Publications
APS Bulletin • Volume 13, Number 2, 2003
Pain and Public Policy
Corey D. Fox, PhD, Department Editor
Interdisciplinary Pain Rehabilitation Programs: An Update from CARF
Christine M. MacDonell and Emmett Ervin
Department Editor’s Note: In the November/December 2002 APS Bulletin article, “Joint Commission Pain Standards: A Progress Report,” the authors detailed the adoption of acute pain evaluation as mandated by JCAHO. The Commission on Accreditation of Rehabilitation Facilities has provided a standardized accreditation model for the interdisciplinary treatment of chronic pain since 1982. The following article presents further information about how pain treatment is advanced via the organizational vehicle of accreditation.
The Commission on Accreditation of Rehabilitation Facilities (CARF) was founded in 1966 as a standards setting and accreditation system for the field of rehabilitation. CARF is a private, not-for-profit organization governed by a Board of Trustees comprised of representatives of sponsoring national organizations and individuals who support CARF’s goal of accreditation.
CARF’s mission is to promote the quality, value, and optimal outcomes of services through a consultative accreditation process that centers on enhancing the lives of the people served. Representatives of the American Academy of Pain Medicine and the American Pain Society are the sponsoring members representing the pain community on the CARF Board of Trustees.
In 1966 CARF had four accredited organizations. Today there are more than 29,000 programs accredited throughout the United States, Canada, and Western Europe. These programs represent the human service delivery model from elder services, behavioral health, vocational services, community-based services and medical rehabilitation. Interdisciplinary Pain Rehabilitation programs are represented in the arena of medical rehabilitation.
CARF Versus JCAHO
Since their inception in 1982, the CARF pain standards have defined a specialized interdisciplinary pain program, with the center of the program the needs of the person served and an emphasis on education, improvement of function, and appropriate use of the healthcare system. This programmatic approach is a main differentiator between CARF and JCAHO. This holds true not only in the arena of pain, but in other areas such as spinal cord systems of care, adult day services, and vocational rehabilitation services.
CARF defines accreditation as a process that allows healthcare organizations to conform with generally accepted standards set by a group of fellow professionals, consumers, and purchasers. It is intended to be a system of accountability that allows providers to demonstrate their organizations provide, monitor, and improve care as necessary to become quality, outcome-focused providers for consumers.
Stakeholder Input
CARF standards provide a framework for providers to operate as good businesses that are willing to share performance information with consumers. The inclusion of stakeholders is integral in the operation of CARF business. CARF defines stakeholders as individuals or groups who have an interest in the activities and outcomes of an organization and its programs and services. Stakeholders may include, but are not limited to, the people served, families, care managers, governance or designated authority, purchasers, regulators, referral sources, personnel, employers, advocacy groups, contributors, supporters, business interests, and the community.
Interdisciplinary Standards
CARF first established customer-focused standards to help pain providers measure and improve the quality, value, and outcomes of their interdisciplinary pain rehabilitation services in 1982. These chronic pain management standards were first applied on surveys in 1983. The pain standards underwent minor revisions during reviews in 1987 and 1990. In the mid 1990s, the pain experts on the International Advisory Committee (IAC) began to define different types of interdisciplinary pain programs, including acute, cancer related, and two levels of chronic pain based on intensity and frequency of programming in relationship to the needs of the person served.
At the end of the 1990s, the field and the IAC redefined and developed new pain standards based on an interdisciplinary approach. To stay current with good pain rehabilitation practices, the CARF standards were amended and changed to “Interdisciplinary Pain Rehabilitation” in the 1999 Medical Rehabilitation Standards Manual.
Interdisciplinary treatment is a major theme of CARF interdisciplinary pain standards. The team is determined by assessment, medical needs of the person served, the rehabilitation needs of the person served, and the predicted outcomes. This team addresses patients’ physical, psychological, social, functional, vocational, and pain-related needs. The team always includes the person served, a pain team physician, and a pain team psychologist. Based upon the assessed needs and predicted outcomes, additional personnel may participate on the team of an individual.
Pain management centers are advertised and marketed nationally. Stakeholders who do not understand the concept of interdisciplinary treatment may not receive “appropriate” care. ABC Pain Management Center may be a misnomer, as the provider may be a single-modality clinic. Some of these centers offer their specific modality without the availability and/or integration of other disciplines. Per CARF’s Interdisciplinary Pain Rehabilitation Program description, the program must provide outcomes-focused, coordinated, goal-oriented interdisciplinary team services to measure and improve the functioning of people with pain and encourage their appropriate use of healthcare systems and services. These programs can benefit people who have limitations that interfere with their physical, psychological, social, and/or vocational functioning. The program shares with stakeholders information about the scope of services and outcomes. If the program does not meet the Interdisciplinary Pain Rehabilitation Program description, key changes must be made before another attempt to obtain accreditation. CARF was responsive to stakeholders’ feedback regarding organizations that offer more than one type of pain program, yet are only accredited in one. For that reason, programs seeking accreditation as Interdisciplinary Pain Rehabilitation Programs must include all portions of their pain program and meet every program description. This assures stakeholders that all portions of programs are operating at acceptable levels.
Competent and qualified medical directors and pain physicians are part of the interdisciplinary team. Standards outline specific requirements for physicians, including their board/certification, required experience following completion of a residency program, continuing medical education in pain rehabilitation, and membership to a regional or national multidisciplinary pain society. Some standards address physician’s active participation in administrative areas.
Standards Development
CARF’s pain standards continue to be developed by the field, which consists of patients receiving services, rehabilitation professionals, and purchasers of services throughout the world. These standards are applied through a peer-review process to determine how well organizations are serving their consumers. The standards are routinely reviewed, and new ones are developed to keep pace with changing conditions and current consumer needs. Process standards are known to be internationally, consensus-based in nature. Specific methods of standards development include a series of leadership panels, international advisory committees, and field reviews. Payers, purchasers, and pain experts participate in these forums. CARF publishes the standards following final acceptance by the Board of Trustees. The pain standards guide pain programs to capably and competently serve their consumers.
Business Practice Standards
CARF standards also focus on the capabilities of the program to operate as an effective and efficient business with which consumers and stakeholders are satisfied. Effective July 1, 2003, organizations must meet a new set of standards called Business Practice Standards. These new standards put a greater emphasis on business practices such as risk management, insurance and performance issues, and corporate citizenship. In development since 1999, these standards were written with input from rehabilitation providers and careful review and study of ISO-9000 and Baldrige quality standards. This uniform set of standards will be applied on all CARF surveys regardless of type of program.
CARF Assessment
CARF standards are effective July 1 through June 30 of the following year. There were no trends noted during the site visits of pain programs conducted July 1, 2001 through June 30, 2002. A peer-based approach allows CARF to fairly assess the program’s level of conformance to standards. The survey team utilizes the Standards Conformance Rating System via a checklist that reflects the unidimensional nature of the standards. Introduced in 1998, this system is used in all surveys but is not applied in making the actual accreditation decision. It is used as a survey tool and is not disseminated. The checklist allows surveyors to assess the organization’s conformance to standards. If a “0” or a “1” is assigned, a recommendation will be cited. These two numbers convey “nonconformance” and “partial conformance,” respectively. A “2” implies the organization is in “conformance,” while a “3” suggests exemplary conformance to the standard. In the event a recommendation is assigned, the organization has 90 days after receiving the formal accreditation outcome to submit a Quality Improvement Plan to CARF. During the 2002 year, there were a total of 124 CARF-accredited pain programs. Among them, 96% received a 3-year accreditation, while 4% received a 1-year accreditation.
Conclusion
As the standards are “driven by the field,” CARF will be proactive and responsive when addressing the needs of stakeholders. CARF will continue to market and grow its premier business by working with pertinent trade associations such as the American Academy of Pain Medicine and APS. CARF continues to have membership to several coalitions, associations, and boards to learn about and provide knowledge of pain management. CARF’s focus remains on the people served in all of its activities and initiatives. Single-modality clinics continue to surface, but, at this time, these clinics are not eligible for accreditation. Only the field of pain experts, stakeholders, and consumers can address with CARF if a particular type of pain clinic needs to have standards that address the quality of services and the outcomes.
Christine M. MacDonell is managing director of CARF. She can be reached at cmacdonell@carf.org.
Emmett Ervin is business development executive of CARF’s Adult Day Services, Assisted Living, and Emerging Markets Customer Service Unit. He can be reached at eervin@carf.org.