Supporting functional independence is a cornerstone of quality care in long-term care settings.
Supporting functional independence is a cornerstone of quality care in long-term care settings. The ability of residents to perform Activities of Daily Living (ADLs) such as eating, toileting, and mobility directly impacts their quality of life and overall well-being.
In this article, we focus on the Long-Stay ADL Quality Measures, which evaluates changes in residents’ functional status over time. A long-stay resident is defined as someone whose episode has a Cumulative Days in Facility (CDIF) greater than or equal to 101 days at the end of the target period. This publicly reported measure plays a significant role in the Five-Star Quality Rating System and serves as a key indicator of a facility’s ability to maintain or slow the decline of residents’ independence in daily care tasks.
Percent of Residents Whose Need for Help with Activities of Daily Living Has Increased - This measure reports the percent of long-stay residents whose need for help with late-loss Activities of Daily Living (ADLs) has increased when compared to the prior assessment.
Late Loss ADLs:
- Eating (GG0130A)
- Sit to Lying (GG0170B)
- Sit to Stand (GG0170D)
- Toilet Transfer (GG0170F)
An increase in need for help is defined as a decrease in two or more coding points in one late-loss ADL item or one point decrease in coding points in two or more late-loss ADL items. Note that for each of these four ADL items, if the value is equal to [07, 09, 10, 88] on either the target or prior assessment, then re-code the item to equal [01] to allow appropriate comparison. Example Provided Below shows Eating is coded one level more dependent on the target assessment and Toilet Transfer is coded one level more dependent on the target assessment; therefore, 2 ADL’s required increased help.
ADL Quality Measure Exclusion Criteria
Exclusions from the Long-Stay Residents Whose Need for Help with ADL has Increased Quality Measure:
- All four Late-Loss ADLs on the prior assessment indicate dependence or the activity was not attempted ([01], [07], [09], [10], or [88]).
- Three Late-Loss ADLs indicate dependence or non-performance, and the fourth indicates substantial/maximal assistance ([02]) on the prior assessment.
- The resident is comatose, receiving hospice care, or has a provider documented life expectancy of less than six months.
- Late-Loss ADL items are dashed or a prior assessment is not available.
These exclusions ensure accurate measurement of functional status over time.
Percent of Residents Whose Ability to Walk Independently Worsened - This measure reports the percent of long-stay residents who experienced a decline in the ability to walk independently during the target period. Decline identified by: A decrease of one or more points on the “Walk 10 feet” GG item between the target assessment and prior assessment. Example Provided Below shows Walking 10 Feet is coded one level more dependent on the target assessment; therefore, a decline is noted in ability to walk.
Walk Independently Worsened Quality Measure Exclusion Criteria:
- Comatose, Prognosis of less than 6 months, Hospice.
- Prior assessment indicates that the resident is dependent on the “Walk 10 Feet” item or activity was not attempted [07, 09, 10, 88, 01]
- Dash, No prior assessment, Prior assessment was a discharge assessment, OBRA Admission, PPS 5-day, or the first assessment after an admission.
To properly “drill-down” on these quality measure we must first ensure the medical record supports the coding of the ADL. Review with your Interdisciplinary Team (IDT) the process for coding ADL items in your organization.
Recommendations to Strengthen GG Documentation and Functional Assessment Practices
- Clarify Documentation Roles:
Confirm whether CNAs are documenting ADL performance daily while licensed nurses focus on documentation during designated assessment periods. Clear role delineation ensures accurate and consistent data collection.
- Assign Responsibility for Usual Performance Determination:
Identify which disciplines will be responsible for reviewing GG documentation during the appropriate assessment windows. The importance of interdisciplinary team (IDT) collaboration in establishing a resident’s usual performance is significant and should not be overlooked in the assessment process.
- Evaluate Staff Training:
Consider when your team last received formal education on GG coding practices. If it’s been a while—or if you're unsure—consider partnering with the Polaris Group. We offer resources and training to support your staff in accurate and compliant GG coding.
- Monitor for Functional Decline:
Regularly review documentation leading up to each assessment period to identify signs of decline. When noted, refer to therapy services as appropriate to support residents in maintaining functional independence. Implementing a screening process for all residents approximately 30 days prior to the scheduled ARD can help identify emerging needs early, allow for timely interventions, and reduce the risk of functional decline.
- Conduct Significant Change Assessments:
If a notable decline is identified, initiate a Significant Change in Status Assessment ensure care plans and services remain aligned with the resident’s needs.
- Address Contributing Factors:
Evaluate whether psychosocial needs, pain management, or comfort concerns are contributing to functional decline. Implement targeted interventions and preventative strategies to address these factors proactively.
By incorporating these recommendations, facilities can strengthen documentation practices, promote interdisciplinary collaboration, and support resident outcomes.
Stay tuned for next month’s "Quality Measure Drill Down" spotlight, where we’ll continue exploring practical strategies to support strong outcomes across your facility.
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