRAI data to drive quality improvement efforts in long-term care (www.seniorsqualityleapinitiative.com).

Health care organizations using interRAI assessments generally use regulated health professionals who are on staff to complete interRAI assessments as part of routine clinical practice. The costs of these assessments are built into organizational budgets because they are seen as part of health care service delivery.

Other countries with similar magnitudes of implementation and use of interRAI systems (either completed or underway) include the United States, Ireland, Finland, Belgium, Switzerland, and New Zealand.

Hence, interRAI has experience and demonstrated success in high resource nations with all the activities proposed in the PAULAS project. The clinician-led systems used in those countries will not be sustainable in primary care in Africa. However, the work we have already completed shows that the use of lay health assessors completing the CUSR is viable and cost effective, and it yields good quality, actionable data for primary care settings. Therefore, we are fully confident that we will be able to achieve the benefits that performance measurement systems have yielded for high resource nations at a dramatically lower cost in Africa.