Functional mobility is a central determinant of independence, safety, and quality of life for residents of skilled nursing facilities (SNFs). Mobility limitations contribute significantly to adverse outcomes in this population. Between 50% and 75% of long-term care residents experience at least one fall annually, with 10% - 20% sustaining serious injury. Approximately 30% -40% of post-acute SNF residents demonstrate measurable functional decline within the first 90 days of admission. In the United States alone, fall-related injuries among older adults generate an estimated $50 billion in annual healthcare costs [1].

Although rehabilitation services are routinely available in SNFs, mobility promotion is frequently fragmented and therapy-centric, with inconsistent reinforcement of therapy-developed mobility plans during nursing care hours when residents spend most of their day. This fragmentation limits carryover of therapeutic gains and undermines fall prevention efforts.

Interdisciplinary and ecological models of care emphasize interactions between individual capacity, environment, and organizational systems. Applying these principles requires structured protocols that embed mobility into daily care routines across disciplines [2][3].

While existing SNF mobility programs have demonstrated feasibility [4][5], most lack comprehensive operational frameworks for sustainable implementation. This protocol advances prior work through three key innovations: First, it provides a structured implementation framework specifying accountability mechanisms and workflow integration strategies adaptable to diverse SNF contexts. Second, it establishes explicit fidelity monitoring with predefined adherence thresholds and corrective action pathways. Third, it integrates implementation science principles with quality improvement methodology to support sustained organizational behavior change. These elements address critical gaps in translating evidence-based mobility practices into routine SNF care delivery.

Table 2 outlines the roles, responsibilities, and documentation requirements for each discipline involved in program implementation.

Table 2. Interdisciplinary roles and responsibilities.

Note: ADL = Activities of Daily Living.

Figure 1 illustrates the interdisciplinary team structure and communication pathways central to program implementation.

Figure 1. Interdisciplinary team structure and communication flow. This illustrative workflow model depicts role relationships and information exchange pathways within skilled nursing facility setting. The model shows bidirectional communication between all disciplines with the resident at the center of care. Weekly interdisciplinary care conferences serve as the formal communication hub, with daily informal communications occurring through electronic health record documentation and verbal handoffs. PT = physical therapy; OT = occupational therapy; RN = registered nurse; CNA = certified nursing assistant; MD = physician medical director.

The program integrates strength training, balance activities, standardized ambulation protocols, environmental modifications, and interdisciplinary staff education.

Implementation is structured to support gradual integration and staff adaptation (Figure 2).

Figure 2. Four-phase implementation timeline. This recommended phased approach for program initiation shows approximate durations and key milestones for a mid-sized (80 - 150 bed) skilled nursing facility. Timeline is adaptable based on facility size, baseline QAPI maturity, and readiness assessment results. Phases may overlap depending on implementation pace and early successes. Smaller facilities may compress timeline; larger facilities or those with limited QI infrastructure may extend phases.

Evaluation Logic Model

This evaluation framework links needs assessment findings to intervention components and expected outcomes:

LogicChain1:FallReduction: 1) Need: 68% of falls occur during transfers; 42% during evening shifts. 2) Intervention: Structured transfer technique training + supervised pre-bedtime mobility routines. 3) Primary outcome: ≥30% reduction in overall fall rate (falls per 1000 resident-days). 4) Secondary outcomes: ≥50% reduction in transfer-related falls; ≥40% reduction in evening shift falls. 5) Measurement: Monthly fall rate analysis; incident report review with root cause categorization.

LogicChain2:DocumentationandCareContinuity: 1) Need: Inconsistent ambulation documentation in 64% of charts. 2) Intervention: Standardized documentation templates + fidelity audits with feedback. 3) Primary outcome: ≥85% documentation compliance across all disciplines. 4) Secondary outcome: Improved continuity of care evidenced by nursing handoff quality. 5) Measurement: Weekly chart audits; quarterly nursing handoff observations.

LogicChain3:StaffCompetenceandSafety: 1) Need: 42% of staff report limited confidence assisting mobility. 2) Intervention: Competency-based education + hands-on skills validation + ongoing mentoring. 3) Primary outcome: ≥80% of staff report confidence ≥4 on 5-point scale at 6-month reassessment. 4) Secondary outcomes: Improved staff safety (≥20% reduction in workplace injuries during transfers). 5) Measurement: Pre-post staff confidence surveys; occupational injury tracking.

LogicChain4:FunctionalOutcomes: 1) Need: 30% - 40% of post-acute residents experience functional decline. 2) Intervention: Progressive strength/balance training + ADL-integrated mobility + tailored intensity tiers. 3) Primary outcome: ≥5-point improvement in Barthel Index scores at 60 days (compared to historical facility baseline). 4) Secondary outcomes: ≥15% increase in residents discharged to community vs. lower level of care. 5) Measurement: Barthel Index [6] and (FIM) [7] at admission, 30 d, 60 d, discharge; discharge disposition tracking.

OperationalDefinitions: 1) Fall: Unintentional descent to floor or lower surface, regardless of injury severity. 2) Transfer-relatedincident: Fall or near-fall occurring during bed-wheelchair, wheelchair-toilet, or chair-standing transitions. 3) Mobilityexposure: Documented assisted ambulation ≥50 feet OR supervised transfer practice, measured as minutes per resident per shift (target: ≥30 minutes/day aggregated across all staff contacts). 4) Seriousfallinjury: Fracture, head trauma requiring imaging, laceration requiring sutures, or any injury requiring emergency department evaluation. 5) Documentationcompliance: All required data fields completed within 24 hours of mobility session.

AssessmentProtocols: Physical therapists administer the Barthel Index and Functional Independence Measure (FIM) at all designated timepoints (admission, 30 days, 60 days, discharge) to ensure consistency and inter-rater reliability. When physical therapy is unavailable due to staffing or scheduling constraints, occupational therapists serve as backup assessors. All assessors (PT and OT) complete standardized training using video-based case examples and must achieve ≥85% agreement with expert scoring before conducting independent assessments. Training includes scoring practice with 10 video cases representing diverse functional levels, with immediate feedback on scoring discrepancies. For ongoing quality assurance, 10% of assessments undergo independent dual rating, with discrepancies triggering case review and consensus scoring. This protocol ensures measurement reliability across assessors and over time.

DataQualityAssurance: All disciplines use unified electronic health record (EHR) templates specifying required data fields (activity type, duration, distance, assistance level, resident response, barriers encountered) to ensure consistent data capture [8]. Templates include dropdown menus for standardized terminology and auto-calculated fields (e.g., total distance walked) to minimize documentation burden and improve accuracy. For missing or incomplete assessment timepoints due to temporary medical decline (hospitalization, acute illness), assessments are rescheduled within 1 week of clinical stability. Residents who discharge before scheduled 60-day assessment have final functional status documented at discharge. For analysis purposes, last-observation-carried-forward is applied for missing intermediate timepoints when discharge data are available. Residents with no post-baseline assessments (e.g., early discharge within first week) are analyzed separately as “early discharge” subgroup to avoid bias from selective attrition. Fall documentation quality is monitored through standardized incident report forms requiring: date/time, location, activity at time of fall, supervision level, contributing factors (environmental/physiological/equipment-related), injury assessment, and immediate interventions. The rehabilitation director reviews all fall reports within 72 hours for completeness and conducts follow-up investigation for serious injuries or recurrent fallers (≥2 falls within 30 days).

Functional measures include the Barthel Index and Functional Independence Measure collected at admission, 30 days, 60 days, and discharge. Falls are documented within 24 hours using standardized reporting procedures. Figure 3 provides an illustrative daily schedule demonstrating mobility integration across disciplines and shifts.

Figure 3. Sample daily mobility integration schedule. This representative schedule shows integration of mobility activities across disciplines and shifts for a Tier 1 (high intensity) resident. Individual schedules are tailored to resident functional level, therapy goals, and facility routines. Color coding indicates discipline responsibility: blue = physical/occupational therapy; green = nursing; yellow = restorative care; purple = group activities. Schedule demonstrates mobility reinforcement throughout waking hours rather than isolated therapy sessions. CNA = certified nursing assistant.

This protocol aligns with implementation science frameworks emphasizing contextual adaptation and sustained behavior change [9]. This protocol is designed for both post-acute rehabilitation and long-term care SNF populations. The three-tier intensity system accommodates the full continuum of mobility needs, from intensive rehabilitation following hospitalization (Tier 1) to maintenance of functional capacity in long-term residents with multiple comorbidities (Tier 3). Previous SNF mobility programs demonstrated feasibility but lacked operational detail [10]. This protocol addresses interdisciplinary accountability, workflow integration, and sustainability [11].

Limitations include development within a limited number of facilities with specific characteristics that may affect transferability. Participating facilities were mid-sized (80 - 150 beds) suburban SNFs in California with mixed post-acute and long-term care populations, existing physical and occupational therapy departments with combined caseloads of 40 - 60 residents, licensed nurse staffing ratios of approximately 1:15 - 20 residents, and certified nursing assistant ratios of approximately 1:8 - 12 residents during day shifts. Average staff tenure was 3 - 5 years with moderate turnover rates (approximately 30% annually). Facilities with different operational characteristics may require protocol modifications: 1) SNFs with minimal therapy services or higher patient-therapist ratios may need extended implementation timelines. 2) Facilities with higher nurse-resident ratios (>1:20) may need modified ambulation frequency targets. 3) Specialized populations (dedicated dementia care units, ventilator-dependent residents, behavioral health units) may require tailored eligibility criteria and safety protocols. 4) Rural settings with limited interdisciplinary resources may benefit from telehealth consultation support. 5) Facilities in early stages of quality improvement may need additional administrative support and change management expertise.

Additional limitations include lack of detailed cost quantification beyond basic equipment needs, and absence of patient-reported outcome measures. Self-reported mobility confidence, quality of life, and fear of falling are important resident-centered outcomes not included in the initial protocol due to cognitive and communication challenges in this population. Future implementations should explore feasible patient-reported measures for cognitively intact residents, such as abbreviated quality of life scales or visual analog scales for mobility confidence.

This project was conducted as an internal quality improvement initiative following established facility quality assurance and performance improvement (QAPI) protocols. The protocol received review and approval from the facility QAPI committee, which confirmed alignment with Centers for Medicare & Medicaid Services (CMS) QAPI requirements and facility quality priorities. As a quality improvement project focused on enhancing standard care delivery, the project did not require institutional review board (IRB) approval per federal regulations (45 CFR 46.102).

All retrospective data analysis adhered to Health Insurance Portability and Accountability Act (HIPAA) privacy standards. Data were accessed only by authorized clinical staff (physical therapists, occupational therapists, nurses, medical director) for quality improvement purposes. No individual resident or staff identifiers are included in any reports or publications. Aggregate data reporting uses cell sizes ≥ 5 to prevent indirect identification.

Resident participation in mobility activities was based on physician orders and individualized care plans developed through standard informed consent processes for clinical care. Residents or their legally authorized representatives provided consent for mobility interventions as part of routine admission agreements. Residents retained the right to decline specific activities without impact on other aspects of care.

As this is a protocol manuscript describing program development methodology, retrospective data from the needs assessment (150 incident reports, 50 patient charts, and 23 staff surveys analyzed during January-December 2024) informed protocol design. These data are not publicly available due to patient privacy protections and institutional confidentiality requirements. The protocol specifies data collection procedures for future prospective implementation.