RAP 2000: Writing Their Own Rules

For providers in the home medical equipment (HME) industry who specialize in rehab equipment, the industry's move to accreditation has been a mixed blessing. Accreditation is a necessary step in today's health care environment, but most rehab companies do not fit the mold many accrediting bodies have established for HME and home care companies.

For this reason, the Consensus Conference on Accreditation for Re/hab Technology, a conference sponsored and attended by representatives from industry rehab organizations, was held in March. The conference was designed to:

  • bring together a broad-based sample of representatives of rehab technology companies and the organizations that represent them
  • discuss, categorize and reach a consensus on the factors that differentiate the rehab technology industry and profession from the HME business
  • reach a consensus on how these differentiating factors might be translated into standards and to what extent existing accreditation programs address these standards

The Re/hab Accreditation Project (RAP 2000) is the product of this conference.

Why Accreditation?

Accreditation helps companies and organizations demonstrate to their customers and purchasers who rely on their services that they have been impartially reviewed and found to meet nationally recognized standards and best practices. As a result, accredited organizations have a competitive advantage over non-accredited organizations. Companies also choose accreditation to improve quality by identifying areas for enhancement through the accreditation process and implementing recommended changes.

Self-policing is another reason for accreditation. Having an industry move towards removing fraud and abuse by itself demonstrates to regulatory agencies and payers that it is willing to weed out fraudulent players. HME providers have begun recognizing this need for accreditation.

The National Association for Medical Equipment Services (NAMES) estimates that 80 percent of its members have obtained accreditation from an outside organization. Many providers whose business mix focuses on respiratory therapy or infusion products and services may have the choice of a specialized accreditation program. However, there is not an accreditation program that has been developed specifically for the rehab industry.

"A lot of the companies have been pursuing accreditation anyway because of the managed care environment," said Elizabeth Gallenagh, NAMES director of Re/hab and Reimbursement. Rehab companies do have accreditation available to them, but they are finding that the surveyors are not knowledgeable about rehab or the standards to which rehab companies adhere, she said.

The types of equipment and methods of doing business utilized by rehab providers are significantly different from typical HME providers, said Gary Gilberti, president, Chesapeake Rehab Equipment, Baltimore. Gilberti, who also serves as the NAMES Re/hab Council co-chair and is a co-facilitator of the RAP 2000 project, said the fittings and evaluations that are done by rehab providers in clinics and facilities emphasize some of the differences between HME and rehab technology providers. These differences limit the ability of current accreditation programs, such as the Joint Commission on Accreditation of Health Care Organizations (JCAHO), to appropriately judge rehab operations.

"We want to have accreditation mechanisms - we need to have something that says you are a good supplier," he said. "But, it has to be appropriate to our standards of practice and our methods of doing business."

"We all have as a goal the need to provide the client or the patient with the best possible products and services that we can," said Simon Margolis, director of the National Re/hab Network, The MED Group, Plymouth, Minn. "That is not only a moral responsibility, but that is good business."

What's the Difference?

Rehab technology companies differ from traditional HME companies in many ways. Finding out about a person's need through a physical assessment and evaluation is a key function of rehab equipment providers, said Margolis, who is also secretary/treasurer of the NAMES Re/hab Council and a co-facilitator of the RAP 2000 project. Rehab equipment providers then tie in educational, vocational, recreational and environmental issues and turn it into a picture of what the person needs, he said.

"That is a very specific, very unique skill set that is not common between HME/DME and rehab," he said.

Attendees at the Consensus Conference on Accreditation for Re/hab Technology listed these differences and defined them as the following, according to information provided by the NAMES Re/hab Section.

Personnel: Rehab technology companies have significantly different needs in terms of the personnel they employ. In order to perform the necessary functions of a rehab company, employees must be specially trained for their jobs. Often, this takes several years of apprenticeship-type experience. In addition, rehab companies are required to:

  • employ at least one certified rehab professional per location
  • employ at least one trained technician per service center who is: trained by manufacturers of the products supplied by the company; experienced in the field of rehab technology; and has completed and can show documentation of at least 10 hours of continuing education that is specific to rehab

A goal of the rehab technology industry, as determined by conference participants, is to develop an industry-wide, technician training program. This would ensure consistency throughout the industry, set a standard knowledge base and provide a means for training and testing for individuals. Conference participants also agreed that there is a need to develop an industry-wide customer service/billing training course that is specifically designed to train individuals in billing and negotiating with various funding sources.

Rehab technology companies should develop and adhere to basic standards of management practice. This includes:

  • compliance with industry standards, which include, but are not limited to, those set forth by the National Registry of Rehabilitation Technology Suppliers (NRRTS), the NAMES Re/hab Section or the Rehabilitation Engineers Society of North America (RESNA)
  • development and implementation of internal operating procedures that are specific to rehab
  • development, implementation and maintenance of a corporate compliance plan.

Evaluation Process: Another key element that differentiates rehab companies from the HME industry is the process by which their clients are evaluated. Rehab technology companies must conduct in-person, individualized assessments of clients' needs in order to provide them with the most appropriate and medically necessary equipment for their functional limitations. The assessment must be conducted in an appropriate setting and should include input from other health professionals. The company should provide the client with demonstration equipment for trial and simulation.

An integral part of the assessment must be the clear identification of the client's goals in relation to what he or she needs or wants to achieve in terms of medical and functional limitations. The company must present the client with the available options, including information on funding possibilities, to accomplish those goals. The process of assessing the client's functional needs and the discussion of choices and options must be documented in some uniform manner and kept in the client's file.

Physical Plant: Because of their individualized service and the technical nature of the rehab field, rehab technology companies also have physical plant needs that differ greatly from standard HME services companies. An example provided by conference attendees stated that if a rehab technology company does on-site client evaluations, the company must have rooms designated for fitting and evaluation that are private, clean and safe for the client. The company site also must comply with the Americans with Disabilities Act.

In addition to the client-related physical plant needs, these companies must have an equipment/inventory management system that is maintained and operates efficiently to ensure the availability of parts and equipment. There must be a repair shop on site and an area designated for assembly and modification of products.

Fitting/Delivery/Follow-up - Client Specific: Serving consumers of rehab technology requires specific and client-intensive service by company personnel. It is imperative in this field that clients are properly assessed and their equipment individually fit. They must also be educated thoroughly in the use and function of their equipment, including how to operate it safely and effectively. Since each piece of equipment is ordered specifically for that client's needs, the job of the rehab technology company does not end upon equipment delivery. It must establish and implement a quality assurance program, which includes a standard procedure for assembly and set-up of equipment. The company must also establish and maintain a procedure for scheduled follow-up versus as-needed follow-up, which can be applied to each client. In addition a qualified individual, one holding a CRTS, RTS, ATS or ATP certification, must have overall responsibility for delivery, checkout and follow-up. The company must also have a standard process and product-specific guidelines for providing patient education regarding new equipment.

Service/Repair - On-site and In-house: Rehab technology companies must provide their clients with a defined service policy upon receiving an order for equipment. The company must also develop and maintain a system for tracking warranty repairs and use collected information to inform consumers about the products provided. Companies must also maintain an inventory that is appropriate to the products they provide and adequate to suit the needs of their clients.

Patient Advocacy: In addition to serving consumers' equipment and service needs, rehab technology companies have a strong, personal involvement with each individual they serve. This includes assisting clients with the funding process - informing them of their options, negotiating with payers for coverage and reimbursement, and complex claims processing. In order to best serve the consumer, the company must employ appropriately trained and qualified personnel to facilitate this process and must offer their clients a pre-screening of coverage and payment options so they are informed about their situation from the beginning. Companies must also have a standard procedure or process specifically designed for providing patient education. That includes information about their rights and responsibilities regarding access to equipment, funding and alternatives available to them, so they are able to acquire the necessary equipment. In addition to providing each patient with appropriate information about fundi ng, the rehab company must also provide education for the patient's other health care providers.

Outcomes: Rehab technology companies do not simply follow policies and procedures without considering the end result for the client. These companies must establish and implement a goal- and client-oriented outcome measurement procedure that measures and assesses point-in-time progress or maintenance of the client's condition and use of his or her equipment. As part of the outcomes measurement process, the survey sample should be extended to include the goal-related opinions and observations of other health care team members and not just those of the consumer. In addition, this process should include internal and external reporting and tracking of data.

The Next Step

The goal of conference attendees was to develop a set of standards and measurement tools that will differentiate the rehab industry from all others, benefit the industry as a whole and help it move into the 21st century. The first step will be to have these standards and measurement tools accepted by the rehab industry. The comment period ended on June 25, giving the conference participants time to hear from the rest of the industry and to make sure that the groups involved have time to get the information out to their membership, Gallenagh said.

Then, the ultimate outcome will be the development of an accreditation program that clearly differentiates the rehab process and its products from HME, complete with its own surveyors who know and understand the rehab technology industry.

"The ultimate goal would be to have an accreditation process in place that took these standards and reflected what rehab really is," Gallenagh said.

There are many accrediting organizations that have the capability of heading such a program, according to those involved in the project. It will come down to who has the desire to move quickly and who will accept the standards. Some involved "would like to start from scratch and do it within the industry," Gilbert said.

He said the critical component is having surveyors who understand the rehab industry.

The final document should be available this fall and project leaders expect to announce the next steps in the process at this year's Medtrade in November. As Margolis said, it will be the first time rules for the rehab industry are written by the industry. And, judging from conference participants' consensus, it's about time.

This article originally appeared in the July 1999 issue of HME Business.

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