Q: What is the difference and similarity between Contact Guard Assist (CGA) and Standby Assist (SBA) for physical rehab in occupational therapy and physical therapy?

Similarities

Typically they are used to document transfers and mobility.

Both can be used in all ADLs for physical rehab such as dressing and toileting.

In both cases, the therapist is close to the client and not more than several steps away in case the client loses their balance, strength, etc. and is considered a risk for falling.

Both CGA and SBA require no immediate assistance from the therapist, e.g. physical support in sitting, standing, walking, or propelling a wheelchair. However, the therapist would intervene and provide assistance as needed to prevent an injury or fall.

In both, the client performs 100% of effort, with the therapist providing 0% assistance at first, but potentially more.

In acute rehab (ARU) / inpatient rehab facility (IRF) that uses the new CARE tool (replacement to FIM), contact guard assist and stand by assist are essentially the same level and earn a CARE tool score of 4.

Both allow the use of an assistive device such as a walker, cane, crutches, AFO, etc.

If a therapist provides “handhold assist“, this should be documented as it is different than the typical CGA and SBA.

Differences

  • Contact guard assist is considered a “lower-level” than Stand by assist, but not in the eyes of CARE tool.
  • Contact guard requires a hand on the client (such as with a gait belt), “hover hands”, “light hands”, contact with the client.
  • Stand by assistance does not include any physical contact.
  • Stand by assist can allow the therapist to be nearby the client.
  • Sometimes SBA is referred to as supervision.
  • A therapist may feel comfortable putting their hands in their pockets with SBA, but would be unable to with CGA.

Contact guard vs stand by assist featured

Determining between CGA vs SBA

Assessment Tools – One way to determine that your client is CGA or SBA is based on their fall risk from a fall scale such as the Morse Fall Scale. A “high fall risk” client would likely need at least CGA if not SBA, but unlikely be supervised or independent.

Evaluation – when evaluating a client for the first time, a therapist can determine the Level of Assistance they need when attempting to mobilize for the first time such as:

  • Supine to Sit
  • Sit to Stand
  • Functional mobility

Documentation – if the client has already been evaluated or treated, you can find their level of assistance from OT or PT notes. Keep in mind when the last date of treatment was as a client could have declined/improved if they have not had a treatment for a day or more, making the level of assistance not reflect their actual performance.

Other therapist or nurse hand-off – you can ask the nurse how much help the client needs or another therapist when treatment planning during chart review or team huddles. Keep in mind some nurses may not be as familiar with the Levels of Assistance terms as CGA or SBA.

Asking the client – not always reliable. However, this can provide therapists some additional insight into the client’s level of cognition and any deficits there (poor insight, denial, overconfidence, etc.).

Observation – sometimes you may just have to be overcautious and provide at least CGA at first and then progress to SBA or

If providing SBA for the first time you are working with a client, be ready to provide CGA if necessary

Other Tips

  • Consider using a gait belt.
  • Consider assistive device just in case (e.g. bringing a walker with you).
  • Consider using one hand for a wheelchair follow or having an aide follow with a wheelchair if going further distances.
  • Pace your clients and allow for rest breaks.
  • During showers, clients may not have anything to be held onto (clothes, gait belt) so therapists should be overly cautious.

Documentation

  • Can be abbreviated CGA and SBA.
  • FIM and CARE Tool do not specifically use CGA and SBA in their official descriptors, but instead:
    • FIM: “Supervision”
    • CARE Tool: “Supervision or Touching Assistance”
  • Both CGA and SBA earn a CARE Tool score of 4, but providing additional detailed descriptions in notes for next therapist to see can help as seeing a 4 is not very descriptive.
  • In FIM, document the lowest level of assistance, e.g. max A, even though you may have started with CGA, for example.
  • CGA and SBA are not used for cognition, communication, socialization (primarily SLP, but OT’s can also document if SLP not involved in case). Instead they are called “Stand By”.

Additional Reading

  • Refer to our Levels of Assistance table and PDF for additional reference.
  • Consider certification for FIM and CARE Tool in ARU/IRFs.
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