The report is available in English with a French summary - KCE

40 Musculoskeletal & Neurological Rehabilitation KCE reports 57
3.6.2 International Classification of Functioning, Disability and Health
The ICF model earlier mentioned, is probably the best candidate to serve as a framework
for therapy planning. Studies reporting the application of ICF for therapy planning, were
searched. One study of the application of ICF was performed for a well described
pathology 116 . No papers are available, which report the application of these models for
the whole set of pathologies requiring rehabilitation. An attempt was made through the
development of linking rules to link the outcomes of ICF to useful interventions 96 . These
linking rules are only a first step in the use of ICF as a connecting framework between
interventions and outcome measures. A lot of study work is necessary to apply these or
comparable rules in clinical practice.
3.6.3 The 3-hour rule
3.6.4 Discussion
The US also struggles with the problem of therapy planning. The Centres for Medicare
and Medicaid Services (CMS’s) solved the problem by implementing a simple “3 hour
rule”. Strictly speaking the 3 hour rule is not a rule at all. The 3 hour rule is not specified
in any regulation, and, therefore, it does not have the force of law. Nevertheless, CMS’s
viewpoint, that the “general threshold for establishing the need for inpatient hospital
rehabilitation services is that the patient must require and receive at least 3 hours a day of
physical and/or occupational therapy” has achieved such general acceptance that it has
become a virtually unquestioned part of the rehabilitation services culture in the US.
CMS’s guidance on the 3 hour rule notes that the daily component of the rule may be
answered by therapy services 5 days a week. Also, while most patients will answer the 3
hour rule through physical or occupational therapy, CMS recognizes that other therapies,
such as speech therapy or prosthetic-orthotic services, may be required, within the 3
hours. Furthermore, if the patient has a secondary diagnosis or medical complication that
rules out 3 hours of therapy a day, inpatient hospital care may nevertheless be the only
reasonable means by which even a low-intensity rehabilitation programme can be safely
carried out. However, in such cases, CMS requires justification of the existence and extent
of complicating conditions affecting the carrying out of a rehabilitation programme.
At long term ICF might be a good framework for therapy planning but not enough
evidence is available yet to implement this now. This opinion is shared by some experts
contacted (see attachments).
3.7 ACCREDITATION OF PROFESSIONALS AND SERVICES
3.7.1 Commission on Accreditation of Rehabilitation Facilities (CARF)
g http://www.carf.org/
Because in scientific literature no information on the development and use of
accreditation systems was found, grey literature was searched. The study of rehabilitation
in The Netherlands, Germany, France, Sweden in a next chapter and the US will also focus
on the use of quality systems in the concerned countries.
The CARF-system was identified as an internationally used accreditation system
(Commission on Accreditation of Rehabilitation Facilities) g . CARF was formed in 1966 in
the US by two national organisations - the Association of Rehabilitation Centres (ARC)
and the National Association of Sheltered Workshops and Homebound Programmes
(NASWHP) - that had been developing standards for their respective memberships for
about a decade. In September 1966, the two organisations agreed to pool their interests
in setting standards, and they formed the Commission on Accreditation of Rehabilitation
Facilities, now known as CARF. In the years since its formation, CARF has steadily grown
in size and stature.