Home-based support services for older people: Follow-up audit


In July 2011, we published a performance audit report, Home-based support services for older people. The report looked at how effectively the Ministry of Health (the Ministry) and district health boards (DHBs) ensured that older people get the care and support they need to remain living independently at home.

In our view, home-based support services were, in general, delivered adequately. However, this was a qualified view because the Ministry and DHBs did not have reliable information for us to confirm this assessment. We found that the Ministry and DHBs needed to address deficiencies in performance information about home-based support. As a result, we made five recommendations to the Ministry and DHBs.

In June 2014, we published Home-based support services for older people: Progress in responding to the Auditor-General’s recommendations. We found that, among other things, the Ministry and DHBs had had mixed progress in improving how they collect and use interRAI™ data.

In our 2014 report, we said that we would continue to monitor the progress of the Ministry and DHBs in making further improvements. For this report, we decided to follow up one of the recommendations – that the Ministry collect and use meaningful and reliable information to ensure ongoing service quality. This involved the Ministry achieving national consistency in interRAI™ data and implementing national indicators of the quality of home-based support services.

What is interRAI™?

interRAI™ is a comprehensive clinical assessment tool that helps staff to select appropriate support requirements for older people needing home-based support services. Staff can access it through the Internet when working in the community. interRAI™ was introduced to DHBs between 2008 and 2012.

interRAI™ is designed to help staff assess an older person’s medical, rehabilitation, and support needs. The person is assessed against several factors, such as mobility and self-care. The Ministry believes that improving assessment outcomes for older people will enable them to stay in their own home for longer.

In 2011, the New Zealand interRAI™ Governance Board (the Board) was established to provide leadership and oversight of the interRAI™ programme in New Zealand. The Board’s goal is to ensure the continuous improvement of health outcomes for New Zealanders as they age. The Director-General of Health appoints members of the Board.

Progress with developing home-care quality indicators and improving performance information

Progress implementing national home-care quality indicators has been slow. However, the Ministry now feels that, with interRAI™ well established in all the DHBs, data to inform quality improvement is now available.

In our 2014 report, we mentioned a set of draft indicators the Ministry was hoping to implement. Since then, the Ministry found that the draft indicators were unfit for purpose and is currently working to produce a better set of new indicators. The Ministry is currently engaging with experts that include the chief executive of the Canadian Institute for Health Information and an interRAI™ Fellow from Brown University, Massachusetts, USA. The Ministry has also reviewed research into new national indicators.

Alongside this, the Ministry has strengthened infrastructure that should help it to better collect and use performance information to monitor the quality of home-care. Important steps the Ministry has taken include:

  • creating a performance monitoring framework through the DHB annual planning process;
  • updating and strengthening interRAI™ New Zealand’s governance arrangements; and
  • entering into a Memorandum of Understanding with Central Region’s Technical Advisory Services Limited to run a national data and analysis reporting service, to run an integrated national training service, and to provide administrative support for the Board.

The Ministry believes that, when completed, the new indicators and the infrastructure improvements will enable it to effectively monitor home-care quality. At this stage, the Ministry is unable to tell us when the indicators will be completed.

We will continue to monitor progress towards more effective monitoring of home-care quality.

Performance Monitoring Framework

As part of the DHB annual planning process, the Ministry has created a performance monitoring framework to measure aspects of DHBs’ performance, including monitoring the use of interRAI™ data. The Ministry sees this planning process as a way to progress measurable improvements and system performance.

DHBs are now required to check that interRAI™ assessments are done as required for all people referred to long-term home-based support and residential care services, and to take corrective action where required. They also need to ensure that people are regularly reassessed. DHBs are required to report to the Ministry against the framework every three months. The Ministry considers that DHBs were on track to meet the framework’s targets by 30 June 2016.

Performance monitoring is one way the Ministry is trying to make interRAI™ data more consistent and useful. The Ministry has made its expectations about collection and reporting clear to each of the DHBs.

Governance arrangements

In 2014, the Ministry evaluated the Board. It made several recommendations about how to strengthen the Board. These were approved by the then Acting Director-General of Health. The recommendations included “board member terms of appointment should be two or three years, to enable staggered replacement of members” and “setting the expectation that the Board would receive enough secretariat support”. The Ministry implemented this by signing a Memorandum of Understanding with Central Region’s Technical Advisory Services Limited.

The Board has met twice since the evaluation. In February 2016, it agreed on a set of protocols for access to data collected through interRAI™ assessments.

In our view, the updated governance arrangements strengthen the Ministry’s ability to use the data collected through interRAI™ assessments, particularly by having Board-sanctioned protocols for data management.

Memorandum of Understanding with the Ministry of Health and Central Region’s Technical Advisory Services Limited

The Ministry has signed a Memorandum of Understanding with Central Region’s Technical Advisory Services Limited to:

  • provide secretariat support for the Board;
  • create and run the national data and analysis reporting service; and
  • deliver a national integrated training and support programme to help ensure that those who carry out interRAI™ assessments are adequately skilled.

In our view, this agreement gives the Ministry a national perspective on the data collected from interRAI™ assessments through which it can monitor home-care quality.