Using Barthel’s Index: Facility Guide and FAQ
Each year in the U.S., around 795,000 people have a stroke, many of whom go on to live with reduced mobility and long-term disability. Barthel’s Index (BI) is a numerical scale used by healthcare facilities to measure a patient’s ability to complete activities of daily living (ADLs) after they’ve had a stroke. The assessment tool computes a score based on the patient’s functional status and helps providers track rehabilitative progress.
By using this index, medical professionals in your facility can accurately measure the physical capabilities of stroke patients and evaluate the effectiveness of therapies and treatments. In this article, we’ll dive into what the Barthel Index is and how it’s used. We’ll discuss best practices for seamlessly incorporating it into your facility’s workflows and answer your most frequently asked questions.
What Is Barthel’s Index?
Developed in 1965, the Barthel Index was one of the first assessments used to measure a person’s functional independence. Although BI can be used to assess patients with a variety of conditions (e.g., Parkinson’s disease, cancer, hip fracture, traumatic brain injury), it was adapted primarily for stroke care.
Typically, the index evaluates 10 activities of daily living (ADLs) and self-care, including:
- Feeding
- Bathing
- Grooming
- Dressing
- Bowels
- Bladder
- Toilet use
- Transfers (bed to chair and back)
- Mobility (on level surfaces)
- Stairs
By measuring each of these functional areas, the clinician can identify specific areas of need and gauge a patient’s overall independence in completing ADLs.
Why Use the Barthel Index?
One of the main reasons to use a tool like BI is to objectively measure a person’s performance and abilities. Without a standardized assessment tool, it becomes particularly difficult to track a person’s progress over time. Rehabilitation goals must be based on objective measures, tracked over time, and considered when establishing discharge plans.
The BI can also be invaluable for informing care plan decisions and documentation. Knowing how much assistance is needed to complete common tasks helps to customize goals for the patient. In addition, care plans are a key component of Medicare documentation for skilled nursing facilities (SNF) and are required for reimbursement.
How Is Barthel Index Scoring Determined?
The index should score what a patient actually does, not what they could do. If the patient requires supervision to safely complete a task, they can’t receive an “independent” score for that activity. Any assistance that’s needed, no matter how minor, reduces the score. Typically, the patient’s performance is based on the previous two days’ activity.
Barthel’s Index: Scoring and Interpretation
Each of the 10 functional areas on the BI is scored individually and then combined for a total score. The number of points assigned to each individual item depends on the version of the BI your facility uses. The original version was based on a three-step scale while the more popular modified Barthel Index (MBI) uses a five-step scale.
The maximum overall score of 100 points shows total independence, while the minimum score of 0 points shows complete dependence. The lower the score, the greater the extent of assistance the person requires, according to the following general ranges:
| Total BI Score | Level of Dependence |
|---|---|
| 91-99 | Slight |
| 61-90 | Moderate |
| 21-60 | Severe |
| 0-20 | Total |
However, variation in categories does exist and a consensus hasn’t been reached for an exact cutoff score. Many facilities use a score of 61 as the limit for assisted independence.
Facility Guide for Implementation
If your facility is considering incorporating the BI within your workflows, here are a few best practices for getting started.
1. Standardize Training
If the scale is new for your staff, be sure to provide training and education. Decide which members of the multidisciplinary team — nurses, nursing assistants, and/or physical therapists — will be responsible for assessments.
2. Use Consistent Timing
Choose standardized, consistent times for staff to complete the BI. Some teams complete assessments early in the morning to optimize a patient’s strength and success in completing the tasks. Other providers find scheduling the assessment after visiting hours easier when managing patient workflow. Whichever time you choose, be sure to include your organization’s expectations in your policies and procedures.
3. Integrate With Other Assessments
The BI captures the physical aspect of completing ADLs, but there are other aspects of the patient’s health — like cognitive function — that you’ll want to assess, too. Completing the assessments simultaneously can save time and help preserve a patient’s stamina.
4. Document Thoroughly
Ensure all assessments are documented with the electronic health record (EHR) system or paper chart. Doing so will help you complete audits and evaluate the effectiveness of the new tool.
Frequently Asked Questions
What are the limitations of Barthel’s Index?
The BI does have limitations based on a “floor and ceiling effect,” meaning the extreme ends of the scale can be less sensitive to changes in patient condition. For example, if a patient is totally dependent, with a total score of 0, it will be more difficult to detect changes in their condition than a patient with moderate dependence and a score of 65. Studies have also shown poor reliability when Barthel Index score interpretation is completed by untrained nursing assistants.
How is it different from other assessment tools?
The BI is valid and reliable for assessing disability in stroke patients. Other similar scales include the Functional Independence Measure (FIM), the Modified Rankin Scale, Instrumental Activities of Daily Living (IADL), and the Stroke Impairment Assessment Set (SIAS). One of the major benefits of the BI is that it’s fast, simple, easy to use, and focuses specifically on ALD assessment whereas other scales assess for cognitive ability or take a more comprehensive approach.
Can the assessment be completed using self-reported information?
Yes, but do so with caution and only when necessary. People can overestimate their ability to complete ADLs. There also may be cognitive impairments present that limit their ability to self-assess accurately. Sometimes the perspectives of caregivers and loved ones can be useful. Direct testing is not required, but direct observations are important.
How long does it take to complete an assessment?
The BI is relatively quick to administer and typically only takes a few minutes.
How often should Barthel Index scores be assessed?
The answer depends on the needs of your patients and specific facility requirements. In acute care settings, it may only need to be used at admission, discharge, and with significant changes in condition. In SNF or rehab settings, the index may be assessed more frequently to track progress over time.
Are there different types of Barthel’s Indexes?
Yes. Many variations have been created over the years, including the MBI, a shortened five-item BI, BI-based supplementary scales (BI-SS), and others. There are a variety of options to ensure a good fit for your facility’s specific needs.
Looking for More Ways to Improve Quality of Care?
After taking a look at Barthel’s Index and answering common questions about it, you might be looking for additional ways to boost patient outcomes at your facility. IntelyCare is here to help — our newsletter is full of free quality improvement resources to support healthcare managers.