4.2 Interdisciplinary Assessment Tools

4.2 Interdisciplinary Assessment Tools

Interprofessional Imperative: In acute care, inpatient rehabilitation facilities (IRFs), skilled nursing facilities (SNFs), and neurological trauma centers, the CTRS functions as a vital member of the interdisciplinary healthcare team. Recreation therapists must be fluent in major standardized multidisciplinary assessment batteries mandated by the Centers for Medicare & Medicaid Services (CMS), CARF, and medical accrediting bodies to coordinate care plans, benchmark patient progress, and secure reimbursement.

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CMS Section GG Functional Abilities & Goals (IRF-PAI & SNF/LTCH/Home Health)

Under the Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014, the Centers for Medicare & Medicaid Services (CMS) established Section GG as the universal standardized functional assessment across all post-acute care settings, including Inpatient Rehabilitation Facilities (via the IRF-PAI), Skilled Nursing Facilities (via MDS 3.0), Long-Term Care Hospitals (LTCH CARE Data Set), and Home Health (OASIS).

The Standardized 6-Level Section GG Rating Scale

Section GG evaluates the patient's actual baseline performance (usual performance during the first 3 days of admission) and discharge performance in Self-Care and Mobility tasks using a standardized 6-point scoring scale:

• 06 = Independent: The patient completes the activity by themselves with no assistance, setup, or supervision.
• 05 = Setup or Clean-up Assistance: The helper sets up or cleans up assistive devices or materials; the patient completes the activity unassisted.
• 04 = Supervision or Touching Assistance: The helper provides verbal cues, coaxing, contact guard, or steadying assistance throughout the activity or during intermittent steps.
• 03 = Partial / Moderate Assistance: The helper provides less than half the effort (helper does 1% to 49% of the effort; patient completes 50% to 99% of the task).
• 02 = Substantial / Maximal Assistance: The helper provides more than half the effort (helper does 50% to 99% of the effort; patient completes 1% to 49% of the task).
• 01 = Dependent: The helper provides all of the effort (100%), or the assistance of two or more helpers is required for safety.

Special Coding for Activity Not Attempted

If a patient does not attempt an activity during the assessment window, CMS mandates specific non-performance reason codes:

• 07 = Patient Refused: Patient chose not to attempt the functional activity.
• 09 = Not Applicable: Activity not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury.
• 10 = Not Attempted due to Environmental Limitations: Lack of necessary equipment, space, or physical barriers.
• 88 = Not Attempted due to Medical Condition or Safety Concerns: Performing the activity is contraindicated by physician orders, acute pain, hemodynamic instability, or severe fall risk.

Role of the CTRS in Section GG Assessment

While physical therapists and occupational therapists frequently score bed mobility and standard hygiene, the CTRS provides critical interprofessional validation by evaluating Section GG mobility items in dynamic, authentic recreational contexts:

• Car Transfers: Assessing transfer safety during community re-entry outings.
• Uneven Surface Mobility: Assessing wheelchair propulsion or ambulation over grass, gravel, ramps, curbs, and community thresholds during adapted outdoor recreation.
• Object Retrieval: Assessing the client's ability to bend down and retrieve an object from the floor (e.g., picking up an adaptive bocce ball or dropped art tool).

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Minimum Data Set (MDS 3.0) in Skilled Nursing Facilities

The Minimum Data Set (MDS 3.0) is a federally mandated clinical assessment instrument required for all residents admitted to Medicare- or Medicaid-certified nursing homes and skilled nursing facilities under OBRA '87.

Section F: Preferences for Customary Routine and Activities

Section F directly assesses resident lifestyle preferences and leisure interests. MDS 3.0 mandates the Resident Voice protocol: the CTRS or activity professional must interview the resident directly whenever feasible, rather than relying on surrogate staff assumptions.

• Standard 5-Point Importance Scale:
  1. Very Important
  2. Somewhat Important
  3. Not Very Important
  4. Not Important at All
  5. Important, But Can't Do (Crucial diagnostic trigger for CTRS to initiate adaptive equipment or environmental modification)
• Key Activity Domains Evaluated: Reading books/newspapers, listening to music, spending time outdoors, participating in preferred religious/spiritual activities, engaging in favorite hobbies, solitary quiet time, and group socialization.
• Staff Assessment of Daily and Activity Preferences: Administered ONLY if the resident is totally non-verbal, comatose, or severely cognitively impaired and unable to communicate preferences.

Section C: Cognitive Patterns & The BIMS

• Brief Interview for Mental Status (BIMS): A standardized, structured cognitive screen evaluating temporal orientation, 3-word immediate recall, and 3-word delayed recall with cues.
  • Score 13–15: Cognitively Intact (resident can direct their own recreational care plan).
  • Score 8–12: Moderately Impaired (requires structured recreation, visual cues, and simplified instructions).
  • Score 0–7: Severely Impaired (requires multi-sensory stimulation, 1:1 validation, and sensory-based RT protocols).
• Confusion Assessment Method (CAM): Screens for acute delirium, fluctuating mental status, and inattention.

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Historical Context: Functional Independence Measure (FIM) & FAM

For over three decades (1987–2019), the Functional Independence Measure (FIM) served as the global gold standard for inpatient physical rehabilitation scoring. While replaced by CMS Section GG for federal prospective payment, understanding FIM architecture remains vital for interpreting legacy clinical records and research literature.

FIM 7-Level Scoring Scale

• Level 7: Complete Independence (timely, safe, no device)
• Level 6: Modified Independence (assistive device, extra time, safety risk)
• Level 5: Supervision / Setup (standby assist, cueing, coaxing)
• Level 4: Minimal Contact Assistance (patient does 75%–99% of effort)
• Level 3: Moderate Assistance (patient does 50%–74% of effort)
• Level 2: Maximal Assistance (patient does 25%–49% of effort)
• Level 1: Total Assistance (patient does <25% of effort / requires 2 helpers)
• Item Composition: 18 items (13 Motor items, 5 Cognitive items; score range 18 to 126).

Functional Assessment Measure (FAM)

Developed to supplement the FIM for individuals with traumatic brain injury and stroke, the FAM added 12 specialized cognitive, behavioral, and communication items, including swallowing, car transfers, community mobility, reading, writing, speech intelligibility, emotional status, adjustment to limitation, use of leisure time, problem-solving, safety judgment, and employability.

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Glasgow Coma Scale (GCS)

Developed by Teasdale and Jennett, the Glasgow Coma Scale (GCS) is the universal acute neurological assessment tool used to quantify depth of coma and impaired consciousness following traumatic brain injury, acute stroke, or anoxic encephalopathy.

The Three Subscales and Scoring Criteria

+-------------------------------------------------------------------------------------------------+
|                                 GLASGOW COMA SCALE (GCS) SCORING                                |
|                                                                                                 |
|   EYE OPENING (E)            VERBAL RESPONSE (V)             MOTOR RESPONSE (M)                 |
|   [Range: 1 to 4]            [Range: 1 to 5]                 [Range: 1 to 6]                    |
|                                                                                                 |
|   4 = Spontaneous            5 = Oriented                    6 = Obeys commands                 |
|   3 = To speech / sound      4 = Confused conversation       5 = Localizes to pain              |
|   2 = To pressure / pain     3 = Inappropriate words         4 = Normal flexion (withdrawal)    |
|   1 = None                   2 = Incomprehensible sounds     3 = Abnormal flexion (decorticate) |
|                              1 = None                        2 = Extension (decerebrate)        |
|                                                              1 = None (flaccid)                 |
+-------------------------------------------------------------------------------------------------+

Total GCS Score Interpretation & TBI Severity Classification

Total score ranges from 3 (deep coma / brain death) to 15 (fully awake, alert, and oriented):

• GCS 13–15 (Mild TBI / Concussion): Patient is conscious; may exhibit mild confusion, headache, or post-traumatic amnesia (<24 hours). RT focuses on gradual physical reconditioning, cognitive pacing, and light-sensitivity accommodations.
• GCS 9–12 (Moderate TBI): Loss of consciousness for >30 minutes to 24 hours. Patient exhibits prominent cognitive, motor, and behavioral deficits. RT provides structured, low-distraction cognitive retraining and adapted motor tasks.
• GCS 3–8 (Severe TBI / Coma): Patient is comatose (clinical rule: "GCS of 8, intubate"). RT interventions focus on passive sensory stimulation, postural alignment, contracture prevention, and coma arousal protocols.

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Rancho Los Amigos Levels of Cognitive Functioning (RLAS)

Developed by Hagen, Malkmus, and Durham, the Rancho Los Amigos Levels of Cognitive Functioning (RLAS) describes the predictable cognitive and behavioral recovery continuum exhibited by patients following traumatic brain injury.

Rancho Los Amigos Levels Matrix & RT Interventions

American Spinal Injury Association (ASIA) Impairment Scale

The International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI), established by the American Spinal Injury Association (ASIA), provides the universal framework for grading the severity of spinal cord lesions.

ASIA Impairment Scale (AIS) Classifications

+-------------------------------------------------------------------------------------------------+
|                                 ASIA IMPAIRMENT SCALE (AIS)                                     |
|                                                                                                 |
|   GRADE A: COMPLETE           No sensory or motor function is preserved in sacral segments       |
|                               S4–S5 (no voluntary anal contraction, no anal sensation).         |
|                                                                                                 |
|   GRADE B: SENSORY            Sensory but NOT motor function is preserved below the             |
|            INCOMPLETE         neurological level and includes the sacral segments S4–S5.        |
|                                                                                                 |
|   GRADE C: MOTOR              Motor function is preserved below neurological level, and MORE     |
|            INCOMPLETE         than half of key muscle functions below the single neurological   |
|                               level have a muscle grade < 3 (Manual Muscle Testing).            |
|                                                                                                 |
|   GRADE D: MOTOR              Motor function is preserved below neurological level, and AT LEAST |
|            INCOMPLETE         half (half or more) of key muscle functions below the single      |
|                               level have a muscle grade >= 3 (active movement against gravity). |
|                                                                                                 |
|   GRADE E: NORMAL             Sensory and motor functions are clinically normal.                |
+-------------------------------------------------------------------------------------------------+

Clinical RT Considerations for Spinal Cord Injury

• Tetraplegia (C1–C8 Lesions): Impairment of upper and lower extremities and trunk. High cervical injuries (C1–C4) require power wheelchairs with sip-and-puff or chin controls, environmental control units (ECUs), and mouth-stick recreation. Mid-to-low cervical injuries (C5–C8) allow adapted sports using wrist splints, universal cuffs, and hand-pedal cycles.
• Paraplegia (T1–S5 Lesions): Full upper extremity motor control preserved; lower extremities and trunk impaired depending on lesion level. Clients excel in wheelchair basketball, wheelchair tennis, handcycling, sit-skiing, and adapted aquatics.
• Critical Clinical Precautions in RT:
  • Autonomic Dysreflexia (Lesions at T6 or above): Life-threatening hypertensive emergency triggered by noxious stimuli below the lesion (distended bladder, kinked catheter, bowel impaction, tight clothing). Symptoms include pounding headache, profuse sweating above lesion, facial flushing, goosebumps, and bradycardia. Immediate CTRS Action: Sit patient upright immediately (never lay flat), loosen tight clothing, inspect catheter for kinks, and call medical team immediately.
  • Thermoregulation / Poikilothermia: Impaired sweating and vasodilation below lesion level. The CTRS must monitor outdoor temperature closely, provide shaded cooling, and prevent hypothermia or heat stroke.
  • Skin Integrity & Pressure Injuries: Decreased sensation requires the CTRS to enforce pressure relief weight shifts every 15–20 minutes during wheelchair recreation activities.