Ever since CMS mandated the use of FIM™ as a methodology requirement to classify patients for payment in IRFs it has become a universal yardstick to describe a patient’s functional status in rehabilitation hospitals. As a metric of rehabilitation effectiveness the FIM™ provides valuable information about the patient’s status and how it is changing in response to our therapeutic interventions. FIM™ change over the course of hospitalization is routinely used to describe both effectiveness and efficiency of the rehabilitation care process.
While the FIM™ instrument was designed to communicate a patient’s overall care burden with respect to functional independence in performing 18 standard tasks, its language and item descriptions have been applied to describing a patient’s participation in many ADL tasks. For example, “modified independent” is used to describe the patient’s ability to feed herself and “maximal assistance” is required to get on or off the toilet and communicate both patient status care expectation to any care giver.
Use of the FIM™ item descriptions are common to daily communication of patient participation in ADLs and care requirements, but should not be considered functional assessments simply because these words appear somewhere in a patient chart. And yet it has become common practice for individuals seeking information to complete the IRF-PAI to search out these words describing patient participation or response to therapy and enter their interpretation as primary assessment data to classify the patient upon admission or discharge.
When asked, how frequently do you FIM™ it is common to hear nurses respond, “Every shift— our aides are trained to capture the true burden of care overnight when the patient is tired.” These practices should not be avoided and may add value in describing a patient’s attendant needs variation; however, caution should be exercised when interpreting these comments as functional independence assessments.
Analysis of IRF-PAI data gives evidence of trend, suggesting that industry practices of documenting functional status at admission and discharge in an IRF is undergoing some change. For example, data presented at the AMRPA meeting in September identified that over the past ten years of the IRF PPS program, patient acuity has generally increased as evidence by the average case weight (CMI) over the period, during the same time the average length of stay has decreased slightly. Literal interpretation would suggest that the Medicare patient population was getting sicker or more impaired but with shorter stays in the hospital. Now with that being the case, one would expect the sicker patient with shorter time in rehab would demonstrate less improvement, however, average FIM™ gain for these patients has increased by almost 20 percent.