NWT Continuing Care Assessment: What the InterRAI Evaluation Covers and How to Prepare

Your parent needs help, and someone mentioned they need "an assessment." In the Northwest Territories, this isn't a casual conversation with a doctor — it's a formal clinical evaluation that determines what publicly funded care services your parent can access and, if their needs are severe enough, whether they qualify for long-term care placement.

Understanding what the assessment actually measures gives your family a real advantage. Here's how the process works.

The Two Assessment Tools

The NWT uses two overlapping frameworks:

The Continuing Care Assessment and Placement Package (CCAP) is the overall assessment process. When a Home Care Case Manager visits your parent, they're working through the CCAP, which captures medical history, functional abilities, safety risks, and the family support already in place.

The InterRAI-HC (Resident Assessment Instrument for Home Care) is the standardized clinical tool embedded within the process. It's a structured digital assessment used across Canadian jurisdictions that generates Clinical Assessment Protocols (CAPs) — automated flags for specific issues like delirium, cognitive decline, falls risk, malnutrition, or pain.

The InterRAI data gets transmitted to the Canadian Institute for Health Information (CIHI) for national quality monitoring. It's not a form your family fills out — the case manager completes it during the home visit based on direct observation and clinical questioning.

What the Case Manager Evaluates

During the CCAP assessment, the case manager is looking at five core dimensions:

Physical functioning — Can your parent bathe, dress, and toilet independently? Do they need one-person or two-person assistance with transfers and mobility? This is measured through Activities of Daily Living (ADLs) and Instrumental Activities of Daily Living (IADLs) like cooking, managing medications, and handling finances.

Cognitive status — Is there evidence of memory loss, confusion, poor judgment, or wandering? The InterRAI tool includes specific cognitive screening items that flag early-stage and advanced dementia patterns.

Clinical stability — Does your parent have unstable medical conditions, wound care needs, or medication management complexity that requires professional nursing intervention?

Fall and safety risk — Has your parent fallen recently? Are there environmental hazards in the home (loose rugs, poor lighting, stairs without railings)? The case manager physically inspects the living environment.

Support network — Who is currently helping? How many hours per week does the family provide direct care? Is the primary caregiver showing signs of burnout? The system explicitly builds on existing family support rather than replacing it.

How to Prepare for the Assessment

Families can influence the outcome by ensuring the case manager sees an accurate picture of daily reality — not a best-case snapshot.

Schedule the visit during a difficult time of day. If your parent sundowns (becomes more confused in the evening), don't schedule the assessment for 10 a.m. when they're at their sharpest.

Document incidents before the visit. Keep a written log of falls, near-misses, wandering episodes, medication errors, and moments where your parent couldn't safely manage alone. Case managers can only assess what they observe and what you report.

Have the primary caregiver present. The assessment measures caregiver capacity and burnout. If the primary caregiver is exhausted or physically struggling, the case manager needs to hear that directly.

Gather medical documentation. Bring a current medication list, recent hospital discharge summaries, and any specialist reports. The more clinical evidence available, the more accurate the assessment.

What Happens After

The assessment results drive one of two pathways:

If your parent can remain safely at home, the case manager builds a personalized home care plan. Services are delivered at no cost through the regional health authority and may include nursing visits, personal support workers, and medical equipment loans.

If your parent's needs exceed what home care can safely manage — meaning they require 24-hour supervision, have unstable behaviours, or need multi-person physical assistance — the case manager begins the formal long-term care application process. The completed assessment package goes to the Territorial Admissions Committee for review.

The assessment is also reviewed regularly. A significant change in your parent's condition — a hospitalization, a major fall, or caregiver breakdown — triggers an immediate reassessment that can escalate their care level or increase their priority on the LTC waitlist.

For a detailed walkthrough of how to prepare for the assessment, what to do if you disagree with the results, and how to navigate the waitlist after approval, the NWT Elder Care Decision Guide covers every step.

See more Northwest Territories guides →