alternatives

alternatives understanding CARF: a referrers guide volume 8 number 3 continued on page 6 C ARF-accredited. Its one of the ways that Rehab Without Walls describes its program. This certainly sounds official, but what does it mean? Actually, it means a lotto clients, payers, physicians and all the other stakeholders in Rehab Without Walls. Heres a look at what CARF is, how Rehab Without Walls meets CARF requirements and what CARF certification means to those who rely upon Rehab Without Walls. An Independent, Nonprofit Accrediting Body Founded more than 40 years ago, the Commission for Accreditation of Rehabilitation Facilities (CARF) is an international, independent accrediting body dedicated to promoting the quality, value and optimal outcomes of services. In short, CARFs mission is to ensure that the persons served by CARF-accredited facilities receive the best services and the most effective out- comes possible. I liken the CARF accreditation to the Good Housekeeping Seal of Approval, says Alison Gyorke, the director of clinical management for the Bay Area Rehab Without Walls. It lets people know that the facility has met rigorous standards and that we have invited others in to examine all of our practices and processes. It shows that we are committed to quality and value. And it says that we are going to consis- tently live up to the CARF standards year after year. Thats impressive to me as an employee of Rehab Without Wallsthat my company has made this kind of commitment. Participation Is Voluntary The fact that participation in CARF accreditation is voluntary speaks volumes about those who choose to undergo such a rigorous survey process. Participating involves a significant investment of time, resources and people over a period of months, explains Gyorke. We open ourselves up internally for checks and bal- ances. During the survey, industry experts examine every aspect of our business. This includes: Business practices (for example, financial soundness, appropriate decision making, quality assurance, pro- fessional advisory committees) Clinical practices (for example, best practices, functional goals, treatment plans, problem-solving, teamwork) The rights of persons served (for example, privacy, communication and medical ethics) Clinical records (for example, documenta- tion) Personnel records (for exam- ple, staff qualifica- tions and training) Data col- lection (for example, methodology and data integrity) Outcomes (for example, length of stay, rehospitalization rates, degree of functionality and independence of clients post-discharge, cost-effectiveness of the program) New to Home and Community Rehabilitation Although CARF has been accrediting rehabilitation facilities for years, surveying home- and community- based rehabilitation is a relatively new area for the organization. In fact, says Gyorke, Rehab Without Walls 2 recreational therapist Donna Young,
Las Vegas Rehab Without Walls What exactly is a recreational therapist (RT)? More formally known as certified therapeutic recreation specialists, recreational therapists, in a nut- shell, serve as a clients bridge to returning to his or her life and the community. We do this by tapping into a clients leisure-time interests and activities, then using these as a foundation for therapy. This goes a long way toward helping a client feel like part of the world again. It increases motivation. And, as in so many cases when a client has gone through a life-altering experience such as a spinal cord injury, it helps them see that there can be a new life for them outside the con- fines of their home. Another big part of our jobs is to be a liai- son between the client and the community. Over the years, I have developed a network of resources that I can refer clients into, for example, support groups or adaptive sports. I also can connect clients with individuals who have the same disability so they can see first-hand how others live full lives post-injury. I feel very fortunate to be in a position where I can help people find their way back into life. Why is the home and community setting
such a good fit for recreational therapists? I think of Rehab Without Walls as change your life rehab because I have the freedom to look at indi- viduals and conduct rehabilitation based on their unique needs. In contrast, when I worked in other settingsincluding long-term care, acute care and outpatientI found that it was difficult to respond to the real changes that occur during therapy because we had to stick to the one size fits all approach. 1 With any kind of rehabilitation, every day is a new challenge and it is important to be flexible. Rehab Without Walls gives us that flexibility. We establish functional goals for clients, but how they meet them is entirely dependent on what their needs are. As the client makes progress or as new needs emerge, we can continually adjust our approach to reflect what is happening in real life in real time. What is your role on the Rehab Without
Walls treatment team? As a regular part of the treatment team, I help the client work toward the functional outcomes based on his or her goals. Often I will perform co-treatments with other therapists so we can maximize treatment sessions. For example, we had one client who was a 20-year-old man who had sustained a spinal cord injury that left him a quadriplegic. He was bed-bound and totally dependent on others for self-care and activities of daily living. He felt that his life was over. My role on the team was to help him understand what he was capable of doing. Within six months, I got him out into the community in a manual wheelchair and linked with several spinal cord injury support groups. 2 3 continued on page 8 I think of Rehab Without Walls as change your life rehab because I have the freedom to look at individuals and conduct rehabilitation based on their unique needswe can continually adjust our approach to reflect what is happening in real life in real time. 3 Rehab Without Walls snapshot:
customer satisfaction client n=586 payer n=528 physician n=549 2006 overall results 2007 third quarter results 97% 100% 96% 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% client n=149 payer n=132 physician n=138 100% 99% 99% 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% At Rehab Without Walls, it is not enough for
us to deliver functional, durable outcomes that
help the client live a more independent and
productive life. We also want to make sure that
each one of our customers is satisfied with all
aspects of care. Thats why we survey not just
the patient, but also the patients supervising
physician and the payer to ensure that we are
meeting their specific needs as well. In our customer satisfaction surveys, we ask
questions about their perception of our profes-
sionalism, our responsiveness, how clearly we
communicate, how well we do what we say
we will, how we accommodate changes in the
plan of treatment, and so on. The figures below
show how our clients, payers and physicians
have rated their overall satisfaction with Rehab
Without Walls. how a busy mother of three has been
sprinting to heal 4 Background: In December 2006, just a month after her 37 th birthday, Maddi Merrill was standing on a lad- der helping her husband hang a light fixture when she reported feeling nauseous, then fainted and plunged 14 feet to the tile floor. She sustained a head injury that left her unconscious. Paramedics described an initial Glasgow Coma Scale of 4. A series of CT scans revealed a traumatic subarachnoid hemorrhage and an epidural hematoma, which required emergency craniotomy evacuation. After a one-month hospital stay, Maddi was discharged home. Three days later, she began rehabilitation with Rehab Without Walls. Rehabilitation Needs: For Maddi, her first goal was to be a mom and do all the things that a mother of an 8-, 6- and 2-year-old needed to do. I was in the hospital for so long that after I got home, my 2-year-old wouldnt come to me because he was so used to going to his dad for everything. My children needed to see me as their mom again. In addition, Maddi had mildly impaired bal- ance, fatigue and impaired strength due to decondition- ingall which interfered with her ability to perform childcare and ongoing activities of daily living. She also experienced mild to moderate dysphasia and oral dyspraxia, exhibited difficulty with verbal and written expression, had reduced reading and auditory comprehension, and demonstrated difficulties with information processing and short-term memory. The Rehab Without Walls interdisciplinary treat- ment team, consisting of an occupational therapist, speech-language pathologist, physical therapist, social worker, neuropsychologist and clinical coordinator, helped her set the following functional goals:
1. Demonstrate the strength and endurance required to return to a full day of productive activity in the home and community environments. 2. Demonstrate the ability to complete ADLs and IADLs, with appropriate use of compensation and minimal to no cueing from significant others in order to return to a full day of productive activity as a wife, mother and homemaker. 3. Demonstrate the cognitive and communication skills necessary to return to a full day of produc- tive childcare and homemaking activities. 4. Along with her husband, demonstrate improved awareness and understanding of the emotional behavioral sequelae of traumatic brain injury in order to effectively compensate for and cope with the physical, cognitive/com- munication and emotional changes post-injury. 5. For the entire family to identify and demonstrate the ability to appropriately uti- lize community resources for information, educa- tion and advocacy. The Rehabilitation
Process: According to Clinical Coordinator Susanne Griffin, Psy.D., Maddi had a number of things going for her that contributed to the high-level success of her recovery. First, Maddi had a lot of family support, which is vital to our model of reha- bilitation. Her husbands parents moved in for four months to help with childcare and the running of the household, which took the burden of worry off of Maddi and allowed her to focus on her recovery. And second, Maddi herself was extremely motivated. As effective as our Rehab Without Walls strategies are, the client has to do the workand Maddi was more than willing to do it. Heres how Maddi and her team tackled her issues: Physical. Maddi started physical therapy with the physical therapist (PT) at a nearby gym, but after two months transitioned to working out with a trainer. The PT met with the trainer and Maddi to review the plan, make appropriate adaptations and monitor progress. continued on page 7 Photo: Maddi Merrill with her husband and three children 5 in her own words: Rehab Without Walls
has helped give me my life back my arm, leg and hand. For three years, my whole right side had been numb and now I can feel it when my husband tickles me. I can use a pen or a pencil to write and draw and use both hands to wash my hair, Before, my arm was limp when I walked. Now I can move both arms when I walk. My speech is better, too. At first I knew what I wanted to say but the words wouldnt come out. I was determined to talk, however. I could only say two words after the stroke bonk and saucebabbling like a child and cussing without wanting to. Now I talk more, even on the telephone, and am much more comfortable with talking in general. Going out into the community was hard because I am shy and didnt want to leave the house. I joined the gym at my husbands workplace and identified a place where I could volunteer and work with animals. My perspective is that animals are very important they dont judge, are kind and loving, and I can be myself with them. Terese, the social worker, helped a lot, too. I found her very relaxed and comforting. I was pessimistic and trying to deal with reality. It was hard to believe For the Alternatives case studies you see on these pages
which, by the way, are one of our most popular features
because they show Rehab Without Walls in actionour
writer interviews the client and the interdisciplinary team
members then crafts the case study to fit our established
format. In this case, however, the client we identified as
having a good story to tell was not comfortable speaking
to a writer. She still wanted the world to know about her
experience so we asked her, instead, if she would be willing
to put a few things in writing that our writer could then
work with. What she sent us was so eloquent and so pow-
erful that we decided to run it as is. Here is what one of
our clients from the Sacramento area has to say about how Rehab Without Walls changed her life. Rehab Without Walls has helped give me my life back. I was a healthy young woman, working full time thenboomone day it all changed. I experienced a stroke, seizures and blood clots in my lung, brain, heart, spleen and leg. I was only 25 years old. No one knew I had blood clots or what caused them. I was very, very mad and went into a deep, deep depression. I tried outpatient therapy and it was all right, but I couldnt get myself out of the house due to the depres- sion. Besides, at outpatient therapy I had to throw balls into a barreltoo easyI didnt want to do that. I wanted harder things. I wanted more challenges. I was sleeping all the time. One day I had a high tem- perature and my husband took me to the hospital. I was terrified of the doctors and nurses because of what had happened in the past. The speech-language pathologist from my outpatient therapy helped me get started with Rehab Without Walls. The neuropsychologist, Dr. Maria Rubino, came to my home. It was wonderful. Thank you God for her coming. At home, I was comfy and could be myself. Because of the fear, I was tense when I went to the doctor. Maria talked to me about the problems I had had with speech therapy in the past and how my mouth wasnt doing what my brain said and that I needed to relearn how to talk. Barbara, my physical therapist, used Kineiso tapes a miracle! Ive now got feeling and movement in continued on page 7 6 cover story continued from page 1 worked closely with CARF at the outset. Rehab Without Walls has done a lot to educate the CARF surveyors on what a home and community program should look like and what it should do, she says. We have helped CARF set the standard of care. A Collaborative Approach Perhaps most interesting about CARF is that it takes not a top-down, prescriptive approach, but a collab- orative one with the participating programs. CARF sees itself as a collaborator to help improve the level of care, explains Debbie Tabor, clinical operations specialist for Rehab Without Walls. The surveyors themselves work in the rehabilitation world, so in a sense the CARF survey is a peer review. During the accreditation process, they look at 450 different standards and interview a wide variety of people at the branch. This can include:
Clients and families (both active and discharged cases) Payer case managers and/or referral sources A referring medical director
The Rehab Without Walls medical director
The director of clinical management
The admissions manager
Clinical team members, including physical therapists, occupational therapists and speech- language pathologists In addition, the location being surveyed prepares documentation on how it meets CARF standards. Our goal is to work toward continuous readiness and not be reactionary, so we try to build CARF standards into everything that we do, says Tabor, Tammy Goulding, the executive director of Rehab Without Walls Michigan, which recently completed a CARF survey, says, When CARF surveyors are on site, it is important to show that we meet the standards and provide day-to-day compliance. For example, one standard is Show that you provide community resource information for the client served. We might share comments from clients and referrers or we also could flag several charts that specifically document those patients and families who have received these services. Each year, CARF updates its standards. Tabor reviews these with other Rehab Without Walls rep- resentatives, then sets up a compliance checklist for Rehab Without Walls so that all locations can begin making modifications if needed. For locations prepar- ing for a CARF survey, she will go on site six to eight months in advance to give support and audit current practices as they relate to CARF standards. What CARF Says About Rehab Without Walls Rehab Without Walls underwent its first CARF surveys in 1999 at six locations. Since then, every single loca- tion has participated in the surveys and received CARF accreditation for home and community in adult and pediatric services (where available). In addition, the Michigan location has been accredited for brain injury. If you pass the survey, you receive either a recom- mended or an exemplary rating. Almost all of the Rehab Without Walls locations have received exemplar- ies, says Gyorke. In addition, all of the Rehab Without Walls locations have received three-year accreditations, which indicates outstanding performance because CARF can also bestow just one-year accreditations. Even if a location receives accreditation, because CARF is focused on continuous improvement, there generally will be recommendations following a survey. The facility then has 90 days to comply. Recommendations are not necessarily a negative. For example, explains Goulding, After our Michigan location survey, one of the surveyors was amazed at what we provided for brain injury clients and how we provided it. She recommended that we market more so that more people could be aware of our services. Overall, adds, Gyorke, One of the things that has consistently been most impressive to CARF survey- ors about Rehab Without Walls is the great level of cohesiveness that we have maintained in client care even though we are not based in a facility. We also are able to maintain the same standard of care at all our locations across the country, which only adds to our cohesiveness. What CARF Means for Clients and Referrers According to CARF, organizations that have received accreditation demonstrate:
A higher degree of internal quality
Greater involvement of persons served in their treatment and services Increased cohesion among staff members at all levels within the organization. Enhanced status of the surveyed services within the community What this means, indicates CARF, is that when your organization is accredited, the public is assured that you are committed to continually improving the quality of your services and your organizations focus is on service outcomes and customer feedback and satisfaction. In addition, says Gyorke, CARF accreditation allows clients and referrers to compare home- and community-based programs on key areas such as durability of outcomes, cost-effectiveness, quality and consistency of care, patient satisfaction, qualifications of staff and all the other factors that influence a refer- ral choice. Bottom line, they want to make a good decision in choosing a rehabilitation provider. CARF accreditation gives them much of the information they need to do so. 7 In the home, the occupational therapist (OT) worked at teaching Maddi to move differently (and to address balance and coordination) by having her walk on every other floor tile, for example, or tap dance her way into the laundry room. It was good and it was fun! says Maddi. Speech. Because Maddi had problems with pronunciation and finding the appropriate words, she would read books with the speech-language pathologist and then get quizzed on them. The speech therapist taped Maddi so she could hear for herself how she talked. She also got her interested in word games like Catch Phrase and Scattergories which Maddi now plays with friends and neighbors. A writer and public relations specialist before becoming a full-time mom, Maddi also worked with the speech therapist on more chal- lenging word constructions. She is now writing letters and e-mails to friends, short articles for her web site and press releases for a friend. Cognitive. The occupational therapist helped Maddi to plan out each week in her day planner, make to do lists, use dry erase boards for prompts and put post-it notes in key places like the garage and the master bath reminding her to check her day planner. I used to keep the running of the house- hold in my head, Maddi explains. Now, I have to write down everythingfrom meal planning to when to put my 2-year-old down for a nap. I even schedule rest time for myself because of my endurance issues. Emotional. Inspired by the gift of a handmade journal from her 16-year-old neighbor, Maddi has begun making additional journals out of materials purchased at scrapbooking stores and using the journals to record her frustrations and worries. The Rehab Without Walls team also encouraged her to write down her achievements so she could map her progress. Community reentry. Maddis therapists took her on various outings in the community to practice wayfinding, following a list, handling money, and dealing with crowds, noise and unfamiliar surroundings. In addition, they connected her with TBI support groups. I saw how some people three and four years post-injury have not progressed and Im amazed at what Rehab Without Walls has had me do in less than a year, Maddi says. It is a very active process. I feel like I got so much better so much faster with Rehab Without Walls. Its like Ive been sprinting toward healing. Recovery and Results. According to both Maddi and her team, her progress has been remarkable. She is now func- tioning at a very high level, says Dr. Griffin. Maddi is back running the house, driving and taking care of her children. She still works with the speech therapist, but often theyll meet at a coffee shop at different times of the day or night so she can practice in an unfamiliar environment and further expand her horizons. Rehab Without Walls is what healed me, says Maddi. The team has helped more than any single doctor because they knew what I needed to go forward in my life. Im recovering myself and my kids at the same time what could be better? case study 1, continued from page 4 that what had happened to me was real. I had had a stroke. It wasnt going away. Now Ive accepted it and found a way to be more positive. I have a family history of depressionmom, dad, brother, sister. Terese showed me ways to deal. She also gave me a relaxation tape. All these tools help the depression to not last so long. They help with stress. I used to be stressed all the time. Now Im not. Before, I wanted to work with ani- mals but couldnt see myself doing it. Now I know I can. I was stagnant. Now the world has opened up. Life has opened up. Thank you so much Rehab Without Walls. It is awesome. case study 2, continued from page 5 I was stagnant. Now the world has opened up. Life has opened up. rehabilitation abcs Here are some commonly used rehabilitation
terms defined: a Aphasiadifficulties, ranging from mild to severe, in understanding or using language.
Forms of aphasia include: Expressive aphasiausually associated with damage to the left hemisphere and results in
problems speaking or expressing oneself Receptive aphasiaproblems understanding language or what is said to you b Balancethe ability to maintain upright posture and position; usually tested when standing
or when sitting, or getting from a sitting to
standing position c Cognitive deficitsrefers to deficits sustained as a result of an injury in the brain involving mental
slowing. These include attentional problems,
decreased cognitive efficiency, decreased ability
to solve problems or think abstractly, and an inability
to do things as well as you did before the injury. alternatives About Rehab Without Walls With a focus on functional goals and measurable, durable outcomes,
Rehab Without Walls

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