Using the AcuteFIM Instrument for Discharge Placement Paulette Niewczyk, MPH, PhD Manager of CFAR / Director of Research Center for Functional Assessment Research Uniform Data System for Medical Rehabilitation Pamela Roberts, PhD, MSHA, OTR/L, SCFES, CPHQ, FAOTA Manager of Rehabilitation and Neuropsychology Cedars-Sinai Medical Center 2014 Uniform Data System for Medical Rehabilitation. AcuteFIM, AlphaFIM, FIM, LIFEware, SigmaFIM, UDSMR, and the UDSMR logo are trademarks of Uniform Data System for Medical Rehabilitation, a division of UB Foundation Activities, Inc.
Measurement of Function Starting in the Acute Hospital and Following throughout the Post-acute Care Continuum Paulette Niewczyk, MPH, PhD Manager of CFAR / Director of Research Center for Functional Assessment Research Uniform Data System for Medical Rehabilitation 2
Background The FIM instrument has been widely recognized as a valid and reliable measure of functional status and disability, which correlate with the amount of time needed to care for a person with disability in activities of daily living Widespread endorsement of the FIM instrument has allowed for a uniform measurement system to track inpatient rehabilitation outcomes There is a recognized need to manage patient outcomes across the continuum of care, starting in the acute care setting and following throughout postacute care 3
The FIM Instrument The FIM instrument was developed out of an NIDDR grant received in 1983 The purpose of the grant was to develop a method to meet the long-standing need to document the severity of patient disability and the outcomes of medical rehabilitation A national task force was assembled and was cosponsored by the American Congress of Rehabilitation Medicine, the American Academy of Physical Medicine and Rehabilitation, and eleven other national professional organizations 4
The FIM Instrument The instrument consists of eighteen items: Thirteen motor items Five cognitive items It uses a seven-level rating system 5
FIM Items Eating Grooming Bathing Dressing Upper Body Dressing Lower Body Toileting Bladder Management Bowel Management Transfers: Bed, Chair, Wheelchair Locomotion: Stairs Transfers: Toilet Transfers: Tub, Shower Locomotion: Walk, Wheelchair Comprehension Expression Social Interaction Problem Solving Memory 6
The FIM Rating Scale No Helper 7: Complete Independence (timely, safely) 6: Modified Independence (device) Helper Modified Dependence 5: Supervision (subject = 100%) 4: Minimal Assistance (subject = 75% or more) 3: Moderate Assistance (subject = 50% or more) Helper Complete Dependence 2: Maximal Assistance (subject = 25% or more) 1: Total Assistance (subject less than 25%) 7
The FIM Instrument: Burden of Care Raw FIM Rating (18 126) Daily Burden of Care 60 ~4 hours of assistance 80 ~2 hours of assistance 90 ~1 hours of assistance 100 Minimal to no assistance 110 No assistance 8
Functional Measurement in Acute Care A number of factors may complicate or prevent performance of a full FIM assessment on patients in the acute care setting: Illness severity Short stays Short contact time with therapeutic staff Interruptions for diagnostic evaluations and procedures Therapeutic procedures, such as intravenous medication running Lack of access to clothes to observe dressing Lack of space to observe walking 150 feet or stair climbing 9
The AlphaFIM Instrument The AlphaFIM instrument was developed for use in the acute care setting It uses the familiar language of the FIM instrument but a three-level rating system, facilitating administration in the acute care environment 10
The AlphaFIM Instrument An abbreviated version of the FIM instrument Six items (four motor items and two cognitive items) selected from the FIM instrument for their practicality and frequent assessment in the acute care setting Uses the same seven-level rating scale the FIM instrument does Requires training and a mastery exam Takes approximately fifteen minutes to administer Because of the need for training and credentialing, its use may be cumbersome for acute hospital clinicians 11
The AlphaFIM Instrument Patient Type B (has walked 150 feet or more): 1. Transfers: Bed, Chair 2. Locomotion: Walk 3. Bowel Management 4. Transfers: Toilet 5. Expression 6. Memory Patient Type A (has not walked at least 150 feet): 1. Eating 2. Grooming 3. Bowel Management 4. Transfers: Toilet 5. Expression 6. Memory 12
The AcuteFIM Instrument Uses the same six items as the AlphaFIM instrument but a three-level rating system (A, B, and C) Does not require extensive training or a mastery exam Developed to be used in acute care to assess burden of care, aid in triage decision making, and project a full FIM rating Created for ease of use in acute care venues Takes approximately five minutes to administer 13
AcuteFIM Utility Monitors the quality and effectiveness of patient care during the patient s stay in an acute care hospital setting Facilitates discussion with the patient/family of the patient s needs in terms of burden of care Facilitates discharge planning and a guide for triage decisions to alternate levels of post-acute care Can be used in the pre-admission screen for rehabilitation venues 14
Links to the Continuum of Care Acute Inpatient Rehabilitation FIM instrument SNF / Subacute Rehabilitation Acute Care Hospital AlphaFIM instrument/ AcuteFIM instrument FIM instrument or SigmaFIM instrument Homecare Rehabilitation SigmaFIM instrument and/or LIFEware SM System Long-term Acute Hospital (LTCH) SigmaFIM instrument Outpatient Rehabilitation 15
Using the AcuteFIM Instrument for Discharge Placement Pamela Roberts, PhD, MSHA, OTR/L, SCFES, CPHQ, FAOTA Manager of Rehabilitation and Neuropsychology Cedars-Sinai Medical Center 16
Objectives To determine the psychometric properties of the AcuteFIM instrument by evaluating its validity and reliability To determine the predictive ability of the AcuteFIM instrument for discharge destination To determine the correlation of the AcuteFIM rating assessed in acute care with the FIM rating assessed at admission to inpatient rehabilitation on the same patients and to determine the predictive ability of the AcuteFIM rating with regard to rehabilitation outcomes 17
Design, Setting, and Participants Design: Prospective cohort study Setting: Urban academic medical center Participants: New onset stroke patients in the acute hospital between January 1, 2013, and September 30, 2013 (n=423) Subset of patients (n=54) who received additional services in an inpatient rehabilitation facility (IRF) and were able to be linked with the total FIM rating assessed at admission to the IRF 18
Data Collection Personnel documented in the electronic medical record Variables were abstracted from the electronic medical record in order to minimize burden 19
The AcuteFIM Instrument The AcuteFIM instrument is a derivative of the FIM instrument It is designed to assess disability and functional status in the acute care setting The instrument provides an objective estimate of the patient s burden of care, as represented by the number of hours a helper would need to spend with the patient on a daily basis This estimate can be used to gauge the feasibility of the likely discharge destination and can be used to triage post-acute care setting 20
The AcuteFIM Instrument The AcuteFIM instrument has six items: Four motor items Two cognitive items The six items: Eating Grooming Bowel Management Transfers: Toilet Expression Memory 21
AcuteFIM Ratings No Helper, Independent: The individual performs all tasks without assistance from a helper but may require more than a reasonable amount of time (three times longer than expected) or an assistive device, or there may be safety concerns during the individual s performance of the activity Helper, Modified Dependence: The individual expends 50% or more of the effort but requires assistance from a helper who provides supervision or preparation (e.g., setup assistance), direct physical contact, coaxing and directions, or a combination of such assistance Helper, Complete Dependence: One or more of the following are true: The individual performs < 50% of the effort, with a helper contributing maximal to total assistance The individual requires assistance from two helpers to complete the task The individual does not perform the activity 22
Results: Characteristics of Acute Stroke Population Variable Mean SD Age 68.1 15.7 Age Groups (Years) 0 44 45 64 65 74 75+ Gender Male Female Ethnicity White Black Other Unknown Marital Status Married Single Unknown n 1 54 197 171 n 223 200 n 268 97 56 2 n 197 218 8 % 0.2 12.8 46.6 40.4 % 52.7 47.3 % 63.7 23.0 13.3 % 47.5 52.5 2014 Uniform Data System for Medical Rehabilitation, a division of UB Foundation Activities, Inc. 23
Results: Characteristics of Acute Stroke Population Variable n % Insurance Blue Cross Medicare non-mco Medicaid non-mco Commercial Insurance MCO HMO Crippled Children s Services Developmental Disabilities Medicare MCO Medicaid MCO Unknown Stroke Type Ischemic Hemorrhagic TIA Other 57 226 4 34 16 1 1 18 21 45 231 71 117 4 15.1 59.8 1.1 9 4.2 0.3 0.3 4.8 5.6 54.6 16.8 27.7 0.9 2014 Uniform Data System for Medical Rehabilitation, a division of UB Foundation Activities, Inc. 24
Results: Characteristics of Acute Stroke Population Variable n % Impairment Code 01.1, Left body involvement 01.2, Right body involvement 01.3, Bilateral involvement 01.4, No paresis 01.9, Other stroke Discharge Living Setting Home Rehabilitation Facility Other 141 158 15 108 1 248 73 102 33.3 37.4 3.5 25.5 0.2 58.6 17.3 24.1 2014 Uniform Data System for Medical Rehabilitation, a division of UB Foundation Activities, Inc. 25
Results: Characteristics of Acute Stroke Population Variable Mean SD Length of Stay 7.7 10.1 Number of Visits Number of PT visits Number of OT visits Number of SLP visits Minutes of Therapy PT minutes OT minutes SLP minutes 1.8 1.7 1.1 68.4 72.8 47.6 2.1 2.0 1.5 77.5 94.1 66.2 2014 Uniform Data System for Medical Rehabilitation, a division of UB Foundation Activities, Inc. 26
Results: Ischemic Stroke Variable Mean SD Age 69.2 14.9 Length of Stay 7.8 9.2 Number of Visits Number of PT visits Number of OT visits Number of SLP visits Minutes of Therapy PT minutes OT minutes SLP minutes 2.0 1.9 1.3 75.8 84.7 56.9 2.1 2.1 1.6 73.2 98.7 69.8 2014 Uniform Data System for Medical Rehabilitation, a division of UB Foundation Activities, Inc. 27
Results: Hemorrhagic Stroke Variable Mean SD Age 62.5 16.3 Length of Stay 13.8 15.1 Number of Visits Number of PT visits Number of OT visits Number of SLP visits Minutes of Therapy PT minutes OT minutes SLP minutes 3.0 2.5 1.5 106.8 108.3 66.0 2.8 2.0 1.7 108.5 88.6 72.2 2014 Uniform Data System for Medical Rehabilitation, a division of UB Foundation Activities, Inc. 28
Results: TIA Variable Mean SD Age 69.1 16.4 Length of Stay 3.8 5.2 Number of Visits Number of PT visits Number of OT visits Number of SLP visits Minutes of Therapy PT minutes OT minutes SLP minutes 0.8 0.6 0.4 31.9 28.8 17.9 1.4 1.3 0.9 45.3 70.1 42.2 2014 Uniform Data System for Medical Rehabilitation, a division of UB Foundation Activities, Inc. 29
Summary: Age, Length of Stay, Visits, and Minutes by Type of Stroke Age: Youngest in hemorrhagic (62.5 vs. 69) Length of stay: Longest in hemorrhagic stroke (13.8 days) Shortest in TIA (3.8 days) Visits (for all; TIA shortest and hemorrhagic longest): PT ranged from 0.8 in TIA to 3.0 in hemorrhagic OT ranged from 0.6 in TIA to 2.5 in hemorrhagic SLP ranged from 0.4 in TIA to 1.5 in hemorrhagic Minutes (for all; TIA shortest and hemorrhagic longest): PT ranged from 31.9 in TIA to 106.8 in hemorrhagic OT ranged from 28.8 in TIA to 108.3 in hemorrhagic SLP ranged from 17.9 in TIA to 66 in hemorrhagic 30
Results: AcuteFIM Variables Variable Mean SD AcuteFIM Total AcuteFIM Motor AcuteFIM Cognitive Eating Independent Modified Dependence Dependent Grooming Independent Modified Dependence Dependent Bathing Independent Modified Dependence Dependent 81.5 55.6 25.9 n 268 62 93 n 247 83 93 n 274 41 108 33.9 25.6 10.0 % 63.4 14.7 22.0 % 58.4 19.6 22.0 % 64.8 23.2 29.1 2014 Uniform Data System for Medical Rehabilitation, a division of UB Foundation Activities, Inc. 31
Results: AcuteFIM Variables Variable n % Transfers: Toilet Independent Modified Dependence Dependent Expression Independent Modified Dependence Dependent Memory Independent Modified Dependence Dependent 202 98 123 224 112 87 244 101 78 47.8 23.2 29.1 53.0 26.5 20.6 57.7 23.9 18.4 2014 Uniform Data System for Medical Rehabilitation, a division of UB Foundation Activities, Inc. 32
Results: Spearman s Inter-item Correlation Coefficients of AcuteFIM Instrument Items in Stroke Patients Eating Grooming Bowel Mgmt. Toilet Transfer Spearman s rank correlation coefficient measures the strength of the associations between two variables Excellent: Correlation coefficient 0.6 Adequate: Correlation coefficient < 0.60 and > 0.30 Poor: Correlation coefficient 0.30 Expression Memory Eating 1.00 0.81 0.72 0.75 0.68 0.65 Grooming 0.81 1.00 0.77 0.82 0.67 0.65 Bowel Mgt. 0.72 0.77 1.00 0.76 0.59 0.63 0.75 0.82 0.76 1.00 0.63 0.64 Toilet Transfers Expression 0.68 0.67 0.59 0.63 1.00 0.74 Memory 0.65 0.65 0.63 0.64 0.74 1.00 2014 Uniform Data System for Medical Rehabilitation, a division of UB Foundation Activities, Inc. All AcuteFIM items demonstrated strong inter-item correlations (above 0.6) and were statistically significant at p < 0.001 33
Results: Internal Consistency Cronbach s alpha is the extent to which items in the same instrument all measure the same trait Excellent: Cronbach s alpha > 0.8 Adequate: Cronbach s alpha < 0.8 and > 0.7 Poor: Cronbach s alpha < 0.7 A Cronbach s alpha of 0.94 was observed, indicating high internal consistency 34
Results: Rehab Characteristics in Patients with Acute and IRF Data (n=54) Variable Mean SD Range AcuteFIM Total 66.3 26.7 20 114 Admission FIM Total 53.3 15.7 24 87 Discharge FIM Total 76.4 18.8 35 105 Total FIM Gain 23.1 12.0 0 49 IRF Length of Stay 13.7 6.4 3 32 Length-of-Stay Efficiency 0.2 1.0-2.5 3.8 2014 Uniform Data System for Medical Rehabilitation, a division of UB Foundation Activities, Inc. The total AcuteFIM rating was a significant predictor of discharge to the community from the acute setting. 35
Results: Rehab Characteristics in Patients with Acute and IRF Data (n=54) The odds ratio (OR) is the measure of the odds of an event happening in one group compared to the odds of the same event happening in another group We compare the odds of exposure in both groups and compare the odds An OR of 1.0 means that both groups had the same odds of exposure OR = 1.06, 95% CI: 1.05 1.07 The C-statistic, or concordance, measures the discriminatory power of a predictive model and is often a measure of the model s fit Values are from 0.5 (random model) to 1.0 (ideal model) C-statistic = 0.89, p < 0.001 36
Conclusions The AcuteFIM instrument demonstrated acceptable predictive validity and high internal consistency It predicted discharge from the acute care setting The AcuteFIM total rating was significantly related to total admission FIM rating, total discharge FIM rating, and length-of-stay efficiency in the rehabilitation setting 37
Implications The AcuteFIM instrument has the potential to be utilized in the acute care setting to determine burden of care based on functional level Because it has a limited number of items and only three levels of assistance, it is easy to utilize It can be integrated into an electronic documentation system 38
Implications May be important to utilize in order to triage discharge destination, especially in light of the Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014 Requires using quality and resource use measures to help providers, suppliers, beneficiaries, and their families with discharge planning from the inpatient hospital It is time to take the next step and utilize a standard assessment in the acute care hospital to determine post-acute care destination and functional needs 39
Contact Information Pamela Roberts, PhD, MSHA, OTR/L, SCFES, CPHQ, FAOTA Program Director, Cedars-Sinai Medical Center pamela.roberts@cshs.org Paulette Niewczyk, MPH, PhD Director of Research, Uniform Data System for Medical Rehabilitation pniewczyk@udsmr.org Jacqueline Mix, MPH Research Associate, Uniform Data System for Medical Rehabilitation jmix@udsmr.org 40
Thank You! Any Questions? 41