RUG-ADL & AKPS Assessment This PowerPoint presentation is part of a series of PowerPoint presentations from the PCOC Assessments Toolkit. It is designed for use in routine or regular education sessions. To undertake this learning activity please have copies of: PCOC assessment tools lanyard card available from your QIF or www.pcoc.org.au Your palliative care assessment form/s or the PCOC Sample assessment form located in the toolkit or available at: www.pcoc.org.au The PCOC Assessment Toolkit Funded under the National Palliative Care Program and is supported by the Australian Government Department of Health and Ageing.

Functional Assessment Tools There are 2 tools that assess function and performance: Australian Karnofsky Performance Scale RUG-ADL The RUG-ADL measures motor function with activities of daily living- bed mobility, toileting, transfer and eating and the AKPS measures overall performance or ability to manage activities of daily living. The use of 2 assessment tools for performance or function ensure that assessment focuses on the patient’s ability, capability and is useful as a prognostic measure.

Resource Utilisation Group Activities Daily Living (RUG-ADL) Inform us about the patient's functional status, the assistance they require to carry out these activities and the resources needed for the patient’s care The RUG-ADL is a 4-item scale measuring motor function with activities of daily living: Based on what the person does not what they are capable of doing Bed mobility Toileting Transfer Eating A patient's RUG-ADL score is an indication of the functional status and in most cases the amount of care and support required. The RUG-ADL score tells us the resources required to care for the patient. It may be used to determine level of home supports needed or suitability of aged care facility placement (low or high level care) or the staff levels required to care for the patient. It can be used in conjunction with other assessments used in discharge planning. The RUG-ADL score can be used in handover descriptions in order to summarise functional condition and can be useful “common language” in palliative care. This assessment is clinically useful in everyday practice and could be completed in conjunction with phase on a daily basis. Integration strategies may include writing the RUG-ADL and Phase score on handover/allocation sheets or whiteboard or documenting in nursing entries in the clinical record (patient progress notes). Further, these scores could be used in care planning/interdisciplinary meetings as together they provide a summary of the patient’s condition and clinical situation.

Bed mobility RUG Item Score Definition Bed mobility Ability to move in bed after the transfer into bed has been completed Independent or Supervision only Able to readjust position in bed, and perform own pressure area relief through spontaneous movement around bed or with prompting from carer. No hands-on assistance required. May be independent with the use of a device. 1 The RUG-ADL assessment has been widely used in Australian palliative care services (Eagar et al, 2004).   The overall RUG-ADL scores may indicate the level of resources required to meet the care needs. For example the number of nursing staff for number of patients and their level of care. This assessment can be used to describe acuity and measure dependency. RUG-ADL assessment changes may trigger Occupational Therapy assessment or increased equipment in the community or inpatient setting. For a community patient a high RUG-ADL (16-18) may trigger a referral to an inpatient palliative care unit or aged care assessment. There is no score of 2 for bed mobility, toileting and transfers. This is quite deliberate. The tool was derived as a measure of resource use, with a score of 2 indicating twice the use of resources of a score of 1, a score of 3 indicating three times the use of resources of a score of 1 etc. For bed mobility, toileting and transfers the change from independent/supervision to limited assistance was found to equate to a three-fold increase in resources. For eating, the same change equated to a two-fold increase in use of resources. Limited physical assistance 3 Able to readjust position in bed and perform area relief with the assistance of one person.

Bed mobility (continued) RUG Item Score Definition Bed mobility Ability to move in bed after the transfer into bed has been completed Other than two persons physical assist Requires the use of a hoist or other assistive device to readjust position and provide pressure relief. Still requires the assistance of one person for task. 4 The RUG-ADL assessment has been widely used in Australian palliative care services (Eagar et al, 2004).   The overall RUG-ADL scores may indicate the level of resources required to meet the care needs. For example the number of nursing staff for number of patients and their level of care. This assessment can be used to describe acuity and measure dependency. RUG-ADL assessment changes may trigger Occupational Therapy assessment or increased equipment in the community or inpatient setting. For a community patient a high RUG-ADL (16-18) may trigger a referral to an inpatient palliative care unit or aged care assessment. There is no score of 2 for bed mobility, toileting and transfers. This is quite deliberate. The tool was derived as a measure of resource use, with a score of 2 indicating twice the use of resources of a score of 1, a score of 3 indicating three times the use of resources of a score of 1 etc. For bed mobility, toileting and transfers the change from independent/supervision to limited assistance was found to equate to a three-fold increase in resources. For eating, the same change equated to a two-fold increase in use of resources. Two or more persons physical assist Requires 2 or more assistants to readjust position in bed and perform pressure area relief. 5

Toileting RUG Item Score Definition Toileting Includes mobilising to the toilet, adjustment of clothing before and after toileting and maintaining perineal hygiene without the incidence of incontinence or soiling of clothes. If level of assistance differs between voiding and bowel movement, record the lower performance Independent or supervision only Able to mobilise to toilet, adjust clothing, cleanse self and has no incontinence or soiling of clothing. All tasks are performed independently or with prompting from carer. No hands-on assistance required. May be independent with the use of a device. 1

Toileting (continued) RUG Item Score Definition Toileting Includes mobilising to the toilet, adjustment of clothing before and after toileting and maintaining perineal hygiene without the incidence of incontinence or soiling of clothes. If level of assistance differs between voiding and bowel movement, record the lower performance Limited physical assistance Requires hands-on assistance of one person for one or more of the tasks. 3

Toileting (continued) RUG Item Score Definition Toileting Includes mobilising to the toilet, adjustment of clothing before and after toileting and maintaining perineal hygiene without the incidence of incontinence or soiling of clothes. If level of assistance differs between voiding and bowel movement, record the lower performance Other than two persons physical assist Requires the use of a catheter/uridome/urinal and/or colostomy/bedpan/commode chair and/or insertion of enema/ suppository. Requires assistance of one person for management of the device. 4

Toileting (continued) RUG Item Score Definition Toileting Includes mobilising to the toilet, adjustment of clothing before and after toileting and maintaining perineal hygiene without the incidence of incontinence or soiling of clothes. If level of assistance differs between voiding and bowel movement, record the lower performance Two or more persons physical assist Requires two or more assistants to perform any step of the task. 5

Transfer RUG Item Score Definition Transfer Includes the transfer in and out of bed, bed to chair, in and out of shower/tub. Record the lowest performance of the day/night. Independent or supervision only Able to perform all transfers independently or with prompting from carer. No hands-on assistance required. May be independent with the use of a device. 1 A score of 4; other than two persons physical assist is obtained if a patient uses a device and requires the assistance of one person to transfer.   If a patient is able to use their device independently the assessment score is 1, independent or supervision only. A device could be a walking frame or shower chair for example. Limited physical assistance 3 Requires hands-on assistance of one person to perform any transfer of the day/night.

Transfer (continued) RUG Item Score Definition Transfer Includes the transfer in and out of bed, bed to chair, in and out of shower/tub. Record the lowest performance of the day/night Other than two persons physical assist 4 Requires use of a device for any of the transfers performed in the day/night. Requires only one person plus a device to perform the task. A score of 4; other than two persons physical assist is obtained if a patient uses a device and requires the assistance of one person to transfer.   If a patient is able to use their device independently the assessment score is 1, independent or supervision only. A device could be a walking frame or shower chair for example. Two or more persons physical assist 5 Requires 2 or more assistants to perform any transfer of the day/night.

Eating RUG Item Score Definition Eating Includes the tasks of cutting food, bringing food to mouth and chewing and swallowing food. Does not include preparation of the meal. Independent or supervision only Once meal has been presented in the customary fashion, able to cut, chew and swallow food independently or with supervision. No hands-on assistance required. If individual relies on parenteral or gastrostomy feeding that he/she administers him/herself, then Score 1. 1 There is a score of 2 for eating (this score is absent for toileting, transfer and bed mobility). A change in eating from independent / supervision to limited assistance for eating has found to equate to a 2 fold increase in resources required. Question = How do you score the unconscious or terminal patient for eating Answer = Score 3 to indicate the highest level of care as full assistance is required to provide mouth care

Eating (continued) RUG Item Score Definition Eating Includes the tasks of cutting food, bringing food to mouth and chewing and swallowing food. Does not include preparation of the meal. Limited assistance 2 Requires hands-on assistance of one person to set up or assist in bringing food to the mouth and/or requires food to be modified (soft or staged diet). There is a score of 2 for eating (this score is absent for toileting, transfer and bed mobility). A change in eating from independent / supervision to limited assistance for eating has found to equate to a 2 fold increase in resources required. Question = How do you score the unconscious or terminal patient for eating Answer = Score 3 to indicate the highest level of care as full assistance is required to provide mouth care

Eating (continued) RUG Item Score Definition Eating Includes the tasks of cutting food, bringing food to mouth and chewing and swallowing food. Does not include preparation of the meal. Extensive assistance/ total dependence/tube fed 3 Person needs to be fed meal by assistant, or the individual does not eat or drink full meals by mouth but relies on parenteral/ gastrostomy feeding and does not administer feeds by him/herself. There is a score of 2 for eating (this score is absent for toileting, transfer and bed mobility). A change in eating from independent / supervision to limited assistance for eating has found to equate to a 2 fold increase in resources required. Question = How do you score the unconscious or terminal patient for eating Answer = Score 3 to indicate the highest level of care as full assistance is required to provide mouth care

How to Assess RUG ADL Determine the score for each of the 4 domains, and total the score Total Score Total Score It is the total score that gives you a picture of the functional status and dependency. When communicating with other colleagues the total score is communicated rather than the individual score of each domain. The RUG-ADL is based on what the person actually does not what they are capable of doing. This is best achieved by asking or assessing “Do you…?” rather than “Can you…?” = Person is Independent = Person requires full assistance of 2 people

Australian-modified Karnofsky Performance Scale (AKPS) Assesses performance in three dimensions: Activity Work Self care The Australian Karnofsky Performance Scale (AKPS) used in PCOC is applicable to both inpatient and community palliative care. It assesses performance and can be used to indicate prognosis and survival times. An Australian Karnofsky Performance assessment of 60 or below may trigger a family conference to discuss performance status and disease progression. Note: the original Karnofsky assessment has slightly different descriptors for scores 40, 30, 20, 10  

Australian-modified Karnofsky Performance Scale 100 Normal with no complaints or evidence of disease 90 Able to carry on normal activity but with minor signs of illness present 80 Normal activity but requiring effort. Signs and symptoms of disease more prominent 70 Able to care for self, but unable to work or carry on other normal activities 60 Able to care for most needs, but requires occasional assistance 50 Considerable assistance and frequent medical care required 40 In bed more than 50% of the time The AKPS is a measure of the patients’ overall function or ability to manage their own activities of daily living. It is a single score between 0 and 100 assigned by a clinician based on observations of a patient's ability to perform common tasks. A score of 100 signifies normal physical abilities with no evidence of disease. Decreasing numbers indicate a reduced ability to perform activities of daily living. There are no half-way measures; 55, 44, 35 for example. 30 Almost completely bedfast 20 Totally bedfast and requiring extensive nursing care by professionals and/or family 10 Comatose or barely rousable 0 Death

(phone or face-to-face assessment) RUG-ADL & AKPS Assessment & Documentation The assessments are undertaken: At contact in consultative or community setting (phone or face-to-face assessment) A minimum of daily in the inpatient setting At Phase change Assess RUG-ADL and AKPS on admission or 1st visit. Reassess RUG-ADL and AKPS when the patient’s phase changes and on discharge. No assessment is required when reason for phase end is death. Follow up assessments may be conducted by telephone in order to change phase, however, a face to face assessment must take place in order to commence an episode. Functional assessment is clinically useful if completed every 24hrs as there are times when a patient functioning changes without the phase changing. For example a RUG-ADL and AKPS score may change without the phase changing. These assessments together provide a clinical picture of the level of dependency and resources required and in the community setting can indicate carer burden. However, the assessments are not intended to measure or capture workload or time spent with the patient.

PCOC assessment workshop V2.9 In Summary Provides a clinical picture: Functional assessment using the RUG-ADL and AKPS Assists in: Level of dependency Resources required Indicate carer burden (community setting) Functional assessment using the RUG-ADL and AKPS provides a clinical picture of the patient’s level of dependency, the resources required to provide care and in the community setting can indicate carer burden. Functional assessment may also assist with prognostication and discharge planning Prognostication Discharge Planning PCOC assessment workshop V2.9 PCOC Assessmet Workshop V 2.9

Thank You For further information please view the resources contained in the PCOC Assessment Toolkit, go to or contact your Quality Improvement Facilitator Please view the other 3 PCOC video presentations and the PCOC DVD, Understanding PCOC. These resources are located in the PCOC Assessment Toolkit or on the PCOC website. Funded under the National Palliative Care Program and is supported by the Australian Government Department of Health and Ageing