How Did We Get Here? A Timeline of interRAI — From Nursing Homes to Ohio DD Waivers

 How Did We Get Here? A Timeline of interRAI — From Nursing Homes to Ohio DD Waivers

If you receive developmental-disability waiver services in Ohio, you may soon hear a lot about interRAI.

But interRAI did not begin as an assessment for people with developmental disabilities.

And it did not begin as a tool for determining an individual’s HCBS budget.

Here is the abbreviated history:

• 1987 — The story begins with U.S. nursing-home reform.
  Congress passed the Nursing Home Reform provisions of OBRA 1987 following serious concerns about nursing-home quality. The federal government required a standardized, comprehensive system for assessing nursing-home residents and planning their care.
• 1990–1991 — The Resident Assessment Instrument (RAI) and Minimum Data Set (MDS) enter U.S. nursing homes.
  The original RAI/MDS was developed primarily for nursing-home residents. Its purpose was comprehensive assessment and individualized care planning. It collected standardized information about areas such as function, cognition, medical conditions, behavior and psychosocial status.
  This is the family tree from which interRAI eventually developed.
• 1992–1994 — The work becomes international.
  Researchers and clinicians from other countries became interested in using comparable assessment information. An international research network formed around the RAI; historical accounts describe the collaborative network emerging in 1992 and its establishment as the interRAI nonprofit organization in 1994. Researchers from Europe, Japan, Canada and elsewhere became involved.
• 1994–1996 — Assessment moves from nursing homes into people’s homes.
  Researchers recognized that an institutional assessment could not simply be transplanted into community care. The RAI-Home Care instrument was developed in the mid-1990s, adding information important in home settings, including informal support, environment and community services.
• 1997 — International comparisons expand.
  Researchers published comparisons of long-term-care populations across 10 countries and three continents. Standardized assessment was increasingly being used not only for individual care planning but also to compare populations, quality and resource use.
• Late 1990s–2000s — interRAI expands into many populations and settings.
  Instruments were developed for home care, mental health, assisted living, palliative care, rehabilitation and other settings. The original focus on predominantly older long-term-care populations broadened considerably.
• 2007 — The interRAI Intellectual Disability assessment is published.
  Researchers Lynn Martin, John Hirdes, Brant Fries and Trevor Smith published the development and initial psychometric study of the interRAI-ID.
  The study involved 160 community-dwelling adults with intellectual disabilities served by four provider agencies. The published validation work examined embedded measures involving cognition, self-care, aggression and depression.
  The authors described this as a “first step” toward a comprehensive standardized assessment for adults with intellectual disabilities.
• 2010s–today — interRAI becomes much more than a questionnaire.
  The interRAI system now supports multiple applications: care-planning protocols, outcome scales, quality indicators, risk algorithms and case-mix/resource-allocation systems.
  interRAI describes case-mix systems as grouping people according to patterns of resource use for purposes that can include reimbursement, staffing and comparison of populations. For intellectual/developmental disabilities, interRAI has a specific case-mix approach for adult HCBS.
• February 2023 — Ohio begins its Waiver Modernization Project.
  According to DODD’s rule-filing documentation, Ohio began Waiver Modernization to change processes involving funding, rate setting and individual waiver budgets. DODD says it studied other states, conducted rate studies and consulted stakeholders.
• 2025 — Ohio announces that it has selected interRAI.
  DODD announced that it selected two interRAI instruments to replace Ohio’s existing ODDP and Acuity Assessment Instrument:
  Adults 18+ → interRAI Intellectual Disability (interRAI-ID)
  Children 17 and younger → interRAI Child and Youth Mental Health and Developmental Disability (ChYMH-DD)
  DODD says the goals include creating a more consistent assessment process, better identifying support needs, helping establish service budgets and developing provider rates that better reflect assessed need.
• 2026 — Ohio begins administering interRAI assessments.
  Ohio Administrative Code now requires people enrolled in DODD-administered HCBS waivers to participate in interRAI assessments. Generally, they will occur every three years or following a significant change.
  Ohio’s rules also specify minimum qualifications for interRAI assessors: SSA certification, at least 18 months of assessment experience, experience engaging people with developmental disabilities, and DODD-approved interRAI training.
  Importantly, the rule currently says that existing funding ranges and individual funding levels continue to be used while the new system is being implemented.
• 2026–2028 — Ohio’s assessment rollout continues.
  DODD’s published rollout calls for people on DODD-administered waivers to receive their initial interRAI assessments over this period.
• July 2027 — A major planned transition point.
  Ohio says the new interRAI-based support levels are planned to begin in July 2027, subject to federal approval. For the IO waiver, interRAI is intended to take over the role currently played by the ODDP in helping determine individual service budgets.
  DODD has also said interRAI data and service-utilization information will help Ohio develop acuity-based provider payment rates.
• Where we are now — September 2026.
  Ohio is no longer merely discussing whether to use interRAI. Assessments are underway, interRAI requirements are now written into Ohio’s waiver rules, and the state is moving through a multi-year implementation.
  DODD says interRAI will not replace person-centered planning or the OhioISP, and waiver eligibility will continue to be determined through the Level of Care process.
  That distinction is important.

Why this history matters

The assessment Ohio is implementing today has a long history.

But that history also shows how much its purpose and population have changed:

Nursing-home clinical assessment
→ international long-term-care assessment
→ home and community assessment
→ intellectual/developmental-disability assessment
→ case-mix/resource classification
→ Ohio HCBS support levels, budgets and provider rates.

Every step expands what the information is being asked to do.

That raises reasonable questions as Ohio moves forward:

Was the instrument validated for the specific decision Ohio intends to make with it?

How well does it represent people whose needs differ substantially from the populations on which the model was developed?

How will it recognize rare medical complexity, unusual technology and people who are cognitively independent but require extensive physical assistance?

Does it distinguish authorized support from support actually available and delivered?

How will unpaid family substitution be recognized rather than mistaken for low need?

What happens when the standardized result conflicts with clinical evidence, the person’s lived reality, or the knowledge of people who have supported that individual for years?

What formal outlier process exists before an assessment result affects funding?

Those questions are not arguments against standardized assessment.

They are questions about how to use standardized assessment safely.

Standardization should organize individualized knowledge — not erase it.

And before a standardized assessment is allowed to substantially influence someone’s supports, the system should be able to recognize something equally important:

“This person may not fit the model.”