UNDERSTANDING THE FIM Functional Independent Measure Part 1

GOALS Understand what the FIM is & how it is used Understand FIM terminology Understand how to accurately document Understand how scores effect payments & length of stay Understand differences between admission & discharge FIM

FIM Performance-based functional assessments which take into account the social and physical contexts of the person Measurement of functional abilities and outcomes must relate to real-life situations and settings

Emphases of rehabilitation programs include improving the functional status of individuals through a system of interdisciplinary interventions Outcomes are determined by periodic reassessment of functional changes over time

FIM Instrument Philosophy The 18 item (motor & cognitive), 7 level FIM instrument allows clinicians to measure the effectiveness of rehabilitation interventions and to describe the outcomes in a uniform way, with respect to functional status and burden of care.

The burden of care represents the amount of assistance, in hours per day, that is required to help the patient, once at home, to perform basic personal care tasks. This can be translated into financial cost. Payment by medicare (CMS) and other insurances is based on the justification that the burden of care is such that the patient must be on the rehabilitation unit.

Burden of Care Refers to the type & amount of assistance required for a disabled individual to perform basic life activities effectively Considers: Time Personnel Assistive devices

Support the Burden of Care! All disciplines, all environments, 24 hours a day Each FIM item MUST be scored every 24 hours Documentation of the burden of care by everyone is imperative.

IRF PPS Payment System

IRF PPS Payment Payment is based on length of stay (LOS) and case mix groups (CMG) CMG is a patient classification system which groups together patients with similar resource utilization needs These are determined from admission FIM data

IRF PPS Payment Therefore: Scoring must be an accurate assessment of the patient’s functional status Scoring must demonstrate all we do

Admissions FIM - Implications of Inaccurate or Higher Scoring - TBI FIM motor rating of 53.5 with a cognitive rating of 24 gives LOS of 8 days and $7100 FIM motor rating of 45 with a cognitive rating of 24 gives LOS of 10 days and $9600 FIM motor rating of 45 with a cognitive rating of 23 gives LOS of 13 days and $11800

Admissions FIM -Implications of Inaccurate or Higher Scoring – LE Fracture FIM motor rating of 43 gives LOS of 9 days and $9000 FIM motor rating of 42 gives LOS of 12 days and $11800 FIM motor rating of 33 gives LOS of 14 days and $14300

Activity Did Not Occur The expectation is minimal use of this selection You must document the reason activity did not occur Use only when the patient did not perform the activity AND the helper (therapist, nurse, or family member) did not perform the activity for the patient during the entire 24 hour assessment time frame

Activity Did Not Occur – For Example: If the patient did not transfer to or from the bed or chair and a helper did not use a mechanical lift or perform the activity for the patient during the entire shift the documentation represents, then it indicates that the patient never got out of bed.

Activity Did Not Occur – Justifiable Reasons Activity is unsafe (stairs for a person with LE paralysis) Current medical status prohibits (walking for a pt. unable to bear weight on LE’s Patient refuses (pt refuses to dress in clothing other than hospital gown or refuses to be dressed by a helper)

Activity Did Not Occur – Implications for Accurate Documentation To ensure we are capturing the burden of care – avoid using the selection of “activity did not occur” When an activity is performed at the end of a shift (toileting or showers at end of night shift) make sure to chart the activity (may need to open a new note if documentation has already occurred).

Where Can I Obtain Information on Burden of Care? Credible reports of performance can be taken from the patient, other staff members, family or friends Credible implies that the patient or family member is cognitively intact

Important Reminders You must understand the definition of the each item in order to document accurately Do NOT merge tasks Do not rate simulations, clinical judgments NEVER copy and paste from a previous document because your FIM scores will not be recorded Each FIM item MUST be scored every 24 hours

Important Reminders A number does not support a number! (You must supply detailed documentation within the document.) Min, Mod or Max does not support a number. (You must document why the need the assistance, i.e., decreased balance, decreased strength) “More than reasonable time” to complete a task independently is defined as 3 times the norm and would be scored as modified independence (6).

Important Reminders If in a hurry & don’t have time to allow the patient to do a task & the therapist/nurse does it for the pt, this is max assist. Consider: How much assist did the pt require in this point in time? Who performed the task? Do not modify the assist in order to factor in how busy you are. If you do perform the task for a patient due to your time constraints, document the assistance and the reason (i.e. time constraints) this level was needed to perform the task.

Important Reminders Plan the care you provide by allowing adequate time for the patient to perform the task versus performing the task for the patient. This is rehab, doing the task for the patient should be a rare occurrence.

Summary Read the prompts carefully each time in order to document accurately Remember we are documenting the burden of care required to help the patient at home perform basic personal tasks Burden of care can be translated into financial cost Careful documentation will support the burden of care and our payments