Assessing patients’ functional status to identify risks for readmission
Study shows it can make a difference
Patients discharged from an acute care hospital to an acute rehabilitation facility are more likely to be readmitted to the hospital within 30 days if they score poorly on the Functional Independence Measure (FIM) test, which measures a person’s ability to perform activities of daily living, according to a study at Johns Hopkins Medicine.1
Rehabilitation facilities are required to conduct the FIM within 24 hours of a patient’s admission, according to Erik Hoyer, MD, assistant professor in the Department of Physician Medicine and Rehabilitation at the Johns Hopkins University School of Medicine, and the department’s deputy director of quality.
The FIM has 18 items that measure a patient’s ability to walk and to transfer themselves from a wheelchair to a chair, bed, or toilet, self-care issues, such as eating, grooming, bathing, dressing themselves, and the ability to effectively communicate, interact socially, solve problems, and remember important information.
"Functional status is an important factor in a patient’s recovery. When a patient cannot move his or her legs or use the bathroom independently, it is telling something about the body’s physiological reserve and the overall ability to be resilient to disease. If someone is debilitated, they are at risk for something else happening," he says.
Hoyer does not recommend using the FIM in the acute hospital setting because it takes too long and requires specialized training to use it. But he does recommend that case managers and discharge planners use a tool that measures functionality as part of their assessment of patients.
"Few hospitals assess patients’ functional status in a standardized way, but with the new Medicare reimbursement guidelines that cut hospital reimbursement when patients are readmitted within 30 days of discharge, that might drive interest in using functional assessments on patients in general," he says.
At Johns Hopkins Hospital, clinicians use the Activity Measure for Post-Acute Care (AMPAC) developed by Boston University’s Rehabilitation Outcomes Center. (For more information on the AMPAC tool, see http://www.bu.edu/bostonroc/instruments/am-pac/.) Nurses administer the tool during the admission assessment and before discharge, he says.
"Using a tool that measures functional ability helps build a picture about the patient’s ability to care for himself and assists care coordinators in determining the best discharge setting," he says.
Patients who stay in the hospital for a week may be at a different functional level when they leave than from when they came in, Hoyer points out.
"If care coordinators have a clear picture of a patient’s functional ability early on, they can have a conversation with family members, discuss their concerns about the patients’ ability to care for themselves, and create a better discharge plan," he says.
Hoyer also recommends helping patients become more mobile and functional during their hospital stay, and that means getting them out of the bed and walking.
"Even patients in the intensive care unit who are on ventilators can benefit from becoming ambulatory. Getting patients out of the bed can improve their outcomes. Every day patients, particularly the elderly, are in bed, they get weaker and more dependent on others. Acute care hospitals have an opportunity to make an impact on that level," he says.
For the study, Johns Hopkins researchers compiled information on 9,405 patients who had been admitted to an inpatient rehab facility directly from an acute care hospital between July 2006 and December 2012. The data included demographic information, primary diagnosis on discharge from the hospital, severity of illness, and FIM scores on admission to rehab. The research showed that patients with low FIM scores were two to three times more likely to be readmitted than those with higher scores, even after considering age, gender, and severity of illness.
- Erik Hoyer, MD, Dale M. Needham, MD, PhD, Levan Atanelov, MD, Brenda Knox, MS, SLP, Michael Friedman, PT, MBA, Daniel J. Brotman, MD: "Association of impaired functional status at hospital discharge and subsequent rehospitalization" Journal of Hospital Medicine, Vo. 9, Issue 5, May 2014, pp 277-282.