3.3 Functional Status and ADLs

ACMA Accredited Case Manager ACM

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1 Introduction & Exam Overview

1.1 About the ACM Credential 1.2 Exam Format and Scoring 1.3 Eligibility, Fees, and Recertification

2 Screening Data & Clinical History

2.1 Assessment Data Sources 2.2 Health Literacy, Behaviors, and Illness Response 2.3 Medical and Psychosocial History

3 Capacity, Culture & Function

3.1 Developmental Level and Cognitive Status 3.2 Belief Systems and Cultural Influences 3.3 Functional Status and ADLs

4 SDOH, Capacity & Directives

4.1 Social Determinants of Health 4.2 Decisional Capacity and Decision Makers 4.3 Advance Directives and Goals of Care

5 Communication, Barriers & Goals

5.1 Communicating Assessment Findings 5.2 Discharge Barriers and Readmission Risk 5.3 Discussing Patient Goals and Plan of Care

6 Collaboration & Plan of Care

6.1 Interdisciplinary Collaboration and Continuum Needs 6.2 Educating Patients About Resources 6.3 Collaborative Plan of Care and Patient Choice

7 Entitlements & Post-Acute Coverage

7.1 Medicare Parts A, B, C, and D 7.2 Medicaid, LTSS, and Managed Care 7.3 VA and Other Entitlement Programs 7.4 SNF 3-Day Qualifying Stay Rule

8 Regulatory, Notices & Ethics

8.1 HIPAA Privacy and TPO 8.2 EMTALA Emergency Obligations 8.3 CMS Notices: IM, MOON, NOMNC, and ABN 8.4 Mandated Reporting and ACMA Ethics

9 Delivery, Placement & Barriers

9.1 Timely Service Delivery Across the Continuum 9.2 Post-Acute Placement: SNF, IRF, LTACH, and Home Health 9.3 Referrals and Clinical/Operational Barriers 9.4 Patient and Family Barriers and Education

10 Status, UM & Authorization

10.1 Observation, Inpatient, and the 2-Midnight Rule 10.2 Medical Necessity Criteria: InterQual and MCG 10.3 Payer Authorization, Denials, and Appeals 10.4 Condition Code 44 and Status Changes

11 Culture, Payer Comms & Delays

11.1 Cultural Competence in the Plan of Care 11.2 Communicating Payer Issues to the Team 11.3 Avoidable Delays and Throughput

12 Evaluation & Safety

12.1 Evaluating Interventions with Data 12.2 External Resources: Payers, Agencies, Providers 12.3 Patient Safety and Risk Management

13 Quality & Transitions Integration

13.1 HRRP and Readmission Penalties 13.2 Value-Based Programs: HVBP, Bundles, and ACOs 13.3 Transitions Models and Post-Discharge Follow-Up

14 Specialty Simulation Prep

14.1 Simulation Format: Information Gathering and Decision Making 14.2 ACM-RN Specialty Simulation Focus 14.3 ACM-SW Specialty Simulation Focus

3.3 Functional Status and ADLs

Key Takeaways Explain This Topic AI

ADLs are basic self-care tasks (bathing, dressing, toileting, transferring, continence, feeding); IADLs are community/household tasks (shopping, cooking, medications, finances, transportation, housekeeping, phone/laundry).

Document what the patient can do safely today versus premorbid baseline; delirium, pain, and acute illness temporarily depress function and can mislead disposition if not reassessed.

Rehab potential depends on medical stability, cognition/motivation to participate, prior function, and therapy recommendations—not on a single nursing note of "weak."

Functional status drives discharge setting: home with self-care or family support, home health, outpatient therapy, IRF, SNF, LTACH, or long-term custodial care.

Case managers synthesize PT/OT/ST findings, nursing mobility scores, and caregiver capacity into a feasible plan that matches payer rules and patient goals.

Last updated: July 2026

3.3 Functional Status and ADLs

Quick Answer: Measure function as safe performance of ADLs and IADLs today compared with premorbid baseline, using PT/OT/ST and nursing observations—not patient hope alone. Match discharge setting to supervision needs and rehab potential, and reassess after delirium, pain, or acute illness clears so temporary dependence does not become an unnecessary institutional placement.

Blueprint 1B8 asks ACM candidates to assess functional status , including activities of daily living, and to understand implications for rehabilitation and transitions. Function is the bridge between “medically ready” and “safe to leave.” A patient can be afebrile with normalized labs and still be unable to toilet, transfer, or manage insulin—making home unsafe without support.

ADLs vs IADLs
Basic ADLs (self-care)

Classic basic ADLs (often remembered with Katz-style domains) include:

ADL Case-management relevance
Bathing Need for aide assistance, shower equipment, fall risk
Dressing Upper/lower extremity function; adaptive equipment
Toileting Continence program; bedside commode; infection risk
Transferring Bed mobility, sit-to-stand, pivot; key for home vs facility
Continence Product needs; caregiver burden; skin integrity
Feeding Swallow safety links to ST; aspiration risk

Some tools also track grooming and walking/locomotion separately. Know your facility’s language (e.g., “max assist ×2 transfer,” “standby assist,” “independent with rolling walker”).

IADLs (independent living skills)

Instrumental ADLs (Lawton-style) include the skills needed to live independently in the community:

Using the telephone / communication devices
Shopping
Food preparation
Housekeeping
Laundry
Transportation / driving or arranging rides
Managing medications
Managing finances

IADL failure with preserved ADLs is common in early dementia and after mild stroke: the patient dresses and feeds but cannot manage a med box or bills. That pattern often means home is only safe with a reliable medication-and-finance support person—even if the patient “walks in the hall.”

How to gather functional data (multi-source)

ACM screening expects triangulation:

Patient report — useful for goals and perceived ability; often overestimates.

Caregiver report — better for baseline and home reality; watch for burnout or conflicting agendas.

Nursing documentation — bed mobility, falls, incontinence, restraint/alarm use, assistance with meals.

PT/OT/ST evaluations — gold standard for objective assist levels, equipment, cognition for safety, swallow, and rehab candidacy.

Premorbid baseline — “What did a usual day look like two weeks before admission?” Living alone, climbing stairs, driving, and prior therapy response matter.

Document assist level + device + distance/endurance when available: “Ambulated 40 feet with rolling walker, contact-guard assist, O₂ 2 L, stopped twice for dyspnea.” Vague “ambulates with help” is weak for payer and placement decisions.

Temporary vs baseline impairment

Acute illness, pain, orthostasis, anemia, and delirium can make a previously independent person look totally dependent. Case-management traps:

Locking in SNF placement on hospital day 1 based on delirious performance

Ignoring that a patient who lived alone last month may recover to that baseline with therapy and medical treatment

Conversely, assuming “they’ll be fine at home” because they were independent historically despite a new dense hemiplegia

Rule: Record both premorbid and current function, note expected trajectory, and time disposition decisions to clinical recovery and therapy reassessments when safe.

Rehab potential — what it means operationally

“Rehab potential” is not optimism. Therapy and medical teams weigh:

Factor Higher rehab potential signals Lower rehab potential signals
Medical stability Able to tolerate therapy intensity Unstable, frequent clinical interruptions

Cognition / behavior Can follow commands, learn, recall precautions Severe untreated delirium, profound advanced dementia without learning

Prior function Recently high function; clear goal to return
Motivation / participation Engages in sessions Refuses therapy persistently after barriers addressed

Prognosis / disease course Recoverable insult (joint replacement, deconditioning) End-stage disease with comfort-focused goals

Support system Caregiver can reinforce skills at next site No support and unsafe home architecture

Settings that hinge on rehab potential and intensity:

Inpatient Rehabilitation Facility (IRF): generally needs ability to tolerate intensive therapy (commonly described as ~3 hours/day across disciplines for appropriate candidates), medical necessity for hospital-level rehab, and qualifying conditions per payer rules.

Skilled Nursing Facility (SNF): skilled nursing and/or therapy at a less intensive daily pace; also used when skilled needs exist without IRF criteria.

Home Health: homebound criteria (for Medicare) plus intermittent skilled need; ADLs may still be impaired but manageable with intermittent visits and caregiver support.

Outpatient therapy: adequate transport and endurance; safer when home supports ADLs between visits.

Long-term acute care (LTACH): complex medical needs more than primary rehab intensity.

Know the clinical picture first; payer authorization rules (Domain 2) build on accurate functional documentation.

Discharge implications by functional pattern

Pattern Typical CM direction
Independent ADLs/IADLs, reliable supports Home; reinforce education; routine follow-up

Independent ADLs; impaired med/finance IADLs Home only with medication supervision / caregiver; consider HH RN teaching

Needs assist with transfers/toileting; caregiver available 24/7 Home with equipment + HH or private aides if skilled need exists

Needs assist; no caregiver; stairs-only access Facility vs temporary stay until environment adapted
Needs intensive daily therapy; qualifies medically IRF consideration
Skilled needs, cannot tolerate IRF intensity SNF consideration

Total care, no rehab goals, custodial only Long-term care planning; Medicaid LTSS pathways may apply (later sections)

Always pair function with environment : stairs, bathroom location, durable medical equipment already in home, and whether the caregiver can physically assist (their own health limits matter).

CM documentation that drives decisions

Strong functional notes include:

Premorbid vs current ADLs/IADLs
Therapy assist levels and frequency of sessions tolerated
Cognitive contribution to safety (impulsivity, carryover of precautions)
Caregiver capacity and willingness
Equipment ordered or needed (walker, bedside commode, hospital bed, grab bars)
Barriers (homelessness, unsafe home, no transportation) linking to 1D/1B5

Explicit recommendation alignment: “OT recommends SNF for ADL retraining; daughter unavailable days; home unsafe alone.”

Exam traps

Confusing ADLs with IADLs (med management is IADL).

Using patient self-report alone for assist levels.

Equating “walks in hall with PT” with safe independent home mobility including toileting at night.

Ignoring swallow/feeding (ST) when planning oral meds and diet at the next site.

Finalizing custodial nursing-home placement during untreated delirium without reassessment.

Forgetting that caregiver absence can convert a “home-appropriate” functional profile into a facility need.

Bridge to the rest of Domain 1 and Domain 2

Functional status connects to cognitive assessment (1B3) , SDOH and living supports (1B5) , discharge barriers/readmission risk (1D) , post-acute placement (2H) , and payer medical-necessity rules (2J). On ACM items, the winning answer usually synthesizes objective therapy data, baseline comparison, caregiver reality, and the least restrictive safe setting that matches goals—not the fastest empty bed.