ORIGINAL RESEARCH| Volume 103, ISSUE 6, P1070-1084.e3, June 2022

Inpatient Rehabilitation Facility Patients’ Functional Abilities and Validity Testing of the Standardized Self-Care and Mobility Data Elements

Published:February 11, 2022DOI:



      To describe the abilities of Medicare patients in inpatient rehabilitation facilities (IRFs) at admission and discharge using the standardized self-care and mobility data elements and examine the validity of the data elements. These data are used in the Center for Medicare & Medicaid's IRF payment and quality reporting programs.


      Descriptive study reporting IRF patients’ self-care and mobility scores. We also examined content validity and the associations between admission scores and length of stay (LOS), discharge scores and discharge destination, and change scores and the number of comorbidities.


      Patients discharged from 1129 IRFs in 2017.


      IRF Medicare fee-for-service and Medicare Advantage patient stays (N = 493,209).


      Not applicable.

      Main Outcome Measure(s)

      Self-care and mobility item scores, IRF LOS, discharge destination, and categories of the number of comorbidities.


      For each self-care and mobility activity, patients in IRFs overall made substantial improvements in function between admission and discharge. For example, the percentage of patients independent with eating and toilet transfers increased from 29.04% to 66.68% and 0.80% to 39.87%, respectively, between admission and discharge. Activities represented in the standardized data elements are included in other functional assessment instruments addressing content validity. Analyses showed a monotonic relationship between admission scores and LOS and between discharge scores and discharge to community percentages with only a few exceptions. Self-care and mobility scale change scores decreased as the number of comorbidities increased across categories.


      Patients in IRFs overall show functional improvement across each of the activities as defined by the standardized self-care and mobility data elements. The results showing the associations between patient functioning and 3 metrics (LOS, discharge to community rates, and number of comorbidities) support the validity of the data elements measuring functional abilities in the IRF Medicare population.

      List of abbreviations:

      CMS (Centers for Medicare & Medicaid Services), IRF (inpatient rehabilitation facility), IRF-PAI (Inpatient Rehabilitation Facility Patient Assessment Instrument), ICF (International Classification of Functioning, Disability and Health), LOS (length of stay), PAC (post-acute care)


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        • Mahoney FI
        • Barthel DW
        Functional evaluation: the Barthel Index: a simple index of independence useful in scoring improvement in the rehabilitation of the chronically ill.
        Md State Med J. 1965;14:61-5;
        • Shah S
        • Vanclay F
        • Cooper B
        Improving the sensitivity of the Barthel Index for stroke rehabilitation.
        J Clin Epidemiol. 1989; 42: 703-709
        • Granger CV
        • Dewis LS
        • Peters NC
        • Sherwood C
        • Barrett J
        Stroke rehabilitation: analysis of repeated Barthel index measures.
        Arch Phys Med Rehabil. 1979; 60: 14-17
        • Quinn TJ
        • Langhorne P
        • Stott DJ
        Barthel index for stroke trials: development, properties, and application.
        Stroke. 2011; 42: 1146-1151
        • Deutsch A
        • Braun S
        • Granger C
        The functional independence measure (FIMSM Instrument) and the functional independence measure for children (WeeFIM® Instrument): ten years of development.
        Crit Rev Phys Rehabil Med. 1996; 8: 267-281
        • Hamilton BB
        • Laughlin JA
        • Fiedler RC
        • Granger CV
        Interrater reliability of the 7-level functional independence measure (FIM).
        Scand J Rehabil Med. 1994; 26: 115-119
        • Deutsch A
        • Fiedler RC
        • Granger CV
        • Russell CF
        The Uniform Data System for Medical Rehabilitation Report of Patients Discharged from Comprehensive Medical Rehabilitation Programs in 1999.
        Am J Phys Med Rehabil. 2002; 81: 133-142
        • Granger CV
        • Hamilton BB
        UDS report: the Uniform Data System for Medical Rehabilitation report of first admissions for 1990.
        Am J Phys Med Rehabil. 1992; 71: 108-113
        • Stineman MG
        • Escarce JJ
        • Goin JE
        • Hamilton BB
        • Granger CV
        • Williams SV
        A case-mix classification system for medical rehabilitation.
        Med Care. 1994;32;366-79;
        • Department of Health and Human Services
        Medicare program; prospective payment system for inpatient rehabilitation facilities; proposed rule.
        Fed Regist. 2000; 65: 66304-66442
        • Granger CV
        • Deutsch A
        • Russell C
        • Black T
        • Ottenbacher KJ
        Modifications of the FIM instrument under the inpatient rehabilitation facility prospective payment system.
        Am J Phys Med Rehabil. 2007; 86: 883-892
      1. The Patient Protection and Afforable Care Act of 2010, Public Law No. 111-148, 124, Stat. 119 through 1025 (2010).

        • DeJong G
        • Hsieh C-H
        • Gassaway J
        • et al.
        Characterizing rehabilitation services for patients with knee and hip replacement in skilled nursing facilities and inpatient rehabilitation facilities.
        Arch Phys Med Rehabil. 2009; 90: 1269-1283
        • Deutsch A
        • Granger CV
        • Heinemann AW
        • et al.
        Poststroke rehabilitation: outcomes and reimbursement of inpatient rehabilitation facilities and subacute rehabilitation programs.
        Stroke. 2006; 37: 1477-1482
        • Mallinson T
        • Deutsch A
        • Bateman J
        • et al.
        Comparison of discharge functional status after rehabilitation in skilled nursing, home health, and medical rehabilitation settings for patients after hip fracture repair.
        Arch Phys Med Rehabil. 2014; 95: 209-217
        • Schmitz R
        • Simon S
        Substitutability across institutional post-acute care settings: 1998-2006.
        Princeton: Mathematica Policy Research;. 2009;
      2. Deficit Reduction Act of 2005, Public Law No: 109-171, Section 5008, 120 Stat 4. (2005).

        • Gage B
        • Stineman M
        • Deutsch A
        • et al.
        Perspectives on the state-of-the-science in rehabilitation medicine and its implications for Medicare postacute care policies.
        Arch Phys Med Rehabil. 2007; 88: 1737-1739
      3. Gage B, Constantine R, Aggarwal J, et al. The development and testing of the Continuity Assessment Record and Evaluation (CARE) item set. Vol 1. Waltham: RTI International; 2012.

      4. Gage B, Ingber M, Smith L, et al. Post-Acute Care Payment Reform Demonstration: final report. Vol 4. Waltham: RTI International; 2012.

      5. Gage B, Smith L, Ross J, et al. The development and testing of the Continuity Assessment Record and Evaluation (CARE) item set: final report on reliability testing. Vol 2. Waltham: RTI International; 2012.

      6. Improving Post-Acute Care tranformation (IMPACT) Act of 2014, Public Law No: 113-185, 128 Stat. 1952 (42 U.S.C. § 1395) (2014).

        • Department of Health and Human Services
        Medicare program; inpatient rehabilitation facility prospective payment system for federal fiscal year 2016.
        Fed Regist. 2015; 80: 47036-47139
        • Deutsch A
        • Kline T
        • Kelleher C
        • et al.
        Analysis of crosscutting Medicare functional status quality metrics using the Continuity and Assessment Record and Evaluation (CARE) item set—final report.
        RTI International, Washington, DC2012
        • Deutsch A
        • Pardasaney P
        • Iriondo-Perez J
        • Ingber MJ
        • Porter KA
        • McMullen T
        Development of a risk-adjustment model for the inpatient rehabilitation facility Discharge Self-care Functional Status Quality Measure.
        Med Care. 2017; 55: 706-715
        • Pardasaney PK
        • Deutsch A
        • Iriondo-Perez J
        • Ingber MJ
        • McMullen T
        Measuring inpatient rehabilitation facility quality of care: Discharge Self-care Functional Status Quality measure.
        Arch Phys Med Rehabil. 2018; 99: 1035-1041
        • Department of Health and Human Services
        Medicare program; prospective payment system for inpatient rehabilitation facilities for federal fiscal year 2020 and updates to the IRF quality reporting program; final rule.
        Fed Regist. 2019; 84: 39054-39173
      7. Deutsch A, Palmer L, Vaughan M, et al. The Inpatient Rehabilitation Facility Change in Self-Care and Change in Mobility Quality measures: development and reliability and validity testing. Arch Phys Med Rehabil; in press.

        • Rehabilitation Institute of Chicago
        RIC-FAS II: Rehabilitation Institute of Chicago Functional Assessment Scale.
        Chicago; Rehabilitation Institute of Chicago; 1989
        • Hall KM
        • Mann N
        • High WM
        • Wright J
        • Kreutzer JS
        • Wood D
        Functional measures after traumatic brain injury: ceiling effects of FIM, FIM+ FAM, DRS, and CIQ.
        J Head Trauma Rehabil. 1996;11:27-39;
        • Linn RT
        • Blair RS
        • Granger CV
        • Harper DW
        • O'Hara PA
        • Maciura E
        Does the functional assessment measure (FAM) extend the functional independence measure (FIM) instrument? A rasch analysis of stroke inpatients.
        J Outcome Meas. 1999; 3: 339-359
        • Graney MJ
        • Engle VF
        Stability of performance of activities of daily living using the MDS.
        Gerontologist. 2000; 40: 582-586
        • Hamilton CB
        • Chesworth BM
        A Rasch-validated version of the upper extremity functional index for interval-level measurement of upper extremity function.
        Phys Ther. 2013; 93: 1507-1519
        • Katz S
        • Downs TD
        • Cash HR
        • Grotz RC
        Progress in development of the index of ADL.
        Gerontologist. 1970; 10: 20-30
        • Mehta SP
        • Fulton A
        • Quach C
        • Thistle M
        • Toledo C
        • Evans NA
        Measurement properties of the lower extremity functional scale: a systematic review.
        J Orthop Sports Phys Ther. 2016; 46: 200-216
        • Stucki G
        • Cieza A
        • Ewert T
        • Kostanjsek N
        • Chatterji S
        • Ustun TB
        Application of the International Classification of Functioning, Disability and Health (ICF) in clinical practice.
        Disabil Rehabil. 2002; 24: 281-282
      8. Smith L, Deutsch A, Hand L, et al. Continuity Assessment Record and Evaluation (CARE) item set: additional provider-type specific interrater reliability analyses. Waltham: RTI International; 2012.