FIM or Foe? Functional Independence Measures Fall Short, Data Show ASHA News
ASHA News  |   May 01, 2003
FIM or Foe?
Author Notes
  • Tobi Frymark, is ASHA’s treatment outcomes manager. Contact her at
    Tobi Frymark, is ASHA’s treatment outcomes manager. Contact her at×
Article Information
Speech, Voice & Prosodic Disorders / Swallowing, Dysphagia & Feeding Disorders / ASHA News & Member Stories / ASHA News
ASHA News   |   May 01, 2003
FIM or Foe?
The ASHA Leader, May 2003, Vol. 8, 10-13. doi:10.1044/leader.BML.08102003.10
The ASHA Leader, May 2003, Vol. 8, 10-13. doi:10.1044/leader.BML.08102003.10
By federal mandate, speech-language pathologists working in inpatient rehabilitation settings now must use the Functional Independence Measures (FIM) to determine payment for Medicare beneficiaries as part of the Inpatient Rehabilitation Facility Prospective Payment System (IRFPPS). The FIM, developed in the late 1980s and trademarked as part of the Uniform Data Set for Medical Rehabilitation, has seven-point rating scales intended to document the severity of a patient’s disability, rather than impairment level, in a uniform and discipline-free way.
The FIM instrument consists of 18 clinical areas, including ambulation, self-care, cognition, and communication. All items can be scored by any trained health care professional. The FIM also requires that each patient be scored at admission and discharge on each of the 18 clinical areas.
Since its inception, however, clinicians working in inpatient rehabilitation settings have reported dissatisfaction with the FIM. They have criticized its lack of sensitivity in measuring cognitive, communication, and swallowing skills, as well as its inability to adequately reflect speech and language services.
Yet, under the new rule of the IRFPPS, the FIM—along with information about the patient’s impairment level, age, and co-morbidities—now becomes the basis for classifying fixed payment rates.
Although functional status seems to be the best predictor of resource utilization, it is clear that no one measure is suitable for all treatment settings or services. Many SLPs argue that the FIM instrument, which emphasizes physical activities of daily living more than cognitive-communication activities, will lead to the misallocation of resources, and potentially limit—or even overlook—necessary speech and language services at the inpatient rehab level of care.
FCMs More Accurate
For more than a year, ASHA has tracked the impact of IRFPPS on speech-language pathology services through a special data collection project using the National Outcomes Measurement System (NOMS.) The cornerstone of NOMS is its Functional Communication Measures (FCMs).
Like the FIM, the FCMs are a series of seven-point rating scales designed to reflect change in a patient’s ability over time. The FCMs, however, specifically measure a patient’s cognitive-communication and/or swallowing abilities, rather than the broad spectrum of abilities targeted by the FIM.
The FCMs consist of 15 cognitive, communication, and swallowing scales, with each scale containing the seven discrete gradations of functional change. Unlike the FIM, all 15 scales are not intended to be measured on admission and discharge for each patient. Instead, selected FCMs are chosen and scored based on the patient’s actual cognitive-communication and/or swallowing impairments.
More importantly, only ASHA-certified SLPs can properly administer the FCMs, which were developed by and for speech-language professionals. By examining targeted FCM scores from admission to discharge, clinicians can measure the patients’ functional progress and better assess the benefits of speech-language pathology treatment at the inpatient rehab level of care.
Through NOMS, ASHA was able to assess whether the federally mandated FIM was suitable as the sole measurement of patient outcomes and determine if the scales underrepresented or undervalued patient progress. To accomplish this, ASHA enlisted the help of 96 data collection sites that participated in the NOMS adult component and implemented the IRFPPS in 2002. Each site reported standard NOMS data, along with admission and discharge FIM scores, to provide an in-depth comparison of the two measurement systems in the study.
Not surprisingly, the study reveals compelling differences between the FCMs and the FIM. Table 1 shows the disparity between the range of speech-language disorders covered by the NOMS FCMs and by the FIM. The FCMs capture progress in four disorders for which there exists no corresponding FIM measure—motor speech, voice, fluency, and attention.
The study of the 96 data collection sites revealed that 46% of the patients made progress in one or more of these four areas—progress that was not recognized by the FIM, and therefore was not reportable under IRFPPS. The FIM’s failure to capture data for these treatment areas significantly devalues the extent of a patient’s overall progress in cognitive, communication, and/or swallowing abilities.
The study suggested other troubling aspects of the FIM. Results showed that in some areas where the FIM and FCMs appear to correspond, the FIM is less sensitive than FCM measures. Data revealed that 35% of patients receiving speech-language pathology treatment make significant functional progress in areas beyond those captured by the corresponding FIM measures.
In areas of direct correspondence—including eating, comprehension (auditory), and social interaction—the FCMs were more sensitive and accurate than some FIM measures, with 22% of patients making progress on one or more FCMs beyond the corresponding FIM scale. All told, the FIM entirely missed or understated progress on 51% of patients in the study.
When compared to the NOMS data, we see that the use of the IRFPPS for Medicare patients provides a distorted and grossly inadequate image of the progress our patients make in resolving communication or swallowing difficulties. These data demonstrate that the FIM cannot be relied upon to give a complete picture of a patient’s cognitive-communication and swallowing functions. Reliance on the FIM as the sole functional measure significantly undervalues the extent of patients’ progress.
ASHA continues to work closely with the Centers for Medicare and Medicaid Services (CMS) to ensure that our services will not be compromised under IRFPPS. The study results dictate the need to supplement the FIM with a more sensitive set of measures, such as the FCMs, to gain a more comprehensive and accurate view of patient outcomes.
ASHA has recommended to CMS that the agency expand the swallowing and communication FIM areas with the use of the FCMs to more accurately assess levels of a patient’s functional skills over time. If these recommendations are incorporated into IRFPPS, clinicians and administrators will be better equipped to evaluate patient outcomes and allocation of resources in the future.
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May 2003
Volume 8, Issue 10