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Written by: Bob Habasevich, PT on Thursday, August 11, 2011 Posted in: Inpatient Rehab

What is the difference and why should we care?

This seems to be an attitude whenever discussion of FIM™ leads to descriptions of effectiveness and value of inpatient rehabilitation.

FIM™, as a description of a patient’s ability to perform select activities of daily living with or without assistance of another, has become a standard requirement of Medicare to classify patients for payment in IRFs.

The communications used by clinicians to describe a patient’s functional impairment often use the same words found in descriptions of FIM ratings of independence.

Last week, I listened to a therapist describe a patient’s goal for therapy as, “Upon discharge we are working to get to a mod-I with meals.”  Everyone on the interdisciplinary team nodded. The physician asked, “ Where is he now?” the therapist said, “4 or 5”, everyone nodded again, the case manager asked, “How long?” the therapist said, “two weeks.” The case manger looked at a calendar and said, “June 13, that’s a Monday, should we move it to Friday, June 10?” Everyone nodded, the physician said, ” Let’s review again in one week. Next …”

What just happened? Depends on who you ask.  Most clinicians will understand completely and take away a perception of the patient and what we expect the outcome of care to be and how much resource will be expended in getting there.  Of course, some latitudes of interpretation will be required to arrive at that perception and in the end, it may be each comes away with a slightly different opinion.

This difference in perceptions is resultant of the lack of precision or consistency in expressing patient status, functional measurement, care objectives or interventions.  Using the same “words” in describing each requirement is the source of generalization and assumptions.

We all know this, right?

Well, I’m just not sure anymore.  In IRF-level rehab, we use the FIM as a measure of functional independence and it is a reasonable expression of a patient’s burden of care imposed upon a caregiver.  However, when we discuss the patient’s care requirements and consider the resource costs associated with treating the patient’s functional impairments, we use a modified version of the rating and apply a CMS weighting factor to certain motor items in consideration of the costs associated with managing those particular functional deficits.

It is reasonable to expect that there is much science and study behind these factors and that it may be more costly to care for a person who cannot get on and off a toilet than someone who can manage with just a little help from a friend. So we may conclude; when we speak about the patient’s level of independence and express it as a total FIM score, we use unweighted FIM items. But when we speak about the economic costs associated with caring for the patient who is functionally impaired,  we apply the appropriate weights to all  FIM items describing the activities to get a total weighted expression of functional impairment.

At least that is what CMS expects we are doing, and should we care?