About 6 Clicks
The AM-PAC 6 Clicks is a commonly used outcome measure in acute care. For example, in the hospital where I work, every acute care patient who is evaluated is scored on the AM-PAC 6 Clicks Short Forms to determine the level of disability and to help guide discharge planning.
The 6 Clicks [calculator] is a quick and easy-to-use outcome measure that contains a mobility form and a daily function (ADL) form. PT often uses the mobility form and OT uses the ADL form. In terms of psychometrics, the 6 Clicks has excellent test-retest reliability.1 Other studies have shown evidence for the validity of 6 Clicks particularly for assessing patient’s activity limitations in acute care settings, which has a large impact on their function and therefore discharge planning.
Discharge Planning in the US
In the US, patients often go to 3 locations from acute care: home (highest level of function), inpatient rehabilitation facility (ARU; somewhere in the middle), and skilled nursing facility (lowest level of function). Discharge planning is influenced by many factors, with pressure to decrease the length of stay and discharge patients from acute care quickly. The average length of stay has been reduced to ~4.7 days for ischemic stroke in the United States.2 Less than 5 days for someone who has had a stroke. One day they are fine and the next minute they lose half the function of their body, cannot communicate, have pain, visual difficulties, cognitive changes, bowel and bladder dysfunction, and the list goes on and on for the symptoms that may be short-term to long-term and possibility even permanent.
Discharge Decision Making
So it is imperative that the rehab team, including the occupational therapy practitioner, not only take part in patients’ discharge planning after stroke but to use reliable measures combined with their clinical expertise to guide their decision. Because what OTs say can have a large influence. I have had doctors and case managers wait for my decision for whether patients are candidates to be admitted to our IRF/ARU. A very helpful tool that I use for this is the 6 Clicks ADL Form.
In a study that researched the utility of the 6 Clicks for discharge destination after acute stroke, cutoff values were determined to be 39.40 for daily activity scores for inpatient rehabilitation. Their study of participants after acute stroke (n=704) with age 66+ found the length of stay for a home discharge from acute care was 5 days (as mentioned earlier) at the hospital. IRF was 11 days and SNF was 15 stays at the hospital before being transferred.
For the ADL form, the mean average 6 Clicks score was 40.28 for home discharge, 31.71 for IRF transfer, and 27.02 for SNF transfer. These results are very insightful as they give a good ballpark idea of what setting a patient is appropriate for. So the implication is that not only is 6 Clicks a useful measure in acute care for patients after stroke, but the score can guide your discharge planning setting.
The Big Picture
Should you only use the 6 Clicks score to determine the setting? Of course not. You should also factor in “preference, cognitive and perceptual ability, home and social support, and insurance coverage”. Additional factors include “social situation, cognitive status, comorbid conditions, age, prior functional level, insurance status, bed availability, and existence of referral relationships between facilities”.3
What I like about the 6 Clicks for OT, particularly the daily function form is it integrates the ADLs already: dressing, bathing, toileting, grooming, and eating meals. While subjective for the level of function scoring, there are not that many degrees of separation between the levels: unable, a lot, a little, or no assistance. So I can see how it has high interrater reliability, such as between two OTs. It’s simple to understand and administer.
To me, the utility of the 6 Clicks reminds me of the Sensory Profile and how you probably already have an idea of what your patient is like in terms of sensory, but the assessment is a more standardized way of arriving at the same conclusion. So with 6 Clicks, you probably already have a good idea of the level of function before even calculating the 6 Clicks score based on how much help a patient needs for their ADLs.
As mentioned in the articles, there are still many factors involved in the discharge planning process. There could be times when the 6 Clicks makes a recommendation for a setting, but it is completely inappropriate based on the factors mentioned such as insurance or even patient preference.
Another highly influential factor based on my experience is the availability of caregivers for physical and psychosocial support. A patient could be the perfect candidate to go home after a stroke from the hospital, but if they need a little assistance and they live alone, then this may change things. Especially if the patient lacks the funds or even lives in an underserved area. While there are things like IHSS, it provides for only limited hours and it may not be enough for what patients need. Many of these personnel are also not trained and so it is crucial that caregiver training be completed in acute care, especially for a home discharge – way before home health OT.
The benefit of the 6 Clicks, especially for a setting such as acute care where things go quickly and are constantly in motion, is that it can be quickly calculated and documented to support your recommendation for the discharge destination of patients after a stroke (and many other conditions actually).
- Jette, D. U., Stilphen, M., Ranganathan, V. K., Passek, S., Frost, F. S., & Jette, A. M. (2015). Interrater reliability of AM-PAC “6-Clicks” basic mobility and daily activity short forms. Physical Therapy, 95, 758–766. https://doi.org/10.2522/ptj.20140174
- Benjamin, E. J., Virani, S. S., Callaway, C. W., Chamberlain, A. M., Chang, A. R., Cheng, S., . . . Muntner, P.; American Heart Association Council on Epidemiology and Prevention, Statistics Committee, and Stroke Statistics Subcommittee. (2018). Heart disease and stroke statistics—2018 update: A report from the American Heart Association. Circulation, 137, e67–e492. https://doi.org/10.1161/CIR.0000000000000558
- Lorenzo O. Casertano, Clare C. Bassile, Jacqueline S. Pfeffer, Theresa M. Morrone, Joel Stein, Joshua Z. Willey, Ashwini K. Rao; Utility of the AM-PAC “6 Clicks” Basic Mobility and Daily Activity Short Forms to Determine Discharge Destination in an Acute Stroke Population. Am J Occup Ther July/August 2022, Vol. 76(4), 7604205060. doi: https://doi.org/10.5014/ajot.2022.047381