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Written by: Darlene D'Altorio-Jones (1959-2015) on Friday, July 5, 2013 Posted in: Inpatient Rehab

This was a lengthy discussion I recently posted to the RehabNurse List Serve, but it really benefits from discussion to our readership as well…so here goes!

I have a fairly philosophical comment on the D/C FIM™ scores discrepancy which was recently discussed with a client at a facility debating these issues. When is the FIM accurate and why would you not use clinical observations AND assessments by all staff that interact with the patient in a 24/7 model of interdisciplinary care? First, we hope that every application of the IRF PAI manual decision tree leads to similar application of scoring. It should. But why are outcome scores at discharge so different between our clinical staff?

This may not be the politically correct thing to say because I realize everyone wants to show ‘progress’ to the greatest denominator possible at discharge, but the real discussion is this; the scoring of the patient is reflective of the burden of care across every 24 hour period. Staff must always understand when and when not to SCORE/ASSESS the patient. The manual states that you should NOT score ‘facility imposed restrictions,’ yet time and again when I question any staff to their scoring practices they often impose facility restrictions and aren’t even aware when they are.

Rehabilitation is a different level of care. The purpose is to assess the level a patient can participate on their own care and to encourage verbally FIRST and then through tactile or assisted intervention with the least amount of action possible so the patient learns to do for themselves, instruct another person or when necessary, be helped physically to only the level they NEED. Helping professions tend to help too much even when not needed. Unfortunately they then apply that help to the patient’s score. This is bad practice!

When possible, all assessments should be a real enactment of how the patient must perform themselves and not to automatically do for the patient what they can do for themselves. If you are only walking a patient to the bathroom because you did not have time to walk beyond although the patient could, why would you score ambulation? The manual uses this example of when not to apply a score. We limit the patient’s ability to perform each day because we apply too much help without asking, without assessing their potential within reasonable time because we as caregivers know we can do it faster for the patient or it’s more convenient. It’s not about us. It’s about the patient. I say STOP. The minute you do something for an individual that they can do for themselves and you can talk them through but you decided to apply assistance for your own needs, it is a non-warranted score. The patient could have had an ‘A’ and you settled for a C or a D! (ok, it’s not a report card but pretend it is!) If you have an aide applying scores and not first seeing what the patient can do and then they tell you how much help they gave, you too are transposing perhaps very incorrect information on the patient’s true burden of care or capability. This is rehab, let’s apply the principles that set us apart in an IRF level of care.

Within the last several days of a planned discharge every staff capable of assessing any of the 18 areas should be encouraging that patient to do exactly for them or to verbally coach another to assist them in the LEAST way possible so they can assume as much of their own care as possible. That’s what rehab professionals signed up to do. Let’s start acting like those professionals. Anytime any clinician performs any of the 18 areas they can assess in their interaction with the patient, always ask first for the patient to show you what they can do or to verbally coach you on how you can assist them to the least level. Keep your hands off as much as possible so that a ’5‘ can be applied whenever possible. When you place your hands on that patient, encourage them to do what they can and apply as little assistance as possible so they can achieve a 4 or 3. When you begin to do more than 50 percent for the patient because they CANNOT do this for themselves then the burden of care will be the same whether you do it or have a family member do it.

If you do it because it’s ‘easier’ for you then scoring is not an option unless it truly is an ‘unreasonable’ amount of time. (Sorry, no definition for this in the manual but let’s be reasonable.) Follow these premises and you will have accurate patient ability to care for themself no matter when the score is applied. Burden is burden. Every professional applying the same principles and not over doing for the patient is capable of having accurate assessments based on the definition/ rules for application. It is a measurement device and the measurement applied should be consistent. How else is it even comparable?

Take a vow to really assess the understanding of how your staff applies scoring. Watch and ask why they may have assisted the patient beyond a particular need. If we are to defend a rehabilitation level of care then we need to start demonstrating expectations with a 24/7 model of encouragement, training and carry over. Doing this will most often align scores without discrepancy and not matter if it is the beginning or end of the patient’s stay. A patient will leave our facility needing to care for themselves or encouraging assistance 24/7 too!
I use this analogy when training. Let’s suppose we are taking the patient’s temperature. But we are in a hurry, we pull the thermometer out and it reads 88 degrees. No time to let it register the ‘real temperature.’ I write that down and move on. REALLY? Tests can only be resulted when the expected care and attention is applied to allowing the result to occur. This information is part of the real medical record and believe it or not, should be applied consistently. Outcomes require accurate comparison to a condition at the beginning and the end and the measurement must be consistent. Let’s encourage and rally the patient from start to finish so we apply real burden measurement, get paid for what we deserve based on those resources and ALIGN the appropriate amount of assistance for the patient upon discharge for their safety 24/7. In the near future, return to acute with 30 days will be an outcome measure for IRF too; let’s give patients as much practice as possible in all these functional areas so we feel confident they are ready at discharge. If it was my family member that is what I would want for them! (Sorry…it was a soap box moment! – I tend to blog often on this topic.)

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