2. Reasons for Outcome Measures:
a) Objectively document patient progress to confirm the
efficacy of our treatment methods
b) To get reimbursed
A top reason for therapy claim denials:
a) Clinical documentation submitted for review does not
support the medical necessity for the services billed7
3. Balance!
Geriatric Fall Statistics (CDC)1
1 in every 3 adults age 65 and
older falls each year
Among older adults, falls are the
leading cause of both fatal and
nonfatal injuries
In 2010, 2.3 million nonfatal fall
injuries among older adults were
treated in emergency
departments and more than
662,000 of these patients were
hospitalized.
In 2010, the direct medical costs
of falls, adjusted for inflation,
was $30 billion.
4. APTA Section on Geriatrics practice committee
recommends:
1. Walking Speed
2. Six Minute Walk Test
3. Timed Up and Go
4. Berg Balance
5. Five Times Sit to Stand
6. Patient Specific Functional Scale
7. Dash or Quick Dash
8. Elderly Mobility Scale
9. Falls Efficacy Scale
*All of the above recommended based on best
evidence, practicality of use, responsiveness, and
psychometrics
5. Most current balance measures focus on standing
activities and may not be appropriate for two types of
patients:
1. Frail, elder adults whom are currently non-
ambulatory but whom may at some point be able to
stand up or ambulate6
2. Individuals with chronic/progressive diseases such as
Alzheimer's, Multiple Sclerosis, or Parkinson's6
6. Current sitting balance quality is typically measured
using a likert scale format
Dynamic vs. Static
Normal -> Good -> Fair -> Poor
Reliability/Validity of this method has not been
established6
7. 64 y.o. obese patient who weighs 300 lbs. suffered a (R)
below the knee amputation secondary to Type II Diabetes.
Patient has been an amputee for several years and has been
in a LTC setting using a hoyer lift since July of 2012. Patient
is alert and oriented x 3, is non-ambulatory, and is unable
to stand up secondary to insufficient upper-body,
abdominal, and LE strength. Patient is aware of condition
but is highly motivated to excel with therapy and desires to
stand up and be re-evaluated for prosthesis since current
prosthesis does not fit.
Which standardized outcome measure would you utilize to
document this patient's progress with the goal of standing
in mind?
8. 1. Tinetti Balance and Gait Assessment?
Patient, at most, may score 1/28
Not appropriate
2. Berg Balance?
Patient would score 0/56
Not appropriate
3. Functional Reach Test?
Patient can't stand
Not appropriate
4. Timed Up and Go?
Patient can't stand
Not Appropriate
5. No outcome measure, just ROM, Strength, Balance, etc?
Will this ensure medical necessity for our services?
Who needs
outcome
measures
anyway?
9. What reliable, valid, and concise outcome measure can
be utilized in the clinic for non-ambulatory patients who
may "bottom out" on measures such as the Tinetti
Assessment, the Berg Balance Test, the Timed Up & Go,
and the Functional Reach Test?
11. 11 item test
Items represent functional abilities
related to sitting balance
Scoring:
0-4 point likert scale (0 = worst
performance) (4 = best
performance)
Reliability:
Inter-rater = Good
Intra-rater = Excellent
Validity:
Can differentiate individuals with
pathology vs. apparently healthy
individuals
Participants with pathology had
lower total SBS score than people
without pathology
Patient Population:
Frail individuals who are primarily
non-ambulatory and who may
exhibit floor effects on other
common clinical assessments
Time to administer:
Less than 10 minutes
Equipment Needed:
12 in. ruler
Stop-watch
Object such as a slipper or sock
Book 3 – 3.5 in. thick
2 lb. cuff weight
15" x 15" x 5 " piece of foam
12.
13.
14.
15. 14 item test
Uses:
Quantify sitting balance through basic
everyday activities while seated
Assess patient performance on various
functional sitting tasks
Track changes in sitting balance over time
Scoring:
0 – 4 point ordinal scale
4 = Independent,
3 = Verbal Cues or Increased Time
2 = Upper Extremity Support
1 = Needs Assistance
0 = Dependent
Minimal Detectable Change = 6 points or
more
Reliability/Validity:
Confirmed for adults post stroke3
Intra/inter-tester reliability and evaluative
validity studies are under way
Patient population:
Known or suspected sitting balance
deficits who are unable to participate in
balance tests involving tasks in standing
and/or gait
Issues with impulsivity or safety while
seated
Working on speed, safety, and motor
control while seated
Time to administer:
Approximately 5 – 10 minutes
Equipment needed:
Step stool or riser (for foot positioning,
dependent on patient height)
Stopwatch or watch with second hand
Tape measure
Small, light weight object (can use small,
retractable tape measure or
stopwatch)
FIST Scoring sheet
16. Standard Patient Position
*This Position should be
maintained throughout the test
Nudge Items
Intended to examine patient's ability to
react to an unknown disruption of their
balance
Randomly administer throughout test
with light pressure
Do NOT tell the patient before you
administer the perturbation
3 nudges:
17. Score Description Selected Example
4 Independent Normal Performance
3 Verbal Cues/Increased
Time
Puts hand down to perserve balance, on second
attempt after cueing to not use hand can
perform without the use of their hand.
2
Upper Extremity
Support
Must put hand down to support self after 1-2
repeated attempts after cueing patient to not use
hands
1
Needs Assistance Generates insufficient balance reaction and
requires min A to maintain upright balance
0
Dependent Cannot generate balance reaction and requires
total A when nudged.
18. FIST Test Item
½ femur on surface; hips & knees flexed to 90°
□ Used step/stool for positioning & foot support
Date: Date: Date:
Randomly
Administered
Once
Anterior Nudge: superior sternum
Posterior Nudge: between scapular
spines
Lateral Nudge: to dominant side at
acromion
Static sitting: 30 seconds
Sitting, shake ‘no’: left and right
Sitting, eyes closed: 30 seconds
Sitting, lift foot: dominant side, lift foot 1 inch twice
Pick up object from behind: object at midline, hands breadth posterior
Forward reach: use dominant arm, must complete full motion
Lateral reach: use dominant arm, clear opposite ischial tuberosity
Pick up object from floor: from between feet
Posterior scooting: move backwards 2 inches
Anterior scooting: move forward 2 inches
Lateral scooting: move to dominant side 2 inches
TOTAL
/ 56 / 56 / 56
Administered by:
Notes/comments:
Scoring Key:
4 = Independent (completes task independently & successfully)
3 = Verbal cues/increased time (completes task independently & successfully and only needs more time/cues)
2 = Upper extremity support (must use UE for support or assistance to complete successfully)
1 = Needs assistance (unable to complete w/o physical assist; document level: min, mod, max)
0 = Dependent (requires complete physical assist; unable to complete successfully even w/physical assist)
19. Limitations:
Although research supports these assessments as being reliable and valid, there
are only a few studies with small sample sizes that have been completed to date
More larger scale studies are needed to further confirm the efficacy of these two
assessments
Cut-Off Scores have not been established yet
Can these two assessments be used in the clinic?
Yes
SBS
2 studies completed to date confirming reliability/validity
Recommended by the APTA Section on Geriatrics practice committee for assessing
low level patients
FIST
2 studies completed to date – results under embargo
Sharon Gorman says:
"I can tell you with confidence that the FIST has good to excellent reliability"
"The FIST admission/discharge scores correlated good to high with the Berg Balance Scale and
the FIM"
"There are many acute care facilities and SNFs that are using the FIST to track individual
progress and find it useful, especially with lower functioning patients"
20.
21. 1. "Falls Among Older Adults: An Overview." Centers for Disease Control and Prevention. Centers for Disease
Control and Prevention, 20 Sept. 2013. Web. 06 Nov. 2013.
http://www.cdc.gov/homeandrecreationalsafety/falls/adultfalls.html
2. "Function in Sitting Test (FIST)." Samuel Merritt University. N.p., n.d. Web. 06 Nov. 2013.
<http://www.samuelmerritt.edu/fist>.
3. Gormon, SL, S. Radtka, ME Melnick, GM Abrams, and NN Byl. "Development and Validation of the
Function In Sitting Test in Adults with Acute Stroke." Journal of Neurologic Physical Therapy 34.3 (2010):
150-60. PubMed. Web. 6 Nov. 2013.
<http://www.ncbi.nlm.nih.gov/pubmed/?term=Development+and+validity+of+the+Function+in+Sitting+
Test+(FIST)+in+adults+with+acute+stroke>.
4. Hartley, Greg, Ellen Strunk, and Michelle Lusardi. Section on Geriatrics Recommended Outcome Measures
for Medicare Functional Limitation/Severity Reporting. Rep. N.p., n.d. Web. 6 Nov. 2013.
<http://www.geriatricspt.org/userfiles/files/SoG-Joint-Report-March-2013.pdf>
5. Miller, Kenneth. "Section on Geriatrics and Home Health." Functional Limitation Reporting: Tests and
Measures for High-Volume Conditions. N.p., n.d. Web. 06 Nov. 2013.
<http://www.ptnow.org/FunctionalLimitationReporting/TestsMeasures/Default.aspx>.
6. Medley A, Thompson M. Development , reliability , and validity of the Sitting Balance Scale.
2011;27(7):471–481.
7. "Skilled Nursing Facilities (SNFs): Top Denial Reason Codes for Medical Review, January - March
2013." Skilled Nursing Facilities (SNFs): Top Denial Reason Codes for Medical Review, January - March 2013.
A Celerian Group Company, n.d. Web. 06 Nov. 2013.
<https://www.cgsmedicare.com/parta/pubs/news/2013/0613/1175.html>.
8. Thompson M, Medley A, Teran S. Validity of the Sitting Balance Scale in older adults who are non-
ambulatory or have limited functional mobility. 2012.
Editor's Notes
-So when I was trying to think of an in-service topic, Kelly expressed a desire to learn more about outcome measures for the lower level geriatric patient. I know that just in my time here, I can think of several patients that we have not been able to objectively asses for balance ability because they are just too low level to participate with the common assessments that we use in this setting. There is the FIM scores which gives us a global picture of the patients independence level, but this does not do a great job of specifically measuring status and progress with specific balance abilities, which we know are important for the well-being of our geriatric patients.
-So with that said, here is kind of an obvious slide but it helps remind us about the importance of outcome measures.
-Both of these are obviously very important. The issues that mainly arise are when we have issues being reimbursed. So, to get reimbursed, we need to be able to show that the services we provide are medically necessary and medical necessity will depend directly on how much we are able to show improvement in regards to the patient’s ability to function.
-Back to slide!!!
-With the changes that are going on with healthcare, it is more important now than ever to objectively measure outcomes by specific, standardized measures that are used consistently throughout the episode of care. Repeated use of the same outcome measure at the initial evaluation, each re-evaluation or progress report, and again at discharge allows a provider to clearly demonstrate the medical necessity of the care provided. We are under a microscope right now so to speak
-So how do we make sure that our skilled services are considered medically necessary? Good documentation and standardized OUTCOME MEASURES that are there to help us objectively show progress
-So I guess it makes a lot of since that most of the research for geriatric outcome measures has been geared toward standing balance and gait abilities.
-In a joint report by the APTA section on geriatrics committee, the reimbursement/legislative affairs committee, and the GeriEdge Task Force, a therapist can and should use as many tools as needed to adequately and comprehensively determine the appropriate G-code category and the level of
severity of the reportable functional impairment.
-May score well on Tinetti or Berg Assessments initially, but as their disease progresses, they may bottom out on these tests and may need a more appropriate outcome measure.
-If appropriate measures are not available to measure change in later stages of chronic/progressive diseases, assessing the efficacy of our interventions will be difficult
-So I feel that we have an idea of what a therapist means when they document Fair+ or Poor – for sitting balance, but it's just important to note that the research does not support this method as a reliable/valid method to be used in the clinic.
-Here's just a patient scenario that gives you a more realistic example of this issue.
-Does anyone recognize who this patient is?
-Outcome measures are there to make it easier for us to show the progress that our patients are making. So I talked with Kelly about this very issue, and if we don't have an objective outcome measure to specifically measure his actual progress, then we have to spend a lot of time tediously writing out and documenting specific things so that we can show that he is in fact progressing and that the services we are providing are medically necessary
-And we do have the FIM scores, but again, for physical therapy, we can only measure abilities with transfers, stairs, and gait distance. This would not help **** ***** out.
-11 item test developed from focus groups and content experts who specialize in the areas relevant to geriatric care
-Inter-rater = many people administering the test can get the same result
-Intra-rater = one person can test over and over again and get the same result
-Go over the SBS items now!!!!!
-14 item test created using survey results from clinicians and physical therapist's specializing in test creation/validation and/or balance, and from existing measures on balance/trunk control
-Nudge just hard enough to initiate a balance reaction
-Go over the FIST items now!!!
-Embargo – just means that the actual results can not be published until a certain date.
-I've printed copies of both of these assessments for you to use if you so choose. Personally, I would recommend the SBS over the FIST just due to the fact that they have actual published and released results confirming the reliability/validity
-In conclusion, I just think that it is important for us to use as many tools as possible to objectively document patient progress to benefit of our patients especially, but also to ensure reimbursement so that we can all continue working in this profession.
