There is no uniform definition, assessment method or scale for functional status to be communicated consistently across care settings. This creates challenges for representing functional status in a standardized vocabulary to support continuity of care, information exchange and reuse. Functional status information is important to assessing an individual’s level of functioning and providing appropriate and needed health and supportive services. Functional status impacts the individual’s quality of life, wellness, and ability to care for oneself, and is often a factor in public and private payment methodologies as well as in quality management and clinical outcome measurement.
Providers and care settings have adopted a variety of instruments and data sets to assess functional status. While there is often some general consistency in the functional status categories covered by many of these instruments and data sets, there is often variation in specific content. This lack of consistency makes sharing and reusing functional status information difficult, including sharing information across care providers as individuals move across the continuum and measuring progress and decline across the continuum.
Several provisions in the Patient Protection and Affordable Care Act (ACA) identify functional status as a key area for which assessment, reporting or information sharing will be needed, including the following sections:
Section 2401 Community First Choice Option: Requires providers to use (when feasible) health IT to report on quality measures in the provision of health home services.
Section 3013 Quality Measurement Development: Prioritize quality measures that allow assessment of health outcomes and functional status of patients.
Section 3023 National Pilot Program on Payment Bundling: Quality measures of process, outcome and structure including measures of functional status related to participants of the pilot program.
Section 3024 Independence at Home Demonstration Program: For individuals with two or more functional dependencies requiring assistance of another person.
Section 3501 Health Care Delivery System Research; Quality: Potential impact of processes and systems on health status and function of patients including vulnerable populations and children.
Section 2503 Medication Management Services in Treatment of Chronic Disease: Performing or obtaining necessary assessments of the health and functional status of each patient receiving such MTM services.
Section 4106 Improving Access to Preventive Services for Eligible Adults in Medicaid: Any medical or remedial services (provided in a facility, a home, or other setting) recommended by a physician or other licensed practitioner of the healing arts within the scope of their practice under state law, for the maximum reduction of physical or mental disability and restoration of an individual to the best possible functional level.
Section 10202: Incentives for States to Offer Home and Community-Based Services as a Long-Term Care Alternative to Nursing Homes: Apply for such services, referral services for services and supports otherwise available in the community, and determinations of financial and functional eligibility for such services and supports, or assistance with assessment processes for financial and functional eligibility. Outcome measures for achieving desired outcomes appropriate to a specific beneficiary, including employment, participation in community life, health stability, and prevention of loss in function.
Section 10331 Public Reporting of Performance Information: Scientifically sound measures that shall include an assessment of patient health outcomes and the functional status of patients.
Further, as new payment models like Accountable Care Organizations emerge, the ability to exchange and re-use functional status information of individuals who are transitioning across care settings and between providers will become critical. This paper provides a brief background on functional status and recommendations on representing functional status in the absence of a standard framework.
What is Functional Status?
A search for definitions indicates some level of consistency in the broad categories included in concept of “functional status.” The HL7 standard for CDA provides a comprehensive summary of the type of information that falls under functional status:
- Ambulatory ability;
- Mental status or competency;
- Activities of Daily Living (ADLs), including bathing, dressing, feeding, grooming;
- Home/living situation having an effect on the health status of the patient;
- Ability to care for self;
- Social activity, including issues with social cognition, participation with friends and acquaintances other than family members;
- Occupation activity, including activities partly or directly related to working, housework or volunteering, family and home responsibilities or activities related to home and family;
- Communication ability, including issues with speech, writing or cognition required for communication;
- Perception, including sight, hearing, taste, skin sensation, kinesthetic sense, proprioception, or balance.
How Functional Status is Assessed by Health Care Provider
The challenge for applying health IT standards occurs with the assessment questions, scales and data used to collect and measure the multiple categories embedded in the concept of functional status. At present, the Federal Government has identified three different assessment instruments for use in nursing homes, home care agencies and rehabilitation units/hospitals -- each collects and measures functional status information differently. In addition to the federally required assessment instruments, a multitude of other instruments are used with no level of consistency. To illustrate the challenge of standardization, the CAST Continuity of Care Workgroup identified 47 different assessment instruments used in the long-term and post-acute care sector for functional status (See Table I-1).
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