FIM

The Functional Independence Measure System or FIM has been one of the more common outcome measures used in the inpatient rehabilitation or skilled nursing setting. If you have been practicing physical therapy within the last couple of decades, you are familiar with the emphasis on outcome measures that has only increased over time. 

Payer sources and insurance companies want to see that your services are justified and that your patients are experiencing a positive response to your interventions. How do you do that? You provide proof using validated outcome measures. This article will examine the Functional Independence Measure in further detail and explain how it is used in clinical practice.

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Understanding the Functional Independence Measure

The Functional Independence Measure (FIM) provides a standardized measure of severity of disability and is typically administered at admission to a subacute rehab facility and at discharge. The Functional Independence Measure assesses activities of daily living. Unlike some other objective outcome measures, the FIM is not free.  

A licensed clinician must be trained in the Functional Independence Measure System and pass a credentialing exam before assigning patients a Functional Independence Measure score. 

Training and credentialing can be obtained through USDMR. This measure is administered by a multidisciplinary team over 72 hours through observation of different activities. 

Because of a ceiling effect, it is considered more useful in an inpatient setting than an outpatient setting and there remains some debate about accuracy in ratings as there may be a tendency to overestimate ratings of a given item if other domain ratings are high and vice versa. Nevertheless, this outcome measure is well-validated in many populations. 

Because the aim of most subacute rehabilitation settings is to facilitate a patient’s safe return to home, the Functional Independence Measure focuses on eighteen items that relate to independence with activities of daily living. These eighteen items are broken down into two subscales–motor and cognition. There are thirteen motor tasks and five cognitive tasks.

The thirteen motor tasks are:

• Eating
• Grooming
• Bathing
• Dressing, upper body
• Dressing, lower body
• Toileting
• Bladder management
• Bowel management
• Transfers - bed/chair/wheelchair
• Transfers - toilet
• Transfers - bath/shower
• Walk/wheelchair
• Stairs

The five cognitive tasks are:

• Comprehension
• Expression
• Social interaction
• Problem solving
• Memory

As outlined above, a licensed therapist must be credentialed before assigning FIM scores to patients, however, let’s take a look at how scoring works for this measure. Each item is scored on an ordinal scale from 1 to 7. Higher scores denote higher levels of independence while lower scores denote lower levels of independence.

Scores are defined as follows:

• 7: Complete independence

• 6: Modified independence

• 5: Supervision (subject performs 100% of task)

• 4: Minimal Assistance (subject performs 75% or more of task)

• 3: Moderate Assistance (subject performs 50% or more of task)

• 2: Maximal Assistance (subject performs 25% or more of task)

• 1: Total Assistance or not testable (subject performs 25% or less of task)

Each subscale is totalled independently then a total score is compiled out of 126 possible points.

Is the Functional Independence Measure right for everyone?

While everyone participates in activities of daily living, the Functional Independence Measure has not been recommended for use in all populations. Recommendation levels for the use of the FIM were published by several EDGE task forces according to the Shirley Ryan Ability Lab. The MS EDGE and TBI EDGE task forces recommend the use of the FIM in inpatient rehabilitation and the StrokeEDGE highly recommends this outcome measure in inpatient rehabilitation. 

In contrast, in a skilled nursing facility, StrokeEDGE was unable to recommend the FIM and TBI EDGE reported it was reasonable to use but their study was limited. It was highly recommended in acute strokes, less than 2 months and in spinal cord injuries. It was not recommended or highly recommended for any level of Parkinson’s based on the Hoehn and Yahr Stage. Follow this link to see a full summary of FIM recommendations by task force.

Utilizing the data

If you are new to using an outcome measure like the FIM, you may be wondering what you should do with this data once you collect it. One of the first things you will do with this information is create goals. After scores have been assigned to each subgroup at admission, you will use your knowledge of the patient’s condition, their current level of independence with different tasks as well as their anticipated length of stay to develop specific, measurable, and time-based goals. Here are some examples of how to set goals using the FIM:

Example 1:

Task: Walking

Admission score: 4–Minimal Assistance

Goal: In two weeks the patient will ambulate with modified independence 150ft using front wheeled walker to be able to walk into his doctor’s appointments from the parking lot

Discharge goal: 2–Modified Independent

Example 2: 

Task: Bed transfer

Admission Score: 1–Total Assistance

Goal: In 21 days the patient will transfer from wheelchair to bed with moderate assistance or less

Discharge goal: 3–Moderate Assistance

Along with creating goals, FIM scores can be utilized to guide an impairment-level exam as well as select interventions. 

Goals tell us where we are going and interventions help us get there but an impairment-level exam helps therapists determine what needs to be addressed to improve function. If you know you have a goal of increasing independence with wheelchair propulsion, toilet transfers or walking, for example, a therapist should look for body structure and function impairments that explain why a person needs so much assistance with a given task. 

For example, leg weakness or impaired sensation may contribute to a high assistance level with walking. Impaired trunk control may be the culprit when a patient needs a lot of assistance with transfers. Poor balance may necessitate the use of an assistive device for walking. By looking for the contributing factors, therapists can then select appropriate interventions that will help them achieve their functional goals.