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Objective. The purpose of this study was to test the reliability of the Activity Measure for Post-Acute Care (AM-PAC) '6-Clicks' mobility and activity short forms between patients and therapist proxies. As a secondary aim, reliability was examined when patients completed their self-report before versus after the therapist evaluation. Methods. Patients being seen for an initial physical therapist (N =70) or occupational therapist (N =71) evaluation in the acute care hospital completed the '6-Clicks' mobility short form (if a physical therapist evaluation) or activity short form (if an occupational therapist evaluation). Whether patients completed their self-assessment before or after the evaluation was randomized. Patient- and therapist-rated '6-Clicks' raw scores were converted to AM-PAC T-scores for comparison. Reliability was assessed with intraclass correlation coefficients (ICCs) and Bland-Altman plots, and agreement was assessed with weighted kappa values. Results. The ICCs for the '6-Clicks' mobility and daily activity short forms were 0.57 (95% CI = 0.42-0.69) and 0.45 (95% CI =0.28-0.59), respectively. For both short forms, reliability was higher when the patient completed the self-assessment after versus before the therapist evaluation (ICC =0.67, 95% CI = 0.47-0.80 vs ICC=0.50, 95% CI = 0.26-0.67 for the mobility short form; and ICC = 0.52, 95% CI =0.29-0.70 vs ICC= 0.34, 95% CI = 0.06-0.56 for the activity short form). Conclusion. Reliability of the '6-Clicks' total scores was moderate for both the mobility and activity short forms, though higher for the mobility short form and when patients' self-report occurred after the therapist evaluation. Impact. Reliability of the AM-PAC '6-Clicks' short forms is moderate when comparing scores from patients with those of therapists responding as proxies. The short forms are useful for measuring participants' function in the acute care hospital; however, it is critical to recognize limitations in reliability between clinician- and patient-reported AM-PAC scores when evaluating longitudinal change and recovery. Keywords: Activities of Daily Living, Acute Care, Measurement: Basic Theory and Science, Mobility, Introduction Many individuals in acute care hospitals experience new or worsening deficits in physical function and their ability to participate in daily activities. (1,2) Individual's functional status in the hospital [...]

Objective. Physical function is associated with important outcomes, yet there is often a lack of continuity in routine assessment. The purpose of this study was to determine data elements and instruments for longitudinal measurement of physical function in routine care among patients transitioning from acute care hospital setting to home with home health care. Methods. A 4-round modified Delphi process was conducted with 13 participants with expertise in physical therapy, health care administration, health services research, physiatry/medicine, and health informatics. Three anonymous rounds identified important and feasible data elements. A fourth in-person round finalized the recommended list of individual data elements. Next, 2 focus groups independently provided additional perspectives from other stakeholders. Results. Response rates were 100% for online rounds 1, 3, and 4 and 92% for round 2. In round 1, 9 domains were identified: physical function, participation, adverse events, behavioral/emotional health, social support, cognition, complexity of illness/disease burden, health care utilization, and demographics. Following the fourth round, 27 individual data elements were recommended. Of these, 20 (74%) are 'administrative' and available from most hospital electronic medical records. Additional focus groups confirmed these selections and provided input on standardizing collection methods. A website has been developed to share these results and invite other health care systems to participate in future data sharing of these identified data elements. Conclusion. A modified Delphi consensus process was used to identify critical data elements to track changes in patient physical function in routine care as they transition from acute hospital to home with home health. Impact. Expert consensus on comprehensive and feasible measurement of physical function in routine care provides health care professionals and institutions with guidance in establishing discrete medical records data that can improve patient care, discharge decisions, and future research. Keywords: Acute Care, Home Care Services, Measurement: Applied, Medical Informatics, Introduction Within the framework of the International Classification of Functioning, Disability and Health, physical function is the result of interaction between a person's body parts, their whole person, and their [...]

Objective. For patients diagnosed with the novel coronavirus, COVID-19, evidence is needed to understand the effect of treatment by physical therapists in the acute hospital on patient outcomes. The primary aims of this study were to examine the relationship of physical therapy visit frequency and duration in the hospital with patients' mobility status at discharge and probability of discharging home. Methods. This retrospective study included patients with COVID-19 admitted to any of 11 hospitals in 1 health system. The primary outcome was mobility status at discharge, measured using the Activity Measure for Post-Acute Care 6-Clicks basic mobility (6-Clicks mobility) and the Johns Hopkins Highest Level of Mobility scales. Discharge to home versus to a facility was a secondary outcome. Associations between these outcomes and physical therapy visit frequency or mean duration were tested using multiple linear or modified Poisson regression. Potential moderation of these relationships by particular patient characteristics was examined using interaction terms in subsequent regression models. Results. For the 312 patients included, increased physical therapy visit frequency was associated with higher 6-Clicks mobility (b = 3.63; 95% CI, 1.54-5.71) and Johns Hopkins Highest Level of Mobility scores (b = 1.15; 95% CI, 0.37-1.93) at hospital discharge and with increased probability of discharging home (adjusted relative risk = 1.82; 95% CI, 1.25-2.63). Longer mean visit duration was also associated with improved mobility at discharge and the probability of discharging home, though the effects were less pronounced. Few moderation effects were observed. Conclusion. Patients with COVID-19 demonstrated improved mobility at hospital discharge and higher probability of discharging home with increased frequency and longer mean duration of physical therapy visits. These associations were not generally moderated by patient characteristics. Impact. Physical therapy should be an integral component of care for patients hospitalized due to COVID-19. Providing sufficient physical therapist interventions to improve outcomes must be balanced against protection from viral spread. Lay Summary. Patients with COVID-19 can benefit from more frequent and longer physical therapy visits in the hospital. Keywords: Acute Care, Mobility, Patient Discharge, Delivery Patterns, Introduction The overall cumulative hospitalization rate associated with the novel coronavirus disease, COVID-19, is 120.9 per 100,000 population and continuously increasing. (1) COVID-19 is associated with varying levels of illness [...]

Objective. Therapists in the hospital are charged with making timely discharge recommendations to improve access to rehabilitation after stroke. The objective of this study was to identify the predictive ability of the Activity Measure for Post-Acute Care '6 Clicks' Basic Mobility Inpatient Short Form (6 Clicks mobility) score and the National Institutes of Health Stroke Scale (NIHSS) score for actual hospital discharge disposition after stroke. Methods. In this retrospective cohort study, data were collected from an academic hospital in the United States for 1543 patients with acute stroke and a 6 Clicks mobility score. Discharge to home, a skilled nursing facility (SNF), or an inpatient rehabilitation facility (IRF) was the primary outcome. Associations among these outcomes and 6 Clicks mobility and NIHSS scores, alone or together, were tested using multinomial logistic regression, and the predictive ability of these scores was calculated using concordance statistics. Results. A higher 6 Clicks mobility score alone was associated with a decreased odds of actual discharge to an IRF or an SNF. The 6 Clicks mobility score alone was a strong predictor of discharge to home versus an IRF or an SNF. However, predicting discharge to an IRF versus an SNF was stronger when the 6 Clicks mobility score was considered in combination with the NIHSS score, age, sex, and race. Conclusion. The 6 Clicks mobility score alone can guide discharge decision making after stroke, particularly for discharge to home versus an SNF or an IRF. Determining discharge to an SNF versus an IRF could be improved by also considering the NIHSS score, age, sex, and race. Future studies should seek to identify which additional characteristics improve predictability for these separate discharge destinations. Impact. The use of outcome measures can improve therapist confidence in making discharge recommendations for people with stroke, can enhance hospital throughput, and can expedite access to rehabilitation, ultimately affecting functional outcomes., Anew or recurrent stroke is experienced by an estimated 795,000 adults annually in the United States and often results in serious long-term disability. (1) Appropriate rehabilitation has been shown to [...]

Background. The Activity Measure for Post-Acute Care (AM-PAC) is a generic metric of patient-reported functional status. The minimal clinically important difference (MCID) in the AM-PAC score has not been determined. Objective. The study objective was to determine the MCID for AM-PAC in people with low back pain. Design. This was a retrospective cohort study. Methods. Anchor-based and distribution-based methods were used to estimate the MCID. The Modified Low Back Pain Disability Questionnaire was used as the anchor. Adults who had a primary ICD-9 code for low back pain in at least 1 outpatient physical therapist visit during an episode of care and who completed both the AM-PAC and the Modified Low Back Pain Disability Questionnaire in at least 2 visits during the care episode were included. The MCID was calculated for the AM-PAC basic mobility version as well its adapted version, which the Cleveland Clinic uses for patients 65 years old or older. Results. A total of 1,271 participants were eligible for study. For the AM-PAC basic mobility version, anchor-based methods yielded MCID estimates of between 3.4 and 5.1, whereas distribution-based methods yielded estimates of 1.7 to 4.2. The minimal detectable change (MDC) for the AM-PAC basic mobility version was 3.3. For the adapted AM-PAC basic mobility version, the MCID was estimated to be between 2.9 and 4.0 via anchor-based methods and between 1.2 to 3.5 via distribution-based methods. The MDC for the adapted AM-PAC basic mobility version was 3.5. Limitations. The estimated MCID was designed for people with low back pain only. Conclusions. The MCID ranged from 3.3 to 5.1 for the AM-PAC basic mobility version and 3.5 to 4 for the adapted version, with the MDC as the lower limit. Changes in the AM-PAC for people with low back pain may be interpreted using the estimated MCID. Future studies are needed to determine the AM-PAC MCID for populations other than those with low back pain., In recent years, the Centers for Medicare and Medicaid Services issued a report highlighting the need for uniform assessment tools to inform policy decisions on discharge placement, care transitions, and [...]

Background. The Centers for Medicare & Medicaid Services has mandated rehabilitation professionals to document patients' impairment levels. There is no evidence of responsiveness to change of functional limitation severity modifier codes. Objective. The purpose of this study was to assess the validity of G-code functional limitation severity modifier codes in determining change in function. Design. This was a retrospective observational study. Methods. Patients completed the Activity Measure for Post-Acute Care (AM-PAC) and were assigned G-codes, with severity modifiers based on AM-PAC scores at initial and follow-up visits. Patients were classified as having AM-PAC scores in the upper or lower range for each severity modifier, and sensitivity, specificity, and positive and negative predictive values for change in severity modifier level and odds of changing by one severity modifier level using a change in AM-PAC score of at least 1 minimal detectable change at the 95% confidence interval ([MDC.sub.95]) as the standard were determined. Results. Sensitivity and specificity of change in severity modifier in determining change in function were dependent on patients' initial AM-PAC scores. Improvement in severity modifier level was 2.2 to 4.5 times more likely with scores at the higher end of the range within a severity modifier level than with scores in the lower end of the range. Decline in severity modifier level was 2.7 to 4.8 times more likely with scores at the lower end of the range within a severity modifier than with scores in the higher end of the range. Limitations. Data were from one health care system, and most patients had orthopedic conditions. The [MDC.sub.95] for AM-PAC tool may not be the best standard for defining functional change. Conclusions. The G-code functional limitation severity modifier system may not be valid for determining change in function and is not recommended for determining if patients have changed over the course of outpatient therapy., Physical therapists have long been encouraged to use well-tested, relevant standardized measures to assess patients' function and progress. Application of standardized measures enhances the ability of therapists to target interventions [...]

Background. The interrater reliability of 2 new inpatient functional short-form measures, Activity Measure for Post-Acute Care (AM-PAC) '6-Clicks' basic mobility and daily activity scores, has yet to be established. Objective. The purpose of this study was to examine the interrater reliability of AM-PAC '6-Clicks' measures. Design. A prospective observational study was conducted. Methods. Four pairs of physical therapists rated basic mobility and 4 pairs of occupational therapists rated daily activity of patients in 1 of 4 hospital services. One therapist in a pair was the primary therapist directing the assessment while the other therapist observed. Each therapist was unaware of the other's AM-PAC '6-Clicks' scores. Reliability was assessed with intraclass correlation coefficients (ICCs), Bland-Altman plots, and weighted kappa. Results. The ICCs for the overall reliability of basic mobility and daily activity were .849 (95% confidence interval [Cl] = .784, .895) and .783 (95% CI=.696, .847), respectively. The ICCs for the reliability of each pair of raters ranged from .581 (95% CI=.260, .789) to .960 (95% CI=.897, .983) for basic mobility and .316 (95% CI= -.061, .611) to .907 (95% CI=.801, .958) for daily activity. The weighted kappa values for item agreement ranged from .492 (95% CI=.382, .601) to .712 (95% CI=.607, .816) for basic mobility and .251 (95% CI=.057, .445) to .751 (95% CI=.653, .848) for daily activity. Mean differences between raters' scores were near zero. Limitations. Raters were from one health system. Each pair of raters assessed different patients in different services. Conclusions. The ICCs for AM-PAC '6-Clicks' total scores were very high. Levels of agreement varied across pairs of raters, from large to nearly perfect for physical therapists and from moderate to nearly perfect for occupational therapists. Levels of agreement for individual item scores ranged from small to very large., A relatively high proportion of patients in acute care hospitals have mobility and self-care limitations. (1) A primary focus for physical therapists and occupational therapists based in hospitals is the [...]

Background. Physical therapists and occupational therapists practicing in acute care hospitals play a crucial role in discharge planning. A standardized assessment of patients' function could be useful for discharge recommendations. Objectives. The study objective was to determine the accuracy of '6-Clicks' basic mobility and daily activity measures for predicting discharge from an acute care hospital to a home or institutional setting. Design. The study was retrospective and observational. Methods. '6-Clicks' scores obtained at initial visits by physical therapists or occupational therapists and patients' discharge destinations were used to develop and validate receiver operating characteristic curves for predicting discharge destination. Positive predictive values (PPV), negative predictive values (NPV), and likelihood ratios were calculated. Results. Areas under the receiver operating characteristic curves for basic mobility scores were 0.857 (95% confidence interval [Cl] =0.852, 0.862) and 0.855 (95% 0= 0.850, 0.860) in development and validation samples, respectively. Areas under the curves for daily activity scores were 0.846 (95% 0= 0.841, 0.851) and 0.845 (95% 0=0.840, 0.850) in development and validation samples, respectively. Cutoff scores providing the best accuracy for determining discharge destination were 42.9 for basic mobility and 39.4 for daily activity. For basic mobility, the PPV was 0.748 and the NPV was 0.801 in both development and validation samples. For daily activity, the PPVs were 0.787 and 0.784 and the NPVs were 0.748 and 0.746 in development and validation samples, respectively. Limitations. Limitations included lack of information on the rater reliability of '6-Clicks' instruments, use of surrogate data for some discharge designations, and use of a clinical database for research purposes. Conclusions. This study provides evidence of the accuracy of '6-Clicks' scores for predicting destination after discharge from an acute care hospital., In acute care hospitals, many patients with neurological, musculoskeletal, and cardiopulmonary problems have limitations in walking and moving, self-care, changing and maintaining body positions, or several of these tasks. (1) [...]

Background. Standardized assessment of patients' activity limitations in acute care settings can provide valuable information. Existing measures have not been widely implemented. Objectives. The aim of this study was to provide evidence for validity of scores on Activity Measure for Post-Acute Care (AM-PAC) '6-Clicks' measures of basic mobility and daily activity in acute care. Design. A retrospective measurement study was conducted. Methods. The study used a database from one health system containing '6-Clicks' scores from first and last physical therapist and occupational therapist visits for 84,446 patients. Validity was analyzed by examining differences in '6-Clicks' scores across categories of patient characteristics; the ability of '6-Clicks' scores to predict patients' having more than one therapy visit; correlation of '6-Clicks' scores with Functional Independence Measure (FIM) scores; and internal responsiveness over the episode of care. Internal consistency reliability also was determined. Results. The '6-Clicks' scores differed across patients' age, preadmission living situation, and number of therapy visits. The areas under receiver operating characteristic curves derived using '6-Clicks' scores at the first visit to predict patients receiving more than one visit were 0.703 and 0.652 using basic mobility and daily activity scores, respectively. The '6-Clicks' scores at the final visit were correlated with scores on subscales of the FIM completed on admission to inpatient rehabilitation facilities (r=.65 and .69). Standardized response means were 1.06 and 0.95 and minimal detectable changes with 90% confidence level ([MDC.sub.90]) were 4.72 and 5.49 for basic mobility and daily activity scores, respectively. Internal consistency reliability of basic mobility and daily activity scores was .96 and .91, respectively. Limitations. Using clinical databases for research purposes has limitations, including missing data, misclassifications, and selection bias. Rater reliability is not known. Conclusions. This study provides evidence for the validity of '6-Clicks' scores for assessing patients' activity limitations in acute care settings., In the acute care setting, the case mix index of hospitals provides a means to measure the medical complexity and burden of illness for the patients they serve and the [...]