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Written by: Darlene D'Altorio-Jones (1959-2015) on Tuesday, May 10, 2011 Posted in: Inpatient Rehab

Functional Scoring Guidance

The main reason patients are admitted to a rehabilitation facility is because they are functionally dependent on others to meet their basic care. The fact that as an interdisciplinary team you felt that you could significantly impact the outcomes of that individual far greater than any other level of care, thereby bringing them to an inpatient rehab facility, means that you need to measure your effectiveness in delivering the outcomes you predicted were possible. Not just at the beginning and at the end, but continuously as the patient regains independence. Otherwise, how do you know you are effective in your day to day delivery of care?

How is updating functional status possible? The answer has always been available to you. You measure functional impairment not just at admission and discharge, but also throughout the stay with notable change. It becomes the patients’ temperature of functional status. It provides vital information on where the interdisciplinary team needs to focus care and retraining.

Vital signs are critical indicators of patient status; heart rate, respirations, 02 saturation, blood pressure, and some would even consider pain to be continuous monitors that indicate the patients’ medical stability. In a rehabilitation facility, the purpose beyond medical care is functional improvement yet we often ignore how important the patients’ functional measurement is changing, even if subtle throughout the stay.

Measuring functional improvement is something that is completed on a daily basis but it is not necessarily something that can or should be done during each shift. The tactics required to validate a real “assessment” is guided by algorithms that were intended to be followed so that all assessments are comparable.

When a facility chooses to score each shift, or each day every item, whether or not that assessment was done in its entirety is not practical, further it violates a premise made in the IRF PAI scoring manual on page III-5, “The patient’s score on measures of function should not reflect arbitrary limitations or circumstances imposed by the facility.” If there is a policy to score at each shift, whether or not engaged in that function, that is a circumstance that is not reflective or purposeful and staff will soon rebut the entire process. A process so precious to validating present status of function regained, it is critical to rethink the reasons behind why the scores are important and  what are we going to do with that knowledge as a team?  Measurement must be meaningful and everyone must know what to do with the results.

The appropriate time to score a patient is when the function is observed, and correctly challenges the patients’ performance during their care. The score is not abbreviated or guessed. It should be meaningful, at several key times during the patient’s care, so it can be measured reliably. Until the next time it is measured, the status is assumed stable as last reflected. Looking at function, just as you would look at a temperature status until re-measured, is a new critical skill that staff must gain in an inpatient rehab facility. If you feel warmth or a change in temperature, you measure to validate your suspicion, and provide care toward the symptoms present.

Functional measurement is no different. Always know the current status, and as a team, work toward the areas that define the greatest need.  If you focus on those items specifically, the patient is truly obtaining an integrated, interdisciplinary plan of care and the effectiveness of that care will be measured as improvements are gained.

Given purpose, staff will not question why they must do something like measure function. It is the qualifying difference for why a person is admitted to rehab and continuous improvement in patient function is a validation of the teams’ effectiveness. Re-engage staff to these purposes.  Align policy toward meaningful use of information, not just a score to be obtained shift after shift or day after day and a real transformation will occur for your staff and your patients.

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