As an occupational therapy professional in the realm of inpatient rehabilitation, understanding and accurately utilizing assessment tools is paramount. For those in this field, the CARE (Continuity Assessment Record and Evaluation) Tool has become a critical instrument, essentially replacing the Functional Independence Measure (FIM) in acute and inpatient rehabilitation settings. This guide provides a detailed overview of the CARE Tool, highlighting its nuances and key differences from the FIM, specifically for occupational therapists striving for excellence in patient care and accurate documentation.
Understanding the CARE Tool in Occupational Therapy
The CARE Tool, or CARE Item Set, stands for Continuity Assessment Record and Evaluation. It’s an outcome measurement tool mandated by the Centers for Medicare & Medicaid Services (CMS) in Acute Rehabilitation Units (ARUs). While primarily discussed within the context of inpatient rehabilitation, similar outcome measures are prevalent across various healthcare settings, including Skilled Nursing Facilities (SNFs) using the Minimum Data Set (MDS), Long-Term Care Facilities, and Home Health agencies employing the Outcome and Assessment Information Set (OASIS).
The adoption of the CARE Tool by Medicare, often considered a benchmark in US healthcare, signifies its importance. Medicare’s endorsement of such tools often influences other insurance providers, suggesting a broader shift towards the CARE Tool and away from the FIM. Despite this transition, familiarity with the FIM remains valuable, particularly as some insurance entities might still utilize or reimburse based on FIM scores. Occupational therapy education often includes training on the FIM, providing a foundational understanding of functional assessments.
For occupational therapists accustomed to the FIM, understanding the CARE Tool involves recognizing key distinctions. A crucial initial point is the CARE Tool’s scoring system, which uses a 6-point scale (01-06) rather than the FIM’s 7-point scale (1-7). It’s important to note the leading zero in CARE Tool scores for single digits (e.g., 01, 02, 03), a detail that differs from FIM scoring.
CARE Tool Scoring vs. FIM: Key Differences for Occupational Therapists
One of the primary shifts from the FIM to the CARE Tool lies in the scoring scale itself. The FIM utilized a 7-point scale, with level 7 denoting “Complete Independence” and level 1 indicating “Total Assistance.” The CARE Tool refines this to a 6-point scale, most notably by merging “Modified Independence” (level 7 in FIM) into the “Independence” category (now 06 in CARE Tool). This means the CARE Tool doesn’t explicitly categorize a client as “modified independent” through scoring alone. However, occupational therapists can still detail nuances of modified independence within the narrative documentation accompanying the score, allowing for comprehensive patient descriptions.
Navigating Levels of Assistance: Partial/Moderate vs. Substantial/Max Assist
A significant area of divergence and potential confusion for OTs familiar with FIM is in defining levels of assistance. Traditional occupational therapy practice often utilizes “minimal assist,” “moderate assist,” and “maximal assist,” roughly corresponding to 25%, 50%, and 75% assistance levels, respectively. The CARE Tool simplifies this into two primary categories based on percentage of assistance:
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Partial/Moderate Assist (03): This category encompasses instances where the patient requires less than 50% assistance. Intriguingly, the CARE Tool also dictates that if a patient’s assistance level is exactly 50%, it should be rounded down, falling into this “partial/moderate assist” category. This means that a client requiring minimal assist in the traditional sense and a client requiring up to 50% assistance are both scored as 03. The term “minimal assist” is no longer directly used in CARE Tool scoring terminology, being encompassed within “partial/moderate assist.”
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Substantial/Max Assist (02): This category applies when a patient requires more than 50% assistance. This is a crucial distinction as it groups together patients who might have been categorized as “moderate assist” (above 50% in a traditional sense) and “maximal assist” under the FIM into a single CARE Tool score.
This consolidation of assistance levels into broader categories means that the CARE Tool may be less sensitive to subtle improvements in function compared to the FIM. For instance, a patient progressing from needing moderate assist (in the traditional sense) to minimal assist might still remain within the “partial/moderate assist” (03) CARE Tool score, potentially masking functional gains solely based on the score.
Other CARE Tool Scoring Options
Beyond levels of assistance, the CARE Tool includes specific codes for other scenarios:
- Refusal (07): Used when a patient declines to perform a task.
- Not Applicable (09): Applied when a task is not relevant to the patient’s situation.
- Not Attempted Due to Environmental Limitations (10): Scoring used when environmental factors prevent task completion.
- Not Attempted Due to Medical Condition or Safety Concerns (88): Used when medical or safety issues preclude task attempts.
These additional codes ensure comprehensive documentation of various factors influencing patient performance beyond just their functional abilities.
Applying CARE Tool Scoring to ADLs: The Showering Example
While the assistance level terminology and scale differ, the practical application of scoring Activities of Daily Living (ADLs) such as showering maintains similarities to the FIM. Occupational therapists still assess performance based on body parts and the level of assistance required for each. The CARE Tool, like the FIM, often involves calculating a percentage of assistance based on the number of body parts requiring help.
For example, if an occupational therapist provides assistance with 70% of body parts during a showering task, this would be categorized as “substantial/max assist,” resulting in a CARE Tool score of 02. The underlying principle of assessing assistance needed for specific components of an ADL remains consistent, although the translation to the final score and terminology shifts with the CARE Tool.
Resources and Training for CARE Tool Competency
To ensure accurate and consistent CARE Tool scoring in occupational therapy practice, CMS provides comprehensive resources, including a detailed handbook. This handbook offers examples and in-depth explanations for scoring various ADLs, cognitive functions, and interdisciplinary sections relevant to physical therapy and speech therapy. Furthermore, formal training and certification are mandated for professionals utilizing the CARE Tool, ensuring competency and adherence to standardized scoring protocols.
For further exploration of the CARE Tool and practical application, resources such as online decision tree calculators can be valuable. These tools can assist occupational therapists in determining the appropriate CARE Tool score based on patient independence levels and limitations, streamlining the scoring process and enhancing accuracy.
Conclusion: Embracing the CARE Tool in Occupational Therapy
The transition from the FIM to the CARE Tool necessitates adaptation and a refined understanding for occupational therapists in inpatient rehabilitation. While the underlying principles of functional assessment remain, the CARE Tool introduces distinct scoring scales and terminology, particularly in defining assistance levels. By understanding these nuances, especially the “partial/moderate assist” and “substantial/max assist” categories, and utilizing available resources and training, occupational therapists can confidently and accurately implement CARE Tool scoring. This mastery ensures not only precise documentation and compliance but, most importantly, contributes to providing the highest quality, evidence-based care for patients in their rehabilitation journey.
