If you’re a Rehab Optima user, you can submit patient data to the national outcomes repository via the Optima Outcomes Module. But first, you are required to complete a certification process. Earning certification requires that you watch three training modules and take corresponding tests. The information you need is provided below.
Click here to download the CARE Item Set Training Manual
Get Certified, Earn Continuing Education CreditsCertification is just one opportunity – there’s more. Did you know the Care Item Set is approved for PT and OT Continuing Education Units (CEUs)? If you are a PT and/or OT, get trained on the Care Item Set and earn CEUs. For details on the number of credits offered in your state, visit our Supporting Education page.
Test Instructions and Videos:
- General – Test 1 is required to be completed by all users.
- Users must also complete EITHER Self-Care – Test 2 OR Mobility – Test 3.
- The determination regarding which test the user should take is to be made by the organization, and depends on which CARE Item Set the organization will require the user to complete within the Optima Outcomes Module. Optima recommends that PTs take Mobility – Test 3 and OTs take Self-Care – Test 2, but that may differ depending on organizational direction.
*Note: Users can take all three tests, but Optima only requires two tests (General – Test 1 and EITHER Self-Care – Test 2 OR Mobility – Test 3) to be completed for certification. All tests are required for CEU credits.
Training videos for the three sections – General – Test 1, Self-Care – Test 2 and Mobility – Test 3 – are listed below. If you are interested in completing CARE Training for Certification, please contact Support@OptimaHCS.com to register.
General VideoView Video Transcript
Welcome to the training on Continuity Assessment and Record Evaluation, also known as the CARE tool. This training was originally developed by the American Health Care Association and the National Association in Support of Long Term Care for their joint work group to measure therapy outcomes. The work group was assembled for the purpose of investigating a functional outcome measure that could be used by therapists and therapy companies across the industry. The work group focused on the CARE tool due to the significant amount of research and data that already existed, which we will talk more about in just a few minutes.
AHCA and NASL gave permission for Optima HealthCARE Solutions, and Rehab Resources and Consulting to update the training materials so it could be used by a larger part of the rehabilitation industry who was interested in finding an outcomes tool that will enable them to measure and improve upon rehabilitation outcomes.
This is the first of three trainings in the series. In order to make your training session more meaningful, you should have with you the CARE Item Set Training Manual, and within this manual is a lot of helpful information, such as the CARE Item Rating Instructions, a chart that defines each CARE item as well as each CARE rating for that item, and at least two or three clinical vignettes for each CARE item to illustrate how the ratings would be applied in a clinic setting.
Finally, you will be required to take the CARE Item Post-Test. This will test your knowledge of the material presented. Why do we test? Because it is important to ensure that each person using the tool understands the definitions of the CARE Rating Scale. Because everyone is receiving the same training, the ratings are more consistent. It also ensures the data collected is consistent.
One of the project’s goals is that we can begin to assemble a database of information across companies and across the nation so that we can truly measure clinical outcomes for our patient populations. This first step in accomplishing that goal is to have consistent measurements gains and consistent items. The training and test also ensures that you, the therapist, understand what each CARE item includes and does not include. As therapists, we may have different ideas about what is included in the task of eating or in the task of bed to chair transfers. This training will define exactly what functions the tasks or items include so we can all measure the same thing. Finally, the training will provide to each PT and OT examples and a clinical algorithm to use when assessing each CARE item. Some therapists listening to this training may never have heard of the CARE tool. Let’s take just a few minutes to review what the tool is and why it has become so significant.
It is important for therapists to understand why they are documenting information and how it might be used. First, the word CARE stands for Continuity Assessment and Record Evaluation. The CARE tool is a set of data elements that was developed after Congress called on the Centers for Medicare and Medicaid Services, which you may know as CMS, to develop one comprehensive patient assessment instrument that could measure health and functional status across the post-acute care continuum. Many of you may be familiar with a Minimum Data Set or MDS, the Outcome Assessment Instrument Set or OASIS, the Patient Assessment Instrument or PAI. While the Long-Term Care Acute Hospital setting or LTACH doesn’t have a tool like these, they do collect certain pieces of information upon admission that categorize the patient’s condition. The original goal of the CARE tool was to eliminate the need to have separate tools in each of these settings.
Congress wanted CMS to determine if one tool could be used in each of these settings. You can imagine how helpful that would be to doctors, nurses, and therapists, to have one tool that asks the same questions all along the way so we could begin to talk in a universal language rather than our own setting specific terms. So CMS contracted with the Research Triangle Institute, or RTI, to develop this instrument. Between 2007 and 2010, the patient assessment instrument was piloted across the country by all four post-acute care settings in a demonstration project called the Post-Acute Care Payment Reform Demonstration, or PAC-PRD. The CARE tool itself was designed to collect standardized information at discharge from acute hospitals and at admission and discharge from the four post-acute care providers, the LTACHs, IRFs, SNFs and home health agencies. Overall, the demonstration found that decisions about which PAC setting to send patients to, who are treated for the same condition in acute hospitals, is highly dependent on the availability of which post-acute care setting option the patient has and what they call other factors not measurable in the Medicare claims data.
So in other words, they suspected that the decisions were not highly dependent on the patient’s condition or diagnosis. The functional items on the tool were found to have good reliability and validity. The clinicians who participated in the demonstration gave mostly positive feedback on the tool and it’s items. Therapists reported they liked specificity for measuring change in function that the items gave them. The degree of inter-rater reliability was found to be high, as well as the validity of the items. So in other words, the tool measured what it was intended to measure. The data gathered in this study has since been analyzed and made public in two separate reports, one delivered in May of 2011 and the other in November of 2012.
Now this training is not intended to cover the entire CARE tool, but rather a specific set of questions from that tool. First, we will introduce the CARE tool rating scores and their definitions. Then we will briefly review the CARE tool items that are scored. There are two sections, self-care and mobility. As you have probably already noticed, there are no items specific to speech therapy. That is because there was not enough data from the items on the CARE tool related to cognitive functioning and/or swallowing to support them as valid and reliable measures. After completing this training on the general items, you will be directed to take a post-test. It is important for every person who is collecting CARE, self-care and CARE mobility data to be certified. Basically what this means is that you must go through this training and take a post-test.
We want to ensure that everyone using the scoring methodology is using the same definitions and understands the items. This ensures the reliability of the data collected. So everyone using the CARE functional items set must complete the general training. That is step one. The next step is dependent upon your company’s protocol. So you will want to be sure you know which path to follow. There is a learning module for the self-care items and a separate learning module for the mobility items. Some organizations will have OT trained to do the self-care items set and PT trained to do the mobility items set. That means for each patient, those would be the only items each discipline would complete. So if a patient was only being seen by OT and not physical therapy, then there would be no mobility items collected on that patient. Some organizations will have PT and OT trained to be able to complete both sets of data.
Once you have completed the learning modules for one or both of these as directed by your company, you will need to complete the post-test. Each of the three learning modules have a separate post-test that must be completed. Every one must score at least 80% on each of the three modules. An 80% score is similar to other certification requirements, such as the FIM testing. At the end of the online version of the test, you will be told what your score is and if you achieved 80%, you can move on to the next test. If you scored less than 80%, you will be allowed to take the test as many times as you need in order to achieve the passing score. At the end of the online version of the test, you will be told which questions you answered incorrectly so you can study those items before taking the test again.
However, you will be required to take the entire test again, rather than only re-answering those questions you missed. Lastly, the test is an open book test, which means you can use your training manual and your notes from these training modules to assist you in answering questions. Once you have completed all these steps, you are certified to begin collecting the CARE item data on your patients. It is important to collect this information at evaluation and discharge of your patients. However, that does not preclude you from measuring these items during the episode of therapy, such as that re-evaluation for progress report updates, because it is important to know whether your patient is progressing throughout the episode, not just at discharge.
So let’s begin to look more closely at the CARE Item coding system. In other words, how the items are rated. Each task or activity is rating on a six point scale. This might be different than what you are used to using. Many therapists may be used to using a seven, eight or even nine point scale. The same level of assistance rating scale is used for both item sets, the self-care and the mobility. A higher rating indicates the patient has more independence with the task or activity. A six on the CARE Item Rating Scale indicates independence with a task or activity, and each number less than six represents increasing levels of dependence.
Next, let’s look a little more closely at each of these levels and what they mean. Independent means the patient completes a task or activity by him or herself with no assistance from a helper. Set-up or clean-up means the patient completes the task activity themselves, and the helper is only needed for assistance before or after the task. Supervision or touching means the helper provides verbal cues or touching or steadying assistance as the patient completes the task. The main differentiator between four and five is that in four, you are providing some level of cuing or assistance during the activity. And in order to achieve a score of five, the therapist is only helping a patient before or after the task.
Also, notice that it does not matter whether the patient uses an assisted device or any kind of adaptive equipment, such as a walker, cane, railing, reacher or anything else. Using these devices or braces is not factored in. Only the level of assistance or help that you provide is factored in. Partial or moderate assistance means the helper provides less than half the effort. They may lift, hold, or support the trunk or limbs, but the patient still is providing most of the effort. Substantial or maximal assistance means the helper does provide more than half the effort to complete the activity. And of course, dependent means the helper does all of the effort and the patient does none of the effort to complete the task or activity. Now you might be asking, “Well, what do I do when the assistance I provide is exactly 50%?” If you feel that way, then use your clinical judgment. You might also think about other aspects of the task.
In other words, are you providing cues, prompts, steadying? Other types of assistance should be factored in. It’s not just about the physical assistance levels. It’s also important to consider the safety and quality of performance for all the items. In other words, if the helper’s assistance is required because the patient’s performance is unsafe or of poor quality, the rating selected should reflect the amount of assistance provided. And it’s also important to keep in mind that tasks and activities may be completed with or without assisted devices. So for example, at evaluation, a patient may require a platform walker to ambulate due to a fractured right wrist and left tibia. The patient requires less than 50% assistance to ambulate 10 feet safely. At re-evaluation, the same patient advances to a rolling walker with ambulation after being allowed weightbearing through the wrist. The patient still requires less than 50% assistance to ambulate 20 feet safely.
At discharge to home health therapy, the patient is ambulating with a straight cane for 30 feet, but still requires less than 50% assistance to complete the distance safely. So as you can see, there have been changes in the patient’s performance but the CARE rating is still a 3 all the way through. For each task or activity the therapist should assess the patient’s level of independence. Another key point to remember with the CARE Item Scale that may be different from other rating scales you have used is that the rating chosen should reflect the patient’s usual level of performance with the activity over a two day period. So if a patient is only seen on one day, such as an evaluation, then the rating is based on the patient’s usual performance during that day or during your evaluation session.
Let’s look at an example of applying these ratings. During a 45 minute evaluation, the patient transferred out of bed to a wheelchair for transport to the therapy gym, which required substantial or maximal assistance. The patient stood from the wheelchair to the parallel bars requiring substantial or maximal assistance. The patient transferred from the wheelchair to the mat table for supine exercises, and required partial or moderate assistance. After the patient completed the exercises and transferred from the mat back to the wheelchair, he or she required again, substantial, maximal assistance. So using the information you’ve been given, take a few moments and determine what you would write as the patient’s usual performance for sit to stand and chair to bed to chair transfers.
In this example, the usual performance also happens to be the lowest performance. So for sit to stand, the best answer would be substantial maximal assistance, and for transfers substantial maximal assistance.
Let’s look at another example. During the 45 minute evaluation, the patient transferred out of bed to a wheelchair for transport to the therapy gym requiring partial or moderate assistance. The patient stood from the wheelchair to the parallel bars requiring substantial or maximal assistance. The patient transferred to the mat table requiring partial, moderate assistance. The patient completed the exercises and then went back to the wheelchair and required substantial or maximal assistance. So using this information, what would you determine to be the usual performance for sit to stand? The answer may be substantial or maximal assistance. What is the usual performance for chair to bed? Partial or moderate assistance. So in this example, the lowest performance is not the usual performance.
Next, we want to review what to do when an item cannot be rated. First, it is very important to point out that every effort should be made to score all items with a one to six rating. Use your clinical judgment when assigning the scores. Perhaps there are some tasks that cannot be attempted because the patient is actually dependent in those areas. The correct response would be dependent rather than not applicable or not attempted due to safety concerns. For example, if the patient is dependent in upper body dressing and they refuse to attempt lower body dressing, the therapist could probably assign a dependent score to lower body dressing as well, based on the natural hierarchy of function.
So we have an alpha score system for these instances. S is used when the task is not attempted due to safety concerns. N, if it’s truly not applicable to the patient. A, when the task is attempted but unable to be completed, and P when the patient absolutely refuses to complete the task. Even if a particular task or activity is not going to be the focus of your therapy program, you must still score the items.
Why? Because if there is one thing our professions have learned over the years it’s that we must have information on our patients in order to be able to support that we, therapy, made a difference in the patient’s outcome. Without the data, we do not have a strong argument to make. When we score tasks or items as NT or not tested, or NA, not applicable, we downplay the role we have on a patient’s overall level of function. Furthermore, the CARE item scores add up to be a composite score of the patient’s overall function. So if items are left not scored, then the patient’s overall level of function and self-care and mobility will be lower than they should be. So while we have alpha scores for those times where it is just not appropriate to assign a merit score, keep in mind that these codes should be used minimally.
So how is the alpha score S used? You want to choose this score when the task or activity is not attempted due to safety concerns, and the therapist cannot infer what the patient’s level of performance would be from another part of the evaluation. For example, an Alzheimer’s patient becomes severely agitated after you have assessed bed mobility, and before any gait training or transfers could be assessed. Walking and chair to bed transfers, then, might be scored an S. How is the alpha score N used? You choose this when the task or activity is clearly not applicable to the individual. So in other words, the person is not expected to perform the task now or in the future. A few examples of when it would be appropriate to use the N score would be if you are evaluating a double amputee patient who is not a candidate for prosthesis, then he or she would be rated N for putting on and taking off footwear.
Perhaps a patient lives in a home that does not have a tub or shower, or your facility does not have tub or shower facilities in which to test the patient. The patient only bathes at bedside or by the sink. So the item shower/bathe self would be correctly coded N. Lastly would be a patient who exclusively uses a wheelchair and for him, walking is not a realistic goal. Any item relating to walking and going up and down the steps would be coded an N. A few examples of when it would not be appropriate to use N would be if you are evaluating a patient who can’t reach down and put anything on their foot due to hip precautions. In this instance, the patient would be rated as a one or dependent because they cannot do the task. And just like in the last example, you may have a patient who only uses a wheelchair on evaluation. But in this example, the plan of care does include returning the patient to ambulation. Therefore, the walking tasks and going up and down steps would be rated as a one or dependent.
How is the alpha score A used? It should be chosen only if the task or activity was interrupted or stopped for reasons other than the patient’s ability to perform the task or activity. Examples of when this might occur are, if a family visits in the middle of your evaluation session, or the patient had to leave to attend another appointment. Perhaps the patient had to receive a medication that interrupted your evaluation or equipment that was necessary to evaluate the task or activity fails. Preferably the evaluating therapist should be able to go back to evaluate the area. This rating should be rarely used, but in all cases use your best judgment.
Next, we want to look at some scenarios when two responses might seem appropriate. Again, these situations should be the exception, but let’s look at how the clinical analysis might be done to choose a rating. A patient has a PICC line that is not supposed to get wet. One or dependent is defined as helper does all of the effort, patient does none of the effort. But, as in this case, if a patient cannot perform a task or activity due to his or her medical condition or medical restrictions, and others would have to help him or her complete the activity safely, then this patient would be coded as dependent.
What if a patient fails one task or activity and that task or activity is logically related to another task or activity? In these cases, it would be appropriate to code the patient as dependent in the related task. For example, if a patient cannot go up one step or curb without maximal assistance, then the patient would also be coded dependent for four steps and 12 steps. Another example is if a patient cannot walk 10 feet on an even surface, then the patient would be correctly coded as dependent in the item, walk 10 feet on uneven surfaces. The last alpha score is P. P should be chosen when the task or activity was not completed because the patient refused to perform the task or activity. Clinical judgment should be carefully applied to these situations in order to determine if the refusal was due to the patient not feeling safe or because he or she was concerned about not being able to accomplish the task.
If that’s the case, the item should be rated as dependent. Again, this rating should be rarely used because the evaluating therapist should attempt to go back to evaluate the task or infer performance from similar activities or apply clinical judgment as in the examples that we’ve already discussed. Lastly, let’s discuss other data sources for rating the CARE items. First and foremost, the rating should be based primarily on the assessment of the patient and direct observation of the task or activity. However, if the task or activity cannot be directly observed, then information from the medical record or from staff observations can supplement your process. For example, it may be necessary to talk with nursing and/or review the record to assess a rating for toilet hygiene, chair, bed to chair transfers and/or toilet transfers. If you assess a patient who is unable to transfer chair to chair or to a standing position, then you may want to check with nursing or the nursing assistants before deciding to infer the patient would score the same for toilet transfers and car transfers.
Finally, before we end this training module, we want to review what the actual items are in the CARE self-care item set and the CARE mobility item set. In the self-care set, there are items for eating, oral hygiene, toilet hygiene, upper body dressing, lower body dressing, washing upper body, shower or bathing self, and putting on and taking off footwear. In the mobility set, there are items for lying to sitting, sit to lying, rolling left and right, sit to stand, chair or bed to chair transfers, toilet transfers, longest distance walked and longest distance wheeled, picking up an object, car transfers, walking 50 feet with two turns and walking 10 feet on uneven surfaces, as well as going up and down one step, four steps or 12 steps.
Now it’s time to take the test. As stated earlier, all occupational therapists and physical therapists will be required to complete this post-test, which tests your knowledge of the rating definitions and alpha scores. Most therapists will take the test electronically. You will find the electronic link provided in your training manual. However, some companies may choose to test therapists using other methods, such as paper and pencil. So if you don’t find the link in your manual, check with your managers. For those of you completing the electronic test, complete Section 1: CARE Items General Questions, which consists of six questions. You are required to score no less than an 80% to pass the test. You can use your training manual and any notes you took during this training to assist you. Your score will display on the last web page after all questions have been completed, so you will know immediately how you did. You will be required to take the test again if you do not score 80% correct, but you can take the test as many times as you need to. This concludes the general training module. Good luck.
Self-Care Video
View Video Transcript
Welcome to the training on the Continuity Assessment and Record Evaluation, also known as the CARE Tool. This training was originally developed by the American Healthcare Association and the National Association in Supportive Long Term Care for their joint work group to measure therapy, outcomes. HCA, and NASL gave permission for Optima Healthcare Solutions and Rehab Resources and Consulting to update the training materials so it could be used by a larger part of the rehabilitation industry who was interested in finding an outcomes tool that will enable them to measure and improve upon rehabilitation outcomes.
This is the second of three trainings in the series. In order to make your training session more meaningful, you should have with you the CARE Item Set Training Manual. Within this manual is a lot of helpful information. The CARE Item Rating Definitions to be used for the self-care items can be found on page three and four. A chart that defines each CARE self-care item, as well as each CARE rating for that self-care item can be found on pages six through 13. And at least two or three clinical vignettes for each CARE self-care item that illustrates how the ratings would be applied in a clinic setting can be found on pages 29 through 37. Finally, you will be required to take the CARE Item Post-Test. This test will test your knowledge of the material presented.
Why is this training necessary? The training and test ensures that you, the therapist, understands what each CARE Item includes and does not include. As therapists, we may have different ideas about what is included in the task of eating or in the task of toilet hygiene. This training will define exactly what functions the self-care tasks or items include so we can all measure the same thing. The training will also provide each therapist examples and a clinical algorithm to use when scoring each CARE Item.
It is important to ensure that each person using the tool understands the definitions of the CARE self-care items and how the CARE rating scale applies to each item. Because everyone is receiving the same training, the ratings are more consistent. It also ensures the data collected is consistent. One of the project’s goals is that we can begin to assemble a database of information across companies and across the nation so that we can truly measure clinical outcomes for our patient populations. This first step in accomplishing that goal is to have consistent item sets and consistent measurement scales.
It is worth repeating that even if a particular task or item is not going to be the focus of your therapy program, you still must score those items. The CARE Item scores add up a composite score of the patient’s overall function. So if items are left not scored, then the patient’s overall level of function in self-care and mobility will be lower than they should be. When we score tasks or items NT, or not tested, or N/A a not applicable, we downplay the role we have on a patient’s overall level of function. So while we have alpha scores for those times when it is just not appropriate to assign a numeric score, keep in mind that these codes should be used minimally.
You see on this slide and on page five of your training manual, the list of items that make up the CARE Item Self-care Set: eating, oral hygiene, toilet hygiene, upper body dressing, lower body dressing, washing the upper body, shower or bathing self, and putting on and taking off footwear. The general format of this training will follow this, as we will have a description of the task, followed by the rating scale for the item, followed by some examples of applying the rating scale to the item. Keep in mind that there are additional clinical vignettes for each of these tasks in your manual, but we won’t be going over all of those examples today in the training meeting.
The first self-care item is eating. This item is defined as the ability to use suitable utensils to bring food to the mouth and swallow food once the meal is presented on a table or tray. Food consistency does not factor into the scoring. So whether a patient eats regular food or modified diet, the same scoring scale is used. This item is not about the patient’s swallowing function, nor about the consistency of food eaten. It’s also not about whether the patient uses adaptive utensils or equipment. The rating is chosen based on the amount of assistance provided by the helper. One coding tip is that if the patient receives tube feeding, the rating for this item would be “N” or not applicable.
This is an example of the rating chart in your training manual for eating, you can find it on page six. The tables are all oriented the same. In the first column on the left hand side will always be the description of the task. In other words, how is it defined and what sub-tasks are included? The next six columns correlate to each of the rating levels. Each column represents one of the six CARE Item ratings and their definitions are repeated in bold font for each item. In each column are examples of when that rating might be applied to the task. Examples of clinical application that might qualify for that rating are listed, but keep in mind it is not an exhausted list. You may encounter situations that are not listed here. So it’s important to always use your best clinical judgment.
So what would a rating of four potentially look like for eating? Look at the table. First, we have a definition of four. If cueing and/or coaxing and/or supervision are provided throughout a meal because of safety concerns about swallowing, possible choking, and/or eating in a hurry, but no physical assistance, then four would be the appropriate score. Or if the helper must verbally guide the patient in completing the task, and/or provide touching or steadying assistance to the patient to scoop food onto the utensil and bring it to the patient’s mouth. Whereas a rating of three would be appropriate if they helper provides less than 50% of the effort in physically assisting the patient in scooping the food onto the utensil and bringing it to the patient’s mouth. Or conversely, if the patient can partially scoop food onto the utensil and partially bring the food to the mouth, but is unable to complete the task without physical health from the helper.
Let’s look at example number 1. Mrs. B. requires help to cut her food and open containers. She is able to scoop food onto the utensil and bring it to her mouth. She requires occasional verbal cues to take smaller bites and tuck her chin and swallowing. So what would be the CARE rating level for Mrs. B? The best choice is four. Since Mrs. B requires a helper, she cannot score about a five for supervision, but since she requires occasional verbal cues to safely swallow the appropriate CARE Tool rating is a four.
Example number two is Mrs. P. She is on a mechanical soft diet with nectar thick liquids. She is able to manage a few bites herself, but quickly fatigues and spills greater than 75% of the food when getting it from the her plate to her mouth. She requires a helper to get food on the fork and provide support to her arm to move the fork from her plate to the mouth. So what is the CARE rating level for Mrs. P? The best rating score is three. She is able to complete a few bites independently, but then requires some physical assistance with getting food onto her utensil and with lifting her arm to her mouth in order to be able to eat her food.
The next CARE Item is oral hygiene. It is defined as the ability to use suitable items to clean the teeth. If a patient has dentures, then it includes the ability to remove the dentures from the mouth and replace them in the mouth, as well as managing the equipment for soaking and rinsing. This item is not about whether the patient brushes her teeth in sitting or standing, nor about the level of assistance needed to get to the bathroom. One tip is to apply the same rating and thought process regardless of whether the patient uses a conventional toothbrush or an electric one.
The rating scale for oral hygiene is on page seven of your training manual. As described before, the column on the far left defines the item, the next six columns correlate to each of the rating levels. So let’s look at the description of rating two, substantial or maximal assistance. You might have a patient who can bring his or her toothbrush to their mouth, but need the helper to assist with applying toothpaste and completing oral care with the toothbrush. Or the patient can remove or replace their dentures, but the helper is required to manage equipment for soaking and rinsing, or maybe they can manage some equipment, but they’re unable to safely or fully remove dentures or replace them for a proper fit. Or to helper may provide guidance to the limb and provides better than 50% of the effort in assisting the patient to clean their teeth or remove or replace dentures.
Let’s look at example number one. Mrs. R. Wears dentures. She is able to remove them from her mouth. The helper sets up the equipment for rinsing and soaking. Mrs. R. can then clean her own dentures. Mrs. R. can place her dentures in her mouth, but requires the helper to apply some pressure to ensure they are fitting snugly in her mouth. So what is the best CARE rating level for Mrs. R? The best choice is a three, partial or moderate assistance, because just as we discussed in the previous slide, Mrs. R. requires the helper to provide less than 50% of the effort in assisting her to replace her dentures.
The next example is Mr. Z. He requires steadying assistance to get to the bathroom. The helper applies toothpaste onto his toothbrush and hands it to Mr. Z. Once Mr. Z. Is done brushing his teeth, he’s reminded to wash his face and hands. The helper provides steadying assistance as he walks back to his bed. What is the CARE rating level from Mr Z? The best answer is five, set-up or cleanup. The helper provides set up assistance by putting toothpaste on the toothbrush so that Mr. Z. can brush his teeth. The fact that assistance was provided in getting him to or from the bathroom should not be considered in scoring oral hygiene.
The next item is toilet hygiene. It is defined as the ability to maintain perineal hygiene as well as adjusting clothing before and after using the toilet, commode, bedpan, or urinal. If a patient has an ostomy, the patient must be able to wipe the opening, but not manage the equipment. This item is not about how the patient gets to the toilet or gets on or off the toilet. It is also not about the level of assistance needed to get the bed pain or the urinal positioned. It’s important to review this item definition thoroughly and regularly, since it may be different than definitions of toilet hygiene on other rating scales you’ve used. You may also find the need to use other sources of data to complete this item, but being wary of relying too much on CNA reports or notes for this item, since they may be providing more help than is necessary. This rating system is about the patient’s usual performance, not the worst or the best.
The rating scale for toilet hygiene is on page eight of your training manual. The difference between a rating of four and five in this item is again, the difference between providing help during the activity versus before or after. When a patient needs prompting or cueing to complete a task or for safety, then the rating is a four. But if the patient only needs the helper to help them before or after the task, such as handing the patient the toilet tissue or placing the bedside commode by the bed or emptying the urinal or bed pain after toileting, the best response would be a five.
Let’s look at example number one. Mr. G cleansed himself and adjusted his clothing before and after using the toilet. He did these tasks independently, but held onto a grab bar to maintain his balance. What is the CARE rating level for Mr. G? The best response would be independent, or six. He was able to perform the toileting tasks independently with the assist of specialized equipment, in other words, the bars.
Example number two is Mrs. P. She has urinary urgency. As soon as she gets in the bathroom, she asks the nursing assistant to lift her gown and pull down her underwear. After voiding, Mrs. P. wipes herself and pulls her underwear back up. What is the CARE rating level for Mrs. P? The best choice is three, partial or moderate assistance. The rationale is that the helper provides more than just touching assistance. The patient does more than half of the effort, but the helper does need to provide less than half of the effort. The patient does two of the three toilet hygiene tasks. Remember, there are more examples for this item in the training manual.
The next item is upper body dressing. It is defined as the ability to put on and remove a shirt or a pajama top. It includes buttoning, snaps, ties, or any other closure mechanism if that is applicable. This item is not about putting on and removing clothes that the patient usually does not wear. In other words, ask yourself if the patient usually wears a bra or a pull over. If the answer is yes, then consider that. But if they don’t, then it is not included. Remember this is about the patient’s usual clothes, not what the therapist thinks they should be wearing. A few other tips for scoring is that the patient can be in a sitting or standing position the item does not indicate which it has to be. A simple method of assessment for this item during evaluation is to ask the patient to put on a shirt or a pajama top, fasten it, and then remove it. And as always, consider the patient’s usual performance, not their lowest.
The descriptions for this item can be found on page nine of your training manual. When scoring consider all of the elements of putting on and taking off upper body clothing when considering the greater than or less than 50% assistance level. For instance, a rating of two, substantial/maximal assistance might look like the patient is able to bring the garment together once it is put on, but is unable to fasten, snap, or button. Or maybe the patient is able to get one arm in and out of the sleeve, but not both arms. Or the patient is able to place the shirt without buttons over their head, but is unable to thread either arm through the sleeves.
Let’s look at example number one, Mrs. G., who wears a bra and a sweatshirt on most days. Mrs. G. Threads her arms through the bra straps and the helper hooks the bra. Mrs. G. puts her sweatshirt on without any assistance. So what is the CARE rating level for Mrs. G? The best answer is partial or moderate assistance because the helper provides assistance with upper body dressing, but the patient performs more than half of the effort.
Example number two, Mr. X. He sits on the side of the bed to dress his upper body. He threads his arms through the sleeves of his button down shirt, but requires steadying as he leans to his left side to ensure he does not fall over. So what is the CARE rating level for Mr. X? The best answer would be four, supervision or touching. The patient can dress his upper body, but requires occasional touching to steady himself as he leans to his weak side, and that’s necessary for safety reasons.
The next item is lower body dressing. It is defined as the ability to dress and undress below the waist, including fasteners. This item however is not about putting on footwear, nor is it about putting on and removing clothes the patient usually does not wear. So think about whether the patient usually wears a belt. A few tips for scoring is to keep in mind the patient can be in sitting or standing. That does not impact whether or not the patient scores independent. The patient can be independent with dressing their lower body in sitting, but moderate assistance to dress their lower body in standing. But what matters is that they complete the functional item in one of the positions. Another tip for assessing the item is to ask the patient to put on pants, fasten, either through button or zipping, and then remove them. And just always consider the patient’s usual performance, not the lowest.
The rating scale is on page 10 of you’re training. A patient would be best scored as five with setup or clean-up if they only have to be handed their garments or handed assistive equipment to help them. Also note here that donning and doffing a prosthesis is not included in their rating of their ability to dress. So perhaps they need a helper to put on a prosthesis, but once it is on, the patient can then dress themselves. They would still be given a score of a five.
Let’s look at example number one. Mrs. Z. Can be impulsive and has a history of falls. She requires supervision when standing to pull up underpants and pants. So what would be the CARE rating for Mrs. Z? The best rating is four, supervision or touching because the helper does not provide any physical assistance, but is required to supervise the patient due to safety concerns.
Example number two is Mr. B. He is unable to remove his pants or underpants independently. Once he is lying down in the bed however, he can unfasten his pants. He can roll slightly to his right and left and assist the helper to pull his pants over his hips. He can lift each leg one at a time, so the helper can remove his pants and underpants. So what would be the CARE rating level for Mr. B? The best response would be two, substantial or maximal assistance. The helper performs physical assistance for more than half of the tasks of lower body dressing. The patient does participate some in the task by unfastening his pants and assisting with pulling his pants down over his hips.
The next item is washing the upper body. It is defined as the ability to wash, rinse, and dry the face, hands, chest, and arms while sitting in a chair or bed. This item is not about washing the back. That is not included in this item, so that’s an important point to consider and maybe different than other scales you have used. This item is also not about whether the patient can wash his upper body in a tub or shower. So remember that the patient is in a sitting position for scoring during evaluation and consider the patient’s usual performance. If there are physician orders not to get these areas wet and/or the patient has medical equipment that precludes them from getting their other body wet, the rating would be NA, unless of course, the rating can be inferred from dressing upper body.
The rating guide is on page 11 for washing upper body. For this item a rating of four would be given if the helper is providing prompting and cueing for sequencing to fully accomplish washing, rinsing, and drying. Or if there are concerns about safety and/or thoroughly washing all areas which require verbal cues from the helper. Or perhaps touching or steadying is required for balance and safety when reaching for the washcloth, the faucet, or the towel to prevent falling, or to enable the patient to thoroughly wash and dry all areas.
Let’s look at example number one. After the helper places the wash basin filled with water, soap, a wash cloth, and a towel on the bedside table, Mrs. L. washes, rinses, and dries her upper body. She asks the helper to wash, rinse, and dry her back only. The helper remove all of the items once Mrs. L. is done. What is the CARE rating level for Mrs. L? The best response is setup or clean-up, the helper provides set up assistance, and remember that assistance with washing the back is not considered when rating this item.
Example number two is Mrs. O, she is recovering from pneumonia. After the helper places to washbasin filled with water, soap, a washcloth, and a towel on the bedside table, Mrs. O. washes and rinses her upper body, but she is too fatigued to dry herself completely, and the helper notices her oxygen saturation levels are at 86% after she finishes rinsing herself. So the helper dries her off and removes all the items. What would be the CARE rating level for Mrs. O? The best response is three, partial or moderate assistance. Mrs. O. was able to complete two of the three activities in washing her upper body, but cannot completely dry herself, which required the helper to provide less than half the effort to complete the task.
The next item is showering or bathing. It is defined as the ability to bathe oneself in a shower or tub, including washing, rinsing, and drying themselves. Note that this item is not about transferring in or out of the tub or shower, and it is not about washing the entire body outside of a tub or shower. So a few tips for scoring are to always remember the patient’s usual performance, and if there are orders to not get these areas wet, and the rating cannot be inferred, the rating would be NA. Also, if the patient doesn’t have bath or shower facilities at home and this task is not going to be a goal, then the response would also be an N.
The rating scale is on page 12 of your training manual, a patient with score independent if once in the shower or tub they can wash, rinse, and dry themselves without any assistance from the helper. So even if they required maximum assistance to get into the tub, and if they used a shower chair and grab bars and bath mit, that does not factor into their score in independence in bathing or showering, if they can wash, rinse, or dry themselves without any assistance.
Let’s look at example number one. Mrs. L. stands while showering herself due to hip precautions. She washes and rinses herself, except she is not able to safely reach from her knees down to her feet and requires the helper to assist with this part of her care. Mrs. L. sits on a raised toilet seat to dry herself except her feet. What is the CARE rating level for Mrs. L? The best response would be partial or moderate assistance. The helper is assisting with less than half the task, but Mrs. L. washed her body, except from the knees to her feet, rinsed her entire body, and only needed assistance in drying for feet.
The next example is Mr. J, who sits on a tub bench as he washes, rinses, and dries himself. The helper stays with him to ensure his safety and provides lifting assistance as he gets onto and off the tub bench. What is the CARE rating level from Mr. J? The best response is supervision or touching because the helper is providing supervision only as he washes, rinses, and dries himself. Again, the transfer on and off the tub bench are not factored into your rating.
The next item is putting on or removing footwear. It is defined as the ability to put on and take off socks and shoes or other footwear that is appropriate for safe mobility. This item however, is not about the ability to put on and remove anti-embolism or compression stockings. A few tips for scoring to keep in mind, especially as it relates to the anti-embolism stockings are that if a patient needs help getting those on, but is independent with everything else in the item, they can still score a five, setup or clean-up because that would be their maximum possible score. Someone has to set them up for putting on their shoes and socks and that set up part is putting on the anti-embolism stockings. Another key tip is that if a patient is a double amputee or even an amputee who will not be a prosthetic candidate, then the score for this item would be “N”.
The rating scale is on page 13 of your training manual. A rating of substantial assistance would be given instead of dependent when the patient does participate in the effort to put on or take off footwear. For instance, the patient is able to bring the sock or shoe to the foot, but is unable to pull them on and snugly fit them onto the foot. Or once the helper starts the sock, the patient is able to pull it on up and the patient is unable, however, to assist with the shoes or the footwear. Or maybe the patient is unable to assist with the socks, but once the helper fits the shoe or footwear on the distal part of the foot, the patient is able to slip the entire foot into the footwear.
Let’s look at example number one. Mrs. K. sits on the side of the bed, the helper puts her slipper over for forefoot and then instruct Mrs. K. to pull the slipper over her heel. Mrs. K. is able to do this and the process is repeated on the other foot. Mrs. K. is able to get the slippers off her feet without assistance. What is the CARE rating for Mrs. K? The best response is partial or moderate assistance because the patient requires assistance from the helper to start the task, but once the slipper is started, the patient can complete the task.
Example number two is Mrs. G. She has orders to wear compression stockings when out of bed to control her lower extremity edema. She can not get them started on her own, but once the stockings are over her ankles, she can assist with pulling them up and smoothing them. After her stockings are on, she is able to put her slippers on without assistance. Mrs. G. occasionally requires assistance to remove or stockings, depending on the amount of swelling she has had. So what is the CARE rating level for Mrs. G? The best response is setup or clean-up. The patient requires assistance, but only to get the compression stockings on or off. And remember this item does not include the amount of assistance necessary to put on and remove anti-symbolism or compression stockings. If a patient is unable to get them on and off independently, their maximum score for this item is a five. If a patient can get them on and off independently, their score would be a six.
Now let’s take a patient example that involves more than one item and put it all together. Mr. F. is referred to OT. On evaluation the patient is able to thread his affected arm through his shirtsleeve that the helper places over his head. He leans forward, the helper pulls the shirt down over his trunk. Mr. F. has been able to lift his legs off the floor to allow his legs to be threaded into the pant legs. He needs greater than 50% support from the helper to keep his balance while he uses his left hand to pull up his pants. Once seated at a table the helper opens up his containers and prepares his food. Mr. F. uses a fork and a spoon in his left hand to scoop his food. He needs occasional touching to ensure he scoops the food entirely on the fork and occasional steadying to keep from hurrying the fork to his mouth, which causes the food to fall off.
What is the CARE rating level for upper body dressing, lower body dressing, and eating? The best response for upper body dressing is two, substantial or maximal assistance because the helper provides more than half the effort of achieving the upper body dressing activity. The best response for lower body dressing is also a two because the helper provides more than half the effort to achieve this activity. The best response for eating is supervision or touching because the helper provides only occasional touching to steady the patient’s physical movements, but the patient can complete the task.
A few closing reminders, every effort should be made to score all items with a one to six rating. Use your clinical judgment when assigning the scores. Perhaps there are some tasks that cannot be attempted because the patient is actually dependent in those areas. The correct response then would be dependent rather than not applicable or not attempted. Even if a patient task or activity is not going to be the focus with your therapy program, you still must score those items because these functional measures are not being looked at as individual items. The CARE Item scores add up to be a composite score of the patient’s overall function. So if items are not scored, the patient’s overall level of function will be lower than it should be.
Now it’s time to take your test. As stated earlier, all occupational therapists will be required to complete this post-test, which tests your knowledge of the rating definitions and alpha scores and the item definitions. Some physical therapists will be required to take this test, so be sure to with your organization. Most therapists will take this test electronically. You will find the electronic link provided in your training manual. However, some companies may choose to test therapists using other methods, such as paper and pencil. So if you don’t find a link in your manual, check with your managers.
For those of you completing the electronic test, complete Section II, CARE Items Self-Care Questions, which consists of eight clinical scenarios and 18 total questions. You are required to score no less than 80% to pass the test. Your score will be displayed on the last webpage after all questions have been completed. You can use your training manual and any notes you took during this training to assist you, but you will be required to take the test again if you don’t score 80% correct, but you can take the test as many times as you need to. This concludes the Self-care Training module. Good luck.
Mobility VideoView Video Transcript
Welcome to the training on the Continuity Assessment and Record Evaluation, also known as the CARE tool. This training was originally developed by the American Health Care Association and the National Association in Support of Long Term Care, for their joint work group to measure therapy outcomes. AHCA and NASL gave permission for Optima Healthcare Solutions and Rehab Resources and Consulting to update the training materials, so it could be used by a larger part of the rehabilitation industry who was interested in finding an outcomes tools that will enable them to measure and improve upon rehabilitation outcomes. This is the third of three trainings in the series.
In order to make your training session more meaningful, you should have with you the CARE Items Set Training Manual. Within this manual, there’s a lot of helpful information. The CARE Item Rating definitions to be used for the mobility items can be found on page three and four. A chart that defines each CARE mobility item as well as each CARE rating for that mobility item can be found on pages 14 through 28. At lest two or three clinical vignettes for each CARE mobility item to illustrate how the ratings would be applied in a clinical setting can be found on pages 38 through 55. Finally, you will be required to take the CARE item post-test. This will test your knowledge of the material presented.
Why is this training necessary? The training and test ensures that you the therapist understands what each CARE item includes and does not include. As therapists. we may have different ideas about what is included in the task of chair to chair or bed to chair transfers, or in the task of picking up objects. This training will define exactly what functions the mobility tasks or items include, so we can all measure the same thing. The training will also provide each therapist examples and a clinical algorithm to use when scoring each item. It is important to ensure that each person using the tool understands the definition of the CARE mobility items and how the CARE rating scale applies to each item.
Because everyone is receiving the same training, the ratings are more consistent. It also ensures the data collected is consistent. One of the project’s goals is that we can begin to assemble a database of information across companies and across the nation, so that we can truly measure clinical outcomes for our patient populations. This first step in accomplishing that goal is to have consistent item sets and consistent measurement scales. It is worth repeating that even if a particular task or activity is not going to be the focus of your therapy program, you still must score those items. The CARE item scores add up to be a composite score of the patient’s overall function.
If items are left not scored, then the patient’s overall level of function in self-care and mobility will be lower than they should be. When we score tasks and items as NT or not tested or NA, not applicable, we downplay the role we have on a patient’s overall level of function. While we have alpha scores for those times where it is just not appropriate to assign a numeric score, please keep in mind that these codes should be used minimally. You see on this slide and on page five of your training manual, the list of 15 items that make up the CARE item mobility set. The first three, lying to sitting on the side of the bed, sit to lying, and rolling are sub-tasks of what many of us might think of as bed mobility.
Items four, five, and six, sit-to-stand, chair, bed to chair transfers, toilet transfers, and car transfers are components of what many of us might think as transfers. Item seven, longest distance walked, longest distance wheeled, and items 11 and 12 walking 50 feet with two turns and 10 feet on uneven surfaces are components of what many of us think as locomotion. Finally, items nine picking up an object 13, 14, and 15 about going up and down steps are higher level mobility items that are helpful in determining someone’s ability to perform at a higher functional level, perhaps in the community.
The general format of this training will include going over a description of the task, followed by the rating scale for the items, followed by some examples of applying the rating scale to the item, but also keep in mind that there are additional clinical vignettes for each of these tasks in your menu for reference, but we won’t be going over all of those today in the training module. The first CARE mobility item is lying to sitting on the side of the bed. This item is defined as the ability to safely move from lying on the back, just sitting on the side of the bed with feet flat on the floor, and no back support. This item is not about returning to lying down because that is covered in another item.
Because there are many steps to completing the task of lying from flat on the back to sitting on the side of the bed with the feet flat and no back support, it is important to keep all those parts of the task in mind when determining whether you are giving more than 50% or less than 50% assistance. On the other hand, touching, steadying for balance, or to guide a limb all the way off the bed may only be needed rather than actual physical assistance. Also keep in mind that equipment does not matter in choosing the rating, so the patient may use assistive devices such as side rails, grab bars, or even elevation of the bed. This is an example of the rating chart in your training manual for lying to sitting on the side of the bed.
The tables are all oriented the same. In the first column on the left hand side will always be the description of the task. In other words, how is it defined and what sub-tasks are included? The next six columns correlate to each of the rating levels. Each column represents one of the six CARE item ratings, and their definitions are repeated in bold font for each item. In each column are examples of when that rating might be applied to the task. Examples of clinical application that might qualify for that rating are listed, but keep in mind, it is not an exhaustive list. You may encounter situations that are not listed here, so it’s important to always use your best clinical judgment.
What would a rating of four potentially look like for lying to sitting on the side of the bed? If a patient requires prompting and cueing for sequencing to fully accomplish safely moving from lying on the back to sitting on the side of the bed with no back support, then four would be the best choice, or if the helper must verbally guide the patient in completing the task and/or provide touching, steadying assistance to the patient completing the task without falling over, or touching or steadying only may be required for hand placement, initial sitting balance, sitting balance after fatigue and/or pelvic stability for sitting without back support. Let’s look at example number one.
Mr. B pushes up on the bed to get himself from a lying to a seated position. The helper provides steadying assistance as Mr. B scoots himself to the edge of the bed and lowers his feet to the floor. What is the CARE rating level for Mr. B? The best choice is four, supervision or touching assistance because the helper provides touching assistance as the patient moves from a lying to a sitting position. Example number two is Mrs. W. She can reach for the bed rails and initiate pulling herself to her side. She can initiate raising one leg in an effort to use her leg to push herself over, but she requires assistance from the helper to roll over. Once she is on her side, she requires the helper to raise her up to a sitting position.
She can sit upright with steadying for less than one second at time, and requires full assistance otherwise to remain upright. What is the CARE rating level for Mrs. W? The best answer is two, substantial or maximal assistance. The patient attempts to participate in the activity, but the helper provides more than half the effort to complete the task. The next item is sit to lying. It is defined as the ability to move from sitting on the side of the bed to lying flat on the bed. This item is not about moving from lying down to sitting up. We just covered that in the last item. A coding tip to remember is always think of usual performance, not the lowest or the best, and once again the patient can use assistive devices such as side rails, grab bars, or bed elevation.
The rating scale for sit to lying is on page 15 of your training manual. As described before, the column on the far left defines the item. The next six columns correlate to each of the rating levels. Let’s look at the description of rating two, substantial or maximal assistance, which is when the patient participates, but provides less than 50% of the effort to complete the task. You might have a patient who is able to initiate the movement by reaching for the bed rail, lowering themselves to the elbow or partially lifting their legs toward the bed, but is unable to initiate a significant physical effort at moving to a lying position.
The patient requires greater than 50% assistance from the helper to get the legs on the bed in a fully flat position, or the patient is unable to initiate positioning themselves for getting to a lying position. Once the movement has started, the patient is able to lift one leg partially, or even completely onto the bed, or maybe the patient is unable to contribute to moving from a sitting position to lying on the side or lift the legs on the bed, and the helper provides greater than 50% of the effort. Once the patient’s legs are up on the bed, the patient can roll to their back. Let’s look at example one.
Mrs. H requires assistance from a helper to transfer from sitting at the edge of the bed to lying in bed due to paralysis on her right side. Mrs. H can use the bed rail to lower herself down to the bed, but cannot lift her legs completely up onto the bed. The helper lifts Mrs. H’s legs and assists her in positioning them. Mrs. H then uses her arms and upper body to position her trunk. What is the CARE rating level for Mrs. H? The best choice would be three, partial or moderate assistance. A helper is needed to transfer from a seated to a lying position, but Mrs. H does the majority of the task. Example two is Mr. A. He is wearing a shoulder immobilizer after fracturing his humerus.
He is able to walk around his room and transfer to the side of the bed. In order to lie down safely and with the least amount of pain, he asks the helper to raise the upper bed rails and the head of the bed for him, so he can use it to assist himself lying down. What is the CARE rating level for Mr. A? The best answer would be five, set up or clean up assistance. A helper is needed to prepare the bed for Mr. A by putting the rails in the optimal position. This would be considered set up help. The next item is rolling left and right. It is defined as the ability to roll from lying on the back to the left and the right side, and then return to lying on the back.
This item is not about sitting up or lying back down. A few tips again with this item, the patient may use assistive devices. The rating scale for rolling left and right is on page 16 of your training manual. The difference between a rating of a four and five for this item is again the difference between providing help during the activity versus before and after. When a patient needs prompting or cueing during the task, then the rating becomes a four, but if the patient only needs the helper to help them before or after the task, such as placing hands on a bed rail or positioning a leg, maybe removing the bed covers so the patient can move more easily, then the score would be a five.
Remember that if the application of a prosthesis or orthosis is necessary to complete the task, this is not considered in the score for rolling. If the helper is needed to do this, it is considered set up only. Let’s look at example number one. Mr. W is able to reach for the right bed rail with his left arm and pull himself over to sideline without assistance from the therapist. With cues, he is able to roll back to supine. With assistance, he can pull his right leg to a hip knee flexion position and initiate pushing himself over to his left side, but needs cues to cradle his right arm, and is not able to reach full sideline without assistance from the helper.
What is the CARE rating level for Mr. W? The best answer would be three, partial or moderate assistance. The patient is able to roll to one side without assistance from the helper, but requires verbal cueing to return to his back and physical assistance to roll to the other side. Overall, the helper is providing less than half the effort and therefore, the patient is coded as three, partial moderate assist. Let’s look at example number two. At discharge, Mr. W, the same patient is able to reach for the right bed rail with his left arm and pull himself over the sideline without assistance from the therapist. When prompted, he is able to roll back to supine.
With prompting, he can pull his right leg to a hip knee flexion, but requires assistance from the helper to stabilize the leg while he pushes himself over to his left side. He still needs cues to cradle his right arm due to his residual neglect. He is able to return to his back without assistance from the helper. What is the CARE rating level for Mr. W now? The best choice is supervision or touching assistance. The patient is able to roll to one side without assistance from the helper and requires verbal cues and steadying from the helper to roll to the other side. He is able to return to his back without assistance from the helper and remember, there are more examples in the training manual.
The next item is sit to stand. It is defined as the ability to safely come to a standing position from sitting in a chair or on the side of the bed. This item is not about sitting back down. Keep in mind a few tips, the patient may use assistive devices and the helper should consider preparatory steps, such as whether assistance is needed with scooting to the edge of the bed or chair, or weight shifting forward. As always consider, the patient’s usual performance, not the lowest. The descriptions for this item can be found on page 17 in your training manual. When scoring, consider all the elements of standing from a sitting position when considering the greater than or less than 50% assistance.
For instance, a rating of two substantial maximal assistance might look like the patient is able to complete steps such as scooting forward to the edge of the chair, or positioning their legs and feet for weight bearing, but they still require physical assist to stand, or the patient cannot do any of the preparatory steps, but once they are in position, they can generate some force in standing. Let’s look at example number one. Mrs. D arrives to the therapy gym in a wheelchair and is ready to start gait training with her new prosthesis. The therapist assists her by putting on her new prosthesis and positions the wheelchair in front of the parallel bars. Once in position, Mrs. D stands up from the wheelchair and steadies herself on the parallel bars.
What is the CARE rating level for Mrs. D? The best answer is five, set up or clean up. The helper assists Mrs. D with getting ready to stand by positioning the wheelchair in front of the parallel bars and putting on her prosthesis. Mrs. D is able to stand up by herself after getting set up. Example number two is Mr. M. He gets from a sitting to a standing position. The helper touches his arm to study him. The best answer for Mr. M is supervision or touching assistance because that is the only assistance the helper provides. The next item is chair to chair or bed to chair transfers. It is defined as the ability to safely transfer to and from a chair or a wheelchair, but the chairs are placed at right angles to each other.
This item is not about walking a short distance to a chair, so the instructions that the chairs are at right angles to each other is important. Keep in mind, the patient can use assistive devices and usual care should be considered. It might be beneficial to assess the patient in transferring to and from several surfaces and surface heights, such as mat tables, wheelchairs, bedside chairs, those with and without arm rests. As always, consider the patient’s usual performance, not the lowest. This is an activity especially where patient’s performance might vary over the assessment period, depending on the patient’s fatigue level. If you are assessing a patient over the course of an hour or even during a morning and afternoon session, the patient may become more fatigued during that time.
You should use your clinical judgment to determine what the usual performance during that assessment period is. The rating scale is on page 18 of your training manual. A patient would be best scored as three, partial or moderate assistance if they could participate in rocking forward or scooting to allow a sliding board or disc to be placed underneath them, or perhaps they lean forward to assist with weight shifting. Perhaps the patient can scoot forward to the edge of the bed or the chair and position their own feet. Perhaps they can even place the sliding board underneath themselves, or maybe they are unable to complete any of these preparatory steps due to cognitive or aphasia regions, but once they are in a position, they can provide some of the effort to move their body weight in the transfer.
Let’s look at example number one. The helper is providing lifting assistance as Mrs. Z moves from the bed to a chair. Mrs. Z provides some effort during the transfer, but the helper provides more effort than the patient. What is the CARE rating for Mrs. Z? The best rating for this patient is a two, substantial or maximal assistance because the helper provides more effort than the patient. In example number two, Mr. L had a stroke three days ago and uses a wheelchair for mobility. When Mr. L gets out of the bed, the helper moves the wheelchair into the correct position and locks the brakes, so that Mr. L can transfer into the wheelchair safely. Mr. L transfers into the wheelchair by himself about 10 minutes later.
What is the CARE rating level for Mr. L? The best rating for this patient is five, set up or clean up. The helper provides setup assistance, but Mr. L does not need help during the transfer. The next item is toilet transfers. It is defined as the ability to safely get on and off a toilet or commode. Note that this item is not about hygiene associated with toileting, nor is this item about managing clothing off or on. Only the transfer on and off the toilet should be considered. Depending on the patient and the circumstances, a patient may have different performance getting on the toilet versus getting off of it. Again, it’s important to consider usual performance.
A few tips for scoring are to remember the patient can use assistive devices. The rating guide is on page 19 for toilet transfers in your manual. For this item, a rating of five would be given if the helper assists with preparing the patient for the transfer. Perhaps by pushing the wheelchair to the toilet or locking the wheelchair or removing leg rests or armrests, or if the patient wears an orthotic or prosthetic, they may need help in donning or doffing it prior to the transfer or after. As we’ve mentioned before, how much assistance the patient needs in donning and doffing the prosthesis is not a factor in choosing the score for this item. Let’s look at example number one.
A helper provides hand-on assistance to steady Mrs. Z as she lowers her underwear and pants, and then lowers herself onto the toilet. After voiding, Mrs. Z cleanses herself. She then stands up and pulls up her underwear and pants as the helper studies her with her hand placement on her back. What is the CARE writing level for Mrs. Z? The best response is supervision or touching assistance. The helper provides studying assistance as the patient transfers on and off the toilet. Assistance with managing clothing and cleansing is coded under the item toilet hygiene. In example number two, Mrs. S is ordered to stay on bed rest. She is able to use a bedpan independently for bladder and bowel management.
What is the CARE rating level for Mrs. Z? The best response is dependent because the patient does not transfer onto or off a toilet due to an order to remain on bed rest, and this item is specifically about transferring on and off a toilet, not a bedpan. The next item is longest distance walked and/or wheeled. These items require the therapist to determine whether one type of locomotion will be a goal, or whether both types will be. If only one type of locomotion is a goal, then that is what is included in the composite score, but if both types of locomotion are goals, then the scores are merged into one score that goes into the patient’s total mobility score.
The therapist should complete both items if the patient achieves locomotion by walking and using a wheelchair, or the patient currently uses a wheelchair and does not ambulate, but ambulation is a goal of the therapy plan of care, or the patient currently ambulates and does not use a wheelchair, but using a wheelchair is a goal of the therapy plan of care. If a patient does not use a wheelchair and it is not going to be a goal of the therapy plan of care, the patient only ambulates, then score the longest distance wheeled as N or not applicable. Conversely, if the patient does not ambulate and it is not a goal of the therapy plan of care and the patient only utilizes a wheelchair, score the longest distance walked as N or not applicable.
The next step is to score the mobility distance, and this is a 2-step process. First, observe the longest distance walked or wheel, choose the response that best describes the longest distance the patient was able to accomplish ranging from 10 to 150 feet. Then secondly, rate their level of independence with a scale of six to one only on the distance they achieved. That is important to remember, you are only scoring one distance, not all of them. Let’s look at the longest distance walked item first.
The item is defined as once standing, the patient’s ability to walk greater than or equal to 150 feet or greater than or equal to 100 feet, but less than or equal to 149 feet, or greater than or equal to 50 feet, but less than or equal to 99 feet, or greater than or equal to 10 feet, but less than or equal to 49 feet. This item is again not scored if the patient currently does not walk and is not expected to walk. You also do not consider the patient’s ability to stand up. The level of assistance is recorded for the patient’s ambulation ability only. A few tips because this item may be different than what you are accustomed to scoring because only one distance is scored.
If the patient is unable to walk 10 feet, then they are scored as dependent. Even if they were able to walk five feet with steadying and touching assistance only, the score for 10 feet which is the minimal choice is still dependent. Why? When the CARE tool was being designed, there was a significant effort given to standardizing items, so they could be used across all post-acute care settings. In other words, home health, skilled nursing facility, inpatient rehab, and long-term acute care hospitals. Therefore, the items needed to be constant. There was also discussion about the fact that distances needed to be meaningful.
While meaningful can be defined in different ways for this item, consideration was given to what the assessment tools in our settings currently are, and what the current literature tells us about measuring locomotion. A few facts filtered to the top. Some items used currently consider whether a patient could walk across a room, and walking speed is a very significant measure in physical therapy, is measured by having a patient walk four meters which is the equivalent of approximately 13 feet. For these reasons and others, the minimal distance to be measured is at least 10 feet. The distance measured increases incrementally after that. This algorithm is also on page 20 of your training manual.
Essentially, you should determine the best score using these steps. First, ask yourself how far did my patient walk, then ask yourself how much assistance did they require. If your patient walks less than 10 feet, then you are done. Your score is dependent, or one for walking in room or greater than equal to 10 feet because the patient did not walk 10 feet. If your patient walks 45 feet on evaluation, your distance would be scored for walking in room or greater than equal to 10 feet. The next step is to choose your level of assistance. Focus on the usual level of performance, even over these walking distances when their performance or level of assistance required is variable.
You might have a situation where a patient is independent walking at 50 feet, but maximum assistance walking at 75 feet due to pulmonary issues. The patient therefore self-limits himself for the 50 feet because that is the distance he needs to be able to travel in his home. The final score would be independent at 50 feet because that is his usual performance. Now this type of scenario would be unusual and infrequent, but it is the correct scoring for that situation. Also, remember that assistive devices do not matter for this item. Take the same patient who uses a walker to ambulate 50 feet at admission independently. At discharge, the patient no longer uses any assistive device and is able to walk the 50 feet independently.
Your score is going to be independent six at admission, and independent at discharge. That might not feel right to you as a clinician, but it is the correct scoring methodology for this CARE item tool. Let’s look at example number one. A helper puts Mrs. W’s walker within reach. Mrs. W needs verbal cues to remind her of the safest way to stand up from the sitting position. Once standing, Mrs. W walks 120 feet down the hall without any assistance from a helper. What is the CARE rating level for Mrs. W? The best response for distance is 100 feet, but less than or equal to 149 feet. The best answer for level of assistance is set up or clean up. Mrs. W walks more than a hundred feet once the helper places the walker within reach.
She needs assistance with getting up from a sitting to a standing position, but that is coded under the item set to stand. This item only considers walking after the patient is standing. Example number two is Mr. C who is one weak status post left hip fracture. He has non-weightbearing orders for his left leg. He’s brought to the therapy gym for gait training, but he is able to use the parallel bars to pull up and requires only minimal assistance to stand. Once standing, he is able to hold the left leg off the floor, but he is unable to hop in the parallel bars due to his upper body weakness and coordination with understanding non-weightbearing. What is the CARE rating level for Mr. C?
The best response is distance walked, walk in room or greater than equal to 10 feet, and the level of assistance is dependent. Mr. C is unable to keep non-weightbearing status and therefore, he is unable to walk at all, but the minimal distance that you have to choose from is 10 feet. The next item is longest distance wheeled. The same clinical analysis should be used with this item that was used with walking. It is defined as once sitting, the patient’s ability to wheel greater than or equal to 150 feet, or greater than or equal to 100 feet but less than or equal to 149 feet, or greater than or equal to 50 feet but less than or equal to 99 feet, or greater than or equal to 10 feet but less than or equal to 49 feet.
This item is again not about how the patient gets in and out of the wheelchair. It is also not scored if the patient does not currently use a wheelchair and is not expected to use a wheelchair. As with the walking item, this item may be different than what you are accustomed to scoring because only one distance is scored. If the patient is unable to wheel 10 feet, then they are scored as dependent. Even if they were able to reel five feet with steadying or touching assistance only, the score would still be dependent for 10 feet. This algorithm is on page 21 of your training manual. Essentially, you should determine the best score using these steps. Ask yourself how far did my patient wheeled, then ask how much assistance did they require?
If your patient wheels less than 10 feet, you are done your score is dependent or a one for wheeling in room or greater than or equal to 10 feet, but if your patient wheels 55 feet on evaluation, then your distance would be scored for wheeling greater than or equal to 50 feet up to 99 feet. The next step then would be to choose your level of assistance. Consider the previous example. A patient is able to wheel 55 feet. He or she can place their hands on the wheels and push themselves for part of the distance, but they need the helper to get started, or perhaps the helper is needed to get around a curb or through the door. In other words, the helper is providing some effort to help them propel the wheelchair forward.
Both of these situations would be scored with partial or moderate assistance. Of course, the therapist would need to determine whether the amount of systems provided over the entire task was greater than or less than 50% of the effort needed for the task. Let’s look at example number one. Mrs. M is unable to bear any weight on her right leg. After the helper provides steadying assistance to transfer from the bed into the wheelchair, Mrs. M propels herself about 120 feet down the hall using her left leg. What is the CARE rating level for Mrs. M? The best response is wheeling 100 feet, but less than or equal to 149 feet and the level of assistance would be independent.
The patient wheels herself more than 100 feet, but less than 150 feet the assistance provided by the helper with the transfer is not considered when scoring long distance wheeled. There is a separate item for scoring bed to chair transfers. Let’s look at example number two. Mrs. P is 3-week status post right CDA. She is able to provide less than half the effort to transfer into the wheelchair. Once she is sitting upright, the helper removes the right leg rest and instructs Mrs. P in how to use her right arm and right leg to propel the wheelchair. Mrs. P is able to move her right leg forward and initiate pulling her wheelchair forward, but is unable to move the chair without assistance from the helper.
What is the CARE rating level for Mrs. P? The best response would be wheeling in room greater than or equal to 10 feet, and the level of assistance would be dependent. The patient is able to provide some effort to wheel her chair, but is unable to wheel herself more than 10 feet. Therefore, the patient’s score is dependent and you would choose the lowest option available for distance. The next item is picking up an object. It is defined as the ability to bend or stoop from a standing position to pick up small objects, such as a spoon from the floor once the patient is in a standing position. Many of the usual and customary assessment tools used by providers in skilled nursing facilities do not include this item.
It does represent a higher level of function and that is the one of the main reasons it was included it goes beyond just walking, transferring, and basic ADLs, but this item is not about how far away from the foot the patient can reach. A few tips for scoring. Use an object that is easy to grip and easy to see. You can place the object in front of or to the side of the foot. Some therapists may not want to test this item on evaluation if the patient has significant balance deficits or requires substantial assistance to stand up, but remember in those cases, the item would not be scored in or not applicable or even S, not attempted due to safety reasons.
The more appropriate answer would be one or dependent since it can be inferred from the patient standing ability and the rest of your assessment that the patient is unable to do the task. The rating guide is on page 22 in your manual. For this item, a rating of four would be given if the helper needs to provide prompting or cueing to sequence the activity safely as if the patient is bending or stooping over, or if the helper has concerns about safety with completing the task, and the therapist needs to remind the patient of some orthopedic precaution. Perhaps the helper needs to study the patient at some point during the task or throughout those tasks. All of these would result in a score of four. Let’s look at example number one.
Mrs. W keeps her reacher beside her at all times. Using her reacher she can pick up her slippers off the floor to put them on. What is the CARE rating level for Mrs. W? The best response is independent. Mrs. W is able to pick up objects from a standing position using her reacher. The use of adaptive equipment does not decrease her score. Example number two, Mr. G stoops down from a standing position to pick up the newspaper from the floor. He requires physical support from the helper to stoop down without falling over. Mr. G can pick up the newspaper, but he is unable to get fully upright again without physical support from the helper. What is the CARE rating level for Mr. G? The best response would be substantial or maximal assistance.
Mr. G is able to pick up the object from the floor, but cannot stoop down or stand back up without physical assist from the helper, so the helper is providing more than half the effort to complete the task. The next item is car transfers. It is defined as the ability to transfer in and out of a car or a van on the passenger side. This item is not about opening or closing the door or about fastening the seatbelt. A couple of tips, once again the patient may use assistive devices. A back seat could also be used to test the item and usual performance is important. The rating guide is on page 23 for car transfers.
For this item, a rating of a three would be given if the patient participates in stooping, bending, or turning to get in position for the car transfer and the helper provides less than 50% of the effort, or perhaps the patient is able to stoop bend or turn and get most of the way in, but the helper still has to provide less than 50% of the effort to transfer in and out of the car, or patient can complete most of the steps to transfer in and out including swinging his or her legs in and out. Once the patient is turned with the feet on the ground, he can use assistive device or car support to initiate most of the force to stand up from the car seat but the helper still needs to provide less than 50% of the total effort to get the patient out of the car.
Let’s look at example number one. Mr. D has a doctor’s appointment to which his wife is going to transport him. He ambulates to the car with supervision or touching assistance using his walker. He turns around with his back to the car seat, but is unable to rotate his trunk and head around without losing his balance. The helper assists Mr. D to bend and lower his body into the car seat. Once he is seated, Mr. D is able to pick his legs up and put them in the car. When he returns from his appointment, he can swing his legs out of the car, but is unable to stand without physical assistance from the helper. Once standing, he is able to ambulate into his house.
What is the CARE rating level for Mr. D? The best answer would be two, substantial or maximal assistance. He is unable to stoop, bend, or turn to get in the car without physical assistance. However, once sitting, he can get his legs into the car, but upon return, he is unable to stand up and the helper provides greater than 50% of the effort. Example number two is Mr. G who has diminished vision. He is able to walk to the car using his cane. The helper lets him know when he is close enough to the car to step in. Before getting out of the car, the helper lets him know what the ground surface is like and hands him his cane. What is the CARE rating level for Mr. G? The best response is set up or clean up.
The patient is physically able to get into and out of the car. The helper only verbally assists him with preparatory activities due to his poor vision. The next item is walking 50 feet with two turns. It is defined as the ability to walk 50 feet and make two turns once standing. The task can thus be described by having the patient walk 25 feet, turn to face the opposite direction, walk 25 feet back, and then turn again to face the other direction he started in. While there are no hard and fast rules in the CARE tool about how far to walk before turning, the two pieces of this task must be met, 50 feet and two turns. However, this item is not about the ability to stand up or sit down.
The patient can use whatever assistive devices he or she wishes, and again if the patient does not ambulate and is not expected to ambulate, this item would be N. If the patient does not ambulate at evaluation, but it is a goal, this item would be rated as one or dependent. This item is important to assess if possible, so marking off 25 foot distance is an important preparatory step for the therapist. You will want to clearly indicate where the turning point is for the patient, either by using a brightly colored piece of tape on the floor or a brightly colored cone. Be sure the patient has enough room to comfortably make the turn, so they don’t feel cramped. The rating scale is on page 24 in your manual.
For this item, a rating of five would be given if the patient only needed the helper to prepare them for the task, such as by positioning the assistive device in reaching or applying a special shoe or orthotic or prosthetic. Example number one is Mrs. F. She is able to stand with maximal assistance. Once standing, she is able to walk 10 feet with less than 50% assistance from the helper. What is the CARE rating level for Mrs. F? The best response is dependent. The patient is able to ambulate, but cannot walk 50 feet. The maximum distance she was able to walk was 10 which was less than the amount required for this item, so the best rating is dependent.
Example two is Mr. W who ambulates 25 feet turns and walks 25 feet back to his chair and sits down. The patient is unsteady on the turns and the helper provides touching to steady him due to some loss of balance when weight shifting. What is the CARE rating level for Mr. W? The best response is supervision or touching assistance. The patient is only unsteady on the turns and that’s when the helper provides touching to steady in. The next item is walking 10 feet on uneven surfaces. It is defined as the ability to walk 10 feet on uneven or sloping surfaces, such as grass or gravel. This item however is not exclusive to outside terrain. You should consider thresholds, carpeted areas, or even buy a piece of turf or carpet to lie down on the floor.
Of course, it is easier outside with gravel and uneven sidewalks. It may be challenging to some to consider doing this task at evaluation, but remember that we should attempt to test the patient on all items. Don’t assume the patient can’t do it until they have tried. Keep in mind that on the uneven surfaces, the patient does not have to turn. It is just 10 feet on a straightaway. The only other aspect of the task to consider is the use of assistive devices. We know that some devices are not made for uneven surfaces. In the past, a therapist might have coded this as NT because of the equipment issue, but again, it is important to consider the concept of dependence.
If the patient has to use a rolling walker because that is what is safest for them, and the rolling walker is not going to be able to roll over large gravel, then the patient would be scored as dependent. Because if the only route the patient could get out of a building is over large gravel, then he or she would be dependent on a helper to get them out. That is the concept we are rating. If the patient is unable to walk on grass with their rolling walker because they are non-weightbearing, then they are dependent. The rating guide is on page 25 in your manual. Once again, remember the key difference between two, substantial or maximal assist and three, partial and moderate assist is whether or not you conclude that less than or greater than 50% assistance was provided to the patient during the entire activity.
Consider sub-tasks such as whether the patient can advance the assistive device with or without assistance, whether the patient needs assists to bear weight, whether the patient needs assist to balance him or herself, whether the patient needs assist to having enough power to get up a slope if that is what the uneven ground is, or if the patient has weightbearing restrictions, whether they are able to manage the 10 feet on uneven surfaces without any assistance. Let’s look at example number one. Mr. B ambulates up to 25 feet on uneven surfaces with partial or moderate assistance from a helper. His front walkway to the car is gravel. Mr. B can manage five feet on the gravel, but then decompensate such that he must sit down.
What is the CARE rating level for Mr. B? The best response is dependent. The patient is able to ambulate on even surfaces greater than 10 feet, but is unable to walk 10 feet on uneven surfaces. A score of A task attempted but not completed would not be the most appropriate response. Let’s look at example number two. Mr. K has a driveway at home with an uneven surface. The physical therapist has been working on ambulation with him outside of the facility to prepare him for this task. Mr. K had a hip replacement and is now using a small based quad cane with which to walk indoors. Upon walking outside on the uneven surface, he requires steadying assistance as he tends to be unsteady while using his device on surface.
What is the CARE rating level for Mr. K? The best response is supervision or touching assistance. That is what he requires in order to perform the activity safely, and he was able to go 10 feet. The next item is one step or curb, and it is defined as the ability to step over a curb or up and down one step. This item is not about wheeling up a ramp, and the patient can use whatever assistive devices he or she wishes. However, if the patient does not ambulate and is not expected to ambulate, rate this item as N, but if the patient does not ambulate at evaluation but it is a goal, this item would be rated as dependent. The rating guide is on page 26 in your manual.
A person who receives a score of five, set up or clean up assistance would only need assistance before or after going up and down the one step. Perhaps the helper applies a prosthesis or brace, or the helper applies shoes, but once the patient is standing at the step, he or she can go up and down independently. Example number one is Mr. G. He was a bilateral amputee who has not used his prosthesis in more than five years. Due to his pulmonary status, he is satisfied with functioning at a wheelchair level. What is the CARE rating level for Mr. G? The best response is N, not applicable because he is not a candidate for prosthetic training due to his pulmonary status, and he is satisfied with functioning at a wheelchair level.
Example two is Mrs. P who has orders for touchdown weightbearing on her right leg. She struggles with keeping her weightbearing precautions on even surfaces, but is able to walk five feet with substantial or maximal assistance and a rolling walker. She approaches a single step, but is visibly concerned about attempting to go up or down one step. What is the CARE rating level for Mrs. P? The best answer would be dependent because the therapist can infer from the patient’s level of performance with walking on uneven surfaces that she is dependent for a single step due to her difficulty in maintaining her weightbearing orders on uneven surfaces.
Therefore, dependent would be the most appropriate score rather than an S, not attempted due to safety concerns, an N, not applicable or a P, patient refused. The next item is four steps. It is defined as the ability to go up and down four steps with or without a rail once standing. The item is not about how quickly the patient accomplishes the task, and it is also about both directions, up and down. Not just one direction but the patient may use whatever assistive device he or she wishes. The rating guide is on page 27 in your manual. A person who receives a score of four or supervision or touching assistance would only need prompting and queuing during the activity.
Perhaps there are concerns about safety when using an assistive device or the correct sequence of stepping up and down if there are weightbearing restrictions. Let’s look at example number one. Mrs. Z has late stage dementia and is being assessed for an appropriate functional maintenance program. She ambulates with a shuffle gate and requires only supervision or touching assistance. She can step up and down one step or curb with partial, moderate assistance. When she is presented with the task of going up and down four steps, she halts and refuses to step up. The therapist gives her verbal and visual prompts and places her hands on the handrail to induce memory.
The patient becomes more agitated and begins to raise her voice, therefore the task is abandoned. What is the CARE rating level for Mrs. Z? The best response in this case would probably be S, not attempted due to safety concerns because the patient became visibly agitated. When the task of walking up and down four steps was presented to her, the therapist decided for safety reasons it would not be appropriate to attempt to try again, but the therapist is unable to infer from the other activities what her ability would be. In other words, even though she went up and down one step with partial or moderate assistance, it’s unknown if she would be partial or moderate assistance with four steps, or perhaps substantial or maximal assistance or even dependent.
That’s why S is the most appropriate response. Example number two is Mrs. B. She has orders for 50% weightbearing on her right leg. She has five steps to get into her home. She wears two liters of oxygen at all times and has orders to keep her oxygen saturation above 90. Using two handrails, she is able to go up two steps with substantial assistance from the helper. After two steps, her oxygen saturation drops to 86%. The helper waits 30 seconds and it does not come back up. Mrs. B begins to get anxious that she is not going to be able to get down. The helper abandons trying to go up any more steps and assists Mrs. B down the steps with substantial or maximum assistance.
What is the CARE rating level for Mrs. B? In this example, the best response would be dependent. The therapist decides not to pursue completing the task for medical reasons. The patient’s oxygen saturation was less than acceptable, and she was becoming more anxious which would only increase her work of breathing. She was unable to go up and down four steps, and while part of this was related to her medical condition, one is the most appropriate score. The next item is 12 steps. It is defined as the ability to go up and down 12 steps with or without a rail once standing. Like the 4-step item, this item is not about how quickly the patient accomplishes the task, and it is about both directions, up and down.
The rating guide is on page 28 of your manual. In determining whether to score a patient two, substantial max assist versus three, partial moderate assist, the helper will need to think about the entire task, up and down the 12 steps and usual performance, and then determine whether greater or less than 50% assistance was provided. Example number one is Mr. K. He is recovering from a fall where he fractured his right proximal humerus and his right patella. He is non-weightbearing on his right arm and weightbearing as tolerated on his right leg with a knee brace to keep his knee in full extension. He is able to ambulate with supervision or touching assistance with a quad cane for 125 feet.
He is unable to step up on one step or curb without the helper providing all the effort to get him up on the step. What is the CARE rating level for Mr. K for 12 steps? The best response would be dependent. The patient is unable to go up and down one step or curb without total assistance of the helper. Therefore, it can be inferred that he would be dependent in the tasks of going up and down 12 steps and four steps. Example number two is Mr. O who is recovering from a CVA with mild left hemiparesis. He wears an AFO on his left foot. He is unable to get the AFO on without assistance, but once the AFO is on, the patient can walk up and down 12 steps using a handrail on the right side on the way up and the way down.
He stops after four steps and rests, and then continues up the steps. He rests for two minutes at the top of the steps before coming down. What is the CARE rating level for Mr. O? The best response is set up or clean up assistance, number five because the patient is able to go up and down the steps without physical assistance from the helper after his AFO is on properly. How long it takes him to go up and down or how many rest breaks he takes is not a consideration in scoring this item. Now let’s take a patient example that involves more than one item and put it all together. Mr. R can go up six steps using a handrail. The first two, she accomplished with verbal cues and the last four, she had one person helping 25%.
She could not go up any more steps. On the way down the stairs, she required the same amount of assistance. How do you rate her on one step, four steps, and 12 steps? The best response for one step is supervision or touching assistance because the helper provides verbal cues on the way up and down. The best response for four steps is partial or moderate assistance because the helper provides less than half the effort of getting up and down steps. The best response for 12 steps is dependent because the patient could not make it up and down 12 steps. All three must be graded which is slightly different than the longest distance walked or wheeled where only the maximum distance is scored.
As this example shows, you don’t have to test each item individually. Assess the patient on a flight of steps which is typically 15, and then score their ability on each item based on their overall performance. Let’s look at another example. Mrs. C is referred to PT. On evaluation, she is able to stand from the side of the bed, but needs a helper to secure her chair and walker, and give 25% of the physical effort to help her stand. Once standing, she can walk 50 feet with a forward wheeled walker, but requires 33% cues for advancing the walker appropriately and taking an adequate step length. The patient is asked to step up one step or curb. She needs assistance from the helper to place her forward wheeled walker up on the curb and to instruct her which legs to step up with first.
Once her left foot is up on the step, she needs the helper to provide 75% assistance to give her enough power to lift her body and right leg up on the step. What is Mrs. C’s CARE rating level for sit to stand, mobility distance, and one step? The best answer for sit to stand is partial and moderate assistance because the helper provides less than half the effort, but the patient needs physical assistance to get standing. The best response for mobility distance would be supervision or touching assistance because the helper provides verbal cues which are necessary to accomplish the mobility distance safely. The best response for going up and down one step is substantial or maximal assistance because the helper provides more than half the effort to assist the patient in getting up onto the step.
As always, remember that there are more clinical examples in the training manual. A few closing reminders, every effort should be made to score all items with a one to six rating. Use your clinical judgment when assigning the scores. Perhaps there are some tasks that cannot be attempted because the patient is actually dependent in those areas. The correct response then would be dependent, rather than not applicable or not attempted due to safety concerns. Even if a particular task or activity is not going to be the focus of your therapy program, you still must score those items. Why? Because these functional measures are not being looked at as individual items.
The CARE item scores add up to a composite score of the patient’s overall function. If items are left not scored, then the patient’s overall level of function in self-care and mobility will be lower than they should be. Now it’s time to take the test. As stated earlier, all physical therapists will be required to complete this post-test which tests your knowledge of the rating definitions, the alpha scores, and the item definitions. Some occupational therapists will be required to take this test, so check with your organization. Most therapists will take the test electronically. You will find the electronic link provided in your training manual. However, some companies may choose to test therapists using other methods, such as paper and pencil.
If you don’t find a link in your manual, check with your managers. For those of you completing the electronic test, complete section three, CARE items mobility questions which consists of nine clinical scenarios and 21 total questions. You are required to score no less than an 80% to pass the test. You can use your training manual and any notes you took during this training to assist you. Your score will display on the last page after all questions have been completed, so you will know immediately how you did. You will be required to take the test again if you do not score 80%, but you can take the test as many times as you need to. This concludes the mobility training module. Good luck.
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