Cognitive Rehabilitation Therapy
for Home and Community-based
Service (HCS) Providers
Eric Stratton, RN, MSN
Office of Chief Deputy Commissioner
February 14, 2013
Objectives
• Define Cognitive Rehabilitation Therapy (CRT)
• Explain history of CRT and legislative intent
• Convey the value of CRT as evidence based practice
which can improve outcomes
• Provide instruction on how to help individuals access
CRT
• Explain who are qualified providers for HCS
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CRT Waiver Service Definition
Cognitive rehabilitation therapy is a service that assists an individual in
learning or relearning cognitive skills that have been lost or altered as a
result of damage to brain cells/chemistry in order to enable the
individual to compensate for the lost cognitive functions. Cognitive
rehabilitation therapy is provided when determined to be medically
necessary through an assessment conducted by an appropriate
professional. Cognitive rehabilitation therapy is provided in
accordance with the plan of care developed by the assessor, and
includes reinforcing, strengthening, or reestablishing previously learned
patterns of behavior, or establishing new patterns of cognitive activity
or compensatory mechanisms for impaired neurological systems.
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CRT Overview
• Learning/relearning cognitive skills after brain
damage
• Traumatic Brain Injury (TBI)
• Acquired Brain Injury (ABI)
• Assessment determines medical need for CRT
• Neurobehavioral OR Neuropsychological
• Covered under State Plan
• Qualified Providers of CRT Services
• Psychologists
• Occupational Therapists (OT)
• Speech and Language Pathologists (SLP)
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CRT History & Legislative Intent
• CRT is evidence based treatment for ABI
• 2006: TBI Advisory Council Report on ABI and
Long-term Care in Texas
• Report to 80th Legislature on gaps in services for brain
injury survivors in Texas
• No care coordination, long waiting periods
• 2007: LBB report to 80th Legislature
recommending TBI coverage through Medicaid
• 2008: HHSC Office of ABI established
• Funded by budget rider in 80th Legislature
• Serves as state lead coordinator for TBI and ABI
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CRT History & Legislative Intent
• 2009: Rider 66, SB 1, 81st Legislature (R)
• Feasibility study regarding need for system of
community support & residential services for ABI
• Concluded separate ABI waiver program was best
• 2011: 82nd Legislature
• Budget Crunch – no action taken
• Further study by HHSC Office of Acquired Brain
Injury and Texas TBI Advisory Council in interim
• 2013: 83rd Legislature
• HHSC requests to add new CRT service to CLASS,
HCS, CBA, & STAR-Plus HCBS for ABI clients
• Legislature funded $1.9 million (GR) for biennium
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CRT History: What Other States Are Doing*
• At least 23 states have a 1915(c) waiver program
specifically for individuals with brain injury
• 11 states include services for both ABI and TBI
• MS & FL add Spinal Cord Injury
• Level of Care
• 14 states have nursing facility level of care
• 4 states have hospital level of care
• IA, MD, MN include multiple levels of care
• Age requirements
• 12 states limit to adults only
• 5 states cover services from infancy
* Data as reported from CMS and HHSC OABI Rider 66 Feasibility Study 2009.
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CRT: Evidence-Based Practice
• CRT “attempts to enhance functioning and
independence in patients with cognitive
impairments as a result of brain damage or
disease (IOM, 2011, p. 76)
• Neurological disorders affecting CRT patients
(Solhberg, Mateer, 2001, p. 25)
•
•
•
•
•
TBI
Stroke
Hypoxic-hypotensive injury
Encephalitis and other infectious disorders
Brain tumors
• Collectively diagnoses are ABI
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CRT: Evidence-Based Practice
Cicerone, K., Langerbahn, D., et al. Evidence-Based Cognitive
Rehabilitation: Updated Review of the Literature From
2003 Through 2008. Archives of Physical Medicine and
Rehabilitation, Vol 92, Apr 2011, 519-527.
Institute of Medicine. Cognitive Rehabilitation Therapy for
Traumatic Brain Injury: Evaluating the Evidence. 2011.
The National Academies Press.
Rohling, Faust, et al. Effectiveness of cognitive rehabilitation
following acquired brain injury: A meta-analytic reexamination of Cicerone et al.'s (2000, 2005) systematic
reviews. Neuropsychology, Vol 23(1), Jan 2009, 20-39.
doi: 10.1037/a0013659
Sohlberg, M.M., Mateer, C.A. Cognitive Rehabilitation: An
Integrative Neuropsychological Approach. 2001. Guilford
Press.
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Definition: Cognitive Rehabilitation Therapy
Cognitive rehabilitation therapy--A service that:
 assists an individual in learning or relearning cognitive
skills that have been lost or altered as a result of
damage to brain cells or brain chemistry in order to
enable the individual to compensate for lost cognitive
functions; and
 includes reinforcing, strengthening, or reestablishing
previously learned patterns of behavior, or establishing
new patterns of cognitive activity or compensatory
mechanisms for impaired neurological systems.
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Service Delivery: CRT
The program provider or CDS Employer must ensure that:
• Cognitive rehabilitation therapy is provided in accordance with the
individual's PDP, IPC, implementation plan, and with Appendix C of
the HCS Program waiver application approved by CMS and found at
www.dads.state.tx.us
• If the service planning team determines that an individual may need
cognitive rehabilitation therapy, the program provider, in coordination
with the service coordinator:
• assists the individual in obtaining an assessment and plan of care
for the cognitive rehabilitation therapy from a qualified
professional in accordance with the Medicaid State Plan; and
• has a qualified professional provide and monitor the provision of
cognitive rehabilitation therapy to the individual in accordance
with the plan of care
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Provider Requirements: CRT
The program provider or, if using the CDS option, CDS
employer and Financial Management Services Agency must
ensure that a service provider of cognitive rehabilitation therapy
is:
 a psychologist licensed in accordance with Texas
Occupations Code, Chapter 501;
 a speech-language pathologist licensed in accordance
with Texas Occupations Code, Chapter 401; or
 an occupational therapist licensed in accordance with
Texas Occupations Code, Chapter 454.
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Service Delivery: CRT
The program provider or CDS employer must:
 Together with an individual's service coordinator,
ensure the coordination and compatibility of HCS
Program services with non-HCS Program services
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CRT Process and Procedure
ASSESSMENT
Neuropsychological
HCS Service
Diagnosis
ABI
OR
CRT
Neurobehavioral
State Plan Assessments: “Gatekeepers” to CRT Service
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CRT Process and Procedure: Assessments
1. Neuropsychological Assessment (State Plan)
• Includes treatment plan in the assessment
• Conducted by Psychiatrist, Psychologist, or LPA under
the supervision of a licensed psychologist
• CRT Assessment “in reality” 
• Conducted by NEURO-psychologist
OR
2. Neurobehavioral Assessment (State Plan)
• Conducted by physician, PA, or NP
• Must result in treatment plan with assessment
 Individual referred to OT/SLP for CRT in HCS (only if
assessment warrants it)
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Entering CRT in CARE
• CARE ID CRT Event type CRT or CRTV (CDS)
• Units Billed in 15 minute increments using
standard rounding rules.
• CDS billed in dollars.
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HHSC/DADS Contacts
Eric Stratton, RN, MSN
Policy Analyst
Health and Human Services Commission
Office of Chief Deputy Commissioner
Eric.Stratton@hhsc.state.tx.us
(512) 487-3372
Curtis Walters
HCS Program Specialist
Department of Aging and Disabilities Services
Center for Policy and Innovation
hcs@dads.state.tx.us
Send questions related to CDS to cds@dasd.state.tx.us.
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