Screening for Functional Cognition in Postacute Care and the Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014

Abstract

Occupational therapists have a long history of assessing functional cognition, defined as the ability to use and integrate thinking and performance skills to accomplish complex everyday activities. In response to passage of the Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014 (Pub. L. 113-185), the American Occupational Therapy Association has been advocating that the Centers for Medicare and Medicaid Services consider functional cognition for inclusion in routine patient assessment in postacute care settings, with important implications for occupational therapy. These efforts have the potential to increase referrals to occupational therapy, emphasize the importance of addressing functional cognition in occupational therapy practice, and support the value of occupational therapy in achieving optimal postacute care outcomes.

Can Brief Cognitive or Medication Management Tasks Identify the Potential for Dependence in Instrumental Activities of Daily Living?

“…Functional cognition has been defined as the ability to use and integrate thinking and performance skills to accomplish complex everyday activities, including instrumental activities of daily living (IADL; Giles et al, 2017). Some IADL are considered essential for community living such as health management and maintenance (e.g., nutrition, medication management), financial management, and community mobility skills (e.g., driving, using public transit; American Occupational Therapy Association, 2014).…”

“…Historically, clinicians have observed clients' attempts to perform complex functional tasks in order to infer general IADL competency (Skidmore, 2017). However, in the simplified environments of the acute or post-acute care (PAC) settings, IADL performance is not typically directly observable (Giles et al, 2017), and other methods of determining the presence of deficits significant enough to impair IADL are needed (Schmitter-Edgecombe et al, 2011;Gold, 2012). Attempts to predict IADL deficits from neuropsychological measures have had limited success (Marcotte et al, 2010;Schmitter-Edgecombe et al, 2011;Gold, 2012), and informant reports often underestimate the need for assistance (Jonas et al, 2011;Schmitter-Edgecombe et al, 2011).…”

“…Impaired functional cognition is associated with IADL impairment (Moore et al, 2007;Puente et al, 2014;Wesson et al, 2016). In attempting to obtain ecologically valid data about a client's ability to meet IADL demands in settings where these demands cannot be observed directly occupational therapists and others have developed performance-based measures of functional cognition (Giles et al, 2017;Skidmore, 2017). Such measures employ potentially familiar IADL tasks, the enactment of which can be influenced by client self-awareness, strategy use, and previously acquired performance skills.…”

Justifying Rehabilitation Intensity Through Functional Performance Measures in Postacute Care

“…These items do not as yet address change in cognition, but such items are in development (for information on AOTA's involvement, see AOTA, 2015a). Data collection in SNFs for the QRP began October 1, 2016 (see also Giles, Edwards, Morrison, Baum, & Wolf, 2017).…”

Making Functional Cognition a Professional Priority

“…Functional cognition, which can be defined as the cognitive ability to perform daily life tasks, is conceptualized as incorporating metacognition, executive function, other domains of cognitive functioning, performance skills (e.g., motor skills that support action), and performance patterns (e.g., habits, routines; Giles et al, 2017;Wolf et al, 2019). Rather than assess specific cognitive skills (e.g., attention, memory, executive function) in isolation from one another, the goal of functional cognition evaluation is to identify clients' capacity to perform essential tasks given the totality of their abilities, including their use of strategies, habits and routines, and contextual and environmental resources.…”