CARE Item Set / Section GG for ARU Inpatient Rehab (vs FIM) Revisited

CARE stands for Continuity Assessment Record and Evaluation.

Let’s talk about the CARE tool, which can be thought of as the FIM – or functional independence measure replacement in acute rehab or inpatient rehab for occupational therapy. This post will be a general overview of how the CARE tool is different than FIM mainly for occupational therapists working in this setting. My name is Jeff and I work in inpatient rehab and am both FIM and CARE tool certified.

I have been using FIM for several years now and the CARE tool since it was first implemented and mandated by CMS in ARU. CARE stands for Continuity Assessment Record and Evaluation (CARE) Item Set. You can think of it as the replacement to FIM. I will be talking about inpatient rehab, but similar outcome measures are used in skilled nursing facilities (or MDS), long-term care facilities, and home health (or OASIS).

Why do we CARE about the CARE tool? No pun intended. Well — in the United States, Medicare can be thought of as the “gold standard”. What they use or recommend for healthcare such as outcome measures sets a trend and oftentimes, other insurances often follow their lead. Although the CMS or center for medicare and medicare replaced the FIM, it’s not to say that the FIM is no longer used. Some insurances may use or reimburse based on the FIM, but it is probably being phased out. In OT school, you will likely learn about the FIM.

As many readers are already familiar with FIM, it will be easiest to compare it to the CARE tool to highlight the differences. One important thing to remember is that the numbers for the CARE tool scores have a 0 prefix before them for the single digits so 01, 02, 03, etc. — not 1, 2, 3. etc.

First of all, while the FIM was a scale from 1-7, the CARE tool scale ranges from 1-6. The CARE tool eliminated 7, which was modified independent. Modified independent is now combined together with independent as 06. So keep in mind that although the score does not describe the client as modified independent for an activity, such as an ADL, the OT can always describe this in the narrative portion to be more specific.

Most OTs are probably familiar with the levels of assistance min assist, mod assist, and max assist. The CARE tool makes this much more confusing now. Rather than increments of 25%, 50, and 75% for min, mod, and max assist respectively, the percentage level of assist is now either less than 50% or more than 50% to come up with the score. Per the CARE tool, a client is never really “supposed to be” exactly 50%. If they are, then the OT gives them the benefit of the doubt and would score in their favor by rounding down. You can think of it as rounding 50% to 49%.

The more confusing part is the terminology. There is no more “min assist” and it is now called “partial assist”. Less than 50% level of assist is known as partial/moderate assist since it includes 1% to up to 50%. Let me repeat. Less than 50% level of assist, or 50% exactly (which is rounded down), is known as partial/moderate assist.

This means a client can technically be min assist and progress to moderate assist in the traditional sense, but in the CARE tool’s eyes, the score will still be the same, 03.

More than 50% is known as substantial/max assist. Let me repeat that one again. More than 50% is known as substantial/max assist. So what this means that it’s now more difficult for a client to show functional changes in the eyes of the CARE tool scores because besides being dependent and supervision, they can only have 2 possible CARE tool scores, 02 for substantial/max assist and 03 for partial/moderate assist. Remember they did away with the term min assist.

There are some other changes to the CARE tool. If a task was refused the score is 07. Other scenarios are not applicable, not attempted to environmental limitations, and not attempted due to medical condition or safety concern.

Overall, scoring such as the body parts for showers are very similar to the FIM and the fraction or sum of the parts is what gives you the percentage, which then translates to the CARE tool score. So if the OT assist with say 70% of body parts for a shower, that would be substantial/max assist, or 02.

CMS has a handbook with examples and goes into each ADL, cognitive function, and interdisciplinary scoring such as for PT and speech in way more detail. And don’t worry – you are required to be trained and certified to score the CARE tool in OT practice.

To read more about the CARE tool, check out my blog post and decision tree calculator which outputs a CARE tool score based on the level of independence or limitations of the patient.