South West Stroke Project

Focus on Measurement in Rehab: Why FIM? Objectives: • Provide background regarding South West Stroke Project

• Review the purpose of the FIM instrument from an organizational and systems planning perspective

Why South West Stroke project?

Improve outcomes for people in the South West LHIN who have a stroke or TIA (transient ischemic attack).

Phase I focus on concentrating stroke expertise by realigning inpatient acute and stroke rehabilitation from 28 hospital sites to 7 Designated Stroke Centres.

Phase II focus on creating recommendations to enhance care for TIA and stroke survivors after they leave the hospital.

4 Stroke Districts

• Grey/Bruce

• Huron/Perth

• London/Middlesex/Oxford

• Elgin/Oxford/ Norfolk

Project focus on implementation of best practice and evidence based care

In evaluating implementation, one component will look to program/system outcomes

For all Ontario health care organizations data collection is mandatory through the Canadian Institute for Health Information

Why FIM review?

CIHI Databases

Emergency: National Ambulatory Care Reporting System (NACRS) Working to build a platform for outpatient rehabilitation

Acute Care: Discharge Abstract Database (DAD) Inpatient Rehabilitation: National Rehabilitation

System (NRS) Health Characteristics (diagnosis, comorbidities) Sociodemographic data (age, pre and post hospital living

setting) Administrative data (admission/discharge date, service

interruption) Functional Independence Measure

What is the FIM? Why use it? Measures independence vs. dependence in

performing personal care activities Discipline free Over 1,000 articles of supporting research and

study since inception If you do not measure it, then you can not

manage it ! Allows comparison or results across sites,

providers or patients over time regardless of treatment modalities (provides common language)

Quantifies the burden of care in terms of the number of hours a helper/caregiver must provide in the home or community (lowest in day)

Admit FIM contributes to Rehab LOS target for Stroke

Aim is to gain 1-2 FIM pts per day

In the US, score of 78 is considered the cut point for discharge to community vs. other institutional setting (equates to 2 hours care needed)

http://www.udsmr.org/Documents/The_FIM_Instrument_Background_Structure_and_Usefulness.pdf

FIM Items: Motor FIM : Eating Grooming Bathing Dressing –Upper Dressing-Lower Toileting Bladder Management Bowel Management Transfers: Bed Transfers: Toilet Transfers: Tub/Shower Walking Stairs

Cognitive FIM : Comprehension Expression Social Interaction Problem Solving Memory

Not Included: • Medically related tasks (wound

dressings) • Supervision required related to

behavioural management or cognitive impairment

• Instrumental ADLs (cleaning, cooking, banking)

S

South West Stroke Project

FIM® instrument Scale

FIM® Scale Client Effort Helper Effort

6–7 100% Absent

5 100% Present

4 75–99% 1–25%

3 50–74% 26–49%

2 25–49% 50–74%

1 0–24% 75–100%

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FIM Certification

UDSMR requires that those who use the FIM® instrument to rate patients be trained and pass a mastery test at least every two years thereby becoming certified raters.

Accurate assignment of the seven categories, especially of levels 1– 5, is extremely important for correct use and interpretation of the results.

Are all staff certified in the FIM?

Are staff regularly recertified?

Are they recertified every 2 years?

Scoring and Burden of Care Level Total Raw

Score Hours of Care needed

Description

1 18 24 30

>8 7-8 6-7

Total Assistance

2 36 45

6-7 5-6

Maximal Assistance

3 54 63

4-5 3-4

Moderate Assistance

4 75 2-3 Minimal Assistance

5 90 100

1-2 <1

Supervision/ Set up

6 115 0 Modified Independence

7 126 0 Complete Independence

Stroke QBP Rehab LOS Targets

South West Stroke Project

Case Examples

Moderate Stroke: Alessandro is 70 years old and suffered a Rt. sided stroke (ischemic infarct, left hemisphere). He lives with his wife and has 2 adult children and 4 grandchildren. Both his son and daughter live close by.

Raw Motor = 56 Raw Cognition = 19

FIM Rating = 75

Help needed = 2-3 hours

RPG = 1140 LOS = 15 days

RPG = 1130 LOS = 25 days

Raw Motor = 53 Raw Cognition = 26

FIM Rating = 79

Help needed < 2 hours

Raw Motor = 49 Raw Cognition = 26

FIM Rating = 75

Help needed = 2-3 hours RPG = 1120 LOS = 36 days A

B

C

Severe Stroke: Edith is an 83 year old lady with Lt sided stroke (ischemic infarct, Rt. hemisphere). She lives alone in an apartment, but has a daughter that lives nearby. Her daughter is married, has 3 teenage sons and works fulltime.

Help needed = 6-7 hours RPG = 1100 LOS = 49 days

Raw Motor < 39

Age < 69

Raw Motor = 18 Raw Cognition = 18

FIM Rating = 36

Help needed = 6-7 hours RPG = 1110 LOS = 42 days

A

B

What is FIM Efficiency/LOS Efficiency?

Definition: The average change in Total Function Score PER DAY of client participation in the inpatient rehabilitation program.

Target is >1.0 = daily change

Alessandro has an admission FIM of 75. He is admitted March 1st and discharged March 30th with a discharge FIM of 107.

107-75 = 1.1 29

Why measure FIM Efficiency?

From a systems level program evaluation has three goals:

1. Provide feedback about program performance

2. For comparison with peer organizations

3. To identify practice leaders

A system measure designed to guide program evaluation at a population level.

Not intended to be used solely to drive decisions at an individual client level.

SW LHIN Report on Performance

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LOS Efficiency: Stroke

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FIM Efficiency vs. Rehab Intensity

All rehabilitation interventions contribute to change on the FIM score e.g. group therapy, nursing, social work, dietician, recreation etc.

Weekend/Day passes

While may not contribute to RI, important gains are made for successful discharge

Considerations

Questions