ATRA Policy Alert
Phase Three of Three

December 15, 2000

Health Care Financing Administration
Department of Health and Human Services
Attention: HCFA-1069-P
P.O. Box 8010
Baltimore, MD 21244-8010

Re: Proposed Rules and Regulations for Medicare Program; Prospective Payment System for Inpatient Rehabilitation Facilities (42 CFR, parts 412 & 413, November 3, 2000)

The American Therapeutic Recreation Association (ATRA) represents recreational therapists providing treatment services in the United States. The U.S. Department of Labor estimates there are over 38,000 individuals employed as recreational therapists in the country. Recreational therapists provide active treatment services that are part of an interdisciplinary plan of care, have a reasonable expectation of improving the patient's condition and are supervised by a physician. Currently, recreational therapists are recognized by the Health Care Financing Administration (HCFA) in the Minimum Data Set 2.0 and Skilled Nursing Facility Prospective Payment System (SNF PPS) and in the HCFA intensity of service, three hour screening criteria (as affirmed in the April 5, 2000 HCFA correspondence to ATRA). In addition, recreational therapists are recognized as qualified rehabilitation therapists by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and CARF… The Rehabilitation Accreditation Commission.

ATRA is pleased to provide our general comments regarding the MDS PAC and transfer policy and follow these with specific comments regarding definitions found in the MDS PAC.

1. MDS PAC General Comments:

a. Efficiency: The MDS PAC is a lengthy and labor consuming instrument. The inclusion of over 400 data elements versus the 134 elements necessary for patient classification seems administratively unnecessary. ATRA recommends the MDS PAC be revisited, compared with the successful FIM assessment and correlated to include only those items necessary for patient classification.

b. Reliability and Validity: The MDS PAC has not been tested for reliability and validity and HCFA has not released

results of the research evaluating the MDS PAC classification to the FIM assessment. ATRA supports a payment system that minimizes the administrative burden and improves efficiency in classifying patients for payment determination.

c. Measurement Scales: The MDS PAC is significantly different from the FIM assessment including a reversed rating scale and different definitions to determine the level of a patient's independence. ATRA recommends the rating scales and definitions be brought into consistent measurement with the FIM assessment.

d. Mid-Stay Assessment: HCFA solicited comments regarding the mid-stay assessment on day 11. ATRA recommends an assessment at day 11 would be unnecessary in a per episode payment system and only add to the labor-intensive data collection duties.

2. Extension of Transfer Policy: HCFA solicited comments regarding the application of the transfer policy to home care or outpatient rehabilitation services. ATRA opposes the extension of the transfer policy to home health and outpatient rehabilitation services as this may inflate length of stays and promote inefficient utilization of rehabilitation alternatives. In essence an expanded transfer policy to include home health and outpatient rehabilitation services would change the payment system from a per-case to a per-diem system.

3. Minimum Data Set Post Acute Care Definitions

Section III. The Minimum Data Set for the Post Acute Care (MDS PAC) Patient Assessment Instrument
E. Performing the MDS PAC Assessment

Add: Qualified recreational therapist as an authorized clinician to perform the MDS PAC.

ATRA recommends: The inclusion of a qualified recreational therapist, or certified therapeutic recreation specialist (CTRS) as a "professional clinician" with the clinical skills to contribute to the MDS-PAC Assessment as interpreted in Section III.

Rationale: Qualified recreational therapists are nationally certified. This national certification requires a field placement that includes training in the performance of patient assessments. The national certification examination tests knowledge specific to the performance of patient assessments. Certified therapeutic recreation specialists are one of the rehabilitation professionals eligible for Functional Independence Measure (FIM) credentialing by UDS. A FIMs credentialed recreational therapist is recognized as qualified to gather FIM assessment data across the spectrum FIM designated functional skill areas. The national standards of practice for recreational therapy provide clear direction regarding assessment as an integral part of the recreational therapy treatment process.

4. 412.602 Definitions for Authorized Clinician

Add: (5) a recreational therapist who is a state licensed or nationally certified Therapeutic Recreation Specialist

ATRA recommends: The inclusion of a qualified recreational therapist or certified therapeutic recreation specialist (CTRS) as a qualified clinician in the attestation sections of the MDS PAC Section AA14. and Section AB1. (reference 412.602 and 412.606).

Rationale: Many recreational therapists, as determined by local facility administration, have served as MDS PAC coordinators (during the pilot testing phase) and are coordinators of care in rehabilitation hospitals and units. HCFA's exclusive recognition of some rehabilitation therapy providers and not others is not consistent with other federal regulations. The qualified clinician determination should be made by the local agency administration, based on mix, qualifications and utility of professional staff. If the MDS PAC is to be imposed in the current form, the local agency administration must be given latitude to determine who is a qualified clinician. Responsibility for determining who will be the agency's leader for the labor-intensive task of MDS PAC coordination must remain at the local agency.

5. Section K. Procedures/Services
#4. Therapy Services (first paragraph)

Revise: (page 66324) to read: "This item involves therapies that occurred after admission to the facility and meet the following criteria: (1) were ordered by a physician, (2) were performed by a qualified therapist (that is, one who meets state credentialing requirements) or a qualified therapy assistant under the direction of a therapist. OR (3) were performed by therapy assistant under the direction of the therapist.

ATRA recommends: The revision of the MDS PAC definition of qualified therapist to be consistent among all therapy definitions.

Rationale: The proposed language implies the three criteria are either/or. The revised language above is consistent with accepted standards of practice for each respective rehabilitation discipline.

6. Section K. Procedures/Services
#4. Therapy Services
f. Therapeutic Recreation

Revise title to: "Recreational Therapy"

Revise definition to: Section K. #4. f. Recreational Therapy "Therapy ordered by a physician that utilizes recreational therapy interventions, provided by a qualified recreational therapist, that restores, remediates, or rehabilitates in order to improve functioning and independence as well as reduce or eliminate the effects of illness or disability. provides therapeutic stimulation beyond the general activity program in a facility. The physician's order must include a statement of frequency, duration and scope of the treatment. A qualified recreational therapist is one who is state licensed or nationally certified therapeutic recreation specialist. or Therapeutic Recreation Assistant. A qualified therapeutic recreation assistant may provide therapy but not supervise others (aides or volunteers) giving therapy. The therapeutic recreation assistant must work under the direction of a Therapeutic Recreation Specialist".

Rationale: The current MDS PAC language on page 66434 defines recreational therapy as "therapy ordered by a physician that provides therapeutic stimulation beyond the general activity program in a facility." This language is not consistent with HCFA's definitions of active treatment nor is it consistent with the national standards of practice for recreational therapy. We support the inclusion of "the physician's orders must include a statement of frequency, duration and scope of treatment" however this requirement should be applied consistent with the skilled nursing facility prospective payment system, across all rehabilitation therapies. Due to recent changes in the national certification program, the therapeutic recreation assistant certification was eliminated. Language must be changed to reflect current practice and national certification standards as well as remain consistent with other rehabilitation therapies in the use of paraprofessionals.

Thank you for the opportunity to review and provide comments to the proposed rules and regulations regarding the Inpatient Rehabilitation Facility Prospective Payment System. If you seek clarification relative to our comments, please contact Ann D. Huston, MPA, CTRS, Executive Director at (703) 683-9420 or national@atra-tr.org.

Sincerely,
S/ADH
Ann D. Huston, MPA, CTRS
Executive Director

Cc: Peter Thomas, ATRA Legislative Counsel
Dick Verville, Powers, Pyles, Sutter & Verville
Carolyn Zollar, Esq., AMRPA Vice President
ATRA Board of Directors
ATRA Public Policy Team

click here > Write to HCFA NOW!