Setting the International Standards for Acquired Brain Injury Providers

By: Christine MacDonell, CARF, Managing Director, Medical Rehabilitation

The Commission on Accreditation of Rehabilitation Facilities (CARF) is an international, third party, independent, consultative accreditation process. It began in 1966 with the development of both medical and vocational rehabilitation standards. CARF’s two main jobs are to develop and revise state of the art standards representing programs in health and human services. The second job is to apply the standards in a peer review, on-site survey process. CARF’s process is a quality framework with a focus on performance improvement that addresses both the business and the clinical service delivery system of the provider. Throughout its history and till this day CARF is a “field driven process” meaning consumers, providers, payers, and regulators all interact with CARF and develop and revise standards. Through an International Standards Advisory Committee and a web-based field review process everyone, whether they are accredited or not can comment and assist with the development/revision of standards. In 2008 CARF served 8.3 million people in their accredited programs around the world. CARF has 4 offices, two in the United States (Tucson, Arizona and Washington, DC), two on Canada (Edmonton, Alberta and Ottawa Ontario and in 2010 one in Toronto, Ontario). CARF is exploring the opening of a European office in 2010.

CARF accredits in North America, South America, Western Europe, South Africa, Israel, Singapore, Bermuda, Guam, and Belize. Organizations are preparing for surveys in Saudi Arabia, New Zealand, and Australia. The uniqueness of CARF is that the same standards are used, no matter the location and it creates for the organizations accredited a network of providers around the world. CARF encourages and arranges dialogue and exchange of ideas between providers to make the world of health and human services smaller. The CARF website is an excellent resource to learn more about the accreditation process and activities we are involved with.

CARF was approached and began interacting with Brain Injury providers, consumers, payers, regulators, the American Congress of Rehabilitation Medicine’s  Brain Injury Interdisciplinary Special Interest Group (ACRM BI-ISIG) and National Head Injury Foundation (NHIF) in the early 80s. At that time there was a percolating thought of a set of Brain Injury standards. The original brain injury standards were developed and represented inpatient programs and what was called community integrative services. This was still in the 1980s. As the field progressed so did the standards. Today we have Brain Injury standards that can be attached to Inpatient settings, Outpatient Programs both single services and interdisciplinary services, Home and Community Services, Residential, Vocational Services, and Case Management. There are also specialized standards if a pediatric population is served. The CARF Brain Injury standards are used in over 150 brain injury programs outside of North America. These programs  outside of North America represent everything from inpatient, outpatient, home and community services, residential, and case management programs. CARF accredited Brain Injury providers have had standards applied to their business practices (Leadership, integrated strategic planning, ability to listen to and use input from persons served, personnel and stakeholders, human resources, risk management, financial planning and management, health and safety, technology, rights of person served, and accessibility), their rehabilitation process (scope of services, admission, transition/discharge, team activities including development of individualized plan, delivery of services, modifications of plans as needs change, discharge planning, and communication and collaboration), and then the standards of what type of program the organization is for example inpatient, residential, case management etc. This process of accreditation has an organization doing a very through review of how they currently function and then applying standards to their system and ensuring that they become an organization focused on being a good business (brain injury provider) with a systematic approach to information that will guide them to improved performance and with opportunities for better results for those they serve.

CARF began in 1995 working with European providers. The first programs were accredited in Europe in 1996. The growth of Brain Injury providers in Europe seeking CARF accreditation has been excellent with over 150 Brain Injury programs accredited in Europe. These range from government run facilities, trusts, and private providers. They deliver services in University and community-based hospitals, residential homes, day program settings, in the community itself, case management companies, and at the place of employment.

In Europe lengths of stay in inpatient settings for individuals with acquired brain injuries are longer than North America.  One reason is the lack of pressure from payers to move individuals from one setting to another. There is growing emphasis from government payers in Europe however, on the efficiency and effectiveness of inpatient providers. When working with providers it is evident that many times the longer inpatient stay is because there are not services in the community or in rural areas. There may be generic services (public health nurse, attendant care) but not services delivered for individuals with acquired brain injuries. The rehabilitation professional expertise to work with this population is limited but expanding. We also see many European organizations using the CARF standards as a guideline or blueprint of how to develop the services in other portions of the continuum.

Countries are now taking a look at their outpatient and home and community settings and realizing that those locations are where integration and participation happen for individuals with acquired brain injuries.  CARF has also seen that those providers who have community based services and residential services are now seeing individuals with acquired brain injuries that may have never received any formal rehabilitation services because of a variety of reasons including lack of rehabilitation inpatient beds, diagnosis that was not focused on the acquired brain injury, and a family thinking they could best handle their family member at home.  These individuals involved in specific brain injury services are now beginning to learn skills to live independently, return to social and vocational activities, and gain a level of independence. The Brain Injury Association of America (BIAA), an association that represents the field of Brain Injury in the United States, developed a special certification for those individuals who work with individuals with acquired brain injuries. The Academy of certified Brain injury Specialists currently certify 4207 individuals in the united States and internationally there are now 52 individuals with the certification.

The certification has been widely accepted as a tool to develop and maintain expertise for personnel working in this field. Some countries outside of the USA have moved toward the use of the BIAA Brain Injury Specialist certification as a way to improve and increase the knowledge of ABI with all staff levels. These countries are assisting the certification body to develop country specific requirements around legislation/regulations, pharmaceuticals etc. The collaboration and work has been beneficial to both the providers and the certification body. The process includes face-to-face training and review and a certification exam. If successfully passed the individual becomes certified as a Brain Injury Specialist. The web site is  For more information on the certification please contact Jessica Kerney, ACBIS Coordinator at 703-761-0750.

Many countries, in attempting to develop a plethora of services outside of institutional settings, are developing rehabilitation strategies that are more generic but brain injury providers in these countries are also advocating for the need for specialized brain injury since they know that a generic model does not work well for those with acquired brain injury.

The world of rehabilitation is small and the world of brain injury providers is even smaller. We all have much to learn from each other to continue our growth as specialty providers for those with acquired brain injuries. The International Brain Injury Association (IBIA) is an excellent opportunity to make the world smaller by participating in the conference and sharing knowledge of what works, what is happening in your part of the world and where are we all struggling. Are there lessons learned that we should and could be sharing to improve our services? How are we using technology to spread the innovations and development of brain injury services with each other?

CARF is excited and pleased to be part of the IBIA conference and bring brain injury providers together in a session to discuss what is happening in their countries and have them share their knowledge and passion for acquired brain injury services with you.