HD66 - Expansion of Public Funding for Cognitive Rehabilitation Services

  • Published: 1995
  • Author: Secretary of Health and Human Resources
  • Enabling Authority: House Joint Resolution 573 (Regular Session, 1993)

Executive Summary:
The report on House Joint Resolution 573 presents the results of a feasibility study to determine methods and resources which would expand public funding for cognitive rehabilitation services. The study agencies included the Department of Rehabilitative Services, the Department of Mental Health, Mental Retardation, and Substance Abuse Services, the Department for the Visually Handicapped, the Department of Education, and the Department of Medical Assistance Services. Each agency examined the feasibility of recognizing and/or providing for cognitive rehabilitation services for eligible individuals with brain injury.

The five study agencies accepted the following common definition of cognitive rehabilitation services:

"Cognitive rehabilitation is the systematic application, by a qualified practitioner, of remedial intervention techniques aimed at improving cognitive processing and the ability to perform daily life tasks. A comprehensive approach to cognitive rehabilitation involves systematic retraining of specific impaired cognitive functions (such as attention, memory, conceptualization, problem-solving, and language) and the teaching of compensatory strategies within a therapeutic environment. The goal of cognitive rehabilitation is to increase an individual's awareness of deficits and improve his/her ability to function more effectively on a daily basis despite underlying cognitive deficits."

This definition is used by the DRS in its "Client Assistance Services Manual" and blends key premises cited in prominent research. In their individual responses to the study directive, the study agencies addressed the following areas:

1. Current status of cognitive rehabilitation services in the respective agencies -- including as appropriate, discussions of criteria for providing and terminating services, available service providers and types of services, avenues for and barriers to accessing services, numbers of individuals served in the last fiscal year, and data and funding issues.

2. Future role of each agency in providing and/or paying for cognitive rehabilitation services, including emerging issues and recommendations for providing and improving these services to persons with brain injury.

In addition to the agencies' responses to the study directives, the study team felt it important to provide the reader with background information on cognitive rehabilitation. Information contained in the body of the report includes characteristics of cognitive rehabilitation programs, clinical approaches to delivering this service, and appropriate settings for delivery of cognitive rehabilitation to persons with brain injury. The study appendices provide additional background information including:

1. Profile of individuals with brain injury: characteristics and service needs;

2. Review of the research on cognitive rehabilitation; and

3. Funding options and practices in other states.

Study Findings and Recommendations

The passage of HJR 573 was one of three recommendations made by the Cognitive Rehabilitation Task Force of the Commission on the Coordination of the Delivery of Services to Facilitate the Self Sufficiency and Support of Persons with Physical and Sensory Disabilities (Disability Commission.) The Cognitive Rehabilitation Task Force was appointed by the Disability Commission after public testimony regarding the lack of available coverage for cognitive rehabilitation and neurobehavioral services. While exploring funding alternatives, it was determined by the Task Force that there was insufficient funding for cognitive rehabilitation by state agencies and a reluctance among insurance companies to cover this service or to authorize such services outside of an established benefits package. (Report of the Cognitive Rehabilitation Task Force, November 1992). The Task Force set forth the following four guiding principles for future work in this area:

"Cognitive rehabilitation is a necessary physical rehabilitation intervention for persons with acquired cognitive impairments.

Current dollars need to be applied more effectively and new dollars need to be found for funding of cognitive rehabilitation.

Fiscal responsibility for cognitive rehabilitation is a collaborative, private/public partnership.

Success of the individual receiving services and of the cognitive rehabilitation program providing services can be accurately measured by pre-determined predictors within a pre-defined time frame."

In responding to the HJR 573 directives, the study team agencies conducted their respective feasibility studies consistent with these guiding principles. Individual agency findings were as follows:

• The Department of Rehabilitative Services does and will continue to recognize, provide, and financially sponsor cognitive rehabilitation as an acceptable pre-vocational training modality for individuals with brain injury who require such services. The Department will increase the number of individuals with access to this service through (1) continued staff training and education; (2) program modification based on the results of the agency's Cognitive Rehabilitation Pilot Project; (3) establishment of criteria and procedures related to cognitive rehabilitation; and (4) development of a statewide Medicaid waiver proposal for traumatic brain injury.

• The Department of Mental Health, Mental Retardation, and Substance Abuse Services recognizes that there are consumers within the service system who have a dual diagnosis of traumatic brain injury and mental retardation, mental illness, or substance abuse. In keeping with its established mission, DMHMRSAS does not directly provide cognitive rehabilitation services but will work collaboratively with other agencies to refer consumers and their families to appropriate services. This will include (1) identifying a traumatic brain injury at intake; (2) ensuring that case managers understand this disability and initiate appropriate referrals; and (3) better integrating current DMHMRSAS services to ensure holistic treatment. DMHMRSAS is also willing to advise DRS in its efforts to develop a statewide Medicaid waiver proposal for community services for individuals with brain injury similar to the current Mental Retardation Waiver program.

• The Department for the Visually Handicapped recognizes cognitive rehabilitation as an acceptable modality of pre-vocational services for persons with concomitant visual impairment and brain injury and will continue to purchase cognitive rehabilitation therapy for individuals who require these services. In addition, the agency will provide in-service training and education to service providers, assess the development of specific policies and procedures relating to this service, and explore the option of providing cognitive rehabilitation services within the agency rather than purchasing such services from other agencies and private vendors.

• The Department of Education recognizes that the Regulations Governing Special Education Programs for Children With Disabilities in Virginia provide the mechanism which allows for cognitive rehabilitation to be provided to a child determined eligible for special education services under the Individuals with Disabilities Education Act. Cognitive rehabilitation is recognized and provided by local education agencies as a related service since it is developmental, corrective, and supportive and thus assists the child to benefit from special education.

• The Department of Medical Assistance Services recognizes the need to expand cognitive rehabilitation services on an out-patient basis for certain individuals with brain injury who do not meet current criteria. Cognitive rehabilitation services are currently provided as a component of DMAS' intensive rehabilitation programs and are also available through the outpatient rehabilitation program when the program is carried out by a speech language-pathologist, occupational therapist, or qualified psychologist. Coverage and reimbursement of outpatient cognitive rehabilitation services as an independent therapy (outside of speech, language, or psychological services) will require regulatory changes in the Virginia State Plan for Medical Assistance.

Interagency Recommendations

The recommendations of the study group seek to (1) expand the availability of cognitive rehabilitation services to all individuals with brain injury who could benefit from these services; (2) enhance inter-agency collaboration with respect to the identification of individuals requiring this service as well as the actual provision/purchase of the service itself; (3) expand available funding for cognitive rehabilitation; and (4) facilitate the development of improved data tracking systems which will enable agencies to monitor costs, service quality, and long-term outcomes for individuals with brain injury. Specific interagency recommendations are as follows:

1. The study agencies shall collaborate to

• explore opportunities for shared funding of cognitive rehabilitation services for mutual clients;

• explore a specific referral system for insuring multi-agency coordination of service delivery to potential consumers and the development of improved client tracking information systems;

• provide cross-agency training on cognitive rehabilitation services;

• develop consistent statewide policy and procedures designed to reduce fiscal and other barriers (described in the study report) for individuals who require cognitive rehabilitation services; and

• assure service quality, monitor client outcomes, and develop methods to assess client and family member satisfaction with service delivery and outcome.

• monitor and remain current with

- efforts of the Task Force on Head Injury of the American Congress of Rehabilitation Medicine and the Society for Cognitive Rehabilitation to develop and enforce standards for the provision of cognitive rehabilitation services;

- research in the area of cognitive rehabilitation; and

- efforts by professional organizations and state/local agencies to develop certification or licensing standards for individuals providing cognitive rehabilitation services.

2. The study agencies should explore in greater detail the impact of having a dedicated funding source for individuals with brain injury such as an Impaired Drivers Trust Fund to expand prevocational cognitive rehabilitation and other services to individuals with brain injury who are unserved or underserved. If appropriate, present recommendation for the development of such a funding source to the Secretary of Health and Human Resources.

Virginia continues to enhance its efforts to become a national leader in recognizing and meeting the needs of persons with brain injury in the Commonwealth. Implementation of the study team's recommendations will support these efforts by helping to establish a coordinated continuum of state-supported services in the area of brain injury and by ensuring that individuals with this disability have affordable access to an important rehabilitation service that can assist them in meeting employment and independent living goals and improving the quality of their lives.