Using the Barthel Scale: Facility Guide and FAQ

Each year in the U.S., around 795,000 people have a stroke, many of whom face lasting mobility limitations and long-term disability. The Barthel Scale — also called the Barthel Index (BI) — is a standardized tool used to measure a patient’s ability to complete activities of daily living (ADLs) after they’ve had a stroke. By assigning a score to the patient’s functional status, providers can more accurately track rehabilitative progress and tailor their treatments accordingly.

In this article, we’ll first provide an overview of the Barthel scoring process before answering some key questions about the scale alongside a few best practices for its effective implementation at your facility. With this guide as a resource, you’ll be able to generate meaningful data around post-stroke challenges, targeting treatments more effectively and enabling better recovery outcomes.

The Barthel Scale: An Overview?

Developed in 1965, the Barthel Index (of activities of daily living) was one of the first assessments used to measure a person’s functional independence. Although the scale 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:

1. Feeding
2. Bathing
3. Grooming
4. Dressing
5. Bowels
6. Bladder
7. Toilet use
8. Transfers (bed to chair and back)
9. Mobility (on level surfaces)
10. Stairs

By measuring each of these functional areas, the clinician can better pinpoint therapeutic needs and gauge a patient’s overall independence in completing ADLs.

The Barthel Scoring System’s Value

One of the main reasons to use a tool like the Barthel functional assessment is to objectively measure a person’s performance and abilities. Without a standardized tool, it becomes particularly difficult to track a person’s progress over time. Rehabilitation goals should be grounded in objective measures (like the Barthel system scores) and meaningful data analysis.

The Barthel Scale also serves as an invaluable source of information for guiding care plan development and documentation. Knowing how much assistance is needed to complete common tasks helps to customize care objectives for the patient. In addition, care plans are a key component of Medicare documentation for skilled nursing facilities (SNFs) and are required for reimbursement.

Barthel Index Scoring Determinations

The scale 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 Score Interpretations

Each of the 10 functional areas on the scale is scored individually and then combined for a total score. The number of points assigned to each individual item depends on the version your facility uses. The original version of the Barthel ADL index 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:

However, variation in categories does exist and a consensus hasn’t been reached for an exact cutoff score for deciding when assistance is required. Many facilities use a score of 61 as the limit for assisted independence.

The Barthel Scale: FAQ

For a more in-depth examination of the Barthel tool and its many applications within healthcare, we’ll answer some common questions below.

What are the limitations of the Barthel functional assessment scale?

The Barthel scoring system 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 zero, 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 staff.

How is it different from other assessment tools?

The Barthel ADL Index 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 Barthel tool is that it’s fast, simple, easy to use, and focuses specifically on ADL assessment whereas other scales are designed to assess cognitive ability or to take a more comprehensive approach.

Can a Barthel 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 crucial to maintaining the accuracy of assigned scores.

How long does it take to complete a Barthel assessment?

The scoring process is relatively quick to administer and typically only takes a few minutes.

How often should Barthel scores be assessed?

The answer depends on the needs of your patients in addition to 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 utilized more frequently to track progress over time.

Are there different types of Barthel Indexes?

Yes. The scale is often referred to by the acronym, BI, and many variations have been created over the years, including the Modified BI (MBI), a shortened five-item BI, BI-based supplementary scales (BI-SS), and others. There are many options to ensure a good fit for your facility’s specific needs.

Implementing the Barthel Scale: Facility Guide

If your facility is considering incorporating an assessment system like Barthel’s within your workflow, here are a few best practices to consider as you plan your change management process to ensure the tool’s successful adoption.

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.

Tips:

• Make sure you’re using a standard scale across departments, too. Whether it’s the traditional BI or the MBI, avoid confusion by settling on one scoring approach.
• Utilize simulation-style training to give staff the chance to practice scoring and iron out any last details before its use in real-time.

2. Use Consistent Timing

Settle on consistent times for staff to complete the index. Some teams complete assessments early in the morning to optimize a patient’s strength and success with completing ADL tasks. Other providers find scheduling the assessment after visiting hours easier with managing the rest of patient workflow. Whichever time you choose, be sure to include your organization’s expectations within policies and procedures.

Tips:

• Consider embedding the tool into documentation processes (like electronic health record, or EHR, workflows), using a stopgap to ensure consistency of assessment timing.
• Engage the patient, alerting them to the test so that they’re prepared for it and hesitation or resistance doesn’t impede the consistency of implementation.

3. Integrate With Other Assessments

The Barthel system captures the physical aspect of completing ADLs, but there are other components 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.

Tips:

• Integrate the Barthel functional assessment index into routine assessment audits or competency checkoffs to ensure its streamlined adoption.
• Create transparency around its care plan significance. For example, incorporate the scale into the talking points within interdisciplinary rounds, creating Barthel-informed recovery objectives with the entire team present.

4. Document Thoroughly

Ensure all assessments are documented with the EHR system or paper chart. Doing so will make the tool’s data accessible across disciplines, allowing clinicians who may not have been present during the assessment to leverage the results for more personalized, targeted care approaches and goals.

Tips:

• Create charting stopgaps and workflows that enforce the necessity of inputting scores and their contributing values.
• Perform routine chart audits to assess for compliance with the tool’s implementation. Consider using incentives and rewards to thank staff members who consistently perform and document their Barthel ADL assessments.

Looking for Smarter Strategies to Improve Quality of Care?

With the Barthel Scale now among your facility resources for improving patient outcomes, you may be interested in other helpful tools. Don’t waste valuable time searching. Instead, use IntelyCare’s consistently updated facility guides and best practice recommendations to stay ahead of the competition.