Using AM-PAC “6-Clicks” Inpatient: Improving Functional Outcomes in Post-Acute Care

AM-PAC inpatient assessment tools are revolutionizing how healthcare providers measure and improve patient functional outcomes. Accurate functional assessment during hospitalization remains a critical yet challenging aspect of patient care, with significant implications for discharge planning and recovery trajectories.

The AM-PAC “6-Clicks” assessment, a validated functional assessment tool, offers a streamlined approach to post-acute care measurement. Initially developed at Boston University, this inpatient mobility assessment provides clinicians with a standardized method to evaluate basic mobility, daily activities, and cognitive function. Additionally, the tool serves as an effective discharge planning tool, helping healthcare teams make evidence-based decisions about appropriate post-discharge care settings. Consequently, implementation of AM-PAC assessments can potentially reduce unnecessary costs while optimizing patient outcomes.

This article explores how AM-PAC inpatient assessments contribute to improved functional outcomes, specifically examining their predictive value for post-acute care needs. We’ll analyze the assessment structure, scoring system, and implementation strategies based on a comprehensive study of 5,236 electronic medical records. Furthermore, we’ll identify key factors influencing recovery success and provide practical guidance for clinical integration of this valuable assessment framework.

Understanding AM-PAC Inpatient Cognitive Scores

The Activity Measure for Post-Acute Care Applied Cognitive Inpatient Short Form (AM-PAC ACISF) offers clinicians a reliable method for assessing cognitive function in hospitalized patients. Unlike other cognitive assessments, this tool focuses primarily on functional cognition relevant to daily activities and discharge planning.

AM-PAC ACISF Structure and Scoring System

The AM-PAC ACISF consists of six carefully selected items that assess discrete cognitive elements essential for independent functioning. These items evaluate a patient’s ability to handle everyday cognitive tasks including: following a speech or presentation, understanding ordinary conversation, taking medications correctly, remembering where items were placed, recalling a list of 4-5 errands, and managing complicated tasks [1].

Each item receives a score from 1 to 4 points based on observed difficulty:

• 1 point (Unable): Patient cannot complete the task or requires help/cueing
• 2 points (A lot of difficulty): Patient can complete independently but with substantial extra time/effort
• 3 points (A little difficulty): Patient needs slightly more time/effort but no assistance
• 4 points (No difficulty): Patient completes task without issues

The raw score totals range from 6-24 points, with higher scores indicating better cognitive function [1]. Notably, the AM-PAC ACISF demonstrates excellent psychometric properties with 91% test-retest reliability and 86% interrater reliability [1]. The assessment takes approximately one minute to administer, making it particularly suitable for the fast-paced acute care environment [2].

Tertile Classification: Low, Middle, High

After obtaining raw scores, clinicians convert them to standardized T-scale scores using a transformation process that enhances interpretability and clinical utility. These standardized scores are then categorized into three distinct tertiles that represent different functional levels:

Tertile

T-Scale Score Range

Functional Level

Highest

47.8 - 62.2

Minimal cognitive limitations

Middle

30.5 - 44.3

Moderate cognitive limitations

Lowest

7.7 - 28.8

Significant cognitive limitations

This tertile classification provides meaningful clinical distinctions between patient groups [1]. According to research, patients with scores in the lowest tertile face nearly four times greater odds of requiring post-acute care compared to those in the highest tertile (OR=3.7, 95%CI 3.1,4.3) [1]. Likewise, patients in the middle tertile have twice the odds of needing post-acute care versus the highest tertile (OR=2.0, 95% CI=1.7, 2.3) [1].

Cutoff Score of 21 for Cognitive Impairment

Beyond tertile classification, research has established that a raw score threshold of 21 points or less indicates cognitive impairment [1]. This cutoff score (corresponding to <22) has been validated as optimal for identifying cognitive dysfunction in acute care settings [2].

Patients scoring below this threshold often demonstrate difficulties with important daily cognitive tasks that could impact their safe discharge home. This standardized cutoff helps clinicians quickly identify patients who may require additional cognitive support or specialized discharge planning.

Although originally designed as a self-reported measure, the AM-PAC ACISF can also be scored by proxy through observations by occupational therapists or speech-language pathologists [1]. This flexibility allows for assessment of patients who may have communication difficulties or limited insight into their cognitive challenges.

Study Design and Patient Cohort Overview

The clinical effectiveness of AM-PAC inpatient assessments stems from robust research methodology and careful patient selection criteria. To better understand how these scores predict post-acute care needs, researchers designed a comprehensive study that balances statistical power with clinical relevance.

Retrospective Analysis of 5,236 EMRs at JHH

The primary investigation employed a retrospective observational design analyzing 5,236 electronic medical records from adult patients admitted to Johns Hopkins Hospital (JHH) [3]. This extensive analysis covered admissions between July 1, 2020, and November 2, 2021, providing a substantial contemporary dataset [3]. The data collection procedures received appropriate oversight, with a waiver of consent approved by the Institutional Review Board at Johns Hopkins University [3]. Moreover, all extracted data underwent validation procedures to ensure accuracy and completeness before analysis [3].

The retrospective approach offered several advantages over prospective designs, such as access to naturally occurring clinical documentation, elimination of observer effects, and the ability to analyze a larger patient population across diverse clinical settings. This approach enabled researchers to examine real-world implementation of functional assessment tools without disrupting standard clinical workflows.

Inclusion and Exclusion Criteria for Data

To maintain methodological rigor, the study established clear boundaries regarding which patient records would be included in the analysis. First, only adult patients admitted to general hospital units were considered eligible. Subsequently, patients from psychiatric units and labor and delivery units were specifically excluded from the analysis [3]. These exclusions helped create a more homogeneous sample focused on medical and surgical patients.

Other studies examining AM-PAC “6-Clicks” assessments have employed similar methodologies with varying sample sizes. For instance, one investigation analyzed 3,999 patients admitted to medical units between June 2019 and February 2020 [4], while another examined 3,739 adults on general medical units between January 2018 and February 2020 [5]. These parallel investigations reinforce the validity of the JHH study design through methodological consistency across research teams.

The sample size of 5,236 patients represents one of the largest cohorts examined for AM-PAC assessments, providing sufficient statistical power to detect clinically meaningful associations between scores and outcomes. Additionally, by collecting data across all hospital services (rather than limiting to specific units), the study produced findings with broader clinical applicability.

Assessment Timing: Within 72 Hours of Admission

A critical methodological decision involved when to measure functional status during hospitalization. The research team determined that the first recorded applied cognition t-scale scores using the AM-PAC ACISF within 72 hours of hospital admission would serve as the primary exposure variable [3]. This early assessment timeframe carries significant clinical implications since it enables prompt identification of patients who might require additional resources or post-acute care planning.

The 72-hour window represents a balance between allowing patients to stabilize after admission yet capturing functional status early enough to inform care planning. In contrast, some complementary studies have used even stricter timeframes, such as collecting AM-PAC scores within 48 hours of admission [6]. These methodological variations help establish whether assessment timing influences predictive accuracy.

Through meticulous record selection and careful timing of assessments, researchers created an analytical framework that maximizes both internal validity and external applicability. The resulting dataset formed the foundation for examining relationships between AM-PAC scores and post-discharge outcomes.

Predictive Power of AM-PAC Scores for Discharge Outcomes

Statistical analysis reveals powerful correlations between AM-PAC scores and patient discharge destinations. Early assessment results offer clinicians valuable insight into potential post-acute care (PAC) needs, enabling proactive discharge planning and resource allocation.

Odds Ratios for PAC Needs by Tertile

AM-PAC “6-Clicks” scores demonstrate remarkable predictive capability when categorized by tertiles. Patients with basic mobility scores in the high-risk category (lowest tertile) show significantly higher odds of requiring post-acute care facility (PACF) placement versus those in the low-risk category (highest tertile). Indeed, admission mobility scores in the high-risk category indicate patients are 9.33 times more likely to be discharged to a PACF than those in the low-risk group [5]. This predictive power becomes even more pronounced at discharge, where high-risk patients are 28.9 times more likely to need PACF placement than low-risk patients [5].

Similar patterns emerge with cognitive assessments. Unadjusted regression models show that patients with AM-PAC ACISF t-scale scores in the lowest tertile (7.7-28.8 points) face four times greater odds of requiring PAC compared to highest tertile patients (47.8-62.2 points) [1]. Even patients in the middle tertile demonstrate 2.1 times higher odds of PAC needs than highest tertile counterparts [3].

10-Point Score Decrease and PAC Risk Increase

Beyond tertile classifications, AM-PAC scores function effectively as continuous variables for predicting discharge needs. Each incremental change in score corresponds to measurable differences in PAC likelihood. Every 10-point decrease in AM-PAC ACISF scores correlates with 1.4 times higher odds for discharge to a PAC facility [1].

Meanwhile, mobility scores exhibit similar patterns. Each point decrease in initial AM-PAC mobility score increases facility discharge odds by 1.15-fold, whereas each point decrease in activity score raises these odds by 1.16-fold [7]. This granular relationship between score changes and outcomes enables clinicians to track progress throughout hospitalization and adjust discharge plans accordingly.

Multivariate Regression Adjustments

The predictive strength of AM-PAC scores persists even after controlling for potential confounding factors. Adjusted regression models demonstrate that patients with AM-PAC ACISF t-scale scores in the lowest tertile still have 3.4 times greater odds of PAC needs compared to highest tertile patients [1]. Likewise, middle tertile patients maintain 1.9 times greater odds for PAC requirements than highest tertile counterparts [3].

Multivariate logistic regression analyzes further confirm that initial mobility and activity scores independently predict discharge destination after accounting for variables like age, diagnosis, and comorbidities [7]. The robustness of these associations is demonstrated through receiver operating characteristic (ROC) curve analyzes, with area under the curve (AUC) values of 0.806 for mobility and 0.796 for activity scores [7]. These figures indicate excellent discriminative ability, far exceeding the 0.70 threshold typically considered clinically useful.

Essentially, AM-PAC inpatient assessments provide clinicians with statistically validated tools for early identification of patients likely to require post-acute care services. These predictions remain stable regardless of demographic factors, making the assessment particularly valuable across diverse patient populations.

Key Factors Influencing Recovery Success

Beyond assessment scores alone, several patient characteristics significantly influence recovery trajectories and post-acute care (PAC) needs. Understanding these factors enables clinicians to better interpret AM-PAC inpatient assessments within a broader clinical context.

Impact of Living Alone and Prior Residence

Living arrangement emerges as a powerful predictor of discharge outcomes. Patients living alone prior to hospitalization face substantially higher odds of requiring post-acute care services [1]. This remains true even after controlling for functional assessment scores. Similarly, individuals not married demonstrate 1.29 times greater likelihood of facility discharge (95% CI, 1.07-1.54; p<.01) [8].

Prior residence status constitutes yet another decisive factor. Patients admitted from settings other than private homes exhibit markedly increased odds of PAC needs (OR 1.2–4.4, p=<0.001) [1]. This correlation holds true across various functional ability levels, suggesting that safe return to previous living environments requires consideration beyond functional assessment scores alone.

Certainly, pre-hospitalization functional status heavily influences recovery trajectories. Acute hospitalization, especially for older adults, often precipitates profound and persistent functional decline that may continue for at least one year post-discharge [9].

Service Type: Neurology, Surgery, Orthopedics

Hospital service type profoundly affects recovery pathways. Interestingly, patients admitted under neurology, general surgery, or orthopedic services demonstrate significantly higher odds of PAC needs relative to medicine service patients (OR 1.2–4.4, p=<0.001) [1].

Length of hospital stay equally affects discharge disposition. Patients with stays exceeding 7.1 days show 29% greater likelihood of skilled nursing facility (SNF) placement versus those discharged within two days (RR=1.29; 95% CI, 1.09-1.51, p<.01) [8].

Timely intervention proves critical, especially with stroke patients. Functional improvement appears most significant within six months after stroke onset, making this period crucial for implementing rehabilitation strategies [10].

Gender and Comorbidity Count as Predictors

Demographic factors contribute substantially to recovery outcomes. Predominantly, male gender correlates with increased odds of PAC needs (OR 1.2–4.4, p=<0.001) [1]. Simultaneously, age represents a meaningful predictor—each 10-year age increase corresponds to 6% higher likelihood of SNF discharge (RR=1.06; 95% CI, 1.01-1.12, p=.01) [8].

People discharged to SNFs typically fit a specific demographic profile: older, Black, female, uninsured, lower income, and having lower premorbid function [8]. Nevertheless, insurance status, geographic location, and hospital complications often influence discharge decisions beyond functional ability assessments [8].

Despite the value of the 6-Clicks assessment as a discharge planning tool, these assessments explain relatively little variance in discharge placement decisions. Less than 19% of variance in discharge placement can be attributed to any variables examined in related studies [8], indicating that discharge planning remains a complex, multifactorial process requiring comprehensive clinical judgment.

Clinical Integration and Implementation Feasibility

Successful implementation of AM-PAC inpatient assessments requires thoughtful integration into existing clinical workflows. Johns Hopkins Hospital (JHH) offers a model for effective adoption across multiple disciplines.

Training Protocols for OT and SLP Staff

JHH leadership integrated AM-PAC ACISF cognitive assessment into daily clinical practice through a structured approach. Prior to implementation, all occupational therapists (OTs) and speech-language pathologists (SLPs) completed standardized training [1]. This preparation involved a 20-minute recorded presentation that covered scoring criteria, assessment rationale, and proper documentation in electronic medical records [3]. The recording ensured consistent delivery across all practitioners after the tool’s initial integration in August 2020 [1].

1-Minute Assessment Time in Routine Care

A key factor in successful adoption was the minimal time burden. The AM-PAC ACISF assessment adds just one minute of additional time to routine patient evaluations [1]. This efficiency makes the tool practical for busy clinical environments without disrupting workflow. Therapists generally report that completing the assessment is “quick and effortless” [11]. One practitioner noted, “It doesn’t take long. It doesn’t really affect us negatively in any sense” [11].

2% Compliance in Clinical Use

JHH achieved remarkably high implementation rates. Initial compliance audits revealed 98.2% adherence among OTs and SLPs in completing the AM-PAC ACISF during patient sessions [1]. Yet, therapist perceptions varied regarding clinical utility. Many viewed the tool primarily as an administrative requirement rather than a clinical decision-making aid [11]. As one participant explained, “It doesn’t really change much of anything. It’s pretty quick, which is nice” [11]. Though not universally embraced for routine clinical decisions, therapists recognized potential value for administrative planning and cross-disciplinary communication [11].

Conclusion

The AM-PAC “6-Clicks” inpatient assessment tools stand as powerful predictors of post-discharge needs and recovery trajectories. Their validated scoring system, particularly the cognitive assessment with its 6-24 point range, offers clinicians a standardized approach to evaluating patient function. Notably, patients scoring in the lowest tertile face nearly four times greater odds of requiring post-acute care compared to highest tertile counterparts. Additionally, each 10-point decrease in cognitive scores correlates with 1.4 times higher odds for facility placement, regardless of demographic factors.

Patient characteristics beyond assessment scores significantly influence recovery outcomes. Living alone, prior residence status, hospital service type, and length of stay all contribute substantially to discharge planning decisions. Therefore, clinicians must consider these factors alongside AM-PAC scores when determining appropriate post-discharge care.

Johns Hopkins Hospital demonstrates successful integration of AM-PAC assessments through structured training protocols and efficient implementation. The minimal time burden—just one minute per assessment—facilitates high compliance rates while maintaining workflow efficiency. Though some practitioners view the tool primarily as an administrative requirement, its value for cross-disciplinary communication remains evident.

AM-PAC “6-Clicks” assessments ultimately provide healthcare teams with early identification of patients likely to need additional support after discharge. This early awareness allows for proactive planning, appropriate resource allocation, and potentially reduced healthcare costs. As healthcare systems continue seeking evidence-based methods to optimize patient outcomes, these standardized functional assessments offer a practical, validated approach to enhancing discharge planning and post-acute care coordination.

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