Inpatient Rehabilitation Facility Patient Assessment Instrument - Section GG

Last Updated

July 07, 2025

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Purpose

The Inpatient Rehabilitation Facility Patient Assessment Instrument Section GG (IRF-PAI Section GG) is a standardized functional assessment tool used to evaluate a patient��s independence in mobility and self-care tasks at admission and discharge across all post-acute care (PAC) settings. Section GG was created to establish uniform data collection for functional status across all PAC settings.

Link to Instrument

Acronym IRF-PAI Section GG

Area of Assessment

Activities & Participation
Bodily Functions
Movement

Administration Mode

Paper & Pencil

Cost

Free

CDE Status

Not a CDE--last searched 7/7/2025

Mixed Conditions

Stroke

Limb Loss and Amputation

The IRF-PAI Section GG consists of four elements:
1. GG0100 Prior Functioning: Everyday Activities
2. GG0110 Prior Device Use
3. GG0130 Self-Care
4. GG0170 Mobility
Self-Care consists of 7 items.
Mobility consists of 17 items, 2 of which are wheelchair specific. Patients are scored on either the walking or wheelchair items based on their primary mode of mobility. If both methods are used equally, both sets of items should be completed.
The items are scored at admission, with a discharge goal, and at discharge for patients at their highest level of functioning over a 3-day period.
Each item is scored on a 6-point scale with 1 indicating complete dependence and 6 indicating independence. Additional codes (07, 09, 10, 88) if the activity was not attempted.
Scores range from 24 to 144 for users scored for both walking and wheelchair items.
The following areas are assessed:
1. Eating
2. Oral hygiene
3. Showering or bathing self
4. Upper body dressing
5. Lower body dressing
6. Toileting hygiene
7. Rolling left to right in bed
8. Moving from lying to sitting on the side of the bed
9. Sitting to standing
10. Chair/bed-to-chair transfer
11. Toilet transfer
12. Car transfer (as applicable)
13. Walking 10 feet
14. Walking 50 feet with two turns
15. Walking 150 feet
16. 1 step (stair navigation)
17. 4 steps
18. 12 steps
19. Picking up an object from the floor
20. Wheelchair mobility (if applicable): 50 feet with two turns and 150 feet

Number of Items

24 (not including prior function section w/4 items and prior device use w/6 check boxes)

Varies based on patient abilities

15-30 minutes

Required Training

No Training

Required Training Description

Training is not required but strongly encouraged. Centers for Medicare and Medicaid Services provides free manuals, videos, and learning modules.

Child

7 - 12

years

Adolescent

13 - 17

years

Adult

18 - 64

years

Elderly Adult

65 +

years

Instrument Reviewers

Damyan Farion, Midwestern University Arizona College of Osteopathic Medicine and Medical Extern, Shirley Ryan ��B�о�Ժ, Spring 2024

Body Structure

Head
Neck
Upper Extremity
Back
Lower Extremity

ICF Domain

Body Function
Activity

Measurement Domain

Activities of Daily Living
Motor

Professional Association Recommendation

None found--last searched 7/7/2025

Considerations

Section GG combines Independence and Modified Independence categories from its predecessor, the Functional Independence Measure (FIM). As a result, maximum scores on the two tools may represent different levels of patient functioning.
Patients may receive higher ratings on Section GG due to scoring differences or bias compared to the FIM.

Cut-Off Scores

Mixed Conditions: (Harmon, 2023a; n = 1,645, age �� 18, median age (IQR) = 71 (60-80), male = 51.3%, Observational quality improvement project at a single acute IRF)

A Section GG score of ��51 can be used to identify patients at higher risk of falling during inpatient rehabilitation.
(Sensitivity: 0.747, Specificity: 0.566, Youden��s Index: 0.313, 45.4% of patients)
A Section GG Self-Care score of ��20 can be used to identify patients with reduced independence who are more likely to fall.
(Sensitivity: 0.660, Specificity: 0.632, Youden��s Index: 0.292, 38.6% of patients)
A Section GG Mobility score of ��28 can be used to identify patients at greater fall risk due to limited mobility. (Sensitivity: 0.690, Specificity: 0.595, Youden��s Index: 0.285, 42.4% of patients)

Normative Data

Mixed Conditions: (Deutsch, 2016; n = 2,922, Skilled Nursing Facility Residents; summary report prepared by RTI International for the Centers for Medicare & Medicaid Services )

Mean Admission, Discharge, and Change in Self-Care by Skilled Nursing Facility Resident Characteristics: Fee-for-Service Medicare Beneficiaries, Post-Acute Care Payment Reform Demonstration (n = 2,922)

	Self-Care at Admission Mean	Self-Care at Discharge Mean	Change in Self-Care Mean	n	%
Total Average	24.51	32.55	8.04	2,922
Age
<35	��	��	��	��	��
35-44	��	��	��	��	��
45-54	25.72	34.09	8.37	47	1.61
55-64	25.87	33.47	7.60	137	4.69
65-74	25.76	34.43	8.67	629	21.53
75-84	24.81	33.08	8.27	1,179	40.35
85-90	23.12	31.03	7.91	649	22.21
90+	22.45	28.56	6.11	265	9.07
Surgical Diagnosis
No	23.63	30.46	6.83	1,491	51.03
Yes	25.42	34.73	9.31	1,431	48.97
Prior Functioning: Indoor Ambulation
Independent	25.72	34.54	8.82	2,256	77.21
Dependent, Some Help	20.82	26.30	5.48	506	17.32
Not Applicable	17.47	22.14	4.67	70	2.4
Unknown/Missing	20.40	25.97	5.57	90	3.08
Prior Functioning: Self-Care
Independent	26.06	35.08	9.02	2,020	69.13
Some Help	21.92	28.19	6.27	727	24.88
Dependent	14.73	18.27	3.54	101	3.46
Unknown/Missing	21.04	26.08	5.04	73	��
Presence of Severe Pressure Ulcer
No	24.60	32.71	8.11	2,873	98.32
Yes	19.12	23.29	4.17	49	1.68
Stage 2 Pressure Ulcer
No	24.75	32.8	8.05	2,745	93.94
Yes	20.81	28.67	7.86	177	6.06
Cognitive Abilities: BIMS score
Intact or Borderline	26.01	34.77	8.76	1,938	66.32
Moderately Impaired	23.84	31.50	7.66	562	19.23
Severely Impaired	18.63	23.88	5.25	397	13.59
Not Assessed	16.84	21.92	5.08	25	0.86
Moderate to Severe Communication Impairment
No	25.22	33.56	8.34	2,682	91.79
Yes	16.53	21.32	4.79	240	8.21
Bladder Incontinence
Always Continent, Stress Incontinent, No Urine Output	26.27	34.87	8.60	2,145	73.41
Less Than Daily, Daily, Always	19.64	25.87	6.23	612	20.94
Not applicable (NA)	19.75	27.15	7.40	165	5.65
Bowel Incontinent
Always Continent, No bowel movement, or NA	25.71	34.31	8.60	2,485	85.04
Always Incontinent	13.99	17.56	3.57	145	4.96
Less Than Daily or Daily	19.50	25.06	5.56	292	9.99
Prior Mobility Device/Aid: Walker
No	25.32	33.61	8.29	1,586	54.28
Yes	23.55	31.30	7.75	1,336	45.72
Prior Mobility Device/Aid: Prosthetics
No	24.52	32.55	8.03	2,904	99.38
Yes	23.61	32.22	8.61	18	0.62
Prior Mobility Device/Aid: Wheelchair
No	25.08	33.5	8.42	2,484	85.01
Yes	21.25	27.19	5.94	438	14.99
Prior Mobility Device/Aid: Mechanical Lift
No	24.60	32.68	8.08	2,898	99.18
Yes	13.92	16.88	2.96	24	0.82
Swallowing Ability: Modified Food
No	24.76	32.86	8.10	2,766	94.66
Yes	20.03	27.14	7.11	156	5.34
Swallowing Ability: Tube Feeding
No	24.59	32.67	8.08	2,898	99.18
Yes	14.25	18.29	4.04	24	0.82

Mean Admission, Discharge, and Change in Mobility Score by Skilled Nursing Facility Resident Characteristics (n = 2,938)

	Mobility at Admission Mean	Mobility at Discharge Mean	Change in Mobility Mean	n	%
Total Average	34.19	55.18	21	2,938	��
Age
<35	��	��	��	��	��
35-44	��	��	��	��	��
45-54	33.94	54.77	20.83	48	1.63
55-64	37.04	54.32	17.28	141	4.80
65-74	35.64	59.24	23.60	633	21.55
75-84	34.51	56.47	21.96	1,185	40.33
85-90	32.64	52.27	19.63	649	22.09
90+	31.55	47.68	16.13	266	9.05
Surgical Diagnosis
No	34.05	51.05	17.00	1,499	51.02
Yes	34.33	59.49	25.16	1,439	48.98
Prior Functioning: Indoor Ambulation
Independent	35.41	59.02	23.61	2,272	77.33
Some Help	31.77	44.38	12.61	439	14.94
Dependent	26.09	39.07	12.98	68	2.31
Not Applicable	23.00	30.30	7.30	70	2.38
Unknown/Missing	29.73	42.38	12.65	89	3.03
Prior Functioning: Stairs
Independent	36.30	61.95	25.66	1,623	55.24
Some Help	34.01	50.42	16.41	384	13.07
Dependent	29.18	44.31	15.13	55	1.87
Not Applicable	30.59	45.96	15.37	660	22.46
Unknown/Missing	30.90	43.75	12.85	216	7.35
Prior Functioning: Functional Cognition
Independent	35.75	59.89	24.14	1,979	67.36
Some Help	31.36	46.36	15.00	606	20.63
Dependent	27.91	39.76	11.85	192	6.54
Not Applicable	37.57	50.77	13.20	47	1.60
Unknown/Missing	31.30	48.15	16.85	114	3.88
Presence of Severe Pressure Ulcer
No	34.32	55.52	21.20	2,888	98.30
Yes	26.54	35.60	9.06	50	1.70
Stage 2 Pressure Ulcer
No	34.53	55.69	21.16	2,761	93.98
Yes	28.84	47.27	18.43	177	6.02
Cognitive Abilities: BIMS score
Intact or Borderline	35.67	59.02	23.35	1,954	66.51
Moderately Impaired	33.47	52.57	19.1	564	19.20
Severely Impaired	28.46	41	12.54	396	13.48
Not Assessed	24.88	38.71	13.83	24	0.82
Communication Impairment
No Impairment	35.31	58.28	22.97	2,319	78.93
Mild	32.52	47.98	15.46	377	12.83
Moderate to Severe	25.81	36.53	10.72	230	7.83
Unable to Assess	30.45	37.64	7.19	11	0.37
Bladder Incontinence
Always Continent, Stress Incontinent, No Urine Output, or NA	35.70	58.44	22.74	2,328	79.24
Less Than Daily, Daily, Always	28.40	42.77	14.37	610	20.76
Bowel Incontinent
Always Continent, No bowel movement, or NA	35.60	58.40	22.80	2,503	85.19
Always Incontinent	22.60	28.72	6.12	144	4.9
Less Than Daily or Daily	27.79	40.58	12.79	291	9.9
History of Falls
No	35.80	57.44	21.64	1,695	57.69
Yes	31.98	52.1	20.12	1,243	42.31
Prior Mobility Device/Aid: Walker
No	35.46	57.78	22.32	1,599	54.42
Yes	32.67	52.08	19.41	1,339	45.58
Prior Mobility Device/Aid: Prosthetics
No	34.21	55.20	20.99	2,920	99.39
Yes	30.39	53.33	22.94	18	0.61
Prior Mobility Device/Aid: Wheelchair
No	35.08	57.41	22.33	2,501	85.13
Yes	29.08	42.43	13.35	437	14.87
Prior Mobility Device/Aid: Mechanical Lift
No	34.29	55.41	21.12	2,914	99.18
Yes	21.29	27.46	6.17	24	0.82
Usual Swallowing Ability: Tube Feeding
No	34.25	55.34	21.09	2,914	99.18
Yes	26.67	36.58	9.91	24	0.82
Major Treatments During Assessment Period: Total Parenteral Nutrition Recode
No	34.19	55.19	21.00	2,933	99.83
Yes	��	��	��	��	��

Mixed Conditions: (Li, 2022; n = 408,491, mean age = 70 (14.4), female = 53.2%, diagnoses: stroke (29.8%), orthopedic disorders (27.3%), neurologic conditions (17.4%), brain dysfunction (14.5%), and debility (11.1%); analysis of 2017 Uniform Data System for Medical Rehabilitation)

Summary data for Section GG (scores recalibrated on a 0-100% scale)

	n	Mean (SD)	Median (Q1, Q3)	Skewness	Kurtosis
Admission
Self-Care	291,836	44.8 (17.4)	45.7 (34.3, 57.1)	-0.1663354	- 0.0815881
Transfer	258,234	42.2 (18.7)	43.3 (30, 56.7)	-0.1308249	0.06177814
Discharge
Self-Care	348,357	77.8 (23.6)	82.9 (62.9, 100)	- 0.972366	0.22010802
Transfer	291,424	77.8 (25.7)	86.7 (60, 100)	- 1.0738632	0.34142441
Change
Self-Care	265,572	32.6 (18.4)	34.3 (20, 45.7)	- 0.1515634	0.0762552
Transfer	200,369	35.9 (20.6)	40 (20, 50)	- 0.1314327	0.01459547

Interrater/Intrarater Reliability

Mixed Conditions: (Deutsch, 2022a; n = 1,117, Inpatient Rehabilitation Facilities with ��20 Medicare stays in 2017)

Excellent interrater reliability for Self-Care quality measure scores by provider volume quartile (ICC = 0.836 - 0.965)
Excellent interrater reliability Mobility quality measure scores by provider volume quartile (ICC = 0.833 - 0.969)

Mixed Conditions: (Deutsch, 2023; n = 1,117, Inpatient Rehabilitation Facilities with ��20 Medicare stays in 2017)

Excellent interrater reliability for mobility quality measure scores overall and when stratified by provider volume (ICC = 0.898 and from 0.806 �C 0.965, respectively (P < .001)
Excellent interrater reliability for self-care quality measure scores overall and when stratified by provider volume (ICC = 0.886 and from 0.793 �C 0.964, respectively (P < .001)

Mixed Conditions: (Smith, 2012b; n = 450, report by RTI International/Brookings Institution for Centers for Medicare & Medicaid Services)

Substantial (weighted kappa = 0.61�C0.80) to Almost Perfect (weighted kappa = 0.81�C1.00) interrater reliability was found for core Self-Care and Mobility items. (Wheel 150 feet, Wheel 100 feet, and Wheel 50 feet were not included due to low sample size.)
- Self-Care item weighted kappa scores (which do not consider not attempted, unavailable, or refused scores) ranged between 0.798 (Eating) to 0.869 (Upper-Body Dressing)
- Mobility item weighted kappa scores ranged between 0.855 (Lying to Sitting on Side of Bed) to 0.901 (Sit to Stand and Chair/Bed to Chair Transfer).
Lower levels of interrater reliability were observed for inpatient rehabilitation facilities (IRFs) and Long-term Care Hospitals (LTCHs) compared to Acute Care, Home Health Agencies (HHAs), and Skilled Nursing Facilities (SNFs).

Mixed Conditions: (Smith, 2012a; report by RTI International/Brookings Institution for Centers for Medicare & Medicaid Services that assessed the interrater reliability of the CARE tool throughout video reliability testing)

Significantly higher level of interrater agreement for Section GG items when clinicians were assessing patients with higher independence. This pattern held across provider types, disciplines, and most functional assessment items (with the exception of lower body dressing and wheelchair use).

Proportion of agreement for selected functional items by dependency level of patients

Item	Agreement on low-function patients n (%)	Agreement on high- function patients n (%)	t
Eating	32 (42.7%)	130 (90.9%)	778.51*
Oral hygiene	102 (54.0%)	95 (83.3%)	583.37*
Toilet hygiene	35 (46.7%)	164 (88.2%)	666.30*
Upper body dressing	74 (62.7%)	169 (90.9%)	571.26*
Lower body dressing	105 (89.0%)	133 (71.5%)	?398.04*
Lying to sitting on side of bed	163 (86.2%)	161 (86.6%)	9.04*
Sit to stand	40 (53.3%)	174 (93.6%)	666.37*
Chair/bed-to-chair transfer	135 (71.4%)	142 (76.3%)	108.42*
Toilet transfer	65 (86.7%)	162 (87.1%)	9.29*
Wheelchair use	73 (97.3%)	175 (94.1%)	?127.53*
Walk in room once standing	51 (68%)	51 (71.8%)	50.50*
Wash upper body	126 (66.7%)	56 (78.9%)	205.55*
Roll left and right	67 (56.8%)	33 (76.74%)	252.87*
Sit to lying	21 (48.8%)	33 (76.74%)	279.53*
Putting on/taking off footwear	145 (76.7%)	163 (87.6%)	279.12*
Total	1,784 (72.9%)	3,152 (82.2%)	1,095.66*

*p < 0.001

Internal Consistency

Mixed Conditions: (Deutsch, 2022c; n = 428,192, Descriptive study of 2017 Medicare and Medicare Advantage Patients)

Excellent: Cronbach's alpha for admission and discharge self-care scores = 0.94*

Mixed Conditions: (Marino, 2024; n = 147, mean age = 77.4 (13.2), age range = 41-101, Long-Stay Nursing Home Residents)

Excellent: Cronbach's alpha for all 16 Section GG items was 0.98*
Excellent: Cronbach's alpha for the seven self-care items was 0.93*
Excellent: Cronbach's alpha for the nine mobility elements was 0.98*

*Scores higher than 0.9 may indicate redundancy in the scale questions.

Criterion Validity (Predictive/Concurrent)

Predictive Validity:

Mixed Conditions: (Harmon, 2022a)

Poor predictive validity of Section GG when predicting fall risk with Section GG Total Scores, AUC (95%CI) = 0.687 (0.638, 0.735) (P < 0.001)
Poor predictive validity of Section GG when predicting fall risk with Section GG Self-Care Scores, AUC (95%CI) = 0.681 (0.629, 0.732) (P < 0.001)
Poor predictive validity of Section GG when predicting fall risk with Section GG Mobility Scores, AUC (95%CI) = 0.666 (0.619, 0.712) (P < 0.001)

Concurrent Validity:

Mixed Conditions: (Li, 2022)

Excellent correlation between Section GG and FIM scores at admission, discharge, and changes in scores (after removing discordant scores)

Correlation Between Section GG and FIM Scores (after removing discordant scores)

Section GG Score	n	Correlation (95% CI)
Admission Score
Self-Care	291,836	0.87 (0.87, 0.87)
Transfer	258,234	0.82 (0.81, 0.82)
Discharge Score
Self-Care	348,357	0.95 (0.95, 0.95)
Transfer	291,424	0.90 (0.90, 0.90)
Change Score
Self-Care	265,572	0.80 (0.79, 0.80)
Transfer	200,369	0.73 (0.73, 0.74)

Substantive agreement between Section GG and FIM scores at admission and discharge (weighted kappa = 0.61-0.80) after removing discordant scores
Moderate agreement between change scores for Section GG and FIM scores (weighted kappa = 0.41-0.60) after removing discordant scores

Agreement between Section GG and FIM scores (after removing discordant scores)

Section GG Score	n	Kappa (95 CI) Weighted Kappa (95 CI)
Admission Score
Self-Care	291836	0.49 (0.49, 0.50) 0.68 (0.68, 0.68)
Transfer	258234	0.43 (0.43, 0.43) 0.62 (0.62, 0.62)
Discharge Score
Self-care	348357	0.60 (0.60, 0.60) 0.76 (0.76, 0.76)
Transfer	291424	0.52 (0.51, 0.52) 0.70 (0.70, 0.70)
Change Score
Self-care	265572	0.40 (0.40, 0.40) 0.58 (0.58, 0.58)
Transfer	200369	0.32 (0.31, 0.32) 0.49 (0.48, 0.49)

By condition, patients with stroke had the strongest correlation and agreement, followed by brain dysfunction, and neurologic conditions

Construct Validity

Convergent validity:

Mixed Conditions: (Marino, 2024)

Adequate to Excellent correlations between Section GG and its predecessor Section G, which employed opposite functional grading scales, ranged from r = -0.531 to -0.844
Acceptable one- and two-construct solutions with Comparative Fit Index (CFI) (r = 0.986) and Tucker-Lewis Index (TLI) (0.984)

Mixed Conditions: (Deutsch, 2022b; n = 493,209, patients discharged from 1,129 inpatient rehabilitation facilities in 2017)

Patients with higher discharge scores (from level 1 �C dependent to level 6 �C independent) were more likely to be discharged to the community This difference was observed for all self-care and mobility elements, with the exception of eating and picking up an object. When comparing more challenging mobility activities to less challenging, a higher percentage of patients were who were independent were discharged to the community.
On average, patients with a lower number of comorbidities had higher changes in mobility and self-care scores from admission to discharge compared to patients with a higher number of comorbidities.

Mixed Conditions: (Toth, 2023; n = 1,458,579, 2017 Medicare Part A SNF patient stays)

Higher percentages of patients with higher scores for self-care and mobility items were discharged to the community, with the exception of mobility items ��Walk 50 Feet with Two Turns�� and ��Walk 150 Feet,�� which had slightly higher ��Dependent�� patients than ��Substantial/maximal assistance�� patients discharged to the community.

Mixed Conditions: (Deutsch, 2022a; n = 1,117, Inpatient Rehabilitation Facilities with ��20 Medicare stays in 2017)

Significantly higher mean and median changes in Section GG Self-Care and Mobility scores at discharge centers with Stroke Rehabilitation Disease-Specific Certification Status (SRD-SCS) compared to the centers without the certification (P < 0.001)

Mean and median change in self-care and mobility quality measure scores by stroke rehabilitation disease-specific certification status (CY2017) (n = 1,117)

Measure	Stroke Rehabilitation Disease-Specific Certification Status (2017) = Yes (n = 176)	Stroke Rehabilitation Disease-Specific Certification Status (2017) = No (n = 941)
Change in Self-care Quality Measure Scores
Mean (SD)	12.1 (1.4)	11.4 (1.7)
Median (IQR)	12.0 (1.6)	11.3 (2.1)
Change in mobility quality measure scores
Mean (SD)	30.0 (3.9)	28.0 (4.6)
Median (IQR)	29.9 (5.7)	27.7 (6.3)

Quintile groups based on Section GG scores with higher percentages of IRFs having certification status were associated with the highest changes in Mobility scores. This same pattern was seen with Self-Care except for groups 4 and 3, which respectively included 25% and 25.6% of IRFs with certification (P < 0.0001)

Mixed Conditions: (Deutsch, 2023; n = 1,117, Inpatient Rehabilitation Facilities with ��20 Medicare stays in 2017)

Significantly higher mean and median Mobility and Self-Care scores on discharge at centers with the SRD-SCS certification compared to centers without the certification. (P < .001)

Mean and median quality measure scores (CY2017) by stroke rehabilitation disease-specific certification status (2017) (n = 1,117)

Measure	Stroke Rehabilitation Disease-Specific Certification Status (2017) = Yes (n = 176)	Stroke Rehabilitation Disease-Specific Certification Status (2017) = No (n = 941)
Discharge Mobility Quality Measure Score
Mean (SD)	56.4 (12.0)	49.7 (14.9)
Median (IQR)	56.5 (19.4)	49.4 (21.5)
Discharge Self-Care Quality Measure Score
Mean (SD)	61.5 (10.6)	54.8 (14.5)
Median (IQR)	62.3 (13.6)	54.7 (19.6)

For quintile groups based on Section GG scores, higher discharge mobility and self-care scores were associated with a higher percentage of certified IRFs. Aside from groups 2 and 3, the opposite was observed with groups with lower quality measure scores on discharge��which were associated with lower percentage of certified IRFs (P < 0.0001)

Discriminant validity

Mixed Conditions: (Li, 2022)

Patients with higher independence tended to have higher Section GG scores compared to their corresponding scores on the Functional Independence Measure (FIM). At admission, lower agreement between the two instruments was observed when evaluating patients lower average ability levels. Similar agreement was observed with higher functioning patients when evaluating changes in scores throughout an admission.

Mixed Conditions: (Harmon, 2023a)

Significantly lower Section GG total, self-care, and mobility scores for patients who experienced a fall during their inpatient stay (P < 0.001)

Patient scores on Section GG and self-care/mobility subscales for fallers and non-fallers

Demographics	Total	Non-fallers	Fallers
Patients, n (%)	1,645	1,545 (93.9)	100 (6.1)
Section GG, median (IQR)	54 (40�C66)	54 (41�C67)	41 (31�C52)
Self-Care	22 (18�C26)	22 (18�C26)	18 (13�C23)
Mobility	31 (22�C40)	31 (22�C41)	24 (20�C31)

IQR = interquartile range

Mixed Conditions: (Marino, 2024; n = 147, Long-Stay Nursing Home Residents)

The following hierarchies, ordered from easiest to difficult were calculated utilizing Rasch Analysis
- Self-Care: eating, oral hygiene, upper body dressing, toileting hygiene, lower body dressing, putting on/taking off footwear, and shower/bathe self
- Mobility: roll left to right, sit to lying, lying to sitting on side of bed, chair/bed-to-chair transfer, sit to stand, toilet transfer, walk 10 feet, walk 50 feet with two turns, and walk 150 feet

Floor/Ceiling Effects

Mixed Conditions: (Li, 2022)

Adequate: Floor and ceiling effects for self-care (<2%) and transfer (<5%) elements at admission
Adequate: Floor effect of <10% for self-care and transfer elements at discharge
Poor: Ceiling effects for self-care and transfer elements at discharge were >20% and >40%, respectively

Cut-Off Scores

Stroke: (Herbold, 2023a; n = 1,051, mean age = 67.9 (13.6), male = 567 (53.8%); retrospective, observational cohort study at one IRF of adults with stroke)

A cut-off score of 33.5 can be used to discharge a patient to home when deciding between a discharge to home (with or without homecare) or to a skilled nursing facility
A cut-off score of 36.5 can be used to discharge a patient to home when deciding between home with outpatient services or a skilled nursing facility

Normative Data

Stroke: (Herbold, 2023b; n = 1,087, male = 585 (53.8%) Retrospective cohort study of stroke patients at one IRF)

Section GG self-care and mobility scores at admission, discharge, and 90-day post-discharge follow-up

Self-Care (scale range = 7-42):

Time/Group	n	Sample Range	Mean (SD)	Median (Q1, Q4)	Skewness (SE)
Admission:
All	1087	7-35	16.8 (6.1)	17 (12, 21)	0.01 (0.07)
Inpatient Only	817	7-35	16.7 (6.1)	17 (12, 17)	0.02 (0.09)
Follow-Up	270	7-31	16.9 (6.1)	17 (12, 22)	-0.03 (0.15)
Discharge:
All	1087	7-42	30.1 (9.0)	30 (23, 38)	-0.34 (0.07)
Inpatient Only	817	7-42	30.1 (9.2)	31 (23, 39)	-0.34 (0.09)
Follow-Up	270	7-42	30.2 (8.5)	30 (24, 38)	-0.33 (0.15)
Post-Discharge Day 90 Follow-Up	270	7-42	34.1 (9.6)	40 (27, 42)	-0.94 (0.15)

Mobility (scale range = 15-90):

Time/Group	n	Sample Range	Mean (SD)	Median (Q1, Q4)	Skewness (SE)
Admission:
All	1087	15-68	29.1 (10.4)	27 (21, 35)	0.73 (0.07)
Inpatient Only	817	15-62	28.8 (9.9)	27 (21, 35)	0.64 (0.09)
Follow-Up	270	15-68	29.8 (11.8)	27.5 (21, 36.3)	0.73 (0.15)
Discharge:
All	1087	15-90	57.3 (21.5)	60 (40, 76)	- 0.24 (0.07)
Inpatient Only	817	15-90	57.0 (21.7)	60 (39, 76)	-0.25 (0.09)
Follow-Up	270	15-90	58.3 (21.1)	60 (42.8, 78)	-0.23 (0.15)
Post-Discharge Day 90 Follow-Up	270	15-90	71.0 (22.0)	80 (57.8, 90)	-1.05 (0.15)

Stroke: (Harmon, 2023b; n = 1,296, mean age = 70 (14), female = 607 (46.8%), Retrospective cohort study at one IRF)

Median Section GG scores at admission and discharge

Section GG Score	Median (IQR)
at Admission	61 (41-78)
at Discharge	97 (81-121)

Stroke: (Harmon, 2024; n = 208, median age (IQR) = 70 (59-79), female = 90 (43.3%), Prospective observational cohort study at an IRF)

Median Section GG scores

Total Physical Functioning
Admission median (IQR)	50 (33 to 65)
Discharge median (IQR)	96 (72 to 119)
Change median (IQR)	42 (24 to 55)
Self-Care
Admission median (IQR)	19 (14 to 24)
Discharge median (IQR)	32 (25 to 40)
Change median (IQR)	13 (8 to 18)
Mobility
Admission median (IQR)	29 (19 to 44)
Discharge median (IQR)	65 (44 to 78)
Change median (IQR)	29 (15 to 39)

IQR = interquartile range

Internal Consistency

Stroke: (Harmon, 2023b)

Excellent: Cronbach's alpha for admission scores = 0.971*. After excluding patients with 7 (patient refusal), 9 (N/A), and 10 (not attempted because of environmental limitations) codes it was 0.973*
Excellent: Cronbach's alpha for discharge scores = 0.983*. After excluding patients with 7, 9, and 10 codes it was 0.985*

Stroke: (Harmon, 2024)

Excellent: Cronbach's alpha for Total functioning, Self-Care, and Mobility scores were >0.95*

*Scores higher than 0.9 may indicate redundancy in the scale questions.

Criterion Validity (Predictive/Concurrent)

Concurrent validity:

Stroke: (Harmon, 2023b)

Excellent correlation between Section GG and the Functional Independence Measure Motor Subscale (FIMm) on admission (�� = 0.919), discharge (�� = 0.929), and when measuring patient gains throughout treatment (�� = 0.789)
- After excluding patients with 7, 9, and 10 codes, �� = 0.925, 0.931, and 0.788, respectively, for the categories listed above

Stroke: (Harmon, 2024)

Excellent correlations between Total physical function, Self-Care, and Mobility Section GG subscales scores and the modified Rankin Scale (mRS) at admission (�� < -0.67) and discharge (�� < -0.71)
Adequate correlations between mRS and Total physical function (�� = -0.49), mobility (�� = -0.47), and self-care (�� = -0.36) score changes on Section GG (all p < 0.001)

Predictive validity:

Stroke: (Herbold, 2023a)

Adequate ability of Section GG to predict discharge destination between home (with or without homecare) vs. skilled nursing facility, AUC (95%CI) = 0.82 (0.80, 0.85)
Adequate ability of Section GG to predict discharge destination between home with homecare vs. skilled nursing facility, AUC (95%CI) = 0.79 (0.76, 0.82)
Adequate ability of Section GG to predict discharge destination between home with outpatient services vs. skilled nursing facility, AUC (95%CI) = 0.89 (0.86, 0.91)
Poor ability of Section GG to predict discharge destination between home with outpatient services vs. home with homecare, AUC (95%CI) = 0.67 (0.63, 0.71)
Logistic regression indicated the presence of a caregiver is the most significant factor for discharge destination decision-making (P < 0.001).

Logistic regression comparisons of discharge destinations with significant prediction variables and model assessment

Discharge Destination	Variable	Odds Ratio (95% CI)	Nagelkerke R²	Hosmer & Lemeshow (P)	Overall Accuracy of the Model	Percent Correctly Predicted
Home with or without Homecare vs SNF*	Admission Section GG	1.13 (1.12-1.15)	0.40	.25	78.4%	87.5% (Home)
	Caregiver Present	2.68 (1.87-3.83)				57.8% (SNF)
	Sex	1.40 (1.02-1.93)
Home with OP* vs Home with Homecare	Admission Section GG	1.06 (1.05-1.08)	0.21	.15	72.6%	41.8% (Home with OP)
	Caregiver Present	1.67 (1.12-2.51)				89.2% (Home with Homecare)
	Age	0.96 (0.95-0.97)
Home with Homecare vs SNF*	Admission Section GG	1.12 (1.10-1.14)	0.34	.77	74.6%	80.6% (Home with Homecare)
	Caregiver Present	2.58 (1.78-3.76)				65.5% (SNF)
Home with OP vs SNF*	Admission Section GG	1.17 (1.14-1.20)	0.62	.29	84.2%	79.5% (Home with OP)
	Caregiver Present	3.71 (2.12-6.50)				87.9% (SNF)
	Age	0.96 (0.94-0.98)

*P < 0.001 for logistic regression

Construct Validity

Stroke: (Harmon, 2023b)

Bias towards higher scores on both admission (Bias = 2.3%, P < 0.001) and discharge (Bias = 6.2%, P < 0.001), along with greater gains in function (Bias=3.9%, P < 0.001), especially with walking and stair usage (Bias = 3.71%, P < 0.001), were seen on Section GG when compared to the Functional Independence Measure Motor Subscale (FIMm). Similar bias was also seen in Section GG Admission (2.2%, P < 0.001), Discharge (6.1%, P < 0.001), and Change (3.9%, P < 0.001) in score data after removing 7, 9, and 10 codes.

Stroke: (Herbold, 2023a)

Throughout one-way ANOVA, Herbold et al. found that age differed based on discharge destination, on average, younger patients were discharged to home with outpatient service compared to home with homecare or SNF discharge. Patients discharged to SNF also had the longest length of stays and the lowest Section GG scores at both admission and discharge. (P < 0.001)
Significant main effect of discharge destination on admission Section GG scores, with scores decreasing as discharge setting became more dependent (F(2,2) = 50.8, P = 0.019), and a significant interaction between discharge destination and caregiver presence (F(2,1045) = 3.68, P = 0.025). Individuals living alone had higher admission Section GG scores than those with caregivers, regardless of discharge destination.

Mean (SD) and range of age, length of stay in inpatient rehabilitation unit, and Section GG scores at admission and discharge

Variable	Statistic	Aggregate Sample (n = 1051)	Home with Outpatient Services (n = 249)	Home with Homecare (n = 480)	SNF (n = 322)
Age (y)	Mean (SD)	67.9 (13.6)	61.8^a (13.6)	69.9^a (13.3)	69.6^a (12.6)
	Range	22-101	22-93	25-101	32-95
Length of Stay (d)	Mean (SD)	21.1 (9.2)	16.4^b (7.3)	20.5^b (9.2)	25.5^b (8.6)
	Range	2-105	2-42	5-105	8-92
Admission Section GG Score	Mean (SD)	36.6^b (12.7)	45.4^b (10.7)	38.6^b (11.1)	27.0^b (9.7)
	Range	16-67	16-67	16-65	16-63
Discharge Section GG Score	Mean (SD)	67.1^b (21.3)	82.5^b (14.7)	73.3^b (16.7)	46.1^b (14.9)
	Range	16-96	20-96	19-96	16-90

^aHome with outpatient services significantly different from home with homecare and SNF, P < 0.001

^bAll groups had statistically significant differences from each other, P < 0.001

Floor/Ceiling Effects

Stroke: (Harmon, 2023b)

Adequate: Floor effect at admission was 2.9%. After excluding patients with 7, 9, and 10 codes it was 3% (n = 35)
Excellent: Ceiling effect at admission was 0%
Adequate: Floor effect at discharge was 0.2%. After excluding patients with 7, 9, and 10 codes it was 0.3% (n = 3)
Adequate: Ceiling effect at discharge was 8.6%. After excluding patients with 7, 9, and 10 codes it was 9.1% (n = 106)

Stroke: (Herbold, 2023b)

Adequate: Floor effect for self-care elements at admission for all patients, inpatient only patients, and patients at follow up were 9.8%, 10.2%, and 9% respectively
Excellent: Ceiling effect for self-care elements at admission for all patients, inpatient only patients, and patients at follow up were all 0%
Adequate: Floor effect for self-care elements at discharge for all patients, inpatient only patients, patients at follow up, and patients at 90-day follow up were 0.3%, 0.2%, 0.4%, and 0.7% respectively
Adequate: Ceiling effect for self-care elements at discharge for all patients, inpatient only patients, and patients at follow up were 11.2%, 12%, and 8.9% respectively
Adequate: Floor effect for mobility elements at admission for all patients, inpatient only patients, and patients at follow up were 7.2%, 6.9%, and 8.1% respectively
Excellent: Ceiling effect for mobility elements at admission for all patients, inpatient only patients, and patients at follow up were all 0%
Adequate: Floor effect for mobility elements at discharge for all patients, inpatient only patients, patients at follow up, and patients at 90-day follow up were 0.5%, 0.5%, 0.4%, and 1.5% respectively
Adequate: Ceiling effect for mobility elements at discharge for all patients, inpatient only patients, and patients at follow up were 4.6%, 4.9%, and 3.7% respectively
Poor: Ceiling effect for self-care and mobility elements at 90-day follow up were 45.2% and 32.2% respectively

Section GG Floor and Ceiling Effects for Self-Care and Mobility Scores at Admission, Discharge, and 90-day Post-Discharge Follow-up

Self-Care:

Time/Group	n	Floor Effect n (%)	Ceiling Effect n (%)
Admission:
All	1087	107 (9.8)	0 (0.0)
Inpatient Only	817	83 (10.2)	0 (0.0)
Follow-Up	270	24 (9.0)	0 (0.0)
Discharge:
All	1087	3 (0.3)	122 (11.2)
Inpatient Only	817	2 (0.2)	98 (12.0)
Follow-Up	270	1 (0.4)	24 (8.9)
Post-Discharge Day 90 Follow-Up	270	2 (0.7)	122 (45.2)

Mobility:

Time/Group	n	Floor Effect n (%)	Ceiling Effect n (%)
Admission:
All	1087	78 (7.2)	0 (0.0)
Inpatient Only	817	56 (6.9)	0 (0.0)
Follow-Up	270	22 (8.1)	0 (0.0)
Discharge:
All	1087	5 (0.5)	50 (4.6)
Inpatient Only	817	4 (0.5)	40 (4.9)
Follow-Up	270	1 (0.4)	10 (3.7)
Post-Discharge Day 90 Follow-Up	270	4 (1.5)	87 (32.2)

Responsiveness

Stroke: (Herbold, 2023b)

Large Standardized Response Means (SRM) for both self-care and mobility were observed from admission to discharge.
A Moderate SRM was observed from discharge to 90-day follow-up for mobility.
A Low SRM was observed from discharge to 90-day follow-up for self-care.

Standardized response means from admission to discharge and from discharge to 90-day post-discharge follow-up by group (all mean changes p < 0.001)

Time/Group	Mean Change (SD)	Standardized Response Mean (SRM)
Self-Care
Admission to Discharge
Inpatient	13.4 (6.4)	2.09
Follow-Up	13.3 (6.3)	2.11
Discharge to Post-Discharge Day 90
Follow-Up	3.9 (8.5)	0.46
Mobility
Admission to Discharge
Inpatient	28.2 (16.1)	1.75
Follow-Up	28.5 (15.5)	1.84
Discharge to Post-Discharge Day 90
Follow-Up	12.7 (18.5)	0.68

Normative Data

Limb Loss and Amputation: (Chang, 2024; n = 156 (29 w/mean age = 62.4 (12.1); male = 21 (72.4%) readmitted to acute care and 137 w/mean age = 64.8 (13.4); male = 90 (70.9%) discharged to community), retrospective cohort study)

Section GG Mean (SD) Total Scores by Patient Status (n = 133)

Variable	Readmission to acute care, n = 23	Discharge to community, n = 110	P value
Section GG score, mean (SD)	37.0 (14.7)	45.0 (14.4)	<0.00

Construct Validity

Discriminant Validity:

Limb Loss and Amputation: (Chang, 2024)

Significant ability of Section GG total scores to discriminate between patients readmitted to acute care and those discharged to the community (P < 0.001)

Bibliography

Chang, C.-H., Lopez, K., Wasser, T., & Mei, H. (2024). Risk factors for readmission of patients with amputation to acute care from inpatient rehabilitation: A retrospective cohort study. PM&R, 16(3), 231�C238.

Deutsch, A., Palmer, L., Kline, T., Ignaczak, M., Toth, M., & Lepore, M. (2016). Technical Expert Panel Summary Report: Development of Functional Outcome Quality Measures for Skilled Nursing Facilities (SNFs). Prepared for Centers for Medicare & Medicaid Services.

Deutsch, A., McMullen, T., Vaughan, M., Palmer, L., Kwon, S., & Ingber, M. J. (2022c). Change in Self-Care Quality Measure for Inpatient Rehabilitation Facilities: Exclusion Criteria and Risk-Adjustment Model. Archives of Physical Medicine and Rehabilitation, 103(6), 1085�C1095.

Deutsch, A., Palmer, L., Vaughan, M., McMullen, T., Karmarkar, A., Kwon, S., & Ingber, M. J. (2022a). Inpatient Rehabilitation Facility Change in Self-Care and Change in Mobility Quality Measures: Development and Reliability and Validity Testing. Archives of Physical Medicine and Rehabilitation, 103(6), 1105�C1112.

Deutsch, A., Palmer, L., Vaughan, M., McMullen, T., Kwon, S., Karmarkar, A., & Ingber, M. J. (2023). Reliability and Validity of the Inpatient Rehabilitation Facility Discharge Mobility and Self-Care Quality Measures. Journal of the American Medical Directors Association, 24(5), 723-728.e4.

Deutsch, A., Palmer, L., Vaughan, M., Schwartz, C., & McMullen, T. (2022b). Inpatient Rehabilitation Facility Patients�� Functional Abilities and Validity Testing of the Standardized Self-Care and Mobility Data Elements. Archives of Physical Medicine and Rehabilitation, 103(6), 1070-1084.e3.

Harmon, E. Y., Cournan, M. C., & Teale, A. E. (2023a). Predicting Falls in Rehabilitation: A Comparison of Three Instruments Including Hester Davis. Rehabilitation Nursing Journal, 48(4), 124.

Harmon, E. Y., Niyirora, J., Teale, A. E., Sonagere, M. B., Linsenmeyer, M. A., & Nicolson, L. (2024). Assessing Clinically Important Differences During Rehabilitation for Stroke: A Pilot Study Evaluating Anchor and Distribution Derived Estimates of Physical Function Change in Classically Summed and Rasch Models of Section GG of the Inpatient Rehabilitation Facility Patient Assessment Instrument. Archives of Physical Medicine and Rehabilitation, 105(7), 1282�C1288.

Harmon, E. Y., & Sonagere, M. B. (2023b). Concurrent Validation of the Inpatient Rehabilitation Facility Patient Assessment Instrument Version 1.4; Sections GG, B, and C. Archives of Physical Medicine and Rehabilitation, 104(12), 1995�C2001.

Herbold, J., Elmohsen, E., Gutierrez, G., Helgesen, M., & Babyar, S. (2023a). Prediction of Discharge Destination After Inpatient Rehabilitation for Stroke Using Mobility and Self-Care Assessment in Section GG of the Inpatient Rehabilitation Facility �C Patient Assessment Instrument. Archives of Rehabilitation ��B�о�Ժ and Clinical Translation, 5(4).

Herbold, J., O��Brien, T., Peters, K., Sanichar, A., & Babyar, S. (2023b). Responsiveness of Section GG Scores in Tracking Post-Stroke Functional Recovery From Inpatient Rehabilitation Admission to 90-Day Follow-Up. Archives of Physical Medicine and Rehabilitation, 104(12), 2002�C2010.

Li, C.-Y., Mallinson, T., Kim, H., Graham, J., Kuo, Y.-F., & Ottenbacher, K. J. (2022). Characterizing Standardized Functional Data at Inpatient Rehabilitation Facilities. Journal of the American Medical Directors Association, 23(11), 1845-1853.e5.

Marino, M., Deutsch, A., Kline, T., Smith, A., Li, Q., Beizer, J., & McMullen, T. (2024). Reliability and Validity of the Minimum Data Set 3.0 Standardized Self-Care and Mobility Data Elements Among Long-Stay Nursing Home Residents. ��B�о�Ժ in Gerontological Nursing, 17(2), 57�C64.

Smith, L., Deutsch, A., Barch, D., Ross, J., Shamsuddin, K., Abbate, J. H., Schwartz, C., & Gage, B. (2012a). Continuity Assessment Record and Evaluation (CARE) Item Set: Video Reliability Testing. Prepared for Centers for Medicare & Medicaid Services.

Smith, L., Deutsch, A., Hand, L., Etlinger, A., Ross, J., Abbate, J. H., Gage-Croll, Z., Barch, D., & Gage, B. (2012b). Continuity Assessment Record and Evaluation (CARE) Item Set: Additional Provider-Type Specific Interrater Reliability Analyses. Prepared for Centers for Medicare & Medicaid Services.

Toth, M., Palmer, L., Marino, M. E., Smith, A., Schwartz, C., Deutsch, A., & McMullen, T. (2023). Validation of the Standardized Function Data Elements among Medicare Skilled Nursing Facility Residents. Journal of the American Medical Directors Association, 24(3), 307-313.e1.

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Bibliography

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