1. Cognitive Rehabilitation Therapy for Home and Community-based Service (HCS) Providers Eric Stratton, RN, MSN Office of Chief Deputy Commissioner February 14, 2013

2. Page 2 Objectives Define Cognitive Rehabilitation Therapy (CRT) Explain history of CRT and legislative intent Convey the value of CRT as evidence based practice which can improve outcomes Provide instruction on how to help individuals access CRT Explain who are qualified providers for HCS

3. Page 3 CRT Waiver Service Definition Cognitive rehabilitation therapy is a service that assists an individual in learning or relearning cognitive skills that have been lost or altered as a result of damage to brain cells/chemistry in order to enable the individual to compensate for the lost cognitive functions. Cognitive rehabilitation therapy is provided when determined to be medically necessary through an assessment conducted by an appropriate professional. Cognitive rehabilitation therapy is provided in accordance with the plan of care developed by the assessor, and includes reinforcing, strengthening, or reestablishing previously learned patterns of behavior, or establishing new patterns of cognitive activity or compensatory mechanisms for impaired neurological systems.

4. Page 4 Learning/relearning cognitive skills after brain damage Traumatic Brain Injury (TBI) Acquired Brain Injury (ABI) Assessment determines medical need for CRT Neurobehavioral OR Neuropsychological Covered under State Plan Qualified Providers of CRT Services Psychologists Occupational Therapists (OT) Speech and Language Pathologists (SLP) CRT Overview

5. Page 5 CRT is evidence based treatment for ABI 2006: TBI Advisory Council Report on ABI and Long-term Care in Texas Report to 80 th Legislature on gaps in services for brain injury survivors in Texas No care coordination, long waiting periods 2007: LBB report to 80 th Legislature recommending TBI coverage through Medicaid 2008: HHSC Office of ABI established Funded by budget rider in 80 th Legislature Serves as state lead coordinator for TBI and ABI CRT History & Legislative Intent

6. Page 6 2009: Rider 66, SB 1, 81 st Legislature (R) Feasibility study regarding need for system of community support & residential services for ABI Concluded separate ABI waiver program was best 2011: 82 nd Legislature Budget Crunch – no action taken Further study by HHSC Office of Acquired Brain Injury and Texas TBI Advisory Council in interim 2013: 83 rd Legislature HHSC requests to add new CRT service to CLASS, HCS, CBA, & STAR-Plus HCBS for ABI clients Legislature funded $1.9 million (GR) for biennium CRT History & Legislative Intent

7. Page 7 At least 23 states have a 1915(c) waiver program specifically for individuals with brain injury 11 states include services for both ABI and TBI MS & FL add Spinal Cord Injury Level of Care 14 states have nursing facility level of care 4 states have hospital level of care IA, MD, MN include multiple levels of care Age requirements 12 states limit to adults only 5 states cover services from infancy CRT History: What Other States Are Doing* * Data as reported from CMS and HHSC OABI Rider 66 Feasibility Study 2009.

8. Page 8 CRT “attempts to enhance functioning and independence in patients with cognitive impairments as a result of brain damage or disease (IOM, 2011, p. 76) Neurological disorders affecting CRT patients (Solhberg, Mateer, 2001, p. 25) TBI Stroke Hypoxic-hypotensive injury Encephalitis and other infectious disorders Brain tumors Collectively diagnoses are ABI CRT: Evidence-Based Practice

9. Page 9 Cicerone, K., Langerbahn, D., et al. Evidence-Based Cognitive Rehabilitation: Updated Review of the Literature From 2003 Through 2008. Archives of Physical Medicine and Rehabilitation, Vol 92, Apr 2011, 519-527. Institute of Medicine. Cognitive Rehabilitation Therapy for Traumatic Brain Injury: Evaluating the Evidence. 2011. The National Academies Press. Rohling, Faust, et al. Effectiveness of cognitive rehabilitation following acquired brain injury: A meta-analytic re- examination of Cicerone et al.'s (2000, 2005) systematic reviews. Neuropsychology, Vol 23(1), Jan 2009, 20-39. doi: 10.1037/a001365910.1037/a0013659 Sohlberg, M.M., Mateer, C.A. Cognitive Rehabilitation: An Integrative Neuropsychological Approach. 2001. Guilford Press. CRT: Evidence-Based Practice

10. Page 10 Definition: Cognitive Rehabilitation Therapy Cognitive rehabilitation therapy--A service that:  assists an individual in learning or relearning cognitive skills that have been lost or altered as a result of damage to brain cells or brain chemistry in order to enable the individual to compensate for lost cognitive functions; and  includes reinforcing, strengthening, or reestablishing previously learned patterns of behavior, or establishing new patterns of cognitive activity or compensatory mechanisms for impaired neurological systems.

11. Page 11 Service Delivery: CRT The program provider or CDS Employer must ensure that: Cognitive rehabilitation therapy is provided in accordance with the individual's PDP, IPC, implementation plan, and with Appendix C of the HCS Program waiver application approved by CMS and found at www.dads.state.tx.us If the service planning team determines that an individual may need cognitive rehabilitation therapy, the program provider, in coordination with the service coordinator: assists the individual in obtaining an assessment and plan of care for the cognitive rehabilitation therapy from a qualified professional in accordance with the Medicaid State Plan; and has a qualified professional provide and monitor the provision of cognitive rehabilitation therapy to the individual in accordance with the plan of care

12. Page 12 Provider Requirements: CRT The program provider or, if using the CDS option, CDS employer and Financial Management Services Agency must ensure that a service provider of cognitive rehabilitation therapy is:  a psychologist licensed in accordance with Texas Occupations Code, Chapter 501;  a speech-language pathologist licensed in accordance with Texas Occupations Code, Chapter 401; or  an occupational therapist licensed in accordance with Texas Occupations Code, Chapter 454.

13. Service Delivery: CRT Page 13 The program provider or CDS employer must:  Together with an individual's service coordinator, ensure the coordination and compatibility of HCS Program services with non-HCS Program services

14. Page 14 CRT Process and Procedure ABI Neuropsychological Neurobehavioral ASSESSMENT OR Diagnosis CRT HCS Service State Plan Assessments: “Gatekeepers” to CRT Service

15. Page 15 1.Neuropsychological Assessment (State Plan) Includes treatment plan in the assessment Conducted by Psychiatrist, Psychologist, or LPA under the supervision of a licensed psychologist CRT Assessment “in reality”  Conducted by NEURO-psychologist OR 2.Neurobehavioral Assessment (State Plan) Conducted by physician, PA, or NP Must result in treatment plan with assessment  Individual referred to OT/SLP for CRT in HCS (only if assessment warrants it) CRT Process and Procedure: Assessments

16. Page 16 CARE ID CRT Event type CRT or CRTV (CDS) Units Billed in 15 minute increments using standard rounding rules. CDS billed in dollars. Entering CRT in CARE

17. HHSC/DADS Contacts Eric Stratton, RN, MSN Policy Analyst Health and Human Services Commission Office of Chief Deputy Commissioner Eric.Stratton@hhsc.state.tx.us (512) 487-3372 Curtis Walters HCS Program Specialist Department of Aging and Disabilities Services Center for Policy and Innovation hcs@dads.state.tx.us Send questions related to CDS to cds@dasd.state.tx.us.cds@dasd.state.tx.us Page 17