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Beyond the ‘Iron Lungs of Gerontology’: Using Evidence to Shape the Future of Nursing Homes in Canada*

  • John P. Hirdes (a1), Lori Mitchell (a2), Colleen J. Maxwell (a3) and Nancy White (a4)


Institutionalization of the Elderly in Canada suggested that efforts to address the underlying causes of age-related declines in health might negate the need for nursing homes. However, the prevalence of chronic disease has increased, and conditions like dementia mean that nursing homes are likely to remain important features of the Canadian health care system. A fundamental problem limiting the ability to understand how nursing homes may change to better meet the needs of an aging population was the lack of person-level clinical information. The introduction of interRAI assessment instruments to most Canadian provinces/territories and the establishment of the national Continuing Care Reporting System represent important steps in our capacity to understand nursing home care in Canada. Evidence from eight provinces and territories shows that the needs of persons in long-term care are highly complex, resource allocations do not always correspond to needs, and quality varies substantially between and within provinces.

Institutionalization of the Elderly in Canada a proposé que les efforts de s’attaquer aux causes sous-jacentes de baisses liées à l’âge de santé pourraient éradiquer la necessité pour les maisons de soins infirmiers. Cependant, la prévalence des maladies chroniques a augmenté, et les conditions comme la démence signifie que les maisons de soins infirmiers sont susceptibles de rester des éléments importants du système de soins de santé canadien. Le manque d’information clinique à l’échelle individuelle a été un problème fondamental qui limite la capacité de comprendre comment les maisons de soins infirmiers peuvent changer pour mieux répondre aux besoins d’une population vieillissante L’introduction d’instruments d’évaluation interRAI pour la plupart des provinces et territoires canadiens et la création du Système d’information sur les soins représentent des étapes importantes dans notre capacité à comprendre les soins dispensés par les maisons de soins infirmiers au Canada. Le témoignage de huit provinces et territoires montre que les besoins des personnes dans les soins de longue durée sont très complexes, que les allocations de ressources ne correspondent pas toujours aux besoins, et que la qualité varie considérablement entre et au sein des provinces.


Corresponding author

Correspondence and requests for offprints should be sent to / La correspondance et les demandes de tirés-à-part doivent être adressées à: John P. Hirdes, Ph.D. Department of Health Studies and Gerontology University of Waterloo Waterloo ON, Canada, N2L 3G1 (


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Dr. Hirdes holds the Ontario Home Care Research and Knowledge Exchange Chair. The authors acknowledge the ACCES team members (particularly Dr. Laurel Strain) and data analysts (Dr. Erin Gilbart and Deanna Wanless) as well as the study participants and family members for their significant contributions to the data presented in this report. We also thank staff at the Canadian Institute for Health Information (CIHI; Joseph Griffiths, Robyn Hastie, Adrian Dalloo, and Maureen Kelly) and Micaela Jantzi who contributed towards the analyses of CCRS and HCRS data. The opinions expressed by Nancy White in this paper are her own and do not necessarily reflect those of CIHI.



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Alberta Health & Wellness. (2007). Supportive living framework. Edmonton: Alberta Seniors and Community Supports.
Alberta Health & Wellness. (2008). Continuing care strategy: Aging in the right place. Edmonton: Alberta Health and Wellness, Retrieved July 11, 2011, from
Alzheimer Society of Canada. (2010). Rising Tide: The impact of dementia on Canadian society. Toronto: Alzheimer Society of Canada.
Armstrong, J.J., Stolee, P., Hirdes, J.P., & Poss, J.W. (2010). Examining three frailty conceptualizations in their ability to predict negative outcomes for home-care clients. Age and Ageing, 39(6), 3246.
Bernabei, R., & Gambassi, G. (1998). The SAGE database: Introducing functional outcomes in geriatric pharmaco-epidemiology. Journal of the American Geriatrics Society, 46(2), 251252.
Bernabei, R., Gray, L., Hirdes, J., Pei, X., Henrard, J.C., Jonsson, P.V., et al. . (2009). International Gerontology. In Halter, J.B., Ouslander, J.G., Tinetti, M.E., Studenski, S., High, K.P., & Asthana, S. (Eds.), Hazzard’s geriatric medicine and gerontology (6th ed., pp. 6996). New York: McGraw Medical.
Bernabei, R., Landi, F., Onder, G., Liperoti, R., & Gambassi, G. (2008). Second and third generation assessment instruments: The birth of standardization in geriatric care. Journals of Gerontology - Series A Biological Sciences and Medical Sciences, 63(3), 308313.
Berta, W., Laporte, A., & Valdmanis, V. (2005). Observations on institutional long-term care in Ontario; 1996-2002. Canadian Journal on Aging, 24(1), 7184.
Björkgren, M.A., & Fries, B.E. (2006). Applying RUG-III for reimbursement of nursing facility care. International Journal of Healthcare Technology and Management, 7(1–2), 8299.
Björkgren, M.A., Fries, B.E., & Shugarman, L.R. (2000). A RUG-III case-mix system for home care. Canadian Journal on Aging, 19(Suppl. 2), 106125.
Björkgren, M.A., Hakkinen, U., Finne-Soveri, U.H., & Fries, B.E. (1999). Validity and reliability of Resource Utilization Groups (RUG-III) in Finnish long-term care facilities. Scandinavian Journal of Public Health, 27(3), 228234.
Blaum, C.S., O’Neill, E.F., Clements, K.M., Fries, B.E., & Fiatarone, M.A. (1997). Validity of the minimum data set for assessing nutritional status in nursing home residents. American Journal of Clinical Nutrition, 66(4), 787794.
Brandeis, G.H., Berlowitz, D.R., Hossain, M., & Morris, J.N. (1995). Pressure ulcers: The Minimum Data Set and the Resident Assessment Protocol. Advanced Wound Care, 8(6), 1825.
Brizioli, E., Bernabei, R., Grechi, F., Masera, F., Landi, F., Bandinelli, S., et al. . (2003). Nursing home case-mix instruments: Validation of the RUG-III system in Italy. Aging Clinical and Experimental Research, 15(3), 243253.
Burrows, A.B., Morris, J.N., Simon, S.E., Hirdes, J.P., & Phillips, C. (2000). Development of a Minimum Data Set-based depression rating scale for use in nursing homes. Age and Ageing, 29(2), 165172.
Canadian Centre for Elder Law. (2010). Discussion paper on assisted living: Past, present and future legal trends in Canada. Vancouver: Canadian Centre for Elder Law.
Carpenter, G.I. (2006). Accuracy, validity and reliability in assessment and in evaluation of services for older people: The role of the interRAI MDS assessment system. Age and Ageing, 35(4), 327329.
Carpenter, I., Perry, M., & Challis, D. (2003). Identification of registered nursing care of residents in English nursing homes using the Minimum Data Set Resident Assessment Instrument (MDS/RAI) and Resource Utilisation Groups version III (RUG-III). Age and Ageing, 32(3), 279285.
Chan, P., & Kenny, S.R. (2001). National consistency and provincial diversity in delivery of long-term care in Canada. Journal of Aging and Social Policy, 13(2/3), 83100.
Chou, K.L., Chi, I., Antony Chi-tat, L., Yee Ming, W., & Liu, C.P. (2001). Validation of Minimum Data Set for nursing home in Hong Kong Chinese elders. Clinical Gerontologist, 23(1–2), 4354.
CIHI (Canadian Institute for Health Information). (2003). Health care in Canada, 2003. Ottawa: CIHI.
CIHI. (2007a). Analysis in Brief: The “younger” generation in Ontario’s complex continuing care. Ottawa: CIHI.
CIHI. (2007b). Analysis in Brief: Resident Safety – Characteristics associated with falling in Ontario complex continuing care. Ottawa: CIHI.
CIHI. (2008). Analysis in Brief: Caring for nursing home residents with behavioural symptoms: Information to support a quality response. Ottawa: CIHI.
CIHI. (2010a). Analysis in Brief: Depression among seniors in residential care. Ottawa: CIHI.
CIHI. (2010b). National health expenditure trends, 1975-2010. Ottawa: CIHI.
Clauser, S.B., & Fries, B.E. (1992). Nursing home resident assessment and case-mix classification: Cross-national perspectives. Health Care Financing Review, 13(4), 135155.
Costa, A., & Hirdes, J.P. (2010). Clinical characteristics and service needs of Alternate-Level-of-Care patients waiting for long term care in Ontario hospitals. Healthcare Policy, 6(1), 3346.
Dagnone, T. (2009). For patients’ sake: Patient first review Commissioner’s report to the Saskatchewan Minister of Health. Regina: Government of Saskatchewan.
Doran, D.M., Harrison, M.B., Laschinger, H.S., Hirdes, J.P., Rukholm, E., Sidani, S., et al. . (2006). Nursing-sensitive outcomes data collection in acute care and long-term-care settings. Nursing Research, 55(2Suppl 1.), S75S81.
Fernandes, N., & Spencer, B.G. (2010). The private cost of long-term care in Canada: Where you live matters. Canadian Journal on Aging, 29(3), 307316.
Forbes, W.F., Jackson, J.A., & Krause, A.S. (1987). Institutionalization of the elderly in Canada. Toronto, Ontario, Canada: Butterworths.
Fries, B.E., & James, M. (2003). Identifying “appropriate” applicants for home and community based services: The MI Choice screening system. Policy Briefs, (13), 16.
Fries, B.E., Morris, J.N., Aliaga, P., & Jones, R. (2003). Risk adjusting outcome measures for post-acute care. American Journal of Medical Quality, 18(2), 6672.
Fries, B.E., Morris, J.N., Bernabei, R., Finne-Soveri, H., & Hirdes, J. (2006). Rethinking the resident assessment protocols. Journal of the American Geriatrics Society, 55(7), 659666.
Fries, B.E., Schneider, D.P., Foley, W.J., Gavazzi, M., Burke, R., & Cornelius, E. (1994). Refining a case-mix measure for nursing homes: Resource Utilization Groups (RUG-III). Medical Care, 32(7), 668685.
Fries, B.E., Simon, S.E., Morris, J.N., Flodstrom, C., & Bookstein, F.L. (2001). Pain in U.S. nursing homes: Validating a pain scale for the Minimum Data Set. Gerontologist, 41(2), 173179.
Gambassi, G., Landi, F., Peng, L., Brostrup-Jensen, C., Calore, K., Hiris, J., et al. . (1998). 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. Medical Care, 36(2), 167179.
Gambassi, G., Lapane, K.L., Sgadari, A., Carbonin, P., Gatsonis, C., Lipsitz, L.A., et al. . (2000). Effects of angiotensin-converting enzyme inhibitors and digoxin on health outcomes of very old patients with heart failure. Archives of Internal Medicine, 160(1), 5360.
Gambassi, G., Lapane, K.L., Sgadari, A., Landi, F., Mor, V., & Bernabei, R. (2000). Measuring health outcomes for older people using the sage database. Canadian Journal on Aging, 19(Suppl. 2), 6786.
Gilbart, E.E., & Hirdes, J.P. (2000). Stress, social engagement and psychological well-being in institutional settings: Evidence based on the minimum data set 2.0. Canadian Journal on Aging, 19(Suppl. 2), 5066.
Gindin, J., Walter-Ginzburg, A., Geitzen, M., Epstein, S., Levi, S., Landi, F., et al. . (2007). Predictors of rehabilitation outcomes: A comparison of Israeli and Italian geriatric post-acute care (PAC) facilities using the minimum data set (MDS). Journal of the American Medical Directors Association, 8(4), 233242.
Gray, L.C., Berg, K., Fries, B.E., Henrard, J.C., Hirdes, J.P., Steel, K., et al. . (2009). Sharing clinical information across care settings: The birth of an integrated assessment system. BMC Health Services Research, 29, 71.
Gray, L.C., Bernabei, R., Berg, K., Finne-Soveri, H., Fries, B.E., Hirdes, J.P., et al. . (2008). Standardizing assessment of elderly people in acute care: The interRAI Acute Care instrument. Journal of the American Geriatrics Society, 56(3), 536541.
Gruneir, A., Anderson, G.F., Rochon, P.A., & Bronskill, S. (2010). Transitions in long-term care and potential implications for quality reporting in Ontario, Canada. Journal of the American Medical Directors Association, 11(9), 629635.
Gruneir, A., Smith, T.F., Hirdes, J., & Cameron, R. (2005). Depression in patients with advanced illness: An examination of Ontario complex continuing care using the Minimum Data Set 2.0. Palliative & Supportive Care, 3(2), 99105.
Hartmaier, S.L., Sloane, P.D., Guess, H.A., Koch, G.G., Mitchell, C.M., & Phillips, C.D. (1995). Validation of the minimum data set cognitive performance scale: Agreement with the mini-mental state examination. Journals of Gerontology - Series A Biological Sciences and Medical Sciences, 50(2), M12833.
Hawes, C., Morris, J.N., Phillips, C.D., Mor, V., Fries, B.E., & Nonemaker, S. (1995). Reliability estimates for the minimum data set for nursing home resident assessment and care screening (MDS). Gerontologist, 35(2), 172178.
Hawes, C., & Phillips, C.D. (2007). Defining quality in assisted living: Comparing apples, oranges, and broccoli. Gerontologist, 47(Spec No. 3), 4050.
Hebert, R., Dubois, M., Chambers, L., & Cohen, C. (2001). Factors associated with long-term institutionalization of older people with dementia: Data from the Canadian Study of Health and Aging. J ournal of Gerontology: Medical Sciences, 56A(11), 693699.
Hirdes, J.P. (2001). Long-term care funding in Canada: A policy mosaic. Journal of Aging and Social Policy, 13(2–3), 6981.
Hirdes, J.P. (2006). Addressing the health needs of frail elderly people: Ontario’s experience with an integrated health information system. Age and Ageing, 35(4), 329331.
Hirdes, J.P., Botz, C.A., Kozak, J., & Lepp, V. (1996). Identifying an appropriate case mix measure for chronic care: evidence from an Ontario pilot study. Healthcare Management Forum, 9(1), 4046.
Hirdes, J.P., & Carpenter, G.I. (1997). Health outcomes among the frail elderly in communities and institutions: Use of the Minimum Data Set (MDS) to create effective linkages between research and policy. Canadian Journal on Aging, 16(Suppl.), 5369.
Hirdes, J.P., Fries, B.E., Morris, J.N., Ikegami, N., Zimmerman, D., Dalby, D.M., et al. . (2004). Home care quality indicators (HCQIs) based on the MDS-HC. Gerontologist, 44(5), 665679.
Hirdes, J.P., Fries, B.E., Morris, J.N., Steel, K., Mor, V., Frijters, D., et al. . (1999). Integrated health information systems based on the RAI/MDS series of instruments. Healthcare Management Forum, 12(4), 3040.
Hirdes, J.P., Frijters, D.H., & Teare, G.F. (2003). The MDS-CHESS scale: A new measure to predict mortality in institutionalized older people. Journal of the American Geriatrics Society, 51(1), 96100.
Hirdes, J.P., Ljunggren, G., Morris, J.N., Frijters, D.H., Finne-Soveri, H., Gray, L., et al. . (2008). Reliability of the interRAI suite of assessment instruments: A 12-country study of an integrated health information system. BMC Health Services Research, 6, 9.
Hirdes, J.P., Marhaba, M., Smith, T.F., Clyburn, L., Mitchell, L., Lemick, R.A., et al. . (2000). Development of the Resident Assessment Instrument–Mental Health (RAI-MH). Hospital Quarterly, 4(2), 4451.
Hirdes, J.P., Poss, J.W., & Curtin-Telegdi, N. (2008). The Method for Assigning Priority Levels (MAPLe): A new decision-support system for allocating home care resources. BMC Medicine, 6.
Hirdes, J.P., Sinclair, D.G., King, J., McKinley, J., & Tuttle, P. (2003). From anecdotes to evidence: Complex continuing care at the dawn of the information age. Retrieved July 11, 2011, from
Hirdes, J.P., Smith, T.F., Rabinowitz, T., Yamauchi, K., Pérez, E., Telegdi, N.C., et al. . (2002). The Resident Assessment Instrument-Mental Health (RAI-MH): Inter-rater reliability and convergent validity. Journal of Behavioral Health Services and Research, 29(4), 419432.
Hogan, D.B. (2007). Proceedings and recommendations of the 2007 Banff Conferences on the Future of Geriatrics in Canada. Canadian Journal of Geriatrics, 10(4), 133148.
Hospital Report Research Collaborative. (2001). Hospital report - Complex continuing care, 2001. Toronto: University of Toronto.
Hutchinson, A.M., Draper, K., & Sales, A.E. (2009). Public reporting of nursing home quality of care: Lessons from the United States experience for Canadian policy discussion. Healthcare Policy, 5(2), 87105.
Ikegami, N., Fries, B.E., Takagi, Y., Ikeda, S., & Ibe, T. (1994). Applying RUG-III in Japanese long-term care facilities. Gerontologist, 34(5), 628639.
Jensdóttir, A.B., Jónsson, P., Noro, A., Jonsén, E., Ljunggren, G., Finne-Soveri, H., et al. . (2008). Comparison of nurses’ and physicians’ documentation of functional abilities of older patients in acute care - Patient records compared with standardized assessment. Scandinavian Journal of Caring Sciences, 22(3), 341347.
Jones, R.N., Hirdes, J.P., Poss, J.W., Kelly, M., Berg, K., Fries, B.E., et al. . (2010). Adjustment of nursing home quality indicators. BMC Health Services Research, 10, 96.
Jones, R.N., Marcantonio, E.R., & Rabinowitz, T. (2003). Prevalence and correlates of recognized depression in U.S. nursing homes. Journal of the American Geriatrics Society, 51(10), 14041409.
Jónsson, P.V., Noro, A., Finne-Soveri, H., Jensdóttir, A.B., Ljunggren, G., Bucht, G., et al. . (2008). Admission profile is predictive of outcome in acute hospital care. Aging Clinical and Experimental Research, 20(6), 533539.
Keays, S., Wister, A.V., & Gutman, G.M. (2009). Administrators and quality of care in long-term care facilities. Journal of Housing for the Elderly, 23(3), 243260.
Kwan, C., Chi, I., Lam, T., Lam, K., & Chou, K. (2000). Validation of Minimum Data Set for Home Care Assessment Instrument (MDS-HC) for Hong Kong Chinese elders. Clinical Gerontologist, 21(4), 3548.
Landi, F., Bernabei, R., Russo, A., Zuccala, G., Onder, G., Carosella, L., et al. . (2002). Predictors of rehabilitation outcomes in frail patients treated in a geriatric hospital. Journal of the American Geriatrics Society, 50(4), 679684.
Landi, F., Tua, E., Onder, G., Carrara, B., Sgadari, A., Rinaldi, C., et al. . (2000). Minimum data set for home care: A valid instrument to assess frail older people living in the community. Medical Care, 38(12), 11841190.
Lawton, M.P., Casten, R., Parmelee, P.A., Van Haitsma, K., Corn, J., & Kleban, M.H. (1998). Psychometric characteristics of the minimum data set II: Validity. Journal of the American Geriatrics Society, 46(6), 736744.
Ljunggren, G., & Brandt, L. (1996). Predicting nursing home length of stay and outcome with a resource-based classification system. International Journal of Technology Assessment in Health Care, 12(1), 7279.
Martin, L., Hirdes, J.P., Morris, J.N., Montague, P., Rabinowitz, T., & Fries, B.E. (2009). Validating the Mental Health Assessment Protocols (MHAPs) in the Resident Assessment Instrument Mental Health (RAI-MH). Journal of Psychiatric and Mental Health Nursing, 16(7), 646653.
Martin, L., Poss, J.W., Hirdes, J.P., Jones, R.N., Stones, M.J., & Fries, B.E. (2008). Predictors of a new depression diagnosis among older adults admitted to complex continuing care: Implications for the depression rating scale (DRS). Age and Ageing, 37(1), 5156.
Mathias, K., Hirdes, J.P., & Pittman, D. (2010). A care planning strategy for traumatic life events in community mental health and inpatient psychiatry based on the InterRAI assessment instruments. Community Mental Health Journal, 46(6), 621627.
Maxwell, C.J., Dalby, D.M., Slater, M., Patten, S.B., Hogan, D.B., Eliasziw, M., et al. . (2008). The prevalence and management of current daily pain among older home care clients. Pain, 138(1), 208216.
McGregor, M.J., Tate, R.B., McGrail, K.M., Ronald, L.A., Broemeling, A., & Cohen, M. (2006). Care outcomes in long-term care facilities in British Columbia, Canada. Medical Care, 44(10), 929935.
Mitchell, L.A., Blandford, A.A., Menec, V., & Nowicki, S. (2007). Long term care strategy: An Examination of Clients Across the Care Continuum. Paper presented at the 2007 Canadian RAI Conference, Ottawa.
Mor, V. (2005). Improving the quality of long-term care with better information. The Milbank Quarterly, 83(3), 333364.
Mor, V. (2007). Defining and measuring quality outcomes in long-term care. Journal of the American Medical Directors Association, 8(3Suppl. 2): 129137.
Mor, V., Angelelli, J., Gifford, D., Morris, J., & Moore, T. (2003). Benchmarking and quality in residential and nursing homes: Lessons from the US. International Journal of Geriatric Psychiatry, 18(3), 258266.
Mor, V., Angelelli, J., Jones, R., Roy, J., Moore, T., & Morris, J. (2003). Inter-rater reliability of nursing home quality indicators in the U.S. BMC Health Services Research, 3, 1.
Mor, V., Berg, K., Angelelli, J., Gifford, D., Morris, J., & Moore, T. (2003). The quality of quality measurement in U.S. nursing homes. Gerontologist, 43(Spec. Iss. 2), 3746.
Mor, V., Branco, K., Fleishman, J., Hawes, C., Phillips, C., Morris, J., et al. . (1995). The structure of social engagement among nursing home residents. The Journals of Gerontology. Series B, Psychological Sciences and Social Sciences, 50(1), P1P8.
Mor, V., Finne-Soveri, H., Hirdes, J.P., Gilgen, R., & Dupasquier, J.N. (2010). Long-term care quality monitoring using the inteRAI common clinical assessment language. In Smith, P.C., Mossialos, E., Papanicolas, I., & Leatherman, S. (Eds.), Performance measurement for health system improvement: Experiences, challenges and prospects (pp. 472505). New York: Cambridge University Press.
Mor, V., Morris, J., Lipsitz, L., & Fogel, B. (1997). The Q-Metrics system for long-term care outcomes management. Nutrition, 13(3), 242244.
Morris, J.N., Belleville-Taylor, P., Berg, K., Bjorkgren, M., Frijters, D., Fries, B.E., et al. . (2008). interRAI Clinical Assessment Protocols (CAPs) for use with community and long term care assessment instruments. Ottawa, Ontario, Canada: Canadian Institute for Health Information; 2008.
Morris, J., Carpenter, G.I., Berg, K., & Jones, R. (2000). Outcome measures for use with Home Care Clients. Canadian Journal on Aging, 19(2), 87105.
Morris, J.N., Fries, B.E., Mehr, D.R., Hawes, C., Phillips, C., Mor, V., et al. . (1994). MDS cognitive performance scale. Journal of Gerontology, 49(4), M174M182.
Morris, J.N., Fries, B.E., & Morris, S.A. (1999). Scaling ADLs within the MDS. The Journals of Gerontology. Series A, Biological Sciences and Medical Sciences, 54(11), M546M553.
Morris, J.N., Fries, B.E., Steel, K., Ikegami, N., Bernabei, R., Carpenter, G.I., et al. . (1997). Comprehensive clinical assessment in community setting: Applicability of the MDS-HC. Journal of the American Geriatrics Society, 45(8), 10171024.
Morris, J.N., Hawes, C., Fries, B.E., Phillips, C.D., Mor, V., Katz, S., et al. . (1990). Designing the national resident assessment instrument for nursing homes. Gerontologist, 30(3), 293307.
Morris, J.N., Jones, R.N., Fries, B.E., & Hirdes, J.P. (2004). Convergent validity of minimum data set-based performance quality indicators in postacute care settings. American Journal of Medical Quality, 19(6), 242247.
Morris, J.N., Nonemaker, S., Murphy, K., Hawes, C., Fries, B.E., Mor, V., et al. . (1997). A commitment to change: revision of HCFA’s RAI. Journal of the American Geriatrics Society, 45(8), 10111016.
Mukamel, D.B., & Brower, C.A. (1998). The influence of risk adjustment methods on conclusions about quality of care in nursing homes based on outcome measures. Gerontologist, 38(6), 695703.
Mukamel, D.B., Watson, N.M., Meng, H., & Spector, W.D. (2003). Development of a risk-adjusted urinary incontinence outcome measure of quality for nursing homes. Medical Care, 41(4), 467478.
Nova Scotia Health. (2008). Continuing care strategy for Nova Scotia - Shaping the future of continuing care. Retrieved July 11, 2011, from
Health Quality Ontario. (2011). Quality monitor - 2011 report on Ontario’s health system. Retrieved from – english.pdf accessed on July 11, 2011.
Perlman, C.M., & Hirdes, J.P. (2008). The aggressive behavior scale: A new scale to measure aggression based on the minimum data set. Journal of the American Geriatrics Society, 56(12), 22982303.
Phillips, C.D., Sloane, P.D., Hawes, C., Koch, G., Han, J., Spry, K., et al. . (1997). Effects of residence in Alzheimer disease special care units on functional outcomes. JAMA, 278(16), 13401344.
Poss, J.W., Hirdes, J.P., Fries, B.E., McKillop, I., & Chase, M. (2008) Validation of Resource Utilization Groups Version III for Home Care (RUG-III/HC): Evidence from a Canadian home care jurisdiction. Medical Care, 46(4), 380387.
Poss, J.W., Jutan, N.M., Hirdes, J.P., Fries, B.E., Morris, J.N., Teare, G.F., et al. . (2008). A review of evidence on the reliability and validity of Minimum Data Set data. Healthcare Management Forum, 21(1), 3339.
Poss, J., Murphy, K.M., Woodbury, M.G., Orsted, H., Stevenson, K., Williams, G., et al. . (2010). Development of the interRAI Pressure Ulcer Risk Scale (PURS) for use in long-term care and home care settings. BMC Geriatrics, 10, 67.
Rantz, M.J., Hicks, L., Grando, V., Petroski, G.F., Madsen, R.W., Mehr, D.R., et al. . (2004). Nursing home quality, cost, staffing, and staff mix. Gerontologist, 44(1), 2438.
Reinhard, S.C. (2010). Diversion, transition programs target nursing homes’ status quo. Health Affairs, 29(1), 4448.
Resnick, N.M., Brandeis, G.H., Baumann, M.M., & Morris, J.N. (1996). Evaluating a national assessment strategy for urinary incontinence in nursing home residents: Reliability of the minimum data set and validity of the resident assessment protocol. Neurourol Urodyn, 15(6), 583598.
Sgadari, A., Morris, J.N., Fries, B.E., Ljunggren, G., Jónsson, P.V., Dupaquier, J.N., et al. . (1997). Efforts to establish the reliability of the Resident Assessment Instrument. Age and Ageing, 26(Suppl. 2), 2730.
Steel, K., Ljunggren, G., Topinkova, E., Morris, J.N., Vitale, C., Parzuchowski, J., et al. . (2003). The RAI-PC: An assessment instrument for palliative care in all settings. American Journal of Hospice and Palliative Medicine, 20(3), 211219.
Stolee, P., Rockwood, K., & Robertson, D. (1981). Saskatchewan Health Status Survey of the Elderly. Report 1. Long-term care of the elderly. Final Report. Saskatoon: University of Saskatchewan.
Strain, L.A., Maxwell, C.J., Wanless, D., & Gilbart, E. (2011). Designated Assisted Living (DAL) and Long-term Care (LTC) in Alberta: Selected highlights from the Alberta Continuing Care Epidemiological Studies (ACCES). Retrieved July 11, 2011, from
Walford, R.L. (1985). Economic impact of life span extension. Anti-Aging News, 5(5), 4952.
Wilson, D.M., & Truman, C.D. (2004). Long-term care residents: Concerns identified by population and care needs. Canadian Journal of Public Health, 95(5), 382387.
Wodchis, W.P., Hirdes, J.P., & Feeny, D.H. (2003). Health-related quality of life measure based on the Minimum Data Set. International Journal of Technology Assessment in Health Care, 19(3), 490506.
Zhu, M., Zhang, Z., Hirdes, J.P., Stolee, P. (2007) Using machine learning algorithms to guide rehabilitation planning for home care clients. BMC Medical Informatics and Decision Making, 7, 41.
Zimmerman, D.R. (1997). The power of information: Using resident assessment data to assure and improve the quality of nursing home care. Generations, 21(4), 52.
Zimmerman, D.R. (2003). Improving nursing home quality of care through outcomes data: The MDS quality indicators. International Journal of Geriatric Psychiatry, 18(3), 250.
Zimmerman, D.R., Jewell, K.E., & Karon, S.L. (1998). Using resident assessment data to improve nutritional care in nursing homes: The power of information. Nutrition, 14(4), 410.
Zimmerman, D.R., Karon, S.L., Arling, G., Clark, B.R., Collins, T., Ross, R., et al. . (1995). Development and testing of nursing home quality indicators. Health Care Financing Review, 16(4), 107127.
Zwakhalen, S.M.G., Koopmans, R.T.C.M., Geels, P.J.E.M., Berger, M.P.F., & Hamers, J.P.H. (2009). The prevalence of pain in nursing home residents with dementia measured using an observational pain scale. European Journal of Pain, 13(1), 8993.
Zyczkowska, J., Szczerbinska, K., Jantzi, M.R., & Hirdes, J.P. (2007). Pain among the oldest old in community and institutional settings. Pain, 129(1–2), 167176.


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