eMedicine Specialties > Physical Medicine and Rehabilitation > Rehabilitation Protocols
Quality and Outcome Measures for Rehabilitation Programs
Updated: Aug 20, 2008
Measuring Outcomes In Rehabilitation Medicine
Functional assessment is a relatively new term. A gerontologist in Philadelphia, A Powell Lawton, wrote the first definition in 1970. He said that functional assessment was any systematic attempt to objectively measure the level at which a person is functioning in a variety of domains.1
Functional assessment, as a scientific endeavor, has not been easily accepted. In fact, during the 1970s, most clinicians regarded functional assessment as an effort to measure the immeasurable. By the 1980s, however, outcome measurement started to gain general interest, and by the late 1980s, medical rehabilitation practitioners recognized functional assessment as a means for measuring outcomes in medical rehabilitation. Through the 1990s, efforts have been made to predict the relationship between doses of therapy and patient responses, including cost-effectiveness. This work is ongoing.2,3,4,5,6
Verbal descriptions of improvements in the functions of persons with disabilities have been customary since rehabilitation medicine came into its own after World War II. This method of keeping records has lacked the consistency needed for making comparisons among patients and for tracking changes in patients over time to study their rehabilitation outcomes. A new standard system was needed to describe and quantify function in persons with disabilities. The Uniform Data System for Medical Rehabilitation (UDSMR) was established in 1987 after many years of research to meet this need.7 This system, used by clinicians in rehabilitation settings, has proven useful around the world to patients, clinicians, and health care payers.
UDSMR is a not-for-profit data management service (a division of UB Foundation Activities, Inc), which also provides such ancillary services as training in the use of its instruments and related data analysis and reporting systems. UDSMR is supported financially by the subscribing medical rehabilitation facilities. This service takes in data and returns information. The number of subscribing facilities increased from 57 in 1988 to 1271 worldwide in 2005. UDSMR instruments and systems are used in the United States, Canada, Italy, Finland, Sweden, South Africa, Australia, Hong Kong, Singapore, Saudi Arabia, Chile, Israel, Belgium, Iceland, Mexico, and Spain.
Approximately 600 articles have been published concerning the use of UDSMR instruments and their corresponding analysis and reporting systems.
Research showed that functional assessment could be developed into a science to provide the tools for understanding the "biology of disability," a term that refers to the fact that certain patterns of response to disability may be dominant and, therefore, may be expected for people who experience the consequences of disability. The concept of the biology of disability is important for clinicians to understand so that they can distinguish patterns of expected functional limitations from unexpected functional limitations.
Much of the conceptual background for understanding the components of disablement has come from the work of Phillip Wood, a rheumatologist and epidemiologist from Manchester, United Kingdom. He wrote the 1980 World Health Organization (WHO) report that first identified the consequences of illness. First there is disease, or the pathophysiologic processes. Next is impairment, or the manifest deficit in organs and organ systems, in terms of anatomy, biochemistry, psychology, and functional limitations. Then there is disability, or the behavioral and performance deficits of the patient. Finally, there is handicap, or the physical and social disadvantages imposed by society.
The key to documenting disability is to record how well patients perform activities of daily living (ADL). The concept is so important that this author has developed a related motto: As we function, so shall we live.
Development of the UDSMR and the FIM™ Instrument
"Once outcomes become measurable, they become manageable." This is another saying coined by this author to condense a lengthy explanation of the applicability of a medical rehabilitation measurement system. The UDSMR was created within the walls of a university medical school, but it functions in rehabilitation settings. It is a complex computerized system of data collection, analysis, and reporting. The purpose of this system is to set the course toward better health care by showing the benefits and efficiency of care.
The restorative patient is typically in an intensive program of medical rehabilitation. Such a patient has lost functional ability subsequent to illness or injury, is near medical stability, and has potential for significant practical recovery of lost abilities. Stroke, orthopedic disorders, and cardiac disorders predominate among restorative patients. Patients also enter rehabilitation facilities as a result of a variety of other illnesses and injuries, including spinal cord injury, traumatic brain injury,8 amputation, and multiple sclerosis. Patients with the latter group of conditions usually have the goal of maintaining a residual level of function rather than of restoring function.
UDSMR and its Functional Independence Measure (FIM™) instrument were developed to enable clinicians and administrators in rehabilitation facilities to document the severity of patient disability and measure outcomes of medical rehabilitation in a uniform way.9,10 To accomplish this, a common language had to be established to discuss disability across the rehabilitation disciplines, including medicine, nursing, physical therapy, and occupational therapy, providing a basis for comparing rehabilitation outcomes.
At this time, 7 types of major settings provide postacute care rehabilitation services:
- Comprehensive medical rehabilitation unit and facility
- Skilled nursing facility
- Skilled nursing facility with a subacute unit
- Long-term acute care hospital
- Outpatient facility
- Home care
- Adult day services
The FIM™ instrument was designed for adult rehabilitation patients and is used with a computerized analysis and reporting system. For nearly 2 decades the FIM™ instrument and its reporting and analysis systems were used in the various rehabilitation settings. The FIM™ instrument also has been embedded in a tool used by the federal government to allow comprehensive inpatient rehabilitation facilities to meet the mandated prospective payment system. (Discussion on this topic follows.) Additional instruments and systems were spun off from the FIM™ instrument for use with different populations in different care settings. UDSMR currently offers the following to facilities on a subscription basis:
- AlphaFIM® instrument (adult acute-hospital inpatients)
- LIFEwareSM system (adult outpatients)
- The FIM System® for Home Care (adult home care patients)
- WeeFIM® instrument and WeeFIM II® system (pediatric)11,12,13,14,15
- UDS-PRO® system (comprehensive medical rehabilitation facilities)
- UDS-PROi™ product (comprehensive medical rehabilitation facilities)
- FIM™ instrument, the FIM System® subscription, and FIMware® software (subacute units, skilled nursing facilities, nursing homes)
A major change occurred on January 1, 2002, in the comprehensive inpatient medical rehabilitation industry. The Centers for Medicare and Medicaid Services (CMS) implemented a Congressional mandate to take medical rehabilitation from the long-standing, cost-based payment system to a prospective payment system, the latter system having already been in use for other types of medical facilities.16 This prospective payment system is for facility reimbursement for Medicare Part A services, which covers a significant portion of medical rehabilitation, for elderly and disabled persons. The CMS created the Inpatient Rehabilitation Facility-Patient Assessment Instrument (IRF-PAI), which has been in use since January 1, 2002. The FIM™ instrument is the centerpiece of the IRF-PAI, with some modifications having been made to the instrument (described later in this section).
For the first time, payment for Medicare Part A inpatient rehabilitation services became tied to the level of severity of the patient's functional status at the time of admission.
The original FIM™ instrument still is used in other types of rehabilitation facilities, such as skilled nursing facilities and subacute units, for measurement of outcomes, not for payment purposes. These facilities also use such instruments as the Minimal Data Set Version 2 (MDS-2) and OASIS. (These are not UDSMR instruments.)
All UDSMR instruments and their analysis and reporting systems were designed to link individuals and groups of patients, from pediatric to geriatric, through various rehabilitation settings. (See Continuum of Care for a discussion.) Data are sent to UDSMR by subscribing medical rehabilitation facilities. Confidential reports are returned to the facilities by UDSMR. These reports show a wealth of information about the facility and display aggregated information on other facilities in the region and nation so that each facility can see how it stacks up. The purpose of this service is to take in data and return information.
The model that typifies medical rehabilitation is characterized by the situation of a previously independently functioning adult who becomes disabled by disease or injury. The patient is stabilized in the acute care hospital and may recover some functional abilities, but recovery is not sufficient to return to community living, which is the ultimate goal. At the point the patient is deemed to have the potential for significant functional improvement, transfer is made to a rehabilitation setting, where therapies are prescribed.
Upon the patient's arrival in a rehabilitation setting, the FIM™ instrument is used to document the patient's independent functioning in 18 ADL: 13 motor items covering self-care, sphincter control, transfers, and locomotion, and 5 cognition items covering communication and social cognition. In each activity, the patient is observed or interviewed by a clinician (usually a nonphysician clinician) and is rated in levels of dependence and independence, with a rating of 1 reflecting total assistance needed by a helper or device (or longer time to perform the activity). The highest rating, 7, reflects complete patient independence.
For comprehensive medical rehabilitation facilities only, the FIM™ instrument was slightly modified when it was embedded in the federal government's IRF-PAI. A code of zero was added to cover an activity that did not occur during the admission assessment period. The assessment periods at admission and discharge were redefined, such that the time frames for admission and discharge assessments, respectively, now are the first 3 days and any 1 of the last 3 days of the hospital stay. If differences in function occur in different environments or at different times of the day, clinicians record the lowest (most dependent) rating. The period of program interruption has been changed from 30 days to 3 days. Function modifiers were added for certain items: bowel, bladder, locomotion, and tub/shower transfer. Item level definitions were modified for bladder and bowel.
In the FIM™ instrument, numbers from 1 to 7 are assigned descriptors to designate levels of minimal, moderate, and maximal assistance needed by a patient. An FIM™ instrument rating at level 3, or moderate assistance, means that the effort of the task is shared equally between the patient and the helper. Patients' total-FIM™ instrument ratings range from a low of 18 (dependent) to a high of 126 (independent). See Images 1-2. The FIM™ instrument is used again at discharge and follow-up, with changes being noted. The instrument also may be used at appropriate times during the stay.
Dividing the gain in FIM™ instrument points by the days of stay provides a measure of efficiency, or the average number of FIM™ instrument points gained per day. Quarterly reports are sent by UDSMR to subscribing facilities, whether they use the FIM™ instrument or the IRF-PAI, which analyze the rehabilitation process for effectiveness and efficiency. Effectiveness suggests how well the rehabilitation worked. Did the patient improve function? Did the burden of care decline? Did the patient return to the community? Efficiency measures how inexpensively the rehabilitation services were delivered. Medical rehabilitation is time intensive; therefore, time is an important measure in considering cost-effectiveness. Length of stay (LOS), a way of expressing cost of care, is included in the quarterly reports. Facility managers then can make changes or reinforce current processes.
The user-friendly UDS-PRO® system and FIMware® software are provided to subscribers for data submission. National and international databases are maintained for comparing outcomes across facilities. Subscribing US facilities are compared in the quarterly reports to appropriate, similar regional and national facilities.
An important feature of the UDS-PRO® system and FIMware® software is the generation of a pictorial representation, or function-level profile, of a patient across the 18 FIM™ instrument motor and cognition activity items. (See Image 3.)
The innermost tiny circle represents the most dependent state, and the outermost circle represents the most independent state. The red area shows a patient with significant limitations across all items at admission.
In Image 4, note the overlay of a yellow goal line that is derived from the median of ratings achieved by discharge for patients with the same impairment and similar severity of disability. The blue area shows a profile of the patient's status at the time of discharge. Some of the item goals have been met.
By follow-up (Image 5), usually 80-180 days after discharge, the turquoise-color area on the profile shows that the patient has generally exceeded the goals. Those functional areas in which the patient has not achieved full independence imply that the community must make accommodations, family care must be provided, or architectural modification must be made to compensate for the deficits in independent functioning.
The FIM™ instrument approximates the burden of care
Burden of care can be approximated using the FIM™ instrument. An average FIM™ instrument item rating of 3 or a total-FIM™ instrument rating of 60 is equivalent to the patient's needing help from another person for approximately 4 hours per day, each and every day of the year, just to perform basic personal care activities. This figure is without consideration of other kinds of needs, such as domestic chores or medical care. A total-FIM™ instrument rating of 60 is common for many patients at the time of admission to a rehabilitation program.
Generally, a total-FIM™ instrument rating of 80-90 is equivalent to a need for 1-2 hours of help each day from another person to perform personal care activities. Usually, this figure represents the level at which discharge to the home is manageable by family members.
When the hours of help needed per day are translated into wages for the assisting person, say, at the rate of $12 per hour, then expenses for a patient with a total-FIM™ instrument rating of 90 might be $84 per week or $4,368 per year. Assistance for a patient with a total-FIM™ instrument rating of 60 might cost $48 per day, $336 per week, or $17,472 per year.
The differences in the above examples of burden of care may appear minor on the basis of a day or a week; however, when viewed over a year, the differences are substantial. Remember that dependence can last for several years. In practice, on average, patients with spinal cord injury are admitted with a motor-FIM™ instrument rating of 32 and are discharged with a motor-FIM™ instrument rating of 56. This translates into a reduction of 200 minutes per day in help required. On average, patients who have sustained a stroke are admitted with a motor-FIM™ instrument rating of 42 and are discharged with a motor-FIM™ instrument rating of 60, resulting in a reduction of 130 minutes per day in help required.
Related eMedicine topic:
Assistive Devices to Improve Independence
Impairment Types
The distribution of impairment types in the UDSMR database (UDS-PRO®) for 2004 for adult comprehensive medical rehabilitation was as follows:
- Orthopedic - 41%
- Other types - 36%
- Stroke - 17%
- Brain dysfunction - 6%
The distribution of impairment types in the UDSMR database (FIM™ instrument) for 2004 for adult subacute medical rehabilitation (these patients are in skilled nursing facilities) is as follows:
In pediatric (WeeFIM® instrument) cases for 2004, the distribution of impairment types was as follows:
- Brain conditions - 43%
- Other - 22%
- Orthopedic - 14%
- Spinal - 8%
- Neurologic - 7%
- Major trauma - 6%
Continuum of Care
Medical rehabilitation rarely is conducted in only 1 care setting. Especially now, with the emphasis on reducing LOS in high-cost inpatient settings, rehabilitation spans a continuum of care in order to be cost-effective, yet complete.
Rehabilitation care settings have become more complicated than they were toward the end of the 20th century. Care for adults with significant functional limitations usually begins in the acute care hospital. In acute care, the where and when of admission and discharge are identified. Persons needing postacute rehabilitation have several options, including the following:
- Traditional inpatient rehabilitation unit of a hospital
- Freestanding rehabilitation hospital
- Subacute rehabilitation, which usually is located in a skilled nursing facility
- Rehabilitation in the home
- Rehabilitation in an outpatient clinic
Patients may be transferred to any of these settings in any order.
From the acute care setting, several alternative settings exist, providing a range of intensities of treatment, resources, and costs to be incurred. Triage should result in selecting the right patient for the right treatment setting at the right time. The ultimate goal at completion of rehabilitation is the patient's return to living in the community, which could mean living at home independently, living with family, receiving home health care, or living in an assisted-living residence.
In order to render cost-effective care, a method for anticipating probable resource needs and outcomes would be helpful to determine, at the time of admission to acute care, what might be expected of each patient after acute care discharge.
The continuum of care has become increasingly complex, ranging from high-cost, high-intensity care in acute care hospitals to lower-cost, lower-intensity care in outpatient settings. Adding to the complexities are insurance payment systems that vary across clinical settings.
The demographics of an aging population mean an increasing prevalence of chronic health conditions, requiring a rational system for linking assessments of patients from the acute care hospital to the rehabilitation program, as well as to outpatient and home-based programs. Assessment of patients across the continuum of care should be understandable, meaningful, cost-effective, and manageable. UDSMR uses Web technology for all its instruments for collecting data and sending information. It has developed continuum software that links the functional status of inpatients from the UDS-PROi™ product and outpatients from the LIFEwareSM system.
Data Analysis and Reporting
The FIM™ instrument is administered to a patient upon entry into rehabilitation and again at discharge, and the difference in gain or loss of function is measured. In addition, interim assessments may be made of patients (eg, on the 10th day after admission) to judge the rate of improvement in functional ability as measured by the FIM™ instrument. Based on data collected from rehabilitation facilities around the country for about 2 decades, predictions can be made, taking into account, of course, such factors as patient age, disability, and severity of disability. Subscribing facilities receive reports on their outcomes in quarterly reports provided by UDSMR, compared with other similar regional and national facilities.
Comparing patients in similar facilities over time makes it apparent that we can calculate average values for age, for example; however, a number of patients on either side of that average are very different from the average and from each other in admission and outcome characteristics. Image 6 shows the age range of 83,421 patients with stroke for 2004.
As for the distribution of admission-FIM™ instrument ratings (upon admission from acute care to rehabilitation treatment) for these patients who have sustained a stroke, a number of patients on either side of the average are very different from the average and from each other. (See Image 7.)
A method was needed for more accurate comparison by controlling for differences. The method developed was a patient classification system called the FIM™ function-related group (FIM-FRG), which was developed with the UDSMR by Penn Ability Systems® (PAS™) at the University of Pennsylvania. For patients undergoing rehabilitation, types of impairment and severity of disability must be known so that physiatrists can order the appropriate types and amounts of treatment. For insurers, knowing clinical characteristics and severity is important so that rehabilitation facilities can be fairly reimbursed for restorative care that is sometimes intense and lengthy.
UDSMR documentation has confirmed that the more disabled the patient, the longer the stay. FRGs and case-mix adjustment for comparability are described in more detail in Function-related Group Classification and Case-mix Adjustment. Since 2002, the FIM-FRG system has been converted to case-mix groups (CMGs) for purposes of prospective payment. See The Federal Payment System and Grouping Patients.
The motor-FIM™ instrument items are constructed so that an expected rating relationship exists among the motor ADL items. This relationship is demonstrated by the staircase in Images 8-9, showing that the patient achieves independence by progressing from easy to intermediate to difficult items, as from eating to stair climbing. A few items can be observed and measured, and the probable rating of unobserved items can be inferred.
This hierarchical expectancy of rating can be used to advantage in estimating the disability level of a patient still in the acute care hospital. The items for eating, grooming, bowel control, and toilet transfer are observable in the acute care setting, while more complex items, such as dressing and walking, may not be. Therefore, the AlphaFIM® instrument was developed for use only in acute-care settings, before the patient enters rehabilitation. It consists of 4 motor items (eating, grooming, bowel control, toilet transfer) plus 2 cognition items (expression, memory) to estimate the level of function in terms of the full-scale rating. The AlphaFIM® instrument items first are assessed within 72 hours of admission to acute care and again at discharge from acute care.
The results of the AlphaFIM® instrument assessment are important, because they provide an estimate of the patient's level of function and the amount of assistance needed for personal care in terms of expected number of hours, or the burden of care. Determination can be made of the most suitable location for postacute discharge, taking into account the expected burden of care.
The FIM™ instrument staircase referred to previously is a simplified version of the assessment tool. The staircase in Image 10 shows that the distances between the risers are uneven across the motor-FIM™ instrument items. This unevenness is taken into account in calculating the full-scale rating or even the rating of a single item, such as walking.
A similar hierarchy exists for rating the cognition items. Image 11 shows that for conditions except stroke with right hemiparesis (left-brain involvement), expression and comprehension are easy, social interaction is intermediate, and memory and problem solving are difficult.17
Image 12 shows the order of difficulty for patients with stroke with right hemiparesis (left-brain involvement). The positions of expression and social interaction are switched from the previous diagram. The pictorial differences illustrate how the pattern of response is altered because of differences in the biology of the disability (ie, the effects of impairment of specialized language centers in the brain).
When conducting FIM™ instrument analysis, the clinician needs to understand Rasch analysis, a method for converting the FIM™ instrument ordinal level ratings into 2 measures with equal intervals, for the 13 motor items and for the 5 cognition items.18,19 In Image 13, the Rasch-converted motor-FIM™ instrument rating on admission on January 25, 1995, was 35; that is, the rating was equivalent to a raw motor-FIM™ instrument rating average of 2, or maximal assistance. On discharge on March 2, 1995, the Rasch-converted rating was 50; that is, the rating was equivalent to a raw motor-FIM™ instrument rating average of 4, or minimal assistance needed. The Rasch-converted cognition rating was 100 on admission and at discharge, indicating complete independence. All rating is performed with 100 representing the most independent rating.
Image 14 shows the results of 4 LIFEwareSM system assessments of an outpatient on the Neuromotor, Neurocognition, Physical Limitations, and Placid measures: June 1, 1996; March 6, 1997; January 15, 1998; and March 19, 1998. The zero value is set at the expected (typical) ratings for the population in the database (51 for neuromotor, 61 for neurocognition, 60 for physical limitations, and 71 for placid). Values for the neuromotor measure (dark blue) are slightly below expected, and values for the neurocognition measure (magenta) are slightly above expected, except for a drop on January 15, 1998, where values for physical limitations (orange) hover near the expected, and values for placid (green) are consistently below expected. The neurocognition (magenta) values tend to be above expected values, while the other measures tend to be below expected values.
The chart in Image 15 demonstrates the items that make up the placid measure. These items form an expected rating hierarchy, with the more common problem of being easily irritated being located to the left, and the less common problem of having panic attacks being located to the right. The zero line represents the expected average value for each item. The green line shows the maximum value for each item. The patient's recent ratings are lower than expected across 6 of the 7 items. The magenta line shows a comparison of the averages of item values for the 3 prior assessments, on June 1, 1996; January 15, 1998; and March 19, 1998.
Image 16 demonstrates the items that make up the measure of physical limitations. These items form an expected scoring hierarchy, the more common problem being fatigue, located to the left, and the less common problem being bowel management, located to the right. The zero line represents the expected average value for each item. The green line shows the maximum value for each item. The patient's recent ratings demonstrate less functional ability in the right upper and lower limbs. This result is consistent with a residual right hemiparesis from the earlier stroke. The magenta line shows a comparison of the averages of item values for the 3 prior assessments on June 1, 1996; January 15, 1998; and March 19, 1998. Some improvement in the right hemiparesis has occurred.
Function-related Group Classification and Case-mix Adjustment
As described earlier, the FIM-FRG system was developed for the FIM™ instrument and the FIM System® to classify patients at the time of admission to rehabilitation to facilitate prediction of LOS and level of function that can be achieved during rehabilitation and to compare outcomes between patients. This section describes the FIM-FRG system that is used with the FIM™ instrument and FIM System®. The Federal Payment System and Grouping Patients section describes how the FIM-FRG system was adapted for use with the IRF-PAI for comprehensive inpatient medical rehabilitation facilities.
Patients are classified by type of impairment and by severity of disability. The FIM-FRG case-mix adjustment methodology permits comparable reporting across different impairment groups, as well as across different levels of functional severity at the time of admission for rehabilitation.20 Stroke, for example, has 14 severity groups as of 2002, expanded from the original 5. Various numbers of severity groups exist for other impairments.
Efficiency pattern analysis is a method for displaying the relationships between motor-FIM™ instrument gain and rehabilitation inpatient hospital stay for patients of comparable severity of impairment at admission. Dr. Margaret Stineman at the University of Pennsylvania and members of the UDSMR staff developed this methodology.
- Image 17 - The patient at the top represents Stroke FRG-1, the most severely disabled in the hierarchy. Note the restricted FIM™ instrument profile and the extensive assistance required from another person to manage the transfer from bed to chair. The successive patients represent lesser degrees of disability and need far less assistance. The fifth patient performs the activity without help.
- Images 18-19 - Assignment of a patient to an FIM-FRG category involves decision-tree analysis. From 1990 UDSMR data, 5 FRG categories were developed to predict LOS for patients diagnosed with stroke. A 65-year-old patient with a motor-FIM™ instrument rating of 30 would be classified as FRG-1, with an average expected LOS of 37.9 days. Patients classified into FRG-2 through FRG-5 would be expected to have an average LOS of 29.4, 31.5, 23.2, and 16.2 days, respectively. The less severe the stroke on admission, the shorter the expected LOS.
- Image 20 - A patient's FIM™ instrument rating is useful in projecting the burden of care as measured in minutes of help needed per day from another person to perform basic personal care activities. An average FIM™ instrument rating of 3 on each item, or a total-FIM™ instrument rating of 60, requires about 4 hours of help per day. Many patients are admitted to rehabilitation with this level of disability. During rehabilitation, the patient becomes more independent, and the FIM™ instrument rating increases. At 90 total-FIM™ instrument rating, the burden of care is reduced to 1 hour per day. At this level, the condition of many patients can be managed effectively at home. The need for assistance in terms of minutes of care per day may be thought of in terms of the financial resources necessary to purchase personal care services. At the rate of $12 per hour, care for a patient needing 4 hours of help per day would cost $48 per day.
- Image 21 - If these persons were at home without rehabilitative care, what might be the cost to the family in time and dollars? The care for the most disabled person in the FRG-1 category might cost $17,472 per year, and the care for the least disabled person in FRG-5 might cost $1,092 per year.
- Image 22 - This illustrates cost to the family in time and dollars. Health care accountability and risk must be considered together in terms of the quality or benefit of the services, the price to deliver the services, and the subjective value as perceived by the payer, the patient, and the family. Use of the FIM-FRG system allows adjustment for more accurate comparison between rehabilitation programs over time.
- Image 23 - In a capitation system of payment, the provider must anticipate the resources that may be required to achieve appropriate outcomes. Thus, each level of severity represents a different level of risk in projecting likely costs.
The formula for a prudent buyer of a product or service shows that value is equivalent to the quality or benefit divided by the price. Value is the level of desirability subjectively perceived by the buyer (or patient). Quality is the level of measurable benefit (eg, gain, improvement) for the buyer (or patient). Price is the amount in dollars charged to the buyer to cover the costs of producing and delivering the product or service. Unless quality is clearly measurable, the value is not likely to be perceived as equal to the price, because quality would not count. Thus, the prudent buyer would purchase on the basis of price, not quality.
A rehabilitation provider in a capitation system of reimbursement may need to practice dose-management of therapy resources to deliver the appropriate amount of services to patients most likely to benefit. For example, a patient who has sustained a stroke with an average per-item FIM™ instrument rating of 4 would be assigned to FRG-3, with a profile of function illustrative of moderate functional ability on admission to rehabilitation. Another patient with an average per-item FIM™ instrument rating of 2 would be assigned to FRG-1, with a profile of function illustrative of low functional ability on admission to rehabilitation. To what extent might improvement be expected to occur during the rehabilitation program? From data in the UDSMR database, the probable functional ability and expected LOS may be projected for each case.
The FIM-FRG classification for stroke was updated from 1990 by Stineman using 1995 UDSMR data. Instead of 5 categories, 9 categories now have been identified, which makes the use of this FIM-FRG Version 2 interesting to use to compare the projected mean LOS for 1990 with that for 1995. In keeping with clinical experience, LOS has dropped, and it has done so rather uniformly across the 9 severity groups. Based on these data, if a rehabilitation facility had 1 case in each category in 1990 and the same in 1995, approximately the same outcomes would have been obtained, but in 37 fewer days (for 9 patients, 1 in each of the 9 categories). On average, from 1990-1995, LOS has been decreasing in all categories, an average of 1 day per year.
In the current FIM-FRG reporting system, it is possible to discern that 2 hospitals have different mixes of case severity. For example, hospital A has patients assigned to FRG-6, and hospital B has patients assigned to FRG-1. The data must be case-mix adjusted for proper comparison. In this situation, a comparison can be made between patients of similar severity treated in the 2 facilities.
- Image 24 - The distribution of stroke and orthopedic cases happens to be similar to the national distribution.
- Image 25 - Outcome characteristics of interest include onset days, which is the time from acute hospital admission to rehabilitation admission. Generally, shorter onset time is preferable. Next, the admission gain and discharge-FIM™ instrument ratings are presented. Lower admission-FIM™ instrument ratings (admission to rehabilitation) indicate more challenging patients; greater gain is preferable, as is higher discharge scores. Lower LOS is preferable, assuming that the FIM™ instrument gain is appropriate. Higher FIM™ instrument efficiency, or gain in FIM™ instrument points divided by LOS in days, is preferable. Higher rate of discharge to the community is preferable. These values from facility A are presented without comparison with national data.
- Image 26 - In this chart, the data from the previous chart are compared with national data. National data values are represented by the zero line. Facilities with higher data show up above the line, and facilities with lower data are shown below the line. These data are not adjusted for differences in severity between the facility and the nation.
- Image 27 - The data in this chart are adjusted for severity differences between the facility and the nation. In this situation, the national data are adjusted as if there existed the same case mix as at the facility, which is called indirect standardization. In addition, confidence limits are drawn to show where the values fall. Values for the facility that lie within the upper and lower confidence limits are not statistically different. Values that lie outside are statistically different.
- Image 28 - In this chart, the distribution of stroke and orthopedic cases happens to be very different from the national distribution.
- Image 29 - Outcome characteristics are shown, as in the prior case, compared with national values, but without case-mix adjustment.
- Image 30 - The data in this chart are adjusted for severity differences between facility B and the nation. Indirect standardization is again used, with national data adjusted as if there existed the same case mix as at the facility. Values that lie outside are statistically different.
- Image 31 - Another adaptation of the FIM-FRG methodology developed by Stineman is shown in this chart of efficiency pattern analysis. In this example, 94 cases from a given facility have been classified in FRG-1 for stroke. These data have been plotted so that the motor-FIM™ instrument gain lies on the vertical axis, and the LOS has been plotted on the horizontal axis. Lines have been drawn to show the national 25th and 75th percentile values for motor-FIM™ instrument gain and for LOS. Thus, in the national data, 50% of the patient values lie within the vertical lines for motor-FIM™ instrument gain, and 50% of the patient values lie within the national 25th and 75th percentiles for LOS. The personnel at the facility prefer to have the data plots lie within the 50th-percentile range or somewhat higher for gain and somewhat lower for LOS.
- Image 32 - In this case, only 10% of cases lie in the middle range. Six percent of the patients lie in the lower LOS range, but these are individuals who failed to gain FIM™ instrument points. Twenty-eight percent have high FIM™ instrument gain, but these are patients who stayed longer.
- Image 33 - Pinpointing these patients will be possible with a refinement of this methodology, still to be implemented. In this case, this designation, or any other that is chosen, would reflect the fact that such patients tend to exhibit low efficiency (51% of patients), with longer LOS and less FIM™ instrument gain.
- Image 34 - Efficiency means high gain and shorter LOS. Which patients demonstrate high efficiency? From that group, a specific patient might be identified and the record made available for examination to determine the particular features that are associated with high efficiency.
The Federal Payment System and Grouping Patients
As explained earlier, for the first time, starting January 1, 2002, payment for Medicare Part A inpatient rehabilitation services in comprehensive medical rehabilitation facilities became tied to the level of severity of the patient's functional status at the time of admission.
The classification of patients in comprehensive medical rehabilitation facilities into payment groups on admission still is based on the FIM-FRG system. Patients now are assigned to 1 of 85 Impairment Group Codes (IGCs) that fall under 17 Impairment Groups. Also, the etiology must be identified in terms of a code found in the document International Classification of Diseases, Ninth Revision, Clinical Modification.21
Each IGC falls into 1 of 21 general diagnostic categories, or Rehabilitation Impairment Categories (RICs). For example, all types of stroke are assigned to the 01 Stroke RIC. The CMG, similar to the FRG, is assigned based on the IGC and on the admission-FIM™ instrument motor rating, as well as, in some cases, on the admission-FIM™ instrument cognition rating and on age. The goal is to group patients with similar use of resources and likely LOS. The CMG designation, along with comorbid conditions and/or complications, determines payment, assuming the patient meets LOS and course-of-rehabilitation requirements.
The physiatrist today faces additional responsibilities in terms of understanding the new coding and providing clear documentation and medical justification for the decision to admit and provide ongoing care in the inpatient rehabilitation facility setting.
Larger Picture for Medical Rehabilitation Outcomes Measurement
Research has demonstrated that the cost of care for patients with chronic health conditions has exceeded the cost of care for persons with acute conditions by at least 2 times. In 1987, with institutional costs excluded, 46% of 193.4 million persons who incurred health care costs had chronic health conditions. People with chronic health conditions used 76% of the $357.9 billion cost. The changing characteristics of persons with chronic versus acute health conditions demand that all health care providers pay attention to issues relating to how effectively patients function and to the outcomes of care.
The health care system needs to be increasingly accountable to achieve expected outcomes effectively and efficiently. Effectively means how well we do this; efficient means how inexpensively we do it.
The Institute of Medicine has defined quality as "the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge."
Currently, the third-party payer is exerting a force on how services are rendered and on the types of outcomes that can be expected. Thus, it is incumbent upon the clinician to balance the benefit of treatment with its cost, while taking into account perceptions of the value of the treatment from the viewpoint of the payer, patient, family, and community.
UDSMR applies scientific research to the process of assessment of outcomes. The goal is to improve patient care and function by (1) identifying the patterns of disability and recovery and (2) providing appropriate and timely feedback to clinicians so they can promote effective and efficient care for the patient.
The more we study function in a systematic fashion, the more it is evident that function transcends everything. As we function, so shall we live.
Multimedia
 | Media file 1: The FIM™ instrument items. |
 | Media file 2: FIM™ instrument rating levels. |
 | Media file 3: Admission FIM™ instrument rating. |
 | Media file 4: Admission and discharge FIM™ instrument rating. |
 | Media file 5: Admission, discharge, and follow-up FIM™ instrument rating. |
 | Media file 6: Patient age distribution for stroke from 2004. |
 | Media file 7: Severity of disability distribution for stroke from 2004. |
 | Media file 8: Staircase from dependence to independence. |
 | Media file 9: Staircase from dependence to independence. Certain items highlighted. |
 | Media file 10: Hierarchy of FIM™ instrument motor items for brain dysfunction. |
 | Media file 11: Hierarchy of FIM™ instrument cognition items for all conditions. |
 | Media file 12: Hierarchy of FIM™ instrument cognition items for right hemiparesis. |
 | Media file 13: E Atkins (stroke): Rasch transformed FIM™ instrument measures. |
 | Media file 14: E Atkins (stroke): Comparison of Neuromotor, Neurocognition, Physical Limitations, and Placid measures with expected (typical) values. |
 | Media file 15: E Atkins (stroke): Placid measure comparison of the mean of the 3 prior and the recent item values against expected. |
 | Media file 16: E Atkins (stroke): Limitations measure comparison of the mean of the 3 prior and the recent item values against expected. |
 | Media file 17: Admission FIM™ instrument rating. Impairment type (diagnosis) with the admission motor FIM™ instrument and cognition FIM™ instrument ratings plus age determine the function-related group (FRG) to which a patient is assigned. Note that the FIM™ instrument rating profile is more constricted for the upper left patient (meaning more dependent functioning). This patient is assigned to the lowest FRG. Thus, the expectation is that length of stay, on average, will be highest. Other patients with the same impairment type have progressively higher FIM™ instrument ratings toward the lower right and are assigned to progressively higher FRGs. Thus, the expectation is that length of stay, on average, will be lower. For example, the upper left patient requires more assistance in bed-to-chair transfers, and the lower right patient performs bed-to-chair transfers without assistance. Note that the FIM™ instrument rating profile is least constricted for this patient. |
 | Media file 18: Length of stay (LOS), FIM™ instrument, using 5 function-related groups (FRGs) for stroke. |
 | Media file 19: Length of stay (LOS), FIM™ instrument, using 5 function-related groups (FRGs) for stroke. |
 | Media file 20: Length of stay (LOS), FIM™ instrument, using 5 function-related groups (FRGs) for stroke. |
 | Media file 21: Burden of care. Rule of thumb as measured by the FIM™ instrument. |
 | Media file 22: Burden of care. |
 | Media file 23: Rehabilitation impairment category (RIC) - Stroke. FRG is function-related group. |
 | Media file 24: Uniform Data System for Medical Rehabilitation (UDSMR) performance report. Comparison of facility with national data. |
 | Media file 25: Uniform Data System for Medical Rehabilitation (UDSMR) common process and outcome. Measures for all patients of facility A. |
 | Media file 26: Uniform Data System for Medical Rehabilitation (UDSMR) performance report. Comparison of facility A with case-mix unadjusted national data. |
 | Media file 27: Uniform Data System for Medical Rehabilitation (UDSMR) performance report. Comparison of facility A with case-mix adjusted national data using 95% confidence limits. |
 | Media file 28: Uniform Data System for Medical Rehabilitation (UDSMR) performance report. Comparison of facility B with national data. |
 | Media file 29: Uniform Data System for Medical Rehabilitation (UDSMR) performance report. Comparison of facility B with case-mix unadjusted national data. |
 | Media file 30: Uniform Data System for Medical Rehabilitation (UDSMR) performance report. Comparison of facility B with case-mix adjusted national data using 95% confidence limits. |
 | Media file 31: Efficiency pattern analysis for facility XYZ. |
 | Media file 32: Efficiency pattern analysis for facility XYZ. |
 | Media file 33: Efficiency pattern analysis for facility XYZ. |
 | Media file 34: Efficiency pattern analysis for facility XYZ. |
 | Media file 35: FIM™ instrument rating level 1 (on 7-level scale). Total assistance: Patient performs less than 25% task (transfers: bed, chair, wheelchair). |
 | Media file 36: FIM™ instrument rating level 2 (on 7-level scale). Maximal assistance: Patient performs 25-49% of task (transfers: bed, chair, wheelchair). |
 | Media file 37: FIM™ instrument rating level 5 (on 7-level scale). Supervision, no touching assistance with task (transfers: bed, chair, wheelchair). |
 | Media file 38: FIM™ instrument rating level 4 (on 7-level scale). Minimal contact, touching assistance only, no lifting: Patient performs 75% or more of task (transfers: bed, chair, wheelchair). |
 | Media file 39: FIM™ instrument rating level 6 (on 7-level scale). Modified independence: Patient requires assistive device (side rail), and no helper is needed with task (transfers: bed, chair, wheelchair). |
Keywords
functional assessment, function assessment, outcome measures, outcome measurement, outcomes measurement, outcomes measures, rehabilitation outcomes measurement, measures of outcome, functional assessment tool, disability measurement, activities of daily living, ADLs, continuum of care
More on Quality and Outcome Measures for Rehabilitation Programs |
| References |
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Further Reading
Keywords
functional assessment, function assessment, outcome measures, outcome measurement, outcomes measurement, outcomes measures, rehabilitation outcomes measurement, measures of outcome, functional assessment tool, disability measurement, activities of daily living, ADLs, continuum of care
