What it means and why it's important

When buying a car, many people look to Consumer Reports as the last word on quality, cost and consumer satisfaction. Or, when seeking a new physician, they carefully examine the doctor's credentials, board certification, hospital affiliation, experience and specializations. Yet when considering a home- and community-based rehabilitation program, do you even know how to evaluate it or to whom to turn for answers?

Most people, including many referring health care professionals, don't. That's why there's CARF -the Commission on Accreditation of Rehabilitation Facilities. CARF is considered the gold standard, the premiere accrediting body for rehabilitation programs: facilities that are CARF-accredited must meet stringent international standards. The most interesting thing about CARF, however, is that it is a voluntary accreditation. This means that organizations seeking CARF accreditation spend their own time, money and efforts to undergo the in-depth assessment and review that the organization demands. Why do all this when home and community rehabilitation programs are not required by law to be accredited?

"That's simple," says Alison Gyorke, director of clinical management Bay Area Rehab Without Walls. It's the best way to ensure that you're providing the highest quality of care for your customers. Basically, CARF assures our clients that this is a specialty that values them so much that it has voluntarily agreed to adhere to vigorous standards and open the specialty up to intense scrutiny.

At Rehab Without Walls, CARF accreditation has always been a priority. All established Rehab Without Walls locations across the country are fully accredited for home and community rehabilitation, and its newer ones are on track for full accreditation. Within the home and community category, Rehab Without Walls is also eligible to seek accreditation for the specific services a location offers, such as pediatrics.

Of note is that the CARF philosophy and Rehab Without Walls' approach to care are remarkably similar. Gyorke explains. At its core, CARF is an advocacy program to ensure that the client remains at the center of the rehabilitation program's focus. It mandates that the persons served are key members of the treatment team and that they take an active role in their recovery. The same is true with Rehab Without Walls.

An independent, not-for-profit accrediting body

CARF provides accreditation not just for rehabilitation but for other human services as well, including employment, child and family, and aging. All share the same approach that of being in partnership. This means that the survey process is not centered on inspection but rather on consultation, where the CARF survey team works with the provider to improve service resources and outcomes.

CARF sees itself as a catalyst for enhancing the quality of life of the persons served by CARF-accredited organizations. In fact, consumers play an active and vital role in the entire accreditation process, from helping to develop and apply the national performance standards to giving input on the quality of services received by individual rehabilitation programs. In doing so, CARF casts a wide net, placing particular emphasis on diversity and cultural competence in all CARF activities and associations. This contributes to what CARF sees as its core values: ensuring that all people have the right to be treated with dignity and respect; that all people have access to needed services that achieve optimum outcomes; and that all people be empowered to exercise informed choice.

CARF standards are continually developed and revised through a series of leadership panels, national advisory committees, focus groups and field reviews relying heavily on active involvement at all levels by persons served.

During the survey process itself, what does CARF look at?

Everything, states Gyorke. Surveyors scrutinize our clinical practices, business practices, policies and procedures, market and strategic planning, retention and recruitment efforts, quality assurance, safety standards, committee meeting minutes, advocacy initiatives in the community, employee credentialing, and information management. CARF pays particular attention to the latter. They are interested in how we collect data and how we use it to improve services and provide durable outcomes for our clients.

Gyorke explains that Rehab Without Walls uses four different tools to collect data: an annual performance evaluation; customer satisfaction surveys sent at discharge to every person who received services, as well as to every payer representative and physician; a professional advisory committee made up of the executive director of each office, the marketing representative, payers and clients that meets several times a year to review practices; and a safety and quality assurance committee that confidentially reviews client records, personnel files and administration records to ensure Rehab Without Walls is meeting its standards. At this time, the committee also sets news goals and standards for each office.

In addition, when the surveyors are on-site at each location, they spend time speaking with everyone involved in the rehabilitation process. For example, explains Gyorke, They will interview one or more of the field staff and talk with the executive director, the director of clinical management, the marketing director and the area vice president. They will also talk with external sources, including physicians, a payer case manager, a referrer and several clients and their families. They will observe a treatment session and may sit in on a team conference. All in all, they are very thorough, says Gyorke. There is only one way to prepare for a CARF survey: to build the CARF standards into everything you do. That, in a nutshell, is why Rehab Without Walls continues to receive the highest CARF accreditations.

CARF offers several levels of accreditation, the highest being the Three-Year Accreditation.

This indicates that the provider is meeting or exceeding CARF standards and will not need to be reviewed again for another three years. This is what all established Rehab Without Walls locations have. The second level is the One -Year Accreditation, which indicates that while there are still some existing deficiencies in conforming to CARF standards, the program shows capability and commitment toward correcting the deficiencies and making progress. The third level is known as Provisional Accreditation, which means the provider is still functioning at the One -Year level the following year, and has one year to correct the deficiencies and meet CARF standards or it will receive an outcome of non-accreditation.

Getting the three-year CARF accreditation lets us know that not only are we doing a good job with our clinical practices and services, but that we have met the most important criteria of all putting the client first, says Gyorke. It also creates a common language for referral sources. Before referring a patient into any home and community rehabilitation program, I suggest they ask questions about CARF accreditation. At Rehab Without Walls we make that information readily available. Each office keeps a copy of the survey report and anyone who asks patient, payer, referrer can read through it. It's like saying the quality of our program is an open book.

Rehab Without Walls is committed to maintaining a high level of ethical standards regarding business practice. We are likewise committed to the provision of high quality services to our persons served as a cost consistent with the type and amount of service provided. We have long maintained a compliance program as evidence of this commitment and consistently strive to set the industry standard as a rehabilitation provider of high quality and as a good corporate citizen.

Referrer's Guide

CARF-accredited. It’s one of the ways that Rehab Without Walls® describes its program. This certainly sounds official, but what does it mean? Actually, it means a lot—to clients, payers, physicians and all the other stakeholders in Rehab Without Walls®. Here’s a look at what CARF is, how Rehab Without Walls® meets CARF requirements and what CARF certification means to those who rely upon Rehab Without Walls®.

An Independent, Nonprofit Accrediting Body

Founded more than 40 years ago, the Commission for Accreditation of Rehabilitation Facilities (CARF) is an international, independent accrediting body dedicated to promoting the quality, value and optimal outcomes of services. In short, CARF’s mission is to ensure that the persons served by CARF-accredited facilities receive the best services and the most effective outcomes possible. “I liken the CARF accreditation to the Good Housekeeping Seal of Approval,” says Alison Gyorke, the director of clinical management for the Bay Area Rehab Without Walls® . “It lets people know that the facility has met rigorous standards and that we have invited others in to examine all of our practices and processes. It shows that we are committed to quality and value. And it says that we are going to consistently live up to the CARF standards year after year. That’s impressive to me as an employee of Rehab Without Walls® —that my company has made this kind of commitment.”

Participation Is Voluntary

The fact that participation in CARF accreditation is voluntary speaks volumes about those who choose to undergo such a rigorous survey process. “Participating involves a significant investment of time, resources and people over a period of months,” explains Gyorke. “We open ourselves up internally for checks and balances. During the survey, industry experts examine every aspect of our business.” This includes:

  • Business practices (for example, financial soundness, appropriate decision making, quality assurance, professional advisory committees)
  • Clinical practices (for example, best practices, functional goals, treatment plans, problem-solving, teamwork)
  • The rights of persons served (for example, privacy, communication and medical ethics)
  • Clinical records (for example, documentation)
  • Personnel records (for example, staff qualifications and training)
  • Data collection (for example, methodology and data integrity)
  • Outcomes (for example, length of stay, rehospitalization rates, degree of functionality and independence of clients post-discharge, cost-effectiveness of the program)

New to Home and Community Rehabilitation

Although CARF has been accrediting rehabilitation facilities for years, surveying home and community based rehabilitation is a relatively new area for the organization. In fact, says Gyorke, Rehab Without Walls® worked closely with CARF at the outset. “Rehab Without Walls® has done a lot to educate the CARF surveyors on what a home and community program should look like and what it should do,” she says. “ We have helped CARF set the standard of care.”

A Collaborative Approach

Perhaps most interesting about CARF is that it takes not a top-down, prescriptive approach, but a collaborative one with the participating programs. “CARF sees itself as a collaborator to help improve the level of care,” explains Debbie Tabor, clinical operations specialist for Rehab Without Walls® . “The surveyors themselves work in the rehabilitation world, so in a sense the CARF survey is a peer review. During the accreditation process, they look at 450 different standards and interview a wide variety of people at the branch.” This can include:

  • Clients and families (both active and discharged cases)
  • Payer case managers and/or referral sources
  • A referring medical director
  • The Rehab Without Walls® medical director
  • The director of clinical management
  • The admissions manager
  • Clinical team members, including physical therapists, occupational therapists and speech language Pathologists

In addition, the location being surveyed prepares documentation on how it meets CARF standards. “Our goal is to work toward continuous readiness and not be reactionary, so we try to build CARF standards into everything that we do,” says Tabor, Tammy Goulding, the executive director of Rehab Without Walls Michigan, which recently completed a CARF survey, says, “When CARF surveyors are on site, it is important to show that we meet the standards and provide day-to-day compliance. For example, one standard is ‘Show that you provide community resource information for the client served.’ We might share comments from clients and referrers or we also could flag several charts that specifically document those patients and families who have received these services.” Each year, CARF updates its standards. Tabor reviews these with other Rehab Without Walls® representatives, then sets up a compliance checklist for Rehab Without Walls® so that all locations can begin making modifications if needed. For locations preparing for a CARF survey, she will go on site six to eight months in advance to give support and audit current practices as they relate to CARF standards.

What CARF Says About Rehab Without Walls®

Rehab Without Walls® underwent its first CARF surveys in 1999 at six locations. Since then, every single location has participated in the surveys and received CARF accreditation for home and community in adult and pediatric services (where available). In addition, the all locations have been accredited for brain injury. “If you pass the survey, you receive either a ‘recommended’ or an ‘exemplary’ rating. Almost all of the Rehab Without Walls® locations have received ‘exemplaries,’ says Gyorke. In addition, all of the Rehab Without Walls® locations have received three-year accreditations, which indicates outstanding performance because CARF can also bestow just one-year accreditations. Even if a location receives accreditation, because CARF is focused on continuous improvement, there generally will be recommendations following a survey. The facility then has 90 days to comply. Recommendations are not necessarily a negative. For example, explains Goulding, “After our Michigan location survey, one of the surveyors was amazed at what we provided for brain injury clients and how we provided it. She recommended that we market more so that more people could be aware of our services.” Overall, adds, Gyorke, “One of the things that has consistently been most impressive to CARF surveyors about Rehab Without Walls® is the great level of cohesiveness that we have maintained in client care even though we are not based in a facility. We also are able to maintain the same standard of care at all our locations across the country, which only adds to our cohesiveness.”

What CARF Means for Clients and Referrers

According to CARF, organizations that have received accreditation demonstrate:

  • A higher degree of internal quality
  • Greater involvement of persons served in their treatment and services
  • Increased cohesion among staff members at all levels within the organization
  • Enhanced status of the surveyed services within the community

What this means, indicates CARF, is that “when your organization is accredited, the public is assured that you are committed to continually improving the quality of your services and your organization’s focus is on service outcomes and customer feedback and satisfaction.” In addition, says Gyorke, CARF accreditation allows clients and referrers to compare home and community based programs on key areas such as durability of outcomes, cost-effectiveness, quality and consistency of care, patient satisfaction, qualifications of staff and all the other factors that influence a referral choice. “Bottom line, they want to make a good decision in choosing a rehabilitation provider. CARF accreditation gives them much of the information they need to do so.”