3.2 Functional Status, Mobility, and Cognitive Screening

Functional Status, Mobility, and Cognitive Screening

In acute care case management, a patient's medical diagnosis explains why they were admitted to the hospital, but their functional and cognitive status determines where they can safely go at discharge. An accurate assessment of functional mobility, self-care ability, and cognitive intactness protects patients from failed discharges, unsafe home environments, and avoidable readmissions.

Case managers do not rely on subjective estimates ("patient seems steady" or "patient appears confused"). Instead, they utilize standardized, validated assessment instruments that generate objective scores recognized across the care continuum by physicians, payers, and post-acute facilities.

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1. Activities of Daily Living (ADLs): The Katz Index

Basic Activities of Daily Living (ADLs) encompass the fundamental physical self-care tasks essential for independent survival. A widely used instrument in case management is the Katz Index of Independence in Activities of Daily Living.

The Katz Index assesses performance across six specific functions, evaluated hierarchically based on how functional skills are naturally lost and regained during illness:

1. Bathing: Cleans body independently or requires assistance with only a single part (e.g., back or disabled extremity).
2. Dressing: Retrieves clothes from closet/drawers and puts on all garments, including outer clothing and fasteners, without assistance (tying shoes is excluded).
3. Toileting: Goes to the toilet room, gets on and off the commode, arranges clothes, and cleans genital/perineal area without assistance.
4. Transferring: Moves in and out of bed and chair independently without human assistance (mechanical aids such as canes or walkers are acceptable).
5. Continence: Exercises complete self-control over both bowel and bladder elimination (no accidental incontinence; manages catheter or colostomy independently if present).
6. Feeding: Gets food from plate to mouth independently without assistance (pre-cutting meat or buttering bread by others is permissible).

Scoring and Level-of-Care Transitions

Each function is scored dichotomously: 1 point for independent performance, and 0 points if human supervision, physical assistance, or total direction is required. The total score ranges from 0 to 6:

The standard interpretation is 6 = full function, 4 = moderate impairment, and 2 or less = severe functional impairment:

• Score 6 (full function): Independent in all six activities. Discharge home alone is reasonable only if cognition, instrumental activities, and supports are also adequate.
• Score around 4 (moderate impairment): Needs help with some basic self-care. A safe home discharge usually needs a capable caregiver, home health aide or personal care services, or an assisted living setting; short-term rehabilitation is appropriate when function is expected to improve.
• Score 2 or less (severe impairment): Needs help with most basic self-care. Home discharge requires substantial, often round-the-clock help. Otherwise the options are skilled nursing facility care when there is a daily skilled need, or long-term nursing facility (custodial) care, which Medicare does not cover.

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2. Instrumental Activities of Daily Living (IADLs): The Lawton-Brody Scale

While basic ADLs measure survival tasks, Instrumental Activities of Daily Living (IADLs) evaluate higher-level cognitive-organizational skills required for independent community living. A patient may have perfect physical strength to dress and feed themselves (Katz 6/6), but if they cannot safely manage medications or handle finances, an unassisted home discharge is clinically unsafe.

The Lawton-Brody IADL Scale assesses eight distinct functional domains:

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3. Cognitive Screening in Acute Care: Mini-Cog and MoCA

Cognitive deficits in hospitalized patients are frequently missed during routine clinical rounds because social communication skills can remain preserved despite profound executive dysfunction. Standardized screening tools provide an objective measure of acute or chronic cognitive impairment.

The Mini-Cog

The Mini-Cog is a rapid, 3-minute instrument validated for acute care and primary care settings. It consists of two components: a 3-item word recall and a Clock Drawing Test (CDT).

[Step 1: 3-Item Registration] ---> [Step 2: Clock Drawing Test (CDT)] ---> [Step 3: 3-Item Recall]
(Say 3 unrelated words;          (Draw clock face, put in numbers,        (Ask patient to repeat
 patient repeats them)           set hands to 10 past 11)                 the 3 words from Step 1)

• Scoring Algorithm:
  • 3 words recalled: Screen negative for dementia/impairment (normal).
  • 0 words recalled: Screen positive for cognitive impairment.
  • 1 or 2 words recalled + Normal Clock: Screen negative for dementia.
  • 1 or 2 words recalled + Abnormal Clock: Screen positive for cognitive impairment.
• Clock Drawing Interpretation: A clock is scored as "normal" only if all numbers are present in the correct sequence and spatial quadrant, and the two hands correctly indicate the designated time (e.g., "10 past 11" requires the short hand pointing to 11 and long hand pointing to 2). Any distortion, missing numbers, or hand placement errors make the clock abnormal.

Montreal Cognitive Assessment (MoCA)

The Montreal Cognitive Assessment (MoCA) is a 30-point, in-depth cognitive screening tool that evaluates eight cognitive domains: visuospatial/executive (trail making, cube copy, clock drawing), naming (animal identification), memory (delayed word recall), attention (digit span, vigilance tapping, serial subtraction), language (sentence repetition, phonemic fluency), abstraction, and orientation (time and place).

• Scoring: A score of 26 or above is considered normal. A score below 26 indicates cognitive impairment. A 1-point correction is added for individuals with 12 years or fewer of formal education.
• Clinical Utility: The MoCA is significantly more sensitive than the older Mini-Mental State Examination (MMSE) in detecting Mild Cognitive Impairment (MCI) and executive dysfunction common in vascular dementia, Parkinson's disease, and post-stroke syndromes.

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4. Differentiating the "3 Ds": Delirium, Dementia, and Depression

Differentiating the "3 Ds" is a core assessment skill. Confusing these conditions results in inappropriate psychiatric medication, missed medical emergencies, or premature long-term facility placement.

Acute Delirium Identification: The Confusion Assessment Method (CAM)

Delirium is an acute medical emergency indicating acute toxic, metabolic, or infectious encephalopathy. The Confusion Assessment Method (CAM) is the gold-standard diagnostic algorithm for acute delirium screening in inpatient settings. Diagnosis requires the presence of:

[Delirium Diagnosis Criteria]
= Feature 1 (Acute Onset and Fluctuating Course)
+ Feature 2 (Inattention)
+ [Feature 3 (Disorganized Thinking) OR Feature 4 (Altered Level of Consciousness)]

• Feature 1: Acute Onset and Fluctuating Course: Evidence of an acute change in mental status from baseline, with fluctuations in severity over hours or shifts.
• Feature 2: Inattention: The patient has difficulty focusing attention, is easily distracted, or cannot track a simple conversation (e.g., unable to spell "WORLD" backwards or recite days of the week backwards).
• Feature 3: Disorganized Thinking: Thinking is rambling, irrelevant, or illogical; erratic shifting from subject to subject.
• Feature 4: Altered Level of Consciousness: The patient's state of alertness is anything other than "alert" (e.g., hyper-vigilant, lethargic, stuporous, or semicomatose).

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5. Fall Risk and Mobility Assessment

Falls and trauma that occur in the hospital (such as fractures and head injuries) are on CMS's hospital-acquired condition list, so they cannot raise the hospital's MS-DRG payment, and post-discharge falls are a leading cause of readmission and loss of independence.

Morse Fall Scale (MFS)

The Morse Fall Scale is a rapid, 6-item fall-risk assessment tool widely embedded in hospital EHR systems:

1. History of falling (immediate or within 3 months): No = 0, Yes = 25
2. Secondary diagnosis (2 or more medical diagnoses in chart): No = 0, Yes = 15
3. Ambulatory aid: None/bed rest/nurse assist = 0; Crutches/cane/walker = 15; Furniture support = 30
4. Intravenous therapy / heparin lock: No = 0, Yes = 20
5. Gait / transferring: Normal/bedbound/immobile = 0; Weak (stooped, short steps) = 10; Impaired (struggles to rise, needs furniture/assist) = 20
6. Mental status: Knows own limits = 0; Overestimates ability / forgets limitations = 15

• Total Score 0 to 24 (No Risk): Basic hospital safety precautions.
• Total Score 25 to 44 (Low/Moderate Risk): Standard fall prevention interventions (yellow non-skid socks, bed low, call light within reach).
• Total Score 45 or Greater (High Risk): Comprehensive fall bundles (bed/chair exit alarms, supervised toileting, physical therapy consult, mobility assist signs).

Cut points vary by organization. Morse's original scale treated 0–24 as no risk, 25–50 as low risk, and 51 or more as high risk; many hospitals use 45 as the high-risk cut point, as shown above.

Timed Up and Go (TUG) Test

The Timed Up and Go (TUG) test evaluates basic dynamic mobility, balance, and transfer safety. The patient begins seated in a standard armchair, stands up upon command, walks 3 meters (10 feet) at a safe and comfortable pace, turns around, walks back to the chair, and sits down.

• Under about 10 seconds: Typical of freely mobile older adults.
• 12 seconds or more: The CDC STEADI threshold for increased fall risk in community-dwelling older adults; warrants a fall-prevention plan, therapy evaluation, and a home safety review.
• 20 seconds or more: Marked mobility limitation; usually needs an assistive device and supervision or help with transfers and walking.

CMS Section GG Functional Abilities and Goals

Under the Improving Medicare Post-Acute Care Transformation (IMPACT) Act, the Centers for Medicare & Medicaid Services (CMS) standardized functional scoring across all post-acute care (PAC) settings (Inpatient Rehabilitation Facilities [IRFs], Long-Term Care Hospitals [LTCHs], Skilled Nursing Facilities [SNFs], and Home Health Agencies [HHAs]) using Section GG.

Section GG evaluates Self-Care (eating, oral hygiene, toileting hygiene, wash upper/lower body, dressing) and Mobility (bed mobility, sit-to-stand, toilet transfers, walking, stairs, wheelchair mobility) using a standardized 6-point rating scale based on the level of assistance required:

• Code 06 (Independent): Patient completes the activity by themselves with no assistance from a helper, with or without assistive devices.
• Code 05 (Setup or Clean-up Assistance): Helper sets up or cleans up; patient completes activity without hands-on assistance.
• Code 04 (Supervision or Touching Assistance): Helper provides verbal cues, steadying assist, or contact guard assistance throughout the activity.
• Code 03 (Partial/Moderate Assistance): Helper provides less than half the effort; patient provides more than half.
• Code 02 (Substantial/Maximal Assistance): Helper provides more than half the effort; patient provides less than half.
• Code 01 (Dependent): Helper provides all the effort, or assistance of 2 or more helpers is required.
• Special Codes: 07 (Patient refused); 09 (Not applicable); 10 (Not attempted due to environmental limitations); 88 (Not attempted due to medical condition or safety concerns).

Section GG items feed post-acute payment classification (e.g., Case-Mix Groups [CMGs] in IRFs and the Patient-Driven Payment Model [PDPM] in SNFs) and help document the need for rehabilitation.