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Written by: Mediware on Sunday, October 14, 2012 Posted in: Inpatient Rehab

When clinical staff score functional measurement for the IRF-PAI, it’s more than just knowing minimal, moderate or maximal (min., mod., max.) assistance to determine scoring. I have spent significant time with the instrument over many years and I still need to review subtle distinguishing characteristics myself to be sure I have headed down the correct side of the decision tree. It’s a lot of detail to memorize and simplifying to min., mod., max. isn’t the best way to distinguish clarity in true care cost burden – the overall purpose of the measurement tool.

The  manual states (page III-2), you must read the definitions of the 18 functional areas carefully before beginning to use the IRF-PAI scoring instrument; “…committing to memory what each activity includes. Rate the subject only with respect to the specific item.”

The  IRF-PAI manual asks assessing clinicians to commit to memory what each activity includes. It’s not easy when attempting to distinguish subtle differences; key words and the caregiver’s efforts are all important when describing how much assistance the patient requires to complete a task. The patient should always be encouraged to do as much for themselves as possible as a baseline when you are “assessing” the patient. Giving them that opportunity is important so that you do not arbitrarily lower capability. Facility imposed restrictions such as this is a major flaw in these hurried healthcare environments.

If all items in a task must be completed, the series of tasks will be connected in the text of the definition by the word “and.”  If only one must be completed, the series of tasks will be connected by the word “or.” (IRF-PAI Manual III-2)

The number scale rates patients on their performance of an activity taking into account their need for assistance from another person or a device. If help is needed, the scale quantifies that need. The need for assistance (care cost burden) translates to the time/energy that another person must expend to serve the dependent needs of the disabled individual so that the individual can achieve and maintain a certain quality of life.  (IRF-PAI Manual III-1)

When therapist speak of min., mod., max., they are often describing their own effort to help the patient with general therapy descriptors and less often utilizing key words that determine the levels defined for burden of care measurement as defined by the IRF-PAI manual decision trees.

There is no provision to “skip” an assessment of any of the 18 areas. “All FIM instrument items (39A – 39R) must be completed.” (IRF-PAI Manual III-1)

At sometime in the range of mandated observation windows, each item must have a real observation to warrant a score.  If you have to use “Does Not Occur,” staff must be familiar with the only times that designation can be made. If an area “Does Not Occur” for a defined CMS purpose is used, that score is the assessment and there are rules as to which areas this condition applies.


Assessment discussions and the errors I often see when reviewing charts.

To Score a 7:

Staff usually understands when someone is independent and safe and they apply a score of 7 quite competently. It’s important for them to always know what questions to ask (device/meds) so they can distinguish a 7 from a 6.  From a motor perspective staff often applies a 7 accurately. More often, however, communication and social cognition are not understood in detail. I often see 7‘s in communication and social cognition when documentation clearly represents  ”constant cues,” “repetition of instruction,” etc., which is less than perfect for comprehension, memory or both. If staff must consistently take time to apply coaching and cuing, they need to understand when a score of 7 is not appropriate in the social/cognition areas.

To Score a 6:

Generally, use of device/medications, reasonable time or safety needs are considered to apply a level 6. Sometimes staff believe they have to be the one to administer the medications in order to apply the 6 level.  In fact, the care cost burden refers to medications used to manage a problem, this is picked up in the score as long as the patient is still actively taking those medications. Burden rests on whether the medication is currently in use to manage that area, even if on a particular shift  someone did or did not administer it. As a burden measurement tool, if the patient was discharged regardless of shift, that particular area of care would exist and need to be managed. Documentation should cover rationale for applying an assessment score.

To Score a 5:

Cuing, coaxing, set-up or setting-out items is fairly easy to recognize to assign a 5 level of care. When it comes to burden, having to be physically present to continually coach or cue is costly; a helper being present is captured in the score of 5. Any facility that utilizes “sitters,” knows constant attendance is costly. If a patient requires constant attendance, it is rare to see scores above a 5, except if a patient has no bowel/bladder accidents but uses medications to manage these areas. When you see scores, ask yourself if clinically they make sense? Teach and train those that aren’t connecting the dots!

To Score a 3 / 4  or 1 / 2:

I believe what is often mis-interpreted is when should staff apply a rating of a 3 or 4, and when does it move to the left of the decision tree to consider a 1 or 2. For the most part, you look to see if there is occasional or incidental input from the caregiver or just steadying assistance. This is minor physical help and warrants a level of 4. If physical assistance is more than occasional, incidental or steadying and the patient is predominantly performing more than half the activity on their own, then a 3 for moderate assistance can be applied.

The moment the activity requires physical assistance that is greater than 50% such as holding, helping, physically lifting (generally more than one limb), then you must go to the left of the decision tree.  You then decide if you are assisting with all the activities even to some degree or if the patient can perform any independently.  If they can still perform some without assistance than a 2 level may be scored.  If the patient essentially performs no part independently and all areas require physical assistance from a caregiver to complete the task,  than a total assistance or 1 is the answer.

If you provide hand over hand assistance (even “minimally”), often the patient is  ”totally” dependent on you to successfully complete the task.  It is a care-cost-burden model and should appropriately reflect the cost of a caregiver attending throughout the activity. Staff needs to understand that this tool is a reflection of how much care the family will need to absorb when taking the patient home. The measurement tool does exactly what it is intended to do, which is to provide  a reliable measurement of care cost burden but everyone must apply the measurement like a yard stick, or more seriously, like a temperature reading if it is to be reliable.

Somehow, taking away the min., mod. and max. vocabulary can sometimes assist staff to see through the portion of the task that the patient is able to perform. Ask key words like, “Is it occasional, steadying or is it lifting, holding, placing that is occurring?” When you can answer these questions, suddenly min., mod. and max. take on an entirely new understanding.  If you don’t believe me, encourage your staff to review my blog posted on August 26 and to participate in the fun survey.  The results are also posted along with discussions that can help you educate and train your team to more accurately assess patients and to pay attention to the subtle cues we give one another when we talk about how much assistance was provided.

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