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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.
KCE reports 57 Musculoskeletal & Neurological Rehabilitation 41 The CARF family of organizations currently accredits more than 4,800 providers at more than 17,000 locations in the United States, Canada, Western Europe, and South America. More than 6.3 million persons of all ages are served annually by CARF-accredited providers. After an organisation applies for accreditation of its services or programmes, CARF sends professionals in the field to conduct an on-site survey to determine the degree to which the organisation meets the standards. CARF surveyors also consult with staff members and offer suggestions for improving the quality of services. CARF-accredited programmes and services have demonstrated that they substantially meet internationally recognized standards. CARF accreditation means that you can be confident that an organization has made a commitment to continually enhance the quality of its services and programmes, and its focus is on consumer satisfaction. 3.7.2 Accreditation systems in Belgium In Belgium there are requirements for rehabilitation services, requirements for services related to a hospital stay during rehabilitation and accreditation criteria for physicians. Requirements for rehabilitation services are included in the description of financing principles and differ per type of payment system (K30/K60, convention 9.50, convention 7.71). Requirements are related to team composition, opening hours, equipment and buildings. These requirements are discussed in detail in chapter 5. Requirements for services related to a hospital stay are also conditions to be paid (B1 and B2: see chapter 5). Requirements include data registration concerning the activities related to social services and discharge management, participation to projects which contribute to the improvement of social services and discharge management, specific numbers of required full time equivalents (FTE) and some infrastructural issues. Accreditation criteria for physicians influence the price of the honoraria and include a minimum participation to further training courses. All these requirements and criteria are related to structure or process but no outcome measurement is performed. 3.7.3 Discussion Accreditation or quality systems for professionals and services will be further discussed in the chapter concerning the international comparison of the five selected countries (chapter 8). 3.8 CONCLUSION In this chapter, existing outcome measures, outcome models, assessment instruments, patient classification systems, criteria for the selection of therapy and accreditation of professionals and services, were discussed. Exploring the published literature an ideal interaction between outcome measures, an outcome model and a patient classification system as a framework for the mapping of a rehabilitation programme as well as for resource allocation, was designed. As proposed in Figure 3.2, outcome measures supply information to an outcome model. In this outcome model data related to diagnosis as well as level of function and environmental factors, should be covered. Starting from this outcome model a patient classification is built. One level in the hierarchy of this patient classification system serves as a framework for resource allocation (rehabilitation budget). Another level serves as a framework for the composition of rehabilitation programmes (rehabilitation services). The rehabilitation programme determines the resource allocation. Resource allocation as well as rehabilitation programmes must be controlled by a quality system.
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Dépôt légal : D/2007/10.273/19
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35. Etude relative aux coûts poten
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