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Written by: Darlene D'Altorio-Jones (1959-2015) on Sunday, August 26, 2012 Posted in: Inpatient Rehab

I challenge you to a “fun” assessment of your staff’s ability to discern min., mod., max. as a burden of caremeasurement; not specifically the words we hear and use every day as therapy lingo, but using the other guiding key words that describe and determine a functional measurement score in the IRF PAI.

Min, mod, max is often what leads staff to incorrectly assign functional measurement scores on the IRF PAI. Why? Because clinicians have not made the subtle connection of key words used in the IRF PAI manual decision trees that lead toward appropriate burden of care measurement.

OK, it might not be “fun” to assess staff’s ability; it may actually be painful, but at least you will begin to help staff capture the thought process required to follow the PAI manual decision trees. Number systems can hold varied interpretation, but when staff are truly cognizant of how the words incidental, cuing, coaxing, steadying, contact, holding, prompted, hand-over-hand and occasional are interpreted, you are halfway toward getting to the correct side of the decision tree.  If  clinicians thought more about the patient’s effort, and which of the words above could describe the assistance provided to accomplish the entire activity, this would help discern just how much effort leads to the correct definition.

Moderate Assistance (level 3) still assumes the patient does more than half of the task independently. It’s the hardest half measurement I know, but it does not have to be that way when using a few key words to help guide which measurement level to select. Moderate is applied for physical assistance one step above“incidental” or “occasional” Minimal (level 4) caregiver help, and the patient is still performing better than half the activity on their own.

The functional “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 (burden of care) 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.” (III-1   2012 IRF PAI Manual)   If your staff generally records a number without use of tools that prompt or assist in scoring accuracy, then the use of key word recognition in writing and describing these activities helps others to apply appropriate assistance going forward.

The General Description for levels of function and scoring found on page III-10 of the 2012 IRF PAI Manual is a good start; however, the specific key words used for each functional area are even more vital. Of importance is how much physical assistance the staff or caregiver is utilizing when they are assessing the patient. Very often I see levels placed on the chart that differ from the patient’s ability to complete a task because too often clinicians do for the patient without assessing what the patient can do for themselves.  They then apply a score and that score is not reflective of the true burden of care.  Truly therapeutic interdisciplinary care rests on the fact that a patient must be encouraged to do for themselves prior to our taking over and doing a task for them.  This is the absolute basis of functional recovery training and with that knowledge each caregiver thereafter builds on the patients ability, continuously challenging improved independent performance.

The manual provides clear examples of walking a shorter distance to the bathroom on a later shift when the patient is capable of walking further.  This example reflects a facility imposed restriction and tasks performed in this manner should not be considered as an assessment or score. Staff should not record measurement scores in an instance like this when the patient can and could walk further, it just so happened it was not challenged as an assessment if the intended goal was to only walk a short distance bed to bathroom in a patient’s room.

To score based on restricted distance is not fair to the patient, it would not reflect a patients real capability. Imagine taking a measurement such as temperature, and removing the thermometer just short of an actual reading. Would you say the patient’s temperature is 88 degrees? Never! Functional assessment is the same. It requires specific details to be followed and challenged before a real determination is made.  Tools are applied to obtain standard information and therefore each time an assessment occurs the same opportunities to perform must be allowed.  If not, the patients consistent ability cannot be measured.  The scores are ‘labels’ of needed resource for an individual to achieve each of the functions and should be closely repeatable between staff members.

Anytime clinicians are unable to assess real details of the patient’s performance, just because they assisted the patient in a task does not mean it can be scored.  If you as a caregiver did not allow the patient to demonstrate their full potential to meet the various levels of measurement,then it should not be considered an assessment.  This can be particularly true when float staff and untrained aides communicate what they did for the patient. Often it appears the patient has regressed when in reality, that individual may not have the detailed training of a rehabilitation professional that prompts, coaches and guides first and then slowly applies graded assistance. Although you would hope that every time we interact with a patient on every functional area that an assessment can occur; it is not always feasible and staff should clearly know when and why they can apply ameaningful score.  Scoring must be meaningful for staff to appreciate its value.

Staff must be aware that recorded assessments act as a label of resource need. When these scores are placed into the legal medical record, they can be confusing and misleading when not applied as a real assessment. As a label of care burden,  the purpose for functional measurement allows us to record patient care resource needs for discharge caregiver carryover.   Beneath the scene is the fact that Medicare fee-for-service Part A  patients are reimbursed based on functional assessment in total along with other IRF PAI factors.  Therefore, the greatest amount of accuracy provides not only the baseline for payment, but where the interdisciplinary team should focus training to effectively assist the individual in learning to care for themselves to the best of their ability. When done correctly, IRF PPS payment is applied for resources actually required to care for the patient and the patient’s capabilities are understood so the staff can improve their independent function through training and guidance.  It’s a win-win!

Below is a link so that you and your staff can take a baseline “test” of key performance words and how they apply to min., mod., max. as a measurement of care burden.

If you follow the link, a future blog will provide you details on how well people grasp key words that guide assessment scores. This is not an official inter-rater reliability test.  This is an exercise that may help you guide staff on their awareness of “key words” that translate to burden of care assistance as those words are used in the IRF PAI Manual to describe level of assistance.  It will also be a way for us to review answers of all those taking the assessment to see what particular questions may pose interpretation inconsistencies even when guiding words are used from the PAI Manual.

Long Version 40 Questions: Test your knowledge

Short Version 20 Questions:  Test your knowledge

It’s all for the fun of learning and improving accuracy of the applied assessment.  The more who participate, the better our ability to learn from each other.  Answers and rationale will be provided in a later blog.

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