Component plan. Traumatic brain injury faciltiies

COMPONENT PLAN TRAUMATIC BRAIN INJURY FACILITIES
GEORGIA STATE HEALTH POLICY COUNCIL
AND
GEORGIA STATE HEALTH PLANNING AGENCY 4 EXECUTIVE PARK DRIVE NE SUITE 2100 ATLANTA, GEORGIA 30329 May 1990

STATE OF GEORGIA
OFFICE OF THE GOVERNOR ATLANTA 30334

Joe Frank Harris
00YIIlN0lIl

May 16, 1990

~llwq

W. Douglas Skelton, M.D. Chairman State Health Policy Council suite 2100 4 Executive Park East, N.E. Atlanta, Georgia 303029

MAY 21 1990
STATE OF GEORGIA HEALTH PlANNING AGENCl
PLANNING SECTION

Dear Doug:

In accordance with your request and with the authority granted me in Code Section 31-6-20 of the Official Code of Georgia Annotated, I have reviewed the Component Plan for Traumatic Brain Injury and do hereby approve it. I would like to commend the Council and the State Health Planning Agency on the time and effort which have gone into the development of this plan.

I am particularly pleased with the open, public participatory process which has been initiated by the Council and the Agency in the development of both the component plan and the certificate of need rules. If I can be of further assistance on this or any other matter of concern to you, please contact me.

With kindest regards, I remain

Sincerely,
Q;],.'/.d-'
Joe Frank Harris

JFH/r~s

4 Executive Park Drive. N.E. Suite 2100
Atlanta, Georgia 30329 (404) 3204821
May 4, 1990

STATE OF GEORGIA
HEALTH POLICY COUNCIL

The Honorable Joe Frank Harris, Governor The State of Georgia The State Capitol Atlanta, Georgia 30334 Honorable Sir: It is with great pleasure that the State Health Policy Council transmits to you for your approval this Component Plan:
Traumatic Brain Injury Facilities. The Plan is a product of the Council and the State Health Planning Agency, which operate within the authority of Georgia Law 552, Code Title 31, Chapter 6 amended. This Component Plan identifies and addresses issues related to Traumatic Brain Injury Facilities and recommends goals, objectives and system changes to insure a statewide system of cost-effective and efficient care. The Plan is designed to achieve official state health policies relating to access to quality care and cost containment. This Plan has been produced through an open, public participatory process initiated and monitored by the Policy Council. The Policy Council and the State Agency commend this Plan to you and urge your approval of it. It is believed that the Plan provides a rational basis for the development of needed Traumatic Brain Injury Facilities. Sincerely,
0
W. Douglas Skelton;M.D. Chairperson WOS:kr Enclosure

PREFACE This Component Plan is a product of the Georgia State Health Policy Council and the Georgia State Health Planning Agency which are funded through and operated within the authority of Georgia Law Act 552 and formerly Federal Public Law 93641 and amendments. The purpose of this Plan is to identify and address health issues, and recommend goals, objectives and system changes to achieve official State Health Policies. This Plan has been produced through an open, public participatory process developed and monitored by the 25-member Governor-appointed State Health Policy Council. The Plan, once approved by the Governor, supersedes all related sections of the 1981, 1983 and 1987 editions of the State Health Plan, and any existing related Component Plan and is designed to be consistent with the overall State Health Policies. For purposes of the administration and implementation of the Georgia Certificate of Need (CON) Program, criteria and standards for review (as stated in the Rules, Chapter 272-1, 272-2 and 272-3) are derived from this Component Plan. The Rules, which are published separately from the Plan and which undergo a separate public review process, are an official interpretation of any official Component Plans which the review function has the legal authority to implement. The Rules are reviewed by the State Health Policy Council (prior to their adoption) for their consistency with the Plan. The Rules, as a legal document, represent the final authority for all review decisions. Any questions or comments on thi s Component Pl an shoul d be di rected to the Planning and Implementation Division of the State Health Planning Agency, 4 Executive Park Drive, N.E., Suite 2100, Atlanta, Georgia 30329; telephone: (404) 320-4829.
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TABLE OF CONTENTS

Page

INTRODUCTION

1

OVERVIEW OF TRAUMATIC BRAIN INJURY

4

1. Types of Brain Injury

4

2.- Incidence and Prevalence of Traumatic Brain Injury

4

3. Leading Causes of Traumatic Brain Injury

7

4. Client Characteristics

8

5. Existing System of Care for Persons Requiring Transitional

and Life Long Living Services

11

6. The Cost of Traumatic Brain Injury Services

11

7. Reimbursement for Traumatic Brain Injury Services

12

8. A Review of Insurance Coverage for Traumatic Brain

Injury Services

15

GUIDELINES FOR THE REVIEW AND DEVELOPMENT

OF TRAUMATIC BRAIN INJURY FACILITIES

24

GOALS, OBJECTIVES AND RECOMMENDED ACTIONS

42

REFERENCES

44

APPENDICES

48

Appendix A: Continuum of Rehabilitation Services and Programs 48

Appendix B: Basic Elements of the Demand-Based Forecasting

Model for Physical Rehabilitation Services

51

Appendix C: Existing Residential (non-hospital) Services

for Traumatic Brain Injury Clients

52

Appendix 0: Technical Advisory Committee on Comprehensive

Inpatient Rehabilitation Services

53

Appendix E: Georgia Senate Bill 360

55

Appendix F: Service Areas for Traumatic Brain Injury

Facilities

59

iii

INTRODUCTION
The National Head Injury Foundation defines traumatic brain injury as an insult to the brain, not of a degenerative or congenital nature but caused by an external force, that may produce a diminished or altered state of consciousness, which results in impairment of cognitive abilities or physical functioning. It can also result in the disturbance of behavioral or emotional functioning. These impairments may be either temporary or permanent and cause partial or total functional disability or psychosocial maladjustment.(38)
Depending upon the type and severity of injury, a traumatically brain injured (TBI) individual might require a range of rehabilitation services, varying in type, intensity and duration, depending upon the needs of the client. Appendix A displays an ideal Continuum of Rehabilitation Programs and Services, all or a selected number of which might be appropriate for a TBI client, depending upon individual rehabilitation needs. This Continuum was developed by the Technical Advisory COlllllittee (TAC) on Comprehensive Inpatient Physical Rehabilitation Services. The TAC was staffed by the Georgia State Health Planning Agency.
This Component Plan focuses on Traumatic Brain Injury Facilities which are considered as one setting for the delivery of Residential Treatment and Rehabilitation Program services as defined in the ideal Continuum. The client population is medically stable, although some may have special medical needs, e. g., ventilator dependent. Program emphasis is on compensatory rather than restorative services, transition to a less restrictive setting, or life long support and management. The two components of a Res ident i a1 Treatment and Rehabilitation Program are Transitional living and life long living.
Transitional living Program refers to treatment and rehabil itative care del ivered to traumatic brain injury clients who require education and training for independent 1iving, with a focus on compensation for skill s which cannot be restored. Such care provides clients with maximum independence, teaches
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necessary skills for community interaction, works with clients on prevocationa1 and vocational training and stresses cognitive, speech and behavioral therapies structured to the individual needs of clients.
Life Long Living Program refers to treatment and rehabilitative care delivered to traumatic brain injury clients who have been discharged from rehabilitation, but who cannot live at home independently, and require on-going lifetime support. This program may include behavioral management and/or monitored daily living services.
The Technical Advisory Committee (TAC) on Comprehensive Inpatient Physical Rehabilitation Services was established in June, 1989 to prepare recommendations for the development and/or revision of the rehabilitation component of the State Health Plan and related Certificate of Need (CON) rules and regulations. (Appendix D) This TAC is the first to address the various issues related to the care of traumatic brain injury (TBI) clients.
Georgia Senate Bill 360, as passed and adopted by the General Assembly in the 1989 session, provided "... that certain facilities and institutions shall include facilities providing care for persons who have traumatic brain injury; to amend Title 37 of the Official Code of Georgia Annotated, relating to mental illness, so as to provide for a definition of "traumatic brain injury" and provide that such injury shall not be considered mental illness ... ". (Appendix E)
Senate Bill 360 further defined "institutions" to include, among other facilities, "... any bUilding or facility which is devoted to the provision of treatment and rehabilitative care for periods continuing for 24 hours or longer for persons who have traumatic brain injury .. ".
Senate Bill 360 defined "traumatic brain injury" as a "... traumatic insult to the brain and its related parts resulting in organic damage thereto which may cause physical, intellectual, emotional, social, or vocational changes in a person. It shall also be recognized that a person having a traumatic brain injury may have organic damage or physical or social disorders, but for the
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purposes of this chapter, traumatic brain injury shall not be considered mental illness as defined in paragraph (11) of this Code section". Senate Bill 360, as adopted, provided the legislative mandate necessary for the Technical Advisory Committee on Comprehensive Inpatient Physical Rehabilitation Services and the State Health Planning Agency to develop a Component Plan for Traumatic Brain Injury Facilities.
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OVERVIEW OF TRAUMATIC BRAIN INJURY
1. Types of Brain Injyry
There are two main categories of brain injury - traumatic and acquired. "Traumatic" refers to brain damage that results from an external (mechanical) force. There are two basic categories of traumatic brain injury (TBI):
Closed Head Injury, which typically results from blunt trauma to the brain (e.g., head into Windshield). Penetrating Head Injury, which refers to a traumatic brain injury whi ch results from a mi ss il e-l ike object (e. g., bull et) . Acquired brain injury can result from a variety of causes, in addition to trauma. Such causes include: 1) neurovascular syndromes (e.g., strokes of various types), 2) anoxic brain damage which occurs when the brain is deprived of oxygen, 3) neoplasms, or cancer, which refers to an abnormal growth of tissue or tumor, and 4) infectious disorders of the central nervous system.
2. Incidence and Prevalence of Traumatic Brain Injury
Estimates of the incidence and prevalence of traumatic brain inJury vary, depending upon definitional, operational and severity of injury considerations. In some injuries, commonly referred to as "mild" or "minor", the patient may suffer no loss of consciousness or only a very brief period of altered consciousness. In other "minor" injuries, a posttraumatic syndrome consisting of headaches, vertigo, fatigue, memory disturbance and emotional irritability may follow and cause a disruption of vocational activity up to three months after the injury. In a small percentage of cases, phys ica1 and psychosoc i a1 symptomatology may be reported for months and years after the injury. Minor brain injuries constitute the vast majority of brain injuries in the U.S. - about 290,000 per year.(26)
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Most rehabilitation efforts are focused on patients with severe closed head injuries (i .e., unconsciousness for six hours or longer). There are 50,000 to 75,000 people per year in the U.S. who suffer severe brain injuries. According to most studies, approximately 5~ of the patients with severe brain injuries die. Even those who achieve a "good recovery" status may have significant psychosocial impairments that preclude a return to former types and levels of functioning. (26)
ANew York State study found that the incidence of traumatic brain injuries in the State was 173.6 per 100,000 population in 1984.(18) In 1982, Kurtzke reported an incidence rate of 200 per 100,000 population using a data base similar to that used to develop the New York State rates.(16)
The New York State study also revealed that in the 1980-1984 period the incidence of traumatic brain injury in the State: 1) declined for those ages 15-24 years and remained unchanged for persons 65 years of age and over; 2) declined for both males and females, although the male rate was twice as high as the female rate (280 per 100,000 population vs. 139 per 100,000 population); and 3) was about 200 per 100,000 population for whites, 250 per 100,000 population for blacks and 341 per 100,000 population for other races and ethnic groups. (18)
The incidence of traumatic brain injury requiring hospitalization has been estimated to be 200-225 per 100,000 population in the U.S. Overall, about 500,000 new cases of traumatic brain injury are estimated to occur annually in the U.S. About 44,000 persons per year survive severe traumatic brain injury with moderate to severe physical or neurobehavioral problems.(26)
The age distribution of traumatic brain injury indicates that young adults (15-24 years) and the elderly (65-75 years) show the highest incidence rates: 200-225 per 100,000 population and 200 per 100,000 population, respectively. The elderly have the highest level of mortality. Elderly clients also have a much slower and uncertain recovery process, compared with young adults.(26)
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In most studies of traumatic brain injurY,males outnumber females by at least 2:1. Furthermore, male brain injury mortalities are three to four times greater than in the female population. Several studies have noted that traumatic brain injury tends to occur with greater frequency among minority groups. (26, 16, 17)
The incidence rate of traumatic brain injury in children is about 200 per 100,000 population per year. This means there are about 110,000 newly brain injured children each year in the U.S. This would indicate a cumulative incidence rate for traumatic brain injury of 4.1% for boys and 2.4% for girls, from infancy through 14 years of age.(25)
A 1981 study by Kraus, et.al. is regarded as one of the more comprehensive in the brain injury literature. Kraus' study provided incidence rates of acute brain injury among the residents of San Diego, California. The 3,358 traumatic brain injury cases identified by the study represented a rate of 180 per 100,000 population.(I5)
The percentage distribution of all persons with traumatic brain injury by general level of severity revealed that 72.5% had mild brain injury, 8.0% were moderately injured, 7.9% were severely injured and 11.5% were dead on arrival at a hospital. Percentage discharge information for all persons admitted to an acute care hospital with a diagnosis of traumatic brain injury included: 82.5% discharged home with no care, 6.9% discharged home with outpatient care and 5.9% died in the hospital.(15)
The Georgia Head Injury Association has estimated that the incidence of traumatic brain injury in Georgia was 160 per 100,000 population in 1989, or about 9,900 individuals.(47)
Another source for determining incidence of traumatic brain injury is hospital discharge data. Data from the National Hospital Discharge Survey show that for the South in 1987 there were 147 hospital discharges per
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100,000 population for selected traumatic brain injury diagnoses.(52) Georgia-specific hospital discharge data from the Georgia Hospital Association Statewide Patient Origin Study indicate that for the same traumatic brain injury diagnoses, there were 121 hospital discharges per 100,000 population in 1987 in Georgia.(42) At this time, there are no other known Georgia-specific data for measuring incidence of traumatic brain injury.
Data to compute traumatic brain injury prevalence rates (i.e., the total number of traumatically brain injured persons at any point in time) is generally inadequate. However, it was estimated by Kurtzke in 1982 that this rate was about 800 per 100,000 population in the U.S., or four times the incidence.(16)
3. leading Cayses of Traymatic Brain Injury
About half of all traumatic brain injuries are caused by transportationrelated accidents. The other half are the result of falls, assaults and other causes. There are age and socioeconomic factors which affect patterns of causation. In one study, the highest mortality group was ages 65-75, with suicide attempts and falls as the main causes of brain injuries.(26) Studies in the Bronx, New York and Harris County, Texas show a '40-44% incidence of gunshot wounds as a cause of traumatic brain injury. (26)
A variety of risk factors have been identified as influential in determining who is likely to sustain a traumatic brain injury. The most common factor cited is alcohol intake prior to the brain injury. Other factors identified are pre-injury personality disturbance, family discord and antisocial behavior. However, there has only been a limited amount of research done to relate these factors to the risk of injury.
Astudy by Shapiro of brain injury in children found that trauma represents the greatest threat to life in childhood. In 1979, the death rate from
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all causes among children under 15 years of age was 42.1 per 100,000 population, with half of the deaths caused by trauma. According to Shapiro, about half of all accidental deaths were due to injury.(25)
A 1988 study of traumatic brain injuries in Massachusetts found that car accidents were the single leading cause of such injuries with almost half (46% of the brain injured surveyed) being involved either as a driver or passenger. This study found that falls were the second leading cause of brain injury (11%). However, for pre-school children, fall s were the leading cause (43%) and for persons over the age of 40, falls accounted for about 25% of the injuries. Ten percent of the brain injury victims were hit by a car.(17)
A 1986 study in New York State found that motor vehicle accidents were the leading cause of traumatic brain injury, accounting for 501 of those sustaining injuries. Falls, particularly in children and the elderly, accounted for about 201 of the injuries, while assaults or violence of other types accounted for over 10%. In New York City, the proportion of traumatic brain injuries caused by motor vehicle accidents was lower and the number attributable to violence was significantly higher than the rest of the State.(18)
Kraus, et.al. found the percentage distribution of persons with traumatic brain injury by major categories of external causes to be motor vehicle accidents (48%), falls (201), assaults, non-firearm (12%), sports and recreation (101), firearms (6%) and other blunt force (4%).(15)
4. Client Characteristics
Traumatic brain injury survivors exhibit a wide range of handicapping conditions which compromise an individual's ability to care for himself/herself and live independently. Cognitive, physical, behavioral .and psychological impairments are seen in varying degrees within this population. The recovery process and successful community reintegration
8

necessitates multiple services, care-givers and funding sources. Case manage_nt is critical to the timely identification, mobilization and coordination of these services and resources.(17)
AMassachusetts study found that traumatic brain injuries occur more often among males (82%) and young people between the ages of six and twentynine. The study also found that brain injured persons are less likely to marry and, if severely brain injured, significantly less likely to be reemployed in a comparable pre-injury position. In fact, of all Massachusetts Statewide Head Injury Program (SHIP) clients eighteen years of age and over who were working full-time before the injury, 84% had not returned to work within five years of the injury. The study also found that 76% of the SHIP clients were living with family, rather than in a hospital or long-term care facility.(17)
A New York State study found that the characteristics of traumatic brain injury survivors are very complex and seldom completely recognized. The extent and type of damage often are not accurately and completely detected and the outcomes are difficult to predict.(18)
One of the primary differences between the traumatic brain injured individual and victims of other types of trauma is the cognitive impairments produced by the injury. Victims typically experience varying degrees of temporary or permanent effects such as long and short term memory deficits, loss of ability to concentrate, difficulty in sequencing, behavior problems, reduced capacity for new learning, speech and/or visual disorders or seizures. As a result, the ability of many victims of brain injury to function on a day-to-day basis without support services is severely hampered. (18)
The majority of survivors of traumatic brain lnJury emerge from coma and achieve progress toward regaining their pre-injury functional abilities. 'However, in most cases the patient is left with a combination of physical, cognitive, and integrative deficits that may persist for many months or
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years after the injury.
In the physical sphere, a variety of movement disorders may be observed, including abnormal muscle tone, contractures and tremors. Even a traumatically brain injured person with many of these deficits may ambulate functionally within a few months after injury. Although gross movement may appear generally intact, finer movements are usually impaired. Sensory deficits frequently observed included impaired sense of smell and hearing disorders.
Cognitive deficits ire almost always present after i severe brain injury. These impairments vary in magnitude but tend to greatly alter the capacity of the patient to acquire, store, and retrieve new information and exercise good judgment. Initially, the patient has i decreased level of alertness and arousil and is observed to fluctuate in the ability to concentrate. Although alertness and arousal levels stabilize, attention deficits are still pronounced.
Brain injuries can produce a variety of impairments in "executive" functions, manifested by impulsive behavior, poor problem solving, and slowness in the rate and complexity of information processing. Speech and language disabilities are commonly found.
The third major sphere of dysfunction can be termed "integrative deficits". This refers to the ability to perform complex tasks that require the operation of numerous perceptual, motor, cognitive, and regulatory processes. Complex activities of daily 1iving and appropriate social functioning may be considered integrative functions.
Behivioril problems range from minor irritability and passivity to psychotic behavior. The severely brain-injured client requires a highly structured, consistent, positive-reinforcing environment. Such a person usually cannot return successfully to previous educational or vocational pursuits. (26)
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5. Existing SYstem of Care for persons ReQyiring Transitional Living and life Long living SerVices
The Demand-Based Forecasting Model developed by the State Health Planning Agency's Technical Advisory Committee on Comprehensive Inpatient Physical Rehabilitation Services was designed to estimate and project the need for Traumatic Brain Injury Facilities (and other types of rehabilitation facilities), with need computed separately for Transitional liVing and life Long Living Programs (Appendix B).
As can be seen from Appendix C, there were four facilities in Georgia, as of January, 1990, which provided services which appear to be similar to Transitional Living Programs as defined in this Plan. There were also two facilities which provided services which appear to be similar to Life Long living Programs as defined in this Plan.
The Continuum of Rehabilitation Programs and Services developed by the Technical Advisory Convnittee on Comprehensive Inpatient Physical Rehabil itation Services incl udes a Residential Treatment and Rehabil itation Facility for medically stable disabled clients. This part of the ideal continuum includes programs such as those prOVided by Traumatic Brain Injury Facilities as defined in this Plan. (Appendix A).
6. The Cost of Traumatic Brain Injurv Services
It has been estimated that the average total lifetime costs for a person with severe traumatic brain injury who is cared for in appropriate settings is about $4.6 million. This includes acute medical care, acute rehabilitative care, extended rehabilitation and life-long residential programs. The yearly cost for the life-Long living Programs (together with Transitional Living Programs, the focus of this plan) portion of the brain injury continuum of care is estimated to range from $60,000 - $125,000 yearly, or $164-$342 per day. (48)
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Information made available to the State Health Planning Agency (SHPA) by the Greenery Rehabilitation Centers and the Tangram Rehabilitation Network indicates that the average daily charge for Transitional Living Programs in the U.S. in 1989 was $504 (Greenery) and $268 (Tangram). The charge for Life Long Living Programs offered by Tangram was $143 per day.(4, 5)
Another study based on a survey of trauma patients ages 16-45 years who were discharged from the Maryland Institute for Emergency Medical Services SysteM and the Shock Trauma Center of Johns Hopkins Hospital in 1983, found the average total charge for all traumatically brain injured patients to be $47,274, ranging from $8,416 to $105,570.(49)
A 1983 survey done for the National Association of Rehabilitation Facilities indicates that the average charge for patients with traumatic brain injury was $21,140 for all payers and $14,279 for Medicare patients. Charges per patient ranged from $3,760 to $38,520, depending upon the charge per day and the average length of stay (ALOS). The ALOS was 46 days for all payers and 32 days for Medicare patients. (50)
7. Reimbursement for Traumatic Brain Injurv Services
Medicare, which became a part of the Social Security Amendments of 1965, ha"s been called a breakthrough in health care for the aged. At the time Medicare was enacted, it was decided to pay hospitals on a retroactive cost basis. However, the ever-increasing costs of the program, caused by the relatively open-ended reimbursement method led to numerous containment efforts over the years.
Major payment revisions were contained in the Tax Equity and Fiscal Responsibility Act of 1982 and subsequent Social Security Amendments in 1983. Under this Act, Medicare began the change from retrospective, costbased reimbursement to prospective payment based on a patient classification system called Diagnosis-Related Groups (DRG's).
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Since 1983, when Congress established the Medicare DRG-based Prospective Payment System (PPS) for inpatient hospital care, rehabilitation hospitals and units which qualify under federal regulations have been exempted from the System because the patient classification system and payment approach developed for acute care hospitals did not seem to fit the models of rehabilitation care generally postulated. Rehabilitative care emphasizes the treatment of functional limitations and disability and it usually follows a period of acute medical and/or surgical care. Although the transition from acute to rehabilitative care is not always precisely demarcated, the emphasis shifts from stabil izing the acute problem to maximizing the patient's ability to function independently. The rationale for this exemption was that not enough was known about the relationship between di agnos is, 1ength of stay and resource use. For PPS-exempt hospitals, reimbursement was to be determined using each hospital's cost expense with each facility paid under a base-year cost system. The rate of reimbursement was capped with a limit determined by using historic data on average cost-per-discharge to project current costs.
Congress required the Secretary of the Department of Health and Human Services (DHHS) to report on the feasibility of developing a PPS for rehabilitation and other excluded hospitals and units. In October 1987, DHHS released its report on "Developing a Prospective Payment System for Excluded Hospitals". The report concluded that further research was necessary before DHHS could develop specific legislative and regulatory recommendations. Yet, the report also indicated DHHS' desire ultimately to implement a capitation-based PPS for rehabilitation. Until this goal is achieved, DHHS would like to develop a transitional PPS for rehabilitation. However, since studies indicate that DRGs are an inappropriate basis for a rehabilitation PPS, and measures that would provide a better basis (e.g., functional status or capitation) have not yet been fully developed for purposes of rehabilitation payment, it is uncertain how DHHS will achieve these goals in the short run.
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Work on developing a DRG-type reimbursement system for rehabilitation services has been underway for several years. A number of studies, e.g., The Rand Corporation/UCLA Center study entitled "Charges and Outcomes for Rehabil itative Care: Impl ications for the Prospective Payment System", have been completed, while others are in the formative stages.(ll)
Inadequate insurance and other third-party reimbursement coverage often become a barrier to obtaining services that may be required for a lifetime. Insurance benefits for services following acute medical care are often limited in duration of coverage and/or by dollar ceilings. Limitations on the scope of coverage of private insurance carriers and programs such as Medicaid, Medicare and Workers' Compensation precl ude payment for nonmedical care. As a result, educational, social and cognitive rehabilitation services often become unaffordable for traumatically brain injured individuals and their families.
The Insurance Conunittee of the National Head Injury Foundation has developed a paper which examines insurance issues which impact the traumatically brain injured population, both in terms of patient and family needs.(14) To set the stage for discussion, the Conunittee included the following quote from a specialist in neuropsychological rehabilitation: "A critical dissociation plagues the insurance industry, and this conflict ultimately limits the care which can be provided the patient. On the one hand, the insurance industry universally covers acute care for brain injured as the services fall within the purview of the medical model. On the other hand, by facilitating the patient's survival, the insurance company has created the need for more long-term services, many of which are poorly understood by the medical and insurance industries. Further, even if the typical insurance company appreciates the need for post-acute services, the provisions, and possibly the premiums, of the policy frequently do not cover the necessary services. Consequently, many companies will not feel able to cover services that are not clearly within the scope of the policy. Since many policies were written prior to the emergence of increased brain injury survivability, the patient and family
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are often left with minimal coverage for post-acute care. On a corporate level, many reimbursers are reluctant to listen to non~medical professionals advocating non-medical services, despite the fact that appropriate post-acute services typically represent only a fraction of the costs associated with the patient's acute care while showing substantial economic benefits.-
8. A Reyiew of Insurance Coverage for Traymatic Brain Injyry Services
The following review is taken from a study done by the National Head Injury Foundation. (14)
A. Workers' Compensation
This form of insurance is provided by an employer without financial contributions by employees. Its purpose is to provide benefits to employees injured on the job, in exchange for a limitation of the right to sue for compensatory damages, such as pain and suffering. Benefits include disability, provision for loss of income, and medical benefits. State statutes have made provisions for medical and vocational rehabilitation.
Workers' Compensation coverage probably provides the greatest opportunity for persons with a traumatic brain injury to reach their maximum rehabilitation potential. Use of the nebulous criterion "reasonable and necessary" as applied to rehabilitation services is usually broadly interpreted. However, experience with Workers' Compensation claims has shown a tendency to rely primarily on medical opinions. This can be detrimental to the brain injured client, especially when higher level cognitive skills are involved. Neuropsychologists and other therapeutic disciplines generally have more expertise in identifying and prescribing appropriate rehabil itation programs than members of the medical profession.
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When a brain injury client is discharged from a medical model facility and begins to use out-patient services, a significant gap in insurance coverage may occur. This is especially true when terminology such as "custodial" or "maintenance care" is applied. Most decisions are based on physical restorative concerns rather than cognitive issues. Quality of life and family care-giver burnout may not be given adequate consideration.
B. Automobile No-Fault and liability
No-Fault benefits are paid through an individual's own insurance carrier, regardless of fault or tort liability. Benefits usually include medical expenses, lost wages, and funeral or survivor's benefits in those cases where the accident results in a fatality. The system permits payment of the costs for rehabilitation at the appropriate stage of recovery.
lost wages in all states currently under No-Fault are capped. As under Workers' Compensation, medical benefit payments are contingent on the "reasonable and necessary" test.
liabil ity coverages, as they pertain to automobile accident victims, provide for compensation resulting from negligent acts or civil wrongs of the insured operator for injuries to innocent third parties. Minimum liability limits start at $15,000 per person. These minimums are insufficient when dealing with a catastrophic injury, such as traumatic brain injury.
No-Fault generally follows the payment parameters established in the Workers' Compensation system. Unfortunately, auto liability insurance syste. carriers have been slow to adopt proactive measures incorporating rehabilitation benefits. Instead, many liability insurers negotiate the proportionate liability of their insured, thereby causing delays in the ~ayment of monies for medical care. This results in delays in initiating rehabilitation efforts. In addition, because of the limited funding available for auto liability coverage, settlement monies may be
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inadequate to provide for the long term needs of persons wHh traumatic brain injury.
C. Health Insyrance
Health insurance is usually a type of group insurance purchased primarily by an employer for the benefit of Hs employees and Hs employees' dependents. Often, the larger the employer, the more generous the benefit plan. Group policies usually incorporate a basic hospital insurance plan, and a major-medical component. A typical policy will contain an aggregate limit from anywhere between S25,000 to SI,OOO,OOO, and include inside limits such as a specific number of hospital days, skilled nursing facil Hy days, or limits on the number of therapy sessions. Health insurance policies rarely specify benefits for rehabilitation, other than by reference to speech or physical therapy.
As in most forms of insurance, deductib1es exist that require the employee, along with any dependent, to cover expenses up to a prescribed threshold, usually $100 to S200. Aside from deductib1es as a risksharing device, most health insurance plans use some form of coinsurance.
As a part of many health insurance programs, there are certain other cost containment features. Examples include pre-certification prior to hospital admission and mandatory second opinions for selected types of elective services. These programs may at some point in the recovery process have an impact on either the type of rehabilitation setting for persons with a brain injury or the duration, amount, or type of therapeutic services received.
In March 1987, the Health Insurance Association of America's Rehabilitation Subcommittee surveyed their membership to determine what, if any, rehabilitation programs had been set up within their companies. The survey found that rehabilitation services were most often prOVided informally, rather than under a policy provision. Vocational
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services were the most frequently offered service. Other services frequently provided were: medical management, job placement, catastrophic case management, financial resources, a structured settlement and self employment.
Traumatic brain injury is not recognized by most insurers as a specific diagnosis, distinct from other medical groupings. This creates problems for the reimbursement of medical services. Problems also exist because of contract terminology related to the licensure of providers. For example, most policies will pay for acute care rehabilitation costs in hospitals accredited by the Joint Commission on Accreditation of Health Care Organizations (JCAHO), but not in hospitals accredited by the Connission on Accreditation of Rehabilitation Facilities (CARF), even though CARF may be in a better position than JCAHO to evaluate rehabilitation facilities and programs.
Aggregate policy limits for health insurance may be so low that long term rehabilitation efforts are impossible. Often there are no benefits for custodial care, home health care or outpatient group therapies. These policies are designed for acute care rehabilitation and are not oriented toward the chronic care needs of persons with traumatic brain injury.
Rehabilitation gains by persons with a brain injury usually occur slowly. This means that traditional insurance cost containment mechanisms, such as length of stay reviews, may result in early discharge to less costly, but inappropriate environments and actually delay the recovery process.
It is indicative of the orientation of most policies that clients in the home setting may be deemed to have plateaued" only a short time after their accidents. Once care is judged to be maintenance level only, most therapies and other in-home services, such as nursing and attendant care, are no longer reimbursed.
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As brain injury clients progress to the point of requiring community re-entry programs for skills development in cognitive and socialization areas, they may find that some policies do not recognize these programs as eligible for coverage. Such programs are considered educational or psychiatric in nature and therefore are excluded, or severely limited. The development of non-medical environments which provide these kinds of programs usually does not meet the insurer's licensure criteria and therefore, are not reimbursed under current policy provisions.
Other problems often identified upon discharge of a brain injured person from an inpat ient program to the home are poor judgement and problem solving skills. Therefore, it becomes difficult to leave the person unattended for long periods of time. In addition, as a result of persistent cognitive disorders, the person may require some prompts or cues to complete more complex activities. Reasoning skill deficits and decision-making difficulties require some form of attendant care, at least for certain periods during the day or evening hours. However, most policies do not make provision for this type of care, and it is often too expensive for the family to provide independently.
D. Preferred Provider Organizations (PPO)
A PPO is an entity that contracts with both providers and payers of health care to establish preferred rates of compensation that contractors or preferred providers will accept as payment in full for the services provided to patients. The providers of health care services form a system of care that will provide, in a given geographic area, the entire range of necessary health care services. As these networks expand, they will probably become more involved in specialized rehabilitation.
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E. Health Majntenance Organizations (HMO)
An HMO is often descri bed as a managed care opt ion, compri sed of an established group of providers serving as the health care network. There can be significant differences in the types of HMO's and the services they provide. There are however, three elements that generally characterize most HMOs: 1) prepaYment on a capitated basis, 2) emphasis on preventive treatment, and 3) comprehensive services. Preventive treatment, such as periodic physicals and screening, are stressed. In an effort to maintain financial viability, HMOs tend to enroll healthier people so as to m&intain a high healthy/sick ratio.
Health Maintenance Organizations (HMO's) and Preferred Provider Organizations (PPO's) have traditionally provided primary care services, with limited attention to rehabilitation efforts. However, the Federal HMO Act of 1983 mandated two months of inpatient rehabilitation care. This is inadequate to meet the needs of brain injured clients. Not only are the benefits of a short term nature, but funding for post-acute programs is virtually non-existent. Issues related to attendant care for traumatic brain injured persons at home who require supervision are also not being addressed.
F. Short and Long Term Disability
This form of health insurance coverage views injury or illness from the perspective of lost wages. An employer may provide short term disability for an employee who can not return to his/her former employment for a limited period of time, such as 26 weeks. As the length of disability increases, the employee may be covered under long term disability for as long as he/she is unable to return to any type of gainful employment based on education, background and experience. Very limited rehabilitation benefits may be prOVided.
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Mandatory under most long-term disability policies are provisions for making application for all social insurance applicable to the individual. Once social insurance systems (Workers' Compensation, Social Security Disability) grant an award, there is an il1lllediate dollar for dollar reduction in long-term disability payments. This provides a disincentive to the long-term disability carrier to pursue rehabilitation interventions designed to return an individual to some form of employment.
Some health insurers are beginning to include limited benefits for vocational rehabilitation in long-term disability policies. Traditionally, insurers have made no provision for payment for any costs to rehabilitate the injured person. Such policies may pay the cost for evaluation or other vocational assistance designed to determine if an individual can be re-employed.
G. Reinsyrance
Because of the catastrophic nature of moderate to severe traumatic brain injury, it is difficult to predict the ultimate financial burden. As a result, an insurance carrier may enter into a reinsurance contract that will allow another company to assume risks above a pre-determined threshold ..
Normally reinsurance companies develop expertise in handling catastrophic injuries, such as traumatic brain injury. Frequently, they have rehabilitation departments or programs designed to handle these types of injuries.
H. Self Insurance
All the various types of insurance, other than reinsurance, can be self funded. The term "self insurance" refers to an entity which elects to underwrite, pay, and handle claims through its own internal financial resources, rather than use an insurance company funded program. Most
21

large corporations use some form of self insurance, either in a true or modified format. The employer's benefit departments have a great deal of control over those benefit provisions that affect persons with a brain injury.
J. Insyrance Coverage Recommendations
The National Head Injury Foundation has developed a comprehensive list of recommendations for insurance coverage for traumatic brain injury based on the work of a special insurance c0llll1ittee.(l4) The following is a summary of the major categories of recollll1endations:
1) Encourage development of individual case management systems as a proven cost effective measure and as an essential element throughout the various stages of rehabilitative care.
2) Continue and expand No-Fault Auto insurance to include improvements in rehabilitation benefits.
3) Provide additional rehabilitation insurance coverage via catastrophic riders.
4)- Encourage establishment of state health insurance pools for hardto-cover individuals such as those with traumatic brain injury.
5) Encourage reforms in Medicare and Medicaid coverage to reduce eligibility waiting periods and other measures to improve access to such coverage when it is needed.
6) Support the concept of Medical Individual Retirement Accounts (IRAs) which would allow a person to accumulate tax deductible and tax deferred assets that, at some later date, could be used to purchase catastrophic insurance on either a group or individual basis. Legislation is pending in Congress to establish medical IRAs.
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7) Develop funding sources for attendant care especially for post acute brain injury rehabilitation which does not fit neatly into the medical model.
8) Encourage development of advocacy groups including providers, payers, regulators and consumers to direct efforts toward increased cooperation in consensus-building and decision-making regarding rehabilitation issues.
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GUIDELINES FOR THE REVIEW AND DEVELOPMENT OF TRAUMATIC BRAIN INJURY FACILITIES
I Use Qf the Gyidelines
The purpQse Qf these guidelines is tQ assist the GeQrgia State Health Planning Agency tQ plan fQr the Qrderly develQpment Qf Traumatic Brain Injury Facilities in the State Qf GeQrgh. These guidelines apply tQ Traumatic Brain Injury Facilities defined herein as prQviding TransitiQnal living PrQgrams and/Qr life lQng living prQgrams. Any facility prQviding services similar tQ TransitiQnal living PrQgrams and life lQng living PrQgrams as defined herein which were in existence priQr tQ the adQptiQn Qf this Plan are nQt Traumatic Brain Injury Facilities until such facilities have applied fQr and received a Certificate Qf Need as a Traumatic Brain Injury Facility under the Certificate Qf Need rules. The Certificate Qf Need shall indicate fQr which prQgram(s) the Traumatic Brain Injury Facility is apprQved, either a TransitiQnal living PrQgram, Qr a life lQng liVing PrQgram, Qr bQth. TQ add a new prQgram nQt previQusly apprQved shall require a new Certificate Qf Need.
The fQllQwing guidelines present and discuss the majQr service characteristics, criteria and standards which apply tQ Traumatic Brain Injury Facilities.
A. DefinitiQns
1. "life lQng living PrQgram" means such treatment and rehabilitative care as shall be delivered tQ traumatic brain injury clients whQ have been discharged frQm a mQre intense level Qf rehabilitatiQn, but whQ cannQt live at hQme independently, and whQ require Qn-gQing lifetime suppQrt. Such clients are medically stable, may have special needs, but need less than 24 hQur per day medical suppQrt.
2. "Official State Health CQmpQnent Plan" means the dQcument related tQ Traumatic Brain Injury Facilities develQped by the State Health Planning
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Agency, established by the Georgia State Health Policy Council and signed by the Governor of Georgia.
3. "Service Areas means substate regions for Traumatic Brain Injury Facilities as defined in the most recent Official State Health Component Plan for Traumatic Brain Injury Facilities.
4. "Transitional living Program means such treatment and rehabilitative care as shall be delivered to traumatic brain injury cl ients who require education and training for independent living with a focus on compensation for skills which cannot be restored. Such care prepares clients for maximum independence, teaches necessary skills for community interaction, works with clients on pre-vocational and vocational training and stresses cognitive, speech, and behavioral therapies structured to the individual needs of clients. Such clients are medically stable, may have special needs, but need less than 24 hour per day medical support.
5. "Traumatic Brain Injury" means a traumatic insult to the brain and its related parts resulting in organic damage thereto which may cause physical, intellectual, emotional, social, or vocational changes in a person. It shall also be recognized that a person having a traumatic brain injury may have organic damage or physical or social disorders, but shall not be considered mentally ill.
6. "Traumatic Brain Injury Facility" means a building or place which is devoted to the provision of residential treatment and rehabilitative care in a Transitional living Program or a life long living Program for periods continuing for 24 hours or longer for persons who have traumatic brain injury. Such a facil ity is not classified by the Office of Regulatory Services in the Georgia Department of Human Resources or the State Health Planning Agency as a hospital, nursing home, intermediate care facility or personal care home.
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B. Guidelines
AVAILABILITY
Criterion - Need for Services
Standard 1: The need for a new or expanded Traumatic Brain Injury Facility in a service area shall be determined through the application of the need method as described in the most recent Official State Health Component Plan for Traumatic Brain Injury Facilities.
Rationale for Standard 1: Specialized programs for traumatic brain injury cl ients should be located in a 1imited number of facil ities so as to serve residents of a given geographic area who are in need of such specialized services. Among the reasons supporting the selection of certain sites are the reliance on skilled staff to use various technologies, the costs associated with these servi ces and the need to ensure staff profi ciency wi th caseloads of sufficient size. Given these criteria, Traumatic Brain Injury Facility programs should be strategically located so as to have access to sufficient resources to maintain appropriate utilization levels.
So as to appropriately address these criteria, the Technical Advisory Committee on Comprehensive Inpatient Physical Rehabilitation Services developed a DemandBased Forecasting Model. The model contains eleven diagnostic categories, including traumatic brain injury, comprised of carefully selected ICD-9 (International Classification of Diseases, 9th Revision) and procedure codes considered to be most likely to benefit from rehabilitation services. The Model process begins with Georgia-specific general hospital discharge rates for each of the eleven rehabilitation-related diagnostic categories under consideration. These discharge rates are based on data obtained from the Georgia Hospital Association's Statewide Hospital Patient Origin Study. (42) For the total
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surviving discharges in each of the eleven diagnostic categories, the percent of survivors likely to use services in a given setting is determined and bed requirements are computed for the selected inpatient settings. Appendix B depicts the basic elements of the Demand-Based Forecasting Hodel.

The Demand-Based Forecasting Hodel developed by the Technical Advisory Committee has been adapted to project the need for beds in Traumatic Brain Injury Facilities, with need computed separately for Transitional Living Programs and Life Long Living Programs. The specific explanation and rationale for the need method for each type of program is outlined below.

The steps in the method for projecting need for beds in Transitional Living Programs are as follows:

Step 1

Project clients for Transitional Living Programs in the planning horizon year, which is the third year. The projected population in the service area is multiplied by the statewide hospital discharge rate for acute care hospi ta1s for pat i ents wi th traumat ic brain injury (TBI) diagnoses. This rate is based on official data accessible to the State Health Planning Agency from the 1987 Georgia Hospital Association Patient Origin Study. This rate will be used unt i1 the Agency has a substant i a1 data base and experi ence in . monitoring the development of these programs. The projected total TBI discharges are multiplied by the estimated percent demand for transitional living which is two percent. Based on several epidemiological studies, most TBI patients (all intensities of brain injury) in acute care hospitals are discharged home with no care (82.S percent), while between four to six percent die in the hospital, six to eight percent are discharged home with some form of home or outpatient care, and four to eight percent go to another type of treatment facility.(IS,17) A survey of selected providers by the Technical Advisory Committee indicated a demand rate among acute care hospital discharges ranging from five to twenty-five percent. (4S) For purposes of this Plan, it is conservatively

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estimated that of those patients discharged home, at least two percent could benefit from a Transitional Living Program.

Step 2.'

Project client days. The projected clients from step one are multiplied by the expected average length of stay for a Transitional Living Program which is 300 days. There is variation among the various sources about length of stay for Transitional Living Programs, with a range froM four to eighteen months. (5,34,35,36,38) The average for the Transitional Living Program at Tangram in Texas is approximately ten months (5) which falls within the range identified by the National Head Injury Foundation. (35) In the four existing facilities in Georgia providing residential transitional 1iving services, the average length of stay ranges from five to seven months (See Append ixC). In th is P1 an, 300 days has been identified as the expected average length of stay, reflecting a midpoint of the national range and inclusive of Georgia's existing programs.

Step 3.

Project the number of beds needed. The client days from step two are divided by 365 days per year to obtain an average daily census and then divided by a desired occupancy rate of 85 percent to determine the number of beds. Any fraction is rounded up to a whole bed.

The steps in the method for projecti ng need for beds in Li fe Long Li vi ng Programs are as follows:

Step 1.

Estimate existing clients who may be candidates for life long living. The current estimated population in the service area is multiplied by the estimated prevalence rate for TSI clients. Existing studies show an incidence rate for brain injury between 180 and 200 per 100,000 population and a prevalence rate of four times the incidence.(15,16,24) This is based on annual incidence times average duration in years, with Kurtzke approximating the years

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duration for TBI as four.(16) In Georgia, the statewide hospital discharges from acute care hospitals for patients with traumatic brain injury (TBI) diagnoses indicate a rate of 1.21 per 1000 population. (42)

This would result in an estimated prevalence of 4.84 per 1000 population. The total existing TBI clients (prevalence) is multiplied by the estimated percent demand for life long living. Little information is available to use in predicting the demand for 1i fe long li vi ng. Cons ideri ng the undocumented record of use of these types of programs, it is recommended for thi s Pl an that a demand rate of 0.5 percent be used at this time.

The Technical Advisory Committee survey of selected providers indicated a demand rate for life long living for acute care hospital discharges ranging from one to thirty percent. (45) Traumatic Brain Injury epidemiological studies do not address demand for life long living specifically, even though it is recognized that treatment of late effects of Traumatic Brain Injuries will be necessary for some clients.(15,17)

As programs are established and utilization and patient origin data are collected, a more precise measure of demand for Life Long Living Programs can be determined. The Planning Agency will assess available information on demand annually and pursue any problems which may be discovered. Two years after the date operation begins for any approved Traumatic Brain Injury Facilities with Life Long Living Programs, the Agency will reevaluate the demand rate used in this Plan.

Step 2.

Project new clients for life long living for year one of the three year planning period. The projected service area population for year one is multiplied by the hospital discharge rate for Georgia acute care hospitals for patients with traumatic brain injury (TBI)

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diagnoses. This rate is based on official data accessible to the State Health Planning Agency from the 1987 Georgia Hospital Association Patient Origin Study. This rate will be used until the Agency has a substantial data base and experience in monitoring development of these programs. The projected total TBI discharges are multiplied by the estimated 0.5 percent demand for life long living.

Step 3

Adjust for annual attrition due to death or discharge to another setting. The estimated existing clients (Step 1) are added to the projected new clients (Step 2) for life long living to determine clients for year one. This number is multiplied by a ten percent attrition rate to account for death of clients or discharge to another setting.

Step 4

Estimate client numbers for year two of the planning period by repeating steps 1-3 using projected population figures provided by the Office of Planning and Budget.

Step 5 Estimate client numbers for year three of the planning period by repeating steps 1-3 using the appropriate population estimates.

[NOTE:

As conceived in this model, for each year of the planning period client numbers are estimated independently based on population project ions provi ded by the Offi ce of Pl ann i ng and Budget. As experience is gained through monitoring the operations of approved programs, both the method of estimation and the provisional estimates of need are subject to revision and re-estimation. At the present time, however, given the lack of a firm historical data base for estimation purposes, it is prudent that the most conservative statistical model be applied to assure that the most essential services are delivered to the target population. The process of monitoring the operations of approved programs will provide the foundation needed to revise the procedures described here.]

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Standard 2: An appl icant shall document that existing and approved Traumatic Brain Injury Facilities are not predicted to be adversely impacted as the result of the establishment of a new or expanded facility.
Rationale for Standard 2: This standard addresses the issue of the impact, or projected impact, of the establishment of a new or expanded Traumatic Brain Injury Facility on existing and approved Traumatic Brain Injury Facilities. To the extent possible, it is necessary to prevent unnecessary duplication of these facil ities so as to achieve and maintain a sufficient number of clients in existing facilities, thus haVing a positive impact on quality of care and costeffectiveness.
Additionally, the establishment of new or expanded facilities should be done in a way which creates and maintains a positive relationship between new and existing Traumatic Brain Injury Facilities.
It is recognized that the establishment of a proposed new or expanded Traumatic Brain Injury Facility may adversely affect only certain existing and approved facilities, rather than all such facilities. Therefore, projected impact should be based on an analysis of referral patterns, current utilization of existing facilities, and other relevant factors. A finding of adverse impact would be made only for existing and approved facilities which actually would be impacted or would be expected to be impacted by a new or expanded facility.
The impact of a proposed new or expanded Traumatic Brain Injury Facility on the availability of staff for existing programs also is a consideration in determining the potential for an adverse impact on established facilities. Proposed new or expanded Traumatic Brain Injury Facilities should have a plan for obtaining necessary staff without the recruitment of staff from existing facil ities, to the extent that performance of an existing facil ity would be reduced. Shortages of experienced and specially trained staff necessary to operate a Traumatic Brain Injury Facility is an important factor when assessing potential adverse impact on the performance of an existing service.(40,41)
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QUALITY
Criterion - Minimym Bed Size
Standard 1: Minimum bed size for a Traumatic Brain Injury Facility is six beds; maximum bed size for a Traumatic Brain Injury Facility is 30 beds.
An app1 icant for a new or expanded Traumatic Brain Injury Facility may be approved for total beds to exceed thirty (30) beds only if the app1 icant provides documentation satisfactory to the State Health Planning Agency that the program design, including staffing patterns and the physical plant, are such as to promote services which are of high quality, are costeffective, and are consistent with client needs.
Rational for Standard 1: So as to help ensure that a Traumatic Brain Injury Facll ity provides high qual ity services in an efficient and cost-effective manner, minimum bed complement is specified. Facilities with bed complements below the levels specified may be too small to be able to prOVide specialized staff and services at a reasonable cost and still maintain program integrity and quality. The Technical Advisory Committee recommended a minimum of six beds for a Transitional Living Program.(34)
One source suggests that a supervised group-living environment, such as a Transitional Living or Life Long Living Program, ordinarily houses six to eight clients who have suffered traumatic brain injury and are at a similar position on the recovery curve. (20) This is consistent with size specifications for other group living settings such as the mentally ill and mentally retarded. (44) An important factor in the group-living environment is maintaining the home-like characteristics which encourage individual development and progress toward rehabilitation goa1s.(43,46)
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In setting maximum facility size, it is recognized that there is a size beyond which home-like characteristics cannot be maintained, contributing to an institutionalized environment. Some experts suggest that the size of facilities where home-like atmosphere is important to the client's well being should be kept to a minimum, with no indication for a specific maximum number of beds. (43, 46, 47) For purposes of this plan, 30 beds is recommended as the desired maximum.
However, there may be circumstances in which an applicant is able to document to the State Health P1 ann ing Agency's sat isfact ion that a new or expanded Traumatic Brain Injury Facility could be expected to deliver high quality, costeffective services in a facility with more than 30 beds. In such a situation, additional beds may be approved. Such documentation should include, but would not be limited to, evidence that the program design, including staffing patterns and the phys ica1 plant, are such as to promote serv ices wh ich are of high quality, are cost-effective, and are consistent with client needs.
Standard 2: An app1 icant for a new or expanded Traumatic Brain Injury Facility shall demonstrate the intent to meet the a) standards of the Commission on Accreditation of Rehabilitation Facil ities (CARF) which apply to post-acute brain injury programs and residential services; and the b) rules of the Georgi a Department of Human Resources for Traumat ic Bra in Injury Facilities (Chapter 290-5-53).
Rationale for Standard 2: Quality is a measure of the degree to which delivered health services meet established standards and judgments of value to the client. The provisions of licensure rules and regulations are to assess the minimal standards for services delivered. Quality is a function of many variables, including but not limited to: a) the education, experience and understanding of health care providers and the availability of these prOViders to assure appropriate staffing; b) the process of service delivery, including the provision of appropriate levels of care to meet specific patient care needs; c) institutional capacity to deliver services in an efficient and cost-effective
33

manner; d) licensure and certification to survey compliance with established standards; and e) the ability of a health care program to satisfy the expectations of the community to deliver quality care according to established community standards.(l)
The Commission on Accreditation of Rehabilitation Facilities (CARF) was formed in 1966 as a national, private, non-profit organization to carry out the functions of a quality control intermediary.
The Commission is the product of a single purpose alliance of various segments of the rehabilitation field to provide services to people with disabilities. This includes those who are disabled and their representatives, those who provide services and their representatives and third party public and private agencies which purchase or use services.
CARF functions as a "quality control intermediary" in the rehabilitation industry. The organization, independent from those it accredits, establishes and maintains a nationwide set of standards of quality, developed in a participatory fashion, which address the needs of people with disabilities.
CARF's brain injury standards for Post Acute Programs and the more general standards for Residential Services should serve as a guide for an appl icant developing a new or expanded Traumatic Brain Injury Facility.(7) A Post Acute Program serves those who do not require a comprehensive inpatient rehabilitation program, but who demonstrate a continuing need for rehabilitation and specialized, supportive services. Services may be directed toward the development and/or maintenance of the most optimal level of independent functioning and community reintegration of the individuals served. Programming can take place in a residential or day care, outpatient, and/or vocational setting and on a short-term, long-term, or respite basis.
Standard 3: An applicant for a new or expanded Traumatic Brain Injury Facility shall have written policies and procedures for utilization review. Such review shall consider the medical
34

necessity for the service, quality of client care, rates of utilization and other considerations generally accepted as appropriate for review.
Rational for Standard 3: Quality control is essential for the consistent high quality required of a Traumatic Brain Injury Facility. Quality control includes an evaluation of the necessity, appropriateness and efficiency of the use of health and health related services, procedures and facilities. Generally, this includes the review of the appropriateness of admissions, services ordered and provided, length of stay, progress toward discharge and discharge practices, both on a concurrent and retrospective basis. Utilization review can be done by a utilization review committee, a Professional Review Organization (PRO), a peer review group and/or a public agency.
Generally, the duties of peer review organizations include the establishment of criteria, norms and standards for diagnosis and treatment of diseases and a review of services to determine any inconsistencies with established norms. The norms may be input, process or outcome measures.

CONTINUITY

Criterion: Availability of Adequate Medical Care

Standard:

An appl icant for a new or expanded Traumatic Brain Injury Facility shall document the existence of referral arrangements with an acute care general hospital to provide acute and emergency medical treatment to any client who requires such care.

Rationale for Standard: In order to assure access to acute and emergency care for clients, it is required that a Traumatic Brain Injury Facility have formal referral arrangements with an acute care general hospital. Care can then be received and continuity with the Facility will be assured.

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ACCESSIBILITY
Criterion 1: Discrimination Policies/Financial Accessibility
Standard 1: An applicant for a new or expanded Traumatic Brain Injury Facility shall provide:
a) evidence of a written policy regarding the prOVision of services regardless of race, age, sex, creed or religion; and
b) evidence of a written policy regarding the provision of services regardless of a client's ability to pay.
Rationale for Standard 1: The provision of services on a nondiscriminatory basis, particularly to the indigent and uninsured or underinsured population, has become a growing concern. Many indigent and uninsured or underinsured individuals cannot afford to purchase traumatic brain injury services. The purpose of this standard is to ensure that equity will occur in the provision of traumatic brain injury services to those individuals who cannot afford such care.
Standard 2: An applicant for a new or expanded Traumatic Brain Injury Facility shall document that the Facility will be financially accessible by:
(i) providing sufficient documentation that unreimbursed services for indigent and charity clients in a new or expanded Facility shall be offered at a standard which meets or exceeds three percent of annual gross revenues for the Facility after provisions have been made for bad debt and Medicaid/Medicare contractual adjustments have been deducted. If an applicant, or any facility owned or operated by the applicant's parent organization, received a Certificate of Need (CON) for a Traumatic Brain Injury Facility and the CON included an
36

expectat ion that a certain 1eve1 of unre imbursed ind igent and/or charity care would be provided in the Facility(ies), the applicant shall provide sufficient documentation of the Facility's provision of such care. An applicant's history, or the history of any facility owned or operated by the applicant's parent organization, of not following through with a CON expectation of providing indigent and/or charity care at or above the level agreed to will constitute sufficient justification to deny an application; and
(ii) agreeing to participate in the Medicare and Medicaid programs, whenever these programs are available to the Facil i ty.
Rationale for Standard 2: The Agency is required by law, Rule 272-2-.08(1)(b)(7} to evaluate the financial accessibility of proposed facilities to all citizens of Georgia. In order to increase financial accessibility, there exists a requirement for the provision of indigent and charity care in these and previous guidelines. The applicant shall document, to the Agency's satisfaction, that unreimbursed services for indigent and charity clients will be offered at or above the stated level. The documentation should include financial projections which acknowledge the costs of providing such care, while still showing financial.feasibility.
The applicant's history, and the history of any Traumatic Brain Injury Facility in Georgia owned or operated by the applicant's parent organization, concerning the provision of indigent and charity care, shall be evaluated. If a previous Certificate of Need for a Traumatic Brain Injury Facility was granted through Certificate of Need Rules which included a standard for the provision of unreimbursed indigent and/or charity care, the applicant shall document to the Agency's satisfaction that the facility provided such care. If a previous Certificate of Need was granted for an application with a specific expectation the facility would provide a certain level of unreimbursed indigent and/or charity care, the applicant shall document to the Agency's satisfaction, that
37

that level of care was provided. An applicant's history, or the history of any facility in Georgia owned or operated by the applicant's parent organization of not providing unreimbursed indigent and/or charity care at or above the level specified, will constitute sufficient justification to deny an application.
Criterion 2: Geographic Accessibility
Standard 3: The service areas for Traumatic Brain Injury Facilities shall be the ten Georgia Department of Human Resources Health Districts (Appendix F).
Rationale for Standard 3: Traumatic brain injury clients should be able to receive care within a reasonable distance of their homes so as to encourage the involvement of their families and friends, and to increase accessibility to and continuity of services upon discharge. In order to plan for a reasonable distribution of services, the ten Department of Human Resources Health Districts will be used for planning purposes. These Districts have been the basis for planning areas for other programs and services analyzed by the State Health Planning Agency.
Since Traumatic Brain Injury Facilities are a new service, there are no data or other information on patient flow, Le., where clients are now receiving services, which could be used to define service areas. However, at such a time as adequate patient flow information is available, the issue of geographic accessibility may be readdressed and, if necessary, service areas will be redefined.
Standard 4: An applicant for a new or expanded Traumatic Brain Injury Facility shall provide evidence that the location of the new or expanded facility beds improves the distribution of beds for similar facilities, existing or approved, within the planning area, based on the geographic and demographic characteristics of the planning area. If the applicant
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provides evidence that there does not exist an appropriate location for the proposed facility in another portion of the planning area, the proposed facility may be approved in the same portion of the planning area as a similar, eXisting or approved, facility(ies). Failure to provide sufficient justification will constitute adequate reason to deny an application.
Ratjonale for Standard 4: The bed need projections for programs in a Traumatic Brain Injury Facility are for an entire service area. This projected need will also be allocated within each service area so as to achieve as optimal a distribution of programs and services as possible.
Because the service areas vary in size and population, it may be appropriate, in some cases, to concentrate the services in one part of the area, while in other areas it may be appropriate to make additional sites available. If the eXisting and approved similar facilities are reasonably well distributed within a planning area,.it may be appropriate to expand such facilities.

COST

Criterion - Patient Charges

Standard:

An app1 icant for a new or expanded Traumatic Brain Injury Facility shall demonstrate that charges for services shall compare favorably with charges for similar services in the same geographic service area, when adjusted for inflation, or an adjacent service area if no similar services are operational in the area of the proposed Facility.

Ratjona1e for Standard: In order to more effectively allocate monies for Traumatic Brain Injury Facilities and to help ensure that services are financially available, costs and charges should be kept at reasonable levels.

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An applicant s~ould provide documentation which demonstrates financial feasibility, while providing necessary programmatic activities, levels of trained staff, levels of indigent and charity care and adequate facility space.

In August, 1989, the Greenery Rehabilitation Center, a national company specializing in the establishment and operation of brain injury programs, made available to the State Health Planning Agency preliminary average daily charge information which the Greenery had collected via survey from 120 brain injury programs across the county. (4) The Survey was done by The Greenery's marketing operations in Greenery facilities across the country. The average daily charge for Extended Care (27 programs) was $347.15.

Information from another brain injury program, the Tangram Rehabilitation Network, indicates the following average daily charges (5):

Program Life long Living Independent living Transitional living

Ayerage Daily Charge $142.86 125.00 267.86

Information from the National Head Injury Foundation indicates that for severe brain injury victims, charges for Extended Rehabilitative Care are about $433 daily, while charges for life long living Programs range from about $164 to $342 per day. (35)

As can be seen from the information above, charges vary significantly according to the provider and type of program.

INFORMATION REQUIREMENTS Criterion: Data Collection System

40

Standard:

An applicant for a new or expanded Traumatic Brain Injury Facility shall agree to provide State Health Planning Agencyrequested information and statistical data related to the operation of such a Facility and to report that information and statistical data to the State Health Planning Agency on a yearly basis, and as needed, in a format requested by the Agency and in a timely manner.

Rationale for Standard: Uniform data related to the provision and utilization of Traumatic Brain Injury Facilities is important to the assessment of service needs and other planning requirements. Information reported to the Agency continues to improve as annual and special surveys are refined. The submission of timely and accurate data allows for a more precise assessment of the current level of programs and services being prOVided, need for additional services, costs, charges, patient origin and other factors important in planning for Traumatic Brain Injury Facilities. The Agency plans to continue conducting annual and specia.1 surveys in order to collect information for planning, Certificate of Need and other appropriate purposes. Failure to provide adequate data could jeopardize the awarding of a future Certificate of Need. Nonreporting also could lead to erroneous Certificate of Need decisions if adequate data are unavailable.

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GOALS, OBJECTIVES AND RECOMMENDED ACTIONS
YQAL:
Traumatic Brain Injury (TBI) Facilities should be available, and geographically and financially accessible to the extent that need is met with efficient, high quality services.
OBJECTIVES: 1. Authorize the development of Traumatic Brain Injury (TBI) Facilities based
on an assessment of the use rate within a service area, with the establishment of new Facilities occurring only if existing Facilities have reached, or are projected to reach within a reasonable period of time, a desired utilization level so that new Facilities are not likely to have an adverse impact.
The proposed Facilities must meet the guidelines in this Component Health Plan.
2. Encourage Traumatic Brain Injury (TBI) Facilities to provide optimal care for c1ients, to evaluate on a conti nu ing bas is the quality of care provided and to develop close linkages between TBI Facilities and a general hospital (s) in the facility's service area so as to expedite client transfers and referrals, especially for emergency care.
3. Support the provision of Traumatic Brain Injury (T81) services to all persons in need, regardl ess of ability to pay, wi th a commitment to provide reasonable levels of service for indigent/charity care and on reasonable charges for paying patients and third party payors.
4. Maintain a data collection system designed to ensure the availability of current and reliable utilization and financial information related to Traumatic Brain Injury (TBI) Facilities in the State so as to provide timely support for the health planning and Certificate of Need (CON) review process of the State Health Planning Agency.
42

5. Support the development of reimbursement and funding mechanisms for TraulAtic Brain Injury (TBI) Facilities which are comprehensive and coordinated and which will encourage the rational development of TBI services, i.e., Transitional living and life long living Programs.
RECOMMENDED ACTIONS
1. Approve Certificate of Need (CON) appl ications for new or expanded Traumatic Brain Injury (TBI) Facilities only when a need for such Facilities is determined to exist.
2. Require applicants for a new or expanded Traumatic Brain Injury (TBI) facility to provide or arrange for the availability of appropriate TBI services (Le., Transitional living and life long living Programs) and workable procedures for the timely transfer of patients and their records, as required and appropriate.
3. Collect data annually, and on an ad hoc basis, if necessary, to maintain current and accurate information related to capacity, utilization, patient origin, charges, services prOVided, staffing and other resource requirements, and such other information as might be necessary to determine the need for services and to support continuing planning efforts.
4. Monitor trends in the provision of Traumatic Brain Injury (TBI) services, including technological advances, and advise the State Health Policy Council of such trends so as to support an ongoing evaluation of policy and to determine the need for plan updates and revisions.
43

REFERENCES
1. A Glossary of Health Care Delivery and Planning Terms, Institute for Health Planning, August, 1981.
2. "The Cost of Trauma", Newsletter of the Robert Wood Johnson Foundation, Spring, 1989.
3. Amendments to Rule 10-5.011(1)(n), Comprehensive Medical Rehabilitation Inpatient Services, State of Florida, Department of Health and Rehabilitative Services, September, 1989.
4. Average Daily Charge for Selected Head Injury Programs, Greenery Rehabilitation Center, San Francisco, CA., September, 1989.
5. Organization Report and Program Description, Tangram Rehabilitation Network, San Marcos, TX., 1989.
6. "Payment Blocks Access to Head-Injury Rehabilitation", Hospitals, April 20, 1988.
7. Standards Manual for Organizations Serving People With Disabilities, Commission on Accreditation of Rehabilitation Facilities, Tucson, Arizona, 1989.
8. Conversation with Allan Toppel, Division Director, Commission on Accreditation of Rehabilitation Facilities, October 31, 1989 re: accreditation standards for brain injury programs.
9. Batavia, I., Andrew, J.D .. ,M.S., The Payment of Medical Rehabilitation Services: Current Mechanisms and Potential Models, for the American Hospital Association, 1988.
10. McGinnis E., Gayle, et a1., "Total Charges for Inpatient Medical Rehabilitation", Health Care Financing Review, Summer, 1988.
11. Hosek, Susan, et a1., Charges and Outcomes for Rehabil itat ion Care. Implications for the Prospective Payment System, The Rand Corporation for the Health Care Financing Administration, November, 1986.
12. Nyrsing HOme Reimbyrsement and the Allocation of Rehabilitation Therapy Resources, U.S. Department of Health and Human Services, Public Health Service, October, 1988.
13. "The Economic Impact of Traumatic Injuries", Hospitals, December 9, 1988, Vol. 260, No. 22.
14. A Review of Gaps and Problems in Insurance Coverages and Their Relationship to Traumatic Brain Injury, National Head Injury Foundation Insurance Committee, September 1988.
44

REFERENCES
1. A Glossary of Health Care Delivery and planning Terms, Institute for Health Planning, August, 1981. 2. "The Cost of Trauma", Newsletter of the RQbert WQQd JQhnson foundation,
Spring, 1989. 3. Amendments to Rule 10-5.011(1)(n), CQmprehensive Medical RehabilitatiQn
Inpatient Services, State of Florida, Department Qf Health and Rehabilitative Services, September, 1989. 4. Average Daily Charge fQr Selected Head Injury PrQgrams, Greenery RehabilitatiQn Center, San FranciscQ, CA., September, 1989. 5. Organization RepQrt and Program DescriptiQn, Tangram Rehabi1itatiQn Network, San MarcQs, TX., 1989. 6. "Payment Blocks Access to Head-Injury Rehabilitation", Hospitals, April 20, 1988. 7. Standards Manual fQr OrganizatiQns Serving People With Disabll ities, CQmmissiQn on Accreditation of Rehabilitation facilities, TucsQn, ArizQna, 1989. 8. Conversation with Allan TQppe1, Division DirectQr, CQmmissiQn Qn Accreditation of Rehabilitation Facilities, October 31, 1989 re: accreditation standards fQr brain injury programs. 9. Batavia, I., Andrew, J.D .. ,M.S., The Payment of Medical RehabilitatiQn Services: Current Mechanisms and Potential MQdels, for the American Hospital AssQciatiQn, 1988. 10. McGinnis E., Gayle, et a1., "TQtal Charges fQr Inpatient Medical Rehabi1itatiQn", Health Care Financing Review, Summer, 1988. II. Hosek, Susan, et a1., Charges and Outcomes fQr RehabilitatiQn Care. ImplicatiQns for the PrQspective Payment System, The Rand CQrporation fQr the Health Care Financing Administration, November, 1986. 12. Nursing Home Reimbursement and the A11QcatiQn of Rehabilitation Therapy ResQurces, U.S. Department of Health and Human Services, Public Health Service, October, 1988. 13. "The EconQmic Impact of Traumatic Injuries", Hospitals, December 9, 1988, Vol. 260, No. 22. 14. A Review of GaDS and PrQblems in Insurance CQverages and Their Relationship to Traumatic Brain Injury, NatiQnal Head Injury FQundatiQn Insurance Committee, September 1988.
44

15. Kraus, Jess F., et a1., "The Incidence of Acute Brain Injury and Serious Impairment in a Defined Population", American Journal of Epidemiology, Vol. 119, No.2, 1984, pages 186-201.
16. Kurtzke, John F., M.D., "The Current Neurologic Burden of Illness and Injury in the United States", Neyro1ogy, No. 32, Nov. 1982, pages 12071214.
17. The Status of People with Brain Injyries in Massachusetts: Epidemiological Aspects and Service Needs, Massachusetts Rehabilitation Commission, Statewide Head Injury Program, May 1988.
18. Head Injury in New York State, A Report to the Governor and the legislature, New York Department of Health, May, 1986.
19. Traymatic Brain Injyry Ideal Rehabilitation System Report, Prepared by the Pennsylvania Interagency Head Injury Committee, September, 1988.
20. Deutsch, Paul M., Ph.D. and Kathleen B. Fra1ish, Ph.D., Innovations in Head Injury Rehabilitation, Matthew Bender and Co., Inc., New York, N.Y., 1988.
21. Medical Rehabilitation-What It Is and Where It Is: ADiscussion, National Association of Rehabilitation Facilities, Washington, D.C., 1988.
22. "Chronic Impairments From Minor Head Injury are limited", Research Activities, National Center for Health Services Research and Health Care Technology Assessment, RockVille, MD., No. 120, August, 1989.
23. Koska, Mary T., "Private Sector Courts low-Cost Subacute Care", Hospitals, February 5, 1989.
24. Kraus, Jess F., MPH,Ph.D., "Injury to the Head and Spinal Cord: The Epidemiological Relevance of the Medical literature Published from 1960 to 1978", Journal of Neurosurgery, Vol. 53, November, 1980.
25. Shapiro, Kenneth, M.D., "Head Injury in Children", CNS Trauma Status Report, National Institute of Health, Bethesda, MD., 1985.
26. Whyte, John and Mitchell Rosenthal, Ph.D., "Rehabilitation of the Patient with Head Injury", Rehabilitation Medicine: Principles and Practice, lippincott, Philadelphia, PA., 1988.
27. Burke, David C., "Needs: Planning a System of Care for Head Injuries", Brain Injury, Vol. 1, No.2, 1987, pages 189 to 198.
28. Farmer, Janet E. and Robert G. Frank, "The Brain Injury Rehabilitation Scale (BIRS): AMeasure of Change During Post-Acute Rehabilitation", Brain Injury, Vol. 2, No.4, 1988, pages 323-331.
45

29. Glenn, Mel B., M.D., and Mitchell Rosenthal, Ph.D., "Rehabil itation Following Severe Traumatic Brain Injury", Seminars in Neyrologv, Vol. 5, No.3, Sept. 1985, pages 233-246.
30. Jennett, Bryan, "Predictors of Recovery in Evaluation of Patients in Coma", Adyances in Neurology, Vol 22, 1979.
31. Kalisky, Zvi; M.D., et al., "Medical Problems Encountered During Rehabilitation of Patients with Head Injury", Archives of physjcal Medicine Rehabilitation, Vol. 65, Jan. 1985, pages 25-29.
32. Glanutsos, Rosamond, Ph.D., "What is Cognitive Rehabilitation?" Journal of Rehabjlitation, July/August/Sept. 1980, pages 37-40.
33. Jacobs, Harvey E., Ph.D., et al., "Family Reactions to Persistent Vegetative State", The Journal of Head Trayma Rehabilitation, March, 1986 pages 55-62.
34. Physical Rehabilitation Contjnyum of Care, Prepared by Subcommittee A on Definitions for the Technical Advisory Committee on Comprehensive Inpatient Physical Rehabilitation Services, State Health Planning Agency, Atlanta, Georgia, October 17, 1989.
35. National Directory of Head Injury Rehabilitation Services, National Head Injury Foundation, Southborough, MA., 1989.
36. Sachs, Paul R., Ph.D., A Family Gyide to Evaluating Transitional Living Programs for Head Injured Adylts, National Head Injury Foundation, Southborough, MA., 1989.
37. Severe Head Trauma: A Comprehensive Medical Approach (Collaboratjve), Volumes 1 and 2, A Report to the National Institute for Handicapped Research, Institute for Medical Research at Santa Clara Valley Medical Center, San Jose, CA., Sept. 1981.
38. Questions About Traumatic Brain Injury, National Head Injury Foundation, Framingham, MA.
39. Chapter 290-5-53. Traumatic Brain Injury Facilities, Rules of the Georgia Department of Human Resources, Atlanta, Georgia, October 19, 1989 DRAFT.
40. Final Report: Summary of Major Findings of October. 1987. Hospital MinjManpower Survey, Georgia Hospital Association and GHA Council on Nursing, Professional Services and Education, August, 1988.
41. Morris, Libby, V., Health professions Personnel in Georgia, Institute of Higher Education, The University of Georgia, Athens, Georgia, 1987.
42. Statewide Hospital Patient Origin Study, April and October, 1988, Georgia Hospital Association.
46

43. A Model Act Regulating Board and Care Homes: Guidelines for the States, prepared for the u.S. Department of Health and Human Services by the American Bar Association, April 1982.
44. Standards for COmmunity Mental Health. Mental Retardation and Substance Abuse Services, Georgia Department of Human Resources, Division of Mental Health, Mental Retardation and Substance Abuse, July 1, 1988.
45. Data From a Survey of Selected providers Regarding Demand for Rehabilitation Services, Technical Advisory Committee on Rehabilitation Services, Subcommittee B on Need and Geographic Access, Georgia State Health Planning Agency, October 1989.
46. Health Care for persons with Mental Retardation, Georgia State Health Policy Council and the Georgia State Health Planning Agency, Atlanta, Georgia, OCtober 1987.
47. Georgia Head Injury Association, A Chapter of the National Head Injury Foundation, Atlanta, Georgia.
48. Deutsch, Paul M., Ph.D. and Associates, Center for Rehabilitation Studies, College of Health Related Professions, University of Florida, Gainesville and The Greenery Group, San Francisco, California.
49. McKenzie, Ellen J., Ph.D., Sam Shapiro and John H. Siegel, M.D., "The Economic Impact of Traumatic Injuries", Journal of the American Medical Association, Vol. 260, No. 22, December 9, 1988, pp. 3290-3296.
50. Summaries of The National Association of Rehabilitation Facilities' Position paper on Inpatient Medical Rehabilitation Services and A Study Regarding a Prospective Payment System for Medical Rehabilitation Inpatient Services: Final Report, Coopers and Lybrand, 1985.
51. The Emory Clinic, Section of Rehabilitation Medicine, Atlanta. 52. Vital and Health Statistics, "Detailed Diagnoses and Procedures, National
Hospital Discharge Survey, 1987", U. S. Department of Health and Human SerVices, Public Health Service, Centers for Disease Control, March, 1989. 53. Severe Head Trauma. A Comprehensive Medical Approach, A Report to the National Institute for Handicapped Research, Vol. I and II, September, 1981. 54. Subacute Care in Hospitals. A Synthesis of Findings From the 1987 Survey of Hospitals and Case Studies in Five States, Lewin/ICF for the Prospective Payment Assessment Commission, September, 1988. 55. McMahon, Brian and Susan M. Flowers, "The High Cost of a Bump on the ~ead", Bysiness and Health, June, 1988. 56. Y1visaher, Mark S., Ph.D., "Key Issues in Pediatric/Youth Head Injury", Headlines, Fall, 1989.
47

APPENDICES

APPENDIX A

Category Acute medical services.
Comprehensive, inpatient rehabilitation program.
c~o

CONTINUUM OF REHABILITATION PROGRAMS AND SERVICES (In Order of Intensity of Rehabilitation Needs)

Medical Needs

Rehabilitation Needs

Setting

Traumatic. crisis, in need of medical stabilization.
Continuous physician coverage; 24 hour per day medical/surgical nursing.
Need hospitalization; medically fragile; medical complications; rehabilitation could jeopardize medical stability without close supervision.
24 hour per day rehabilitation nursing.
Likely to benefit significantly from an intensive inpatient rehabilitation program.
Access to appropriate medical consultants.

Crisis oriented; minimize secondary complications; discipline-specific therapy.
Severe functional impairments; intense coordinated, interdisciplinary team services.
Close. daily, onsite, active medical management and supervision by rehabilitation physician 24 hours per day; the physician provides services to the program for at least 20 hours per week.
Average of 8.5 therapy/ nursing hours per day.
In the course of recovery for a client in a comprehensive, inpatient rehabilitation program, there may be short-term needs for rehabilitation. evaluation and client education.

Inpatient acute-care general hospital.
Special unit in acute-care general hospital or specialty hospital. ' Freestanding rehabilitation hospital.

Notes

/'

Continuum of Rehabilitation Programs and Services: Page 2

Category

Medical Needs

Rehabilitation Needs

Specialized skilled nurs Ing rehabilitation program.
+:\0

Require long-term institutional support; medically stable; unlikely to develop secondary complications. etc; or require short-term Institutional support In preparation for a comprehensive. inpatient rehabilitation program or for other acutecare interventions.
24 hour per day rehabilitation nursing.

Severe functional impairments usually caused by catastrophic event; ~ tended, coordinated interdisciplinary team ser vices.
Medical management available 24 hours per day by rehabilitation physician; medical management services provided at least once per week by the rehabilitation physician.
Average therapy and nursing hours per day: range 5 to 7; example: catastrophic (long-term) rehabilitation program, e.g., coma stimulation and behavioral management.

Residential treatment and habilitation/rehabilitation program.
General nursing rehabilitation services.

Medically stable; may have special medical needs, e.g. ventilator dependent; less than 24 hour per day medical support.
Medically stable but may have special custodial nursing needs; 24 hour per day nursing; specific care hours and Intensity related to acuity of client.

Medically necessary rehabilitation may be pre. scribed by a physician; focus on (1) compensatory vs. restoration or (2) transition to less restrictive setting or (3) life. long support and man- . . 8gement. -.
Single or multidisciplinary rehabilitation services; example: coma management

,;.-

Setting Specialty nursing home (freestanding or hospitalbased). Specialty unit in a general nursing home.
TBI facility (new).
General nursing home.

Notes

Continuum of Rehabilitation Programs and Services: Page 3

Category

Medical Needs

Rehabilitation Needs

Other residential rehabIlitation services (primary focus: housing and nonmedical rehabilitation and support).
* Community resi-
dential services.

Medically stable but may have special medical needs.

Community-based rehabilitation; family support, respite; home health rehabilitation.

a01

Non-residential, com-

munity-based programs

and services.

* Day rehabilitation
program.

Medically stable but may have special medical needs.

* Comprehensive
outpatient rehabilitation program (CORP).

Medically stable but may have special medical needs.

* Outpatient ser-
vices. .'_'" __ __ _

Medically stable but may
have special medical needs..__ - ..

* Vocational evalu-
ation and rehabilitation services.

Medically stable but may have special medical needs.

Interdisciplinary approach.
Coordinated interdisciplinary team services.
Single or multidisciplinary services.
Services designed toward employment.

Setting
Residential services: home. personal care home (under 25 beds not covered by CON), congregate housing, supervised independent living. Access to rehabilitation services Is through home health agency, CORF, outpatient facility, day rehabilitation facility.
Freestanding day rehabilItation facility; CORP; or medical facility based. Freestanding or medical facility based.
Freestanding or part of another facUlty.
Freestanding or part of another facility.

,.(.

Notes

STATE HEAlTH PLANNING AGENCY: J~

APPENDIX B Basic Elements of the Demand-Based Forecasting Model for Physical Rehabilitation Services

The concepts in this Model were developed by the Technical Advisory Committee on Physical Rehabil itation Services. The Model has been adapted for use in determining need for physical rehabilitation services in selected settings.

Step 1

Determine the disorders most likely to require physical rehabilitation services. The Technical Advisory Committee's Subcommittee Bon Need and Access spent considerable time identifying diagnoses and procedures from the International Classification of Diseases (ICD 9) and categorizing them into 12 diagnostic categories for rehabilitation services planning purposes.

Step 2.

Determine incidence and/or prevalence of selected disorders in the population which may require physical rehabilitation services. Various sources in the literature contain national, regional, state or area-specific studies and data on incidence and prevalence of physical disorders. Another source of Georgia-specific data as a proxy measure of incidence is general acute care hospital discharges by di agnost i c category from the Georgi a Hospital Associat ion's Patient Origin Study. National and regional general acute care hospital discharge data are available for comparison.

Step 3. Determine the survival rate among the population with disorders identified in each diagnostic category. The literature provides a basis for these data.

Step 4.

Determine the demand for services in selected settings for the surviving population in each diagnostic category. The Technical Advisory Committee's Subcommittee B on Need and Access developed a survey of providers to estimate demand rates (percents) for services in the different settings in the rehabilitation continuum of care. Also a review of the literature revealed studies showing demand for rehabilitation services in various settings.

Step 5.

Determine the projected client census and client days of care within a gi ven peri od of time for each selected rehabil i tat ion servi ce setting. Based on the results of steps 1 through 4, the expected number of clients is derived. The expected average length of stay for each client in a specific setting multiplied by the projected number of clients within a year equals projected client days. If the 1ength of stay is a number of years, it is necessary to determi ne the expected existing and new clients during the planning period, accounting for attrition, to derive clients and client days of care.

Step 6.

Determine the projected number of beds (for residential settings) needed to serve the client population. The projected number of clients in a year (client days divided by 365 days per year) divided by a des i red occupancy rate equals the projected number of beds needed.

51

APPENDIX C

Existing Residential (Non-hospital) Services for Traumatic Brain Injury Clients Georgia, January, 1990

City

Co~nt}'

SERVICES OFFERED

TrgnsitiQ!'l~l ~hjn(l

li fe LonQ Li vi nQ

Facil itv

24 hr.

1

24 hr.

1

Res ident i a1 Beds ALOS

Residential Beds ALOS

2

Transitions-Atlanta Marietta

Cobb

Yes

14

5

No

2 01 Meadowbrook-Atlanta Decatur
N

DeKalb

Yes

2

Learning Services-

Peachtree

Lawrenceville Gwinnett

Yes

17

5

18

7

No

Yes

1 Unknown

2 Delphi House

Eatonton

Putnam

No

-

-

Yes

10 Unknown

3

Atlanta Rehabilitation

-

Inst itute

Fulton

Yes

6

5

No

1. Average length of stay (months) 2. Licensed as Personal Care Homes 3. Accredited by Commission on Accreditation of Rehabilitation Facilities. State license not required. Source: Telephone survey of facilities conducted by the State Health Planning Agency, January, 1990.

APPENDIX 0 TECHNICAL ADVISORY COMMITTEE ON COMPREHENSIVE
INPATIENT PHYSICAL REHABILITATION SERVICES January, 1990

Mr. W. Douglas Arnold Administrator Grady General Hospital Ms. Linda Asta Hi11haven Corporation

1155 Fifth Street, S.E. Cairo GA 31728 450 Bedford Street Lexington MA 02173

Ms. Beth Cayce Vice President, Program Development Renaissance America, Inc. Ms. Mary Lou Dykes Phoenix Health Strategies

400 Embassy Row Suite 460 Atlanta GA 30328 2049 Harbour Oaks Drive Snellville GA 30278

Ms. Lois T. Ellison M.D. Associate VP for Planning Medical College of GA Ms. Catherine J. Futch R.N. Assistant Director of Nursing Emory University Hospital Ms. Harriet S. Gill Managing Partner Fowler Hea1thcare Affiliates, Inc. Dr. Brigitta B. Jann M.D. Emory Clinic
Mr. Tom Kent Administrator Central GA Rehabilitation Hospital Ms. Joyce Maddox Division Director Atlanta Easter Seal Society Ms. Linda Melvin Satellite Health Resources

Augusta GA 30912
3443 Vinings North Trail Smyrna GA 30080
100 Galleria Parkway Suite 610 Atlanta GA 30339 Rehabilitation Medicine Sect. 1441 Clifton Road, NE Atlanta GA 30322 3351 Northside Drive Macon GA 31210
2030 Powers Ferry Road Suite 140 Atlanta GA 30339 1675 Chevron Way Atlanta GA 30350

Mr. William L. Minnix Jr. Director and Vice President Wesley Woods Center

1817 Clifton Road, NE Atlanta GA 30329 53

APPENDIX 0 TECHNICAL ADVISORY COMMITTEE ON COMPREHENSIVE
INPATIENT PHYSICAL REHABILITATION SERVICES January, 1990

Mr. Gary L. Naylor Asst VP Institutional Affairs Blue Cross Blue Shield of GA Dr. Paul Peach M.D. Medical Director Roosevelt Warm Springs Institute Mr. Larry Pocino Assistant Administrator Henrietta Egleston Hospital Ms. Nancy Roddy P.T. Dir of Rehabilitation Services Piedmont Hospital Ms. Elizabeth Rosenberg Rehabilitation Coordinator State Board of Workers Compensation Ms. Susan Saleska Executive Director Georgia Head Injury Foundation Mr. Hal Sanders
Dir. of Admin. &Rehab. Svs
Candler Hospital Mr. James H. Shepherd Jr. Shepherd Spinal Center
Mr. Dennis Skelley President Walton Rehabilitation Hospital Ms. Peggy Thomas Deputy Director Office of Regulatory Services

PO Box 4445 Atlanta GA 30302 PO Box 1000 Warm Springs GA 31830 1405 Clifton Road, NE Atlanta GA 30322 1968 Peachtree Road, NW Atlanta GA 30309 1000 South Tower 1 CNN Center Atlanta GA 30303-2705 PO Box 95217 Atlanta GA 30347 PO Box 9787 Savannah GA 31412 1600 Cave Road Atlanta GA 30327 1355 Independence Drive Augusta GA 30901
Standards &Licensure Section
878 Peachtree St NE, Room 803 Atlanta GA 30309

54

,

A BILL TO BB ENTITLED AN ACT

AS PASSED.

1

To amend Title 31 of the Official Code of Georgia 31

2 Annotated, relating to health, so as to provide that certain 32

3

and institutions shall include facilities 33

" providing care for persons who have traumatic brain injury;

5 to amend Title 37 of the Official Code of Georgia Annotated, 34

6 relating to mental illness, so as to provide for a 3S

7 definition of "traumatic brain injury" and provide that such JG

8 injury shall not be considered a mental illne.s; to provide 37

9 .. effective dates; to repeal conflicting laws; and for other

10 purposes.

11

BB IT ENACTED BY THE GBNERAL ASSEMBLY or GEORGIAI

40

12

Section 1. Title 31 of the Official Code of 43

13 Georgia Annotated, relating to health, is amended by 44

14 striking in its entirety paragraph (8) of Code Section 45

15 31-6-2, relating to definitions with respect to state health

16 planning and development, and inserting in lieu thereof a 46

17 new paragraph (8) to read as follows:

47

18

"(8) 'Health care facility' means hospitals; other 49

U

special care units, including podiatric facilities, 50

20

skilled nursing facilities, and kidney disease treatment 51

21

centers, including freestanding hemodialysis units; 52

22

intermediate care facilities; personal care homes not in

23

existence on the effective date of this chapter;

24

ambulatory surgical or obstetrical facilities; health

25

main~enance organizations; .ft~ home health agencies; and S5

26

facilities which are devoted to the provision of

27

treatment and rehabilitative care for periods continuing 56

.~.
55

LC 11 68875

1

for 24 hours or longer for persons who have traumatic 57

2

brain in1ury, as defined in Code Section 37-3-1."

3

Section 2. Said title is further amended by 60

4 striking in its entirety paragraph (1) of Code Section 61

5 31-7-1, relating to definitions with respect to the 62

6 regulation and construction of hospitals and other health 63

7 care facilities, and inserting in lieu thereof a new

8 paragraph (1) to read as follows I

64

9

"(1) 'Institution' meansl

66

10

(A) Any community mental health and mental 68

11

retardation facility;

12

"(8) Any building, facility, or place in which 70

13 ..

are provided two or more beds and other facilities 71

14

and services that are used for persons received for 72

15

examination, dilignosis , treatment, surgery,

16

maternity care, nursing care, or personal care for 73

17

periods continuing for 24 hours or longer and which 74

18

is classified by the department, as provided for in

19

this chapter, as either a hospital, nursing home, 75

20

or personal care home;

21

(e) Any health facility wherein abortion 77

22

procedures under subsections (b) and (c) of Code 78

23

Section 16-12-141 are performed or are to be 79

24

performed;

25

( D) Any building or facility, not under the 81

26

operation or control of a hospital, which is 82

27

primarily devoted to the provision of surgical 83

28

treatment to patient. not requiring hospitalization

29

and which is cla.sified by the department a8 an 84

30

ambulatory surgical treatment center; "

31

(B) Any fixed or mobile specimen collection 86

32

center or health testing facility where specimens 87

33

are taken fro. the human body for delivery to and

56

1 2 J 4 5 6 7 8 9 10
11
12 13
14 -
15 16. 17 18 19 20 21 22 23 24 25
26

LC 11 6887S
examination in a licen.ed clinical laboratory or 88 where certain measurements such as height and 89 weight determination, limited audio and visual tests, and electrocardiograms are made, excluding 90 public health services operated by the state, its 91 counties, or municipalities;
(F) Any building or facility, not ~irectly 93 aociated with a hospital, which i. devoted 94 primarily to the provision, on a nonrecurring 95 basis, of medical treatment to patients with acute injuries or conditions and which is classified by 96 the Department of Human Resources as a freestanding 97 emergency care clinic; e.
(G) Any bUilding or facility where human 99 births occur on a regular and ongoing basis and 100 which is classified by the Department of Human 101 Resources as a birthing center; or
(HI Any building or facility which is devoted 103 to the provision of treatment and rehabilitative 104 care for periods continuing for 24 hours or longer 105 for persons who have traumatic brain injury, as defined in Code Section 37-3-1. The term 'institution' shall exclude all physicians' and 107 dentists' private offices and treatment rooms in which 108 such dentists or physicians primarily see, consult with, 109 and treat patients.-

27

Section 3. Title 37 of the Official Code of 112

28 Georgia Annotated, relating to mental health, is amended by 113

29 adding between paragraph. (16) and (17) of Code Section 114

30 37-3-1, relating to definitions with respect to the

31 examination and treatment for mental illness, a new 115

32 paragraph (16.1) to read as follows.

57

..: ,\
1 2 3 4 S 6 7 8 9 10

LC 11 69875
-(16.1) 'Traumatic ,brain injury' means a traumatic 117 inlult to the brain and its related parts resulting in 118 organic damage thereto which may cause physical, 119 intellectual, emotional, social, or vocational changes in a person. It shall al.o be recognized that a person 120 having a traumatic brain injury may have organic damage 121 or phylical or locial disorder., but for the purpose. of thil chapter, traumatic brain injury .hall not be 122 con.Ldered mental illne a. defined in paragraph (11) 123 of thil Code .ection.-

11

Section 4. Thi. Act shall become effective July 1, 126

12 1989, except that Section. 1 and 2 of this Act shall become 127

13 .. effective 'January 1, 1990.

14

Section S. All laws and parts of laws in conflict 130

15 with this Act are repealed.

131

APPENDIX F SERVICE AREAS FOR TRAUMATIC BRAIN INJURY FACILITIES

GEORGIA
Counties
These Service Areas are based on the Department of Human Resources
Health Districts

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