The present study selected six LTC instruments—three of which were international LTC instruments, while the other three were newly published or widely applied Chinese instruments. The international instruments were the MDS 3.0 [7], IAI [6], and NBA [5], while the Chinese instruments were the Chinese Disability Assessment of Long-Term Care (DA-LTC) [15], Chinese Specification for Elderly Care Unified Need Assessment in Shanghai Version 2.0 (SEC-UNA 2.0) [16], and the pictorial-based Longshi Scale (LS) [17].
The established and refined ICF linking rules developed by the ICF Research Branch were used to link the items in the instruments to the most precise ICF categories [13-14]. Two of the authors (Gao and Zhao) performed the linkage separately. Both were familiar with the concepts, definitions, and structure of the ICF and had prior linkage experience. Any differences between the two linkers were resolved through discussion. Where agreement could not be reached, the third author made an informed decision. The online ICF Browser (https://apps.who.int/classifications/icfbrowser/) is applied as a resource for linkage [18].
Linkage of items to the ICF
The ICF is a hierarchical coding system divided into two parts: functioning and disability, as well as contextual factors. Functioning and disability refer to the components of body function (b), body structure (s), activities and participation (d). Contextual factors were divided into the components of environment (e) and an unclassified set of personal factors (pf). As the basic unit of ICF, each category starts with a component letter, followed by the chapter number or first level (one digit), the second level (two digits), the third level (one digit), and the fourth level (one digit). An example of component b is presented in the following code:
b2 sensory functions and pain (first- or chapter level)
b280 sensation of pain (second-level)
b2801 pain in body part (third-level)
b28010 pain in head and neck (fourth-level)
To ensure that the linkage process was conducted in a meaningful and transparent way, the linking process was guided by the ICF linking decision tree [14].
Instruments
The number of domains/sections, the items, the published country/region, and the mode of administration of these instruments are presented in Table 1.
MDS 3.0 is a systematized and standardized multi-dimensional assessment that addresses the problems of LTC facility residents and their potential needs [7]. The data collected from residents can be aggregated to help in the planning of their care and to improve their quality of care. The MDS 3.0 has 21 sections in total. This study excludes the identification information and four summary sections (participation in assessment and goal setting, care area assessment summary, correction request, and assessment administration). Therefore, 96 items were included for the linkage.
The IAI has two subscales, physical and mental status, as well as the use of medical procedures [6]. Trained local government officials completed this form through home visits. Based on standard evaluation scores, the assessors estimate the time needed for the nine categories of care (grooming/bathing, eating, toileting, transferring, assistance with instrumental activities of daily living (ADL), behavioral problems, rehabilitation, and medical services) per day, and assign a care-needs level to applicants according to the total estimated care minutes: not eligible (≤25 minutes), need support (<30minutes), level 1(<50minutes), level 2(<70minutes), level 3(<90minutes), level 4(<110minutes), and level 5(≥110minutes).
NBA has eight modules [5]. Six of them (mobility, cognition and behavior, self-care, management of illness-related demands, everyday life, and social contacts) were included in the scoring system. The scores of the six modules were weighted and integrated into an overall score between 0 and 100. Five degrees of dependency were identified according to the threshold scores: 1st degree of dependency (15-29), 2nd degree (30-49), 3rd degree (50-69), 4th degree (70-89), and 5th degree of dependency (either 90+, or 90+ and additional specific need constellation).
The DA-LTC was newly published by the National Healthcare Security Administration and the Ministry of Civil Affairs of the People’s Republic of China in 2021[15]. It has 27 items and is divided into three domains: activities of daily living (ADL), cognitive ability, and perceptive and communitive ability. It classifies applicants into six levels: no impairment, slightly impairment, moderate impairment, and severe impairment I. severe impairment II, and severe impairment .
The SEC-UNA version 2.0 has 83 items and is divided into two subscales, applicants’ self-care ability and disease severity [16]. The SEC-UNA classifies applicants into seven degrees (from 0 to 6) depending on the threshold scores of each subscale, with 0 corresponding to totally independent and 6 corresponding to totally dependent. This study excluded the items on identification information (items 1 to 26).
The LS is a pictorial-based self-care assessment tool that has been widely applied in Chinese communities and nursing homes [17]. The LS has nine items that evaluate self-care ability in ADLs. It classifies applicants into six grades, with 1 corresponding to totally dependent and 6 corresponding to totally independent.
Data analysis
The reliability of the linking process between the two researchers was evaluated using the statistic and nonparametric bootstrapped 95% confidence intervals. The values were categorized as follows: value of 0.00-0.20 = slight agreement, 0.21-0.40 = fair, 0.41-0.60 = moderate, 0.61-0.80 = substantial, and 0.81-1.00 = almost perfect [19].
Content analysis and comparison of selected LTC instruments were based on linked ICF categories. The number of linked ICF categories was calculated and grouped by the ICF components.