FAM Syllabus

Purpose:
The purpose of the 12 Functional Assessment Measure items (FAM) is to provide a measure of disability to reflect communication, psychosocial adjustment and cognitive functions of the patient. The 7 point rating scale is modeled after the FIM and assesses the individual's level or degree of independence, amount of assistance required, use of adaptive or assistive devices, and the percentage of a given task completed successfully. The FAM is an addition of 12 items to the Functional Independence Measure (FIM) which contains 18 items (Uniform Data System (UDS) for Medical Rehabilitation, 1987). The FAM items have been added to the FIM to provide more detailed data appropriate for our traumatic brain injury (TBI) and stroke (CVA) population.

When to Rate:
All items should be rated on admission, discharge and at the annual follow up interval post injury. Admission ratings for all items are to be established within 72 hours of admission by those clinical disciplines assigned to rate each item. Discharge ratings for all items should be established within 72 hours of discharge, preferably discussed during the discharge conference.

What Items to Rate:
Ratings are to reflect actual observed performance, not capability. The type of activity evaluated for Bathing, Transfers, and walking/wheelchair should be specified on the worksheet and rated the same way by all raters of the discipline required to assess those items.

A blank rating on any item indicates "not applicable," or "untested" or" unknown." Rarely is this rating appropriate to use, especially when a backup rater is available. Two examples of when it is appropriate to leave a blank are when Speech Pathology or Therapeutic Recreation has not evaluated a patient because no referral was made, the patient does not speak English, or patient refused the service, i.e. Therapeutic Recreation, and no backup discipline is available.

Caution in Processing and Interpreting Scale Values: The functional abilities of the patient are rated on an ordinal scale which reflects a "better than" or "worse than" relationship between adjacent categories. Although numbers have been assigned to each level of the scale to facilitate computerization of the data, the reader is cautioned that these numbers do not necessarily represent equal distances between any comparable points on the scale. Therefore, mathematical operations performed on these ordinal data points will not necessarily result in valid computations. Conclusions drawn from invalid computations will be of questionable validity.

Tips: FIM+FAM ratings
It is easiest and most accurate, from our experience, to use the Decision Tree (flow chart) to rate the FIM+FAM rather than the GUIDE (syllabus). If you use the syllabus, read all definitions of ratings under an item, i.e., do not focus on a definition that may appear to describe the patient without also looking at the definitions of ratings above and below your choice. Also, sub-headings in bold (e.g., moderate assistance, etc.) can be misleading without reading the definitions that follow.

Note that a FIM+FAM rating of 1 (total assistance) does not necessarily describe a person in coma or persistent vegetative state. A person can do up to 25% of a task and still be rated as 1.

THE FUNCTIONAL INDEPENDENCE MEASURE (FIM)
AND FUNCTIONAL ASSESSMENT MEASURE (FAM)

History of FAM ITEMS:
The FAM (1) was developed at SCMVC specifically for the brain injured population, and consists of 12 items added to the 18 items of the Functional Independence Measure (FIM) (2) .

1. Developed at Santa Clara Valley Medical Center, 751 So. Bascom Ave., Box 70, San Jose, California 95128. Contact: Karyl Hall Ed.D., (408) 295-9896 x16; FAX (408) 295-9913.

2. Developed by the Uniform Data System for Medical Rehabilitation, State University of New York at Buffalo, 232 Parker Hall, SUNY So. Campus, 3435 Main St., Buffalo, New York 14214. (716) 829-2076, FAX (716) 829-2080.

The 7 point Rating Scale is as follows:

INDEPENDENT Another person is not required for the activity (NO HELPER).

7 Complete Independence - All of the tasks described as making up the activity are typically performed safely without modification, assistive devices, or aids and within reasonable time.

6 Modified Independence - Activity requires any one or more of the following: An assistive device, more than reasonable time, or there are safety (risk) considerations.

DEPENDENT Another person is required for either supervision or physical assistance in order for the activity to be performed, or it is not performed (REQUIRES HELPER).

MODIFIED DEPENDENCE - The subject expends half (50%) or more of the effort. The levels of assistance required are:

5 Supervision or Setup - Subject requires no more help than standby, cueing or coaxing, without physical contact. Or, helper sets up needed items or applies orthoses.

4 Minimal Contact Assistance - With physical contact the subject requires no more help than touching, and subject expends 75% or more of the effort.

3 Moderate Assistance - Subject requires more help than touching, or expends half (50%) or more (up to 75%) of the effort.

COMPLETE DEPENDENCE - The subject expends less than half (less than 50%) of the effort, maximal or total assistance is required, or the activity is not performed. The levels of assistance required are:

2 Maximal Assistance - Subject expends less than 50% of the effort, but at least 25%.

1 Total Assistance - Subject expends less than 25% of the effort.

Each item is operationally defined in terms of these 7 levels.

Decsion Trees

The FAM Decsion Trees are rating tools. They guide raters to a final score by asking a series of questions for each item. They can improve both accuracy and reliability.

You can download a Portable Document Format (PDF) version of the FAM Decision Trees.

(What is PDF and How do I use PDF Files?)

7. SWALLOWING

Ability to safely eat a regular diet by mouth.

7 Complete Independence - able to eat a regular diet of choice in a reasonable period of time.

6 Modified Independence - able to eat a regular diet by mouth. May require excessive time for eating. May require assistive devices or multiple swallows to clear food.

5 Supervision (Modified Dependence) - able to take all nourishment by mouth. May need modified diet. Supervision required for cueing, coaxing. May need assistance with food choices.

4 Minimal Assistance (Modified Dependence) -able to take primary nourishment by mouth. May require diet restrictions. Minimal assistance required to monitor speed and amount of food intake. Subject performs 75% of the activity.

3 Moderate Assistance (Modified Dependence) - able to take some nourishment by mouth. May require diet restrictions and modifications. May require moderate assistance to monitor speed and amount of food intake. Subject performs 50 - 74% of the activity.

2 Maximal Assistance (Dependent) - unable to receive adequate nourishment via oral feedings. Tube feedings provide primary nutrition. Oral feedings are limited and require maximal assistance. Subject performs 25 - 49% of the activity.

1 Total Assistance - unable to take anything by mouth. Nutrition is provided via tube feedings.

13. CAR TRANSFERS

The activity includes approaching the car, managing the car door and lock, getting on or off the car seat and managing the seat belt. If a wheelchair is used for mobility, the activity includes loading and unloading the wheelchair.

7 Complete Independence - The patient is able to complete the activity without assistive devices, or aids, and within a reasonable amount of time.

6 Modified Independence - The patient requires an assistive device or aid, requires more than a reasonable amount of time or there is a safety risk in completing the activity.

5 Supervision (Modified Dependence) - The patient requires cueing, but no physical assistance, to complete the activity.

4 Minimal Assistance (Modified Dependence) - The patient performs at least 75% of the activity, requiring some contact assistance.

3 Moderate Assistance (Modified Dependence) - The patient performs 50-75% of the activity, but requires assistance.

2 Maximal Assistance (Complete Dependence) - The patient performs 25-49% of activity and requires heavy assistance.

1 Total Assistance (Complete Dependence) - The patient performs less than 25% of the activity and requires heavy assistance.

16. COMMUNITY ACCESS

Ability to manage transportation including planning a route, time management, paying fares, and anticipating access barriers (excluding car transfers).

7 Complete Independence - The patient independently uses public transportation (bus, van or taxi) or is able to drive a car.

6 Modified Independence - The patient uses adaptive devices to drive, must keep trips to a short distance due to needed rest periods; or there are safety considerations in using public transportation.

5 Supervision (Modified Dependence) - The patient requires cueing to use public transportation or ride in a car.

4 Minimal Assistance (Modified Dependence) - The patient is able to use public transportation or ride in a car, but needs some assistance. Performs at least 75% of the task without assistance.

3 Moderate Assistance (Modified Dependence) - The patient uses public transportation or rides in a car, performing 25-49% of the activity without assistance.

2 Maximal Assistance (Complete Dependence) - The patient may use public transportation or ride in a car but needs assistance for 50- 75% of the activity.

1 Total Assistance (Complete Dependence) - The patient may be able to use public transportation or ride in a car, but performs less than 25% of the activity without heavy assistance.

19. READING

Ability to understand non-vocal written material

7 Complete Independence - Completely able to read and understand complex, lengthy paragraphs (newspapers, books, etc).

6 Modified Independence - Able to read and understand complex sentences or short paragraphs. May demonstrate reduced speed or retention problems.

5 Standby Prompting - Able to read and understand short, simple sentences but shows increased difficulty with length or complexity.

4 Minimal Prompting - Able to recognize single words and familiar short phrases.

3 Moderate Prompting - Able to recognize letters, objects, forms, etc. Able to match words to pictures (50-75% accuracy).

2 Maximal Prompting - Able to match identical objects, forms, letters (25- 49% accuracy) but may require cues.

1 Total Assistance - Unable to consistently match or recognize identicalletters, objects or forms (under 25% accuracy).

20. WRITING

Includes spelling, grammar, and completeness of written communication.

7 Complete Independence - Able to write with complete average accuracy in spelling, grammar, syntax, punctuation, and completeness.

6 Modified Independence - Able to accurately write sentences and form short paragraphs. May have occasional spelling or grammatical errors.

5 Standby Prompting - Able to write phrases or simple sentences. Evidences spelling, grammar, syntax errors.

4 Minimal Prompting - Able to write simple words, occasional phrases to express ideas. Spelling errors and reduced legibility are evident.

3 Moderate Prompting - Able to write name (cueing may be
required) and some familiar words. Legibility is poor.

2 Maximal Prompting - Able to write some letters spontaneously. Able to trace or copy letters and numbers.

1 Total Assistance - Unable to copy letters or simple shapes.

21. SPEECH INTELLIGIBILITY

Includes articulation, rate, volume, and quality of vocal communication.

7 Complete Independence - Able to converse with well articulated, well modulated articulation and voice. No difficulty understanding what is being said.

6 Modified Independence - Evidence of minor sound distortions but generally adequate intelligibility. Speaking rate may be reduced.

5 Standby Prompting - Speech intelligibility is always reduced. Articulation is consistently distorted. May attempt self- corrections.

4 Minimal Prompting - Able to intelligibly produce single words and simple phrases. General conversation intelligibility.

3 Moderate Prompting - Can produce single syllable words with adequate intelligibility. Listener burden evident for sentences or longer verbalization.

2 Maximal Prompting - Can produce vowels, some consonants. Can imitate some single words but productions may require listener guessing.

1 Total Assistance - No intelligible speech.

23. EMOTIONAL STATUS

Includes frequency and severity of depression, anxiety, frustration, ability, unresponsiveness, agitation, interference with general life functioning, ability to cope with and take responsibility for emotional behavior.

7 Complete Independence - Patient rarely exhibits depression, anxiety, frustration, lability and/or agitation and is effectively able to control this behavior reflecting self responsibility and involvement in general life functioning.

6 Modified Independence - Patient may exhibit occasional but minimal depression, anxiety, frustration, lability and/or agitation. Coping skills are adequate to keep distress within manageable limits. Behavior does not interfere with general life functioning.

5 Supervision - Patient exhibits occasional and mild depression, anxiety, frustration, lability and/or agitation. Patient has assumed responsibility for most of this behavior and is learning to cope with his/her condition. This behavior does not significantly interfere with general life functioning.

4 Minimal Direction - Patient exhibits frequent and moderate depression, anxiety, frustration, lability and/or agitation. Patient assumes responsibility for this behavior and it does not interfere with general life functioning 75% or more of the time.

3 Moderate Direction - Patient exhibits frequent and moderate depression, anxiety, frustration, lability and/or agitation. Patient assumes responsibility for some behavior. Behavior does not interfere with general life functioning 50-75% of the time.

2 Maximal Direction - Patient exhibits constant and severe depression, anxiety, frustration, lability and/or agitation. Patient is able to control this behavior 25-49% of the time. This behavior interferes with general life functioning.

1 Total Assistance - Patient exhibits constant and severe depression, anxiety, frustration, lability, unresponsiveness, and/or agitation. Patient is aware and able to control this behavior less than 25% of the time. Behavior continually interferes with general life functioning.

24. ADJUSTMENT TO LIMITATIONS

Includes denial/awareness, acceptance of limitations, willingness to learn new ways of functioning, compensating, taking appropriate safety precautions, and realistic expectations for long term recovery.

7 Complete Independence - Patient demonstrates ability to compensate for limitations which are the result of the patient's disease or injury, exercise safe judgement in ADL's, and have realistic expectations for long term recovery.

6 Modified Independence - Patient may have some difficulty coping with physical, emotional or social limitations, but this does not interfere with general life functioning. Patient compensates for most of these limitations and has learned new ways of functioning. Patient may have some unrealistic expectations for long term recovery. Patient exercises safe judgement in ADL's most of the time.

5 Supervision - Patient has difficulty coping with physical, emotional and social limitations. Patient is beginning to compensate for some of these limitations and is willing to learn new ways of functioning. Patient may still have unrealistic expectations for long term recovery.

4 Minimal Direction - Patient copes with limitations in general life functioning 75% or more of the time. However, patient resists compensating for limitations and learning new ways of functioning.

3 Moderate Direction - Patient may have some awareness of physical, emotional, or social limitations which are the result of the patient's disease or injury. Successful coping with limitations occurs 50-75% of the time.

2 Maximal Direction - Patient may have limited awareness of physical, emotional, or social limitations which are the result of the patient's injury or disease. Successful coping with limitations occurs 25-49% of the time.

1 Total Assistance - Patient has no awareness of physical, emotional or social limitations which are the result of the patient's disease or injury. Patient copes with these limitations in general life functioning less than 25% of the time.

25. EMPLOYABILITY

The term employed or employability as used in this scale
represents involvement in one or more of the following categories:

. in the work force
. as a student
. as a homemaker

If the person is of retirement age and retired, score should reflect the person's potential for employment. If the person is a student and/or homemaker, score should reflect how well the person is functioning in that capacity, in determining potential for employment. If the person is in a sheltered workshop, (s)he will score a 2,3,or 4 depending on the level of functioning. The disability may be physical, cognitive, and/or psychosocial.

7 Complete Independence - Can compete in the open market for a relatively wide range of jobs commensurate with existing skills; or can initiate, plan, execute and assume responsibilities associated with homemaking; or can understand and carry out most age relevant school assignments and maintain at least a C average.

6 Modified Independence - Because of disability can only compete in a limited job market. Person may have an adjusted workload, or requires an assistive device, but is able to do selected jobs competitively, maintain the home and/or stay in school.

5 Supervision - Person requires re-training to develop necessary skills and requires supervision. There may be some safety considerations. Student may require tutoring to pass courses.

4 Minimal Assistance - Person not only requires supervision but also some assistance to get the job done or stay in school, e.g., special classes. Person could not compete in the job market.

3 Moderate Assistance - Level of assistance requires someone available at all times to assist in the task if necessary. This person could not be left alone to do homemaking, nor function successfully in a school environment.

2 Maximal Assistance - Cannot function effectively, is unable to fulfill responsibilities of a job, homemaker or student. Requires maximum assistance on all tasks.

1 Total Assistance - Not employable. Not re-trainable at this time. Cannot complete even the simplest tasks, even with maximum assistance. A person in coma or totally dependent would fall into this category.

28. ORIENTATION

Includes consistent orientation to person, place, time and situation.

7 Complete Independence - Completely oriented to person, place, time and situation 100% of the time without cues.

6 Modified Independence - Patient may require more than a reasonable amount of time to respond. May use self-initiating or environmental cues, prompts or aids but does not require the assistance of another person.

5 Supervision - Patient requires cues from others, but is oriented to person, place, time and situation.

4 Minimal Prompting - Patient is oriented to 3 out of 4 aspects and requires no external cues from others 75% or more of the time.

3 Moderate Prompting - Patient is oriented to 2 out of 4 aspects and requires no external cues from others 50-75% of the time.

2 Maximal - Patient is oriented to only 1 out of 4 aspects and requires no external cues from others 25-49% of the time.

1 Total Assistance - Patient is oriented to person, place, time or situation less than 25% of the time.

29. ATTENTION

Defined as the length of time able to concentrate on a task, taking into consideration distractibility, level of responsiveness, and the difficulty and length of task.

7 Complete Independence - Patient is able to attend continuously to a task for 60 minutes without assistance in maintaining attention to the task.

6 Modified Independence - Patient is able to attend to a task for 60 minutes without assistance in maintaining attention, but distractibility may delay completion of the task.

5 Supervision - Patient is able to attend to a task for 30-59 minutes, but needs supervision to assist in coping with the effects of distractibility.

4 Minimal Direction - Patient is able to attend to a task for 15- 29 minutes but needs assistance to minimize distractibility. Able to attend more than 75% of the time on the task.

3 Moderate Direction - Patient is able to attend to a task for 5- 14 minutes, but needs assistance to minimize distractibility. Able to attend 50-75% of the time on the task.

2 Maximal Direction - Patient is able to attend to a task for 1-4 minutes, but is frequently distracted. Able to attend 25-49% of the time on the task.

1 Total Assistance - Patient is not able to attend to a task for more than 1 minute and attends less than 25% of the time on the task.

30. SAFETY JUDGEMENT

Includes orientation to one's situation, awareness of one's deficits and their implications, ability to plan ahead, ability to understand the nature of situations involving potential danger and to identify risks involved, freedom from impulsivity, ability to remember safety related information, and ability to respond appropriately if danger arises.

7 Complete Independence - Patient has no impairment on any of the above safety judgement related abilities and can be left alone indefinitely and/or can pursue all normal activities alone.

6 Modified Independence - Patient can be left alone for an entire day but may need some degree of supervision with new or complex activities. Routine activities can be pursued independently.

5 Supervision - Patient has sufficient impairment in one or more of the above activities to need some degree of supervision in the community, i.e., person needs daily supervision and/or some degree of help with routine activities in the community (patient can be left alone at home for short periods--routine activities only).

4 Minimal Direction - Patient is independent only within the hospital or other structured setting, and needs no supervision in this setting once an activity is learned. Patient needs close supervision by staff or trained family when leaving this setting. Patient could not be left alone in the home, due to safety considerations.

3 Moderate Direction - Patient needs supervision for safety in unstructured hospital/community settings, e.g. patient may go to therapies, dayroom and patio alone, but must be supervised in all other areas. Patient could not be left alone in the home.

2 Maximal Direction - Patient needs supervision for safety in all settings. Patient is allowed off the ward for treatments only when accompanied by staff or trained family. Posey restraint is optional.

1 Total Assistance - Patient requires close supervision (poseyed or one on one supervision) i.e., if in hospital patient is allowed off the unit only for treatments and only with staff (or family with specific physician order).

Note: Rate lowest category applicable