1320.00 Cognitive Remediation Services Policy
(Rev. June 1989)
Table of Contents
- Evaluation of Consumer's Need for Cognitive Remediation
- Cognitive Remediation Program Planning
- Approved Vendors of Cognitive Remediation Services
- Duration and Rates for Cognitive Remediation Service Providers
Cognition is basic to the acquisition of knowledge and includes learning, reasoning, problem solving, perception, judgment and concentration. Cognition also involves the ability to analyze, discriminate, organize, categorize, memorize and perform other functions influenced by emotions and social feelings. These processes, when operating normally, allow individuals to process information and to appropriately interact with the environment. Cognitive deficits are impaired skills that are a result of a head injury or other neurological impairments that require careful neuropsychological evaluation to determine their nature and severity.
Cognitive remediation is a service that assists individuals to develop skills and strategies that maximize their intact cognitive abilities in order to compensate for cognitive deficits. Cognitive remediation services, which vary for each consumer, combine a variety of techniques to provide consumers with alternative strategies for impaired functions while enhancing existing abilities. The actual services include direct intervention by skilled providers and may use, but not be limited to, standardized written simulations, structured computer programs, and video taping.
This service may be considered as a part of vocational programming for persons with acquired brain dysfunctions that include traumatic brain injuries (TBI), demonstrated neoplasms, metabolic disorders, cerebrovascular accidents and other neurological traumas. Remediation for lost cognitive processes is counseling, etc., but rather to enhance the consumer's ability to respond effectively to these and other vocational rehabilitation programs.
Cognitive remediation services may be indicated if an individual demonstrates functional neurological deficits in cognitive skills that limit his/her potential for vocational success. Remediation will be provided by ACCES-VR only when directly related to a specific vocational goal that is documented in the consumer's IPE. An important factor to consider when determining whether remediation should be provided is the discrepancy between the consumer's current abilities and deficits and the functional skills that will be required for vocational placement.
The Ranchos Los Amigos Scale for Cognitive Functioning (which is completely detailed in the Traumatic Brain Injury Manual Section 1281.00) is one of many tools that can be used to determine the level of cognitive functioning of consumers. Generally, the consumer should be at least at Stage 7 for ACCES-VR to provide cognitive remediation services for consumers with TBI. Consumers at Stage 7 show automatic and appropriate behavior, requiring at least minimal supervision for learning purposes. The consumer can process information and can respond to complex commands.
Often severely disabled consumers have received cognitive remediation in acute care facilities, rehabilitation hospitals and specialized programs. The cognitive remediation services provided by ACCES-VR during the vocational rehabilitation program are meant to "fine tune" the skills needed to accomplish the vocational goal. The service is not meant to be provided by ACCES-VR for prevocational issues including but not limited to unresolved impairments in basic activities of daily living, or uncontrolled behavior or emotions. If the consumer has major cognitive deficits in these prevocational areas, feasibility at this time for ACCES-VR is questionable.
Cognitive remediation services cannot be provided as part of the process to determine eligibility unless there is an inability to determine whether the services provided by ACCES-VR can benefit the individual in assisting him/her to achieve a vocational goal. In this situation, cognitive remediation can be provided in the extended evaluation status for up to a maximum expenditure of $650. The amount spent in the extended evaluation status must be deducted from the allowable maximum expenditure for cognitive remediation services of $6500.
- Neuropsychological Evaluation and Other Reports
A neuropsychological evaluation is required to objectively document the need for cognitive remediation. The neuropsychologist should:
- Determine if there are cognitive deficits and if these deficits will impact on the consumer's vocational program;
- Determine if the consumer has the capacity to benefit from cognitive remediation;
- Outline the elements of a cognitive remediation program;
- Indicate baseline of functional performance and how to determine progress and successful outcomes in specific steps.
The ACCES-VR counselor should adapt the recommendations from the neuropsychological evaluation to the goals of the consumer's IPE. Existing neuropsychological evaluations, as well as other reports from hospitals and rehabilitation centers, should be used whenever possible. (Refer to the ACCES-VR policy concerning Neuropsychological Evaluations, Manual Section 1282.00 for further information.)
- Consumer Criteria
The consumer must meet all of the following criteria in order to be considered for cognitive remediation services through NYSED :: ACCES :: VR :
- Must be medically stable;
- Must demonstrate capacity for learning (based on neuropsychological evaluation);
- Must have the capacity for two-way communication, either directly or through adaptive equipment;
- Cannot exhibit behavior that presents a physical threat to self or others.
- Must be free from alcoholism or substance abuse so it does not interfere with cognitive remediation efforts or the pursuit of a vocational goal;
- Must express the desire to participate in the program;
- Must need these services to acquire skills essential to training or for securing and maintaining suitable employment.
- The plan for cognitive remediation provided by ACCES-VR should be developed by the ACCES-VR counselor with the consumer and the family (if appropriate). The service provider should be consulted to assure that the appropriate services are available to meet the objectives of the cognitive remediation plan. The plan must be fully documented in case notes and must contain:
- Specific objectives defined in functional terms;
- An outline of the remediation methods to be used;
- How the objectives of the cognitive program coordinate with the vocational goals of the consumer.
- A statement as to the duration of program.
- Criteria for measuring achievement and for successful or unsuccessful outcomes.
- Progress reports to ACCES-VR must be issued at least quarterly during the cognitive remediation program and should be measured by using the neuropsychological evaluation as the base level. The reports should focus on the consumer's functional behavior as it relates to the demands and expectations of real life work circumstances.
- The family and/or significant others should take an active role in the cognitive remediation plan including the development of compensatory techniques and coping strategies for the individual with a disability in order to facilitate progress towards the vocational goal.
- Authorization of cognitive remediation services must be approved by the District Office Manager or Director of Counseling Services with input from the District Office Medical Consultant as necessary.
- Cognitive remediation services may be purchased from:
- Comprehensive TBI programs; or
- Qualified individual providers not currently affiliated with a TBI program.
- Any person providing cognitive remediation services, either as an individual service provider or as a staff member of a comprehensive program, must have:
- A master's degree in either a human services field (psychology, social work, rehabilitation counseling or a related degree) or education field from a college or university accredited by the new York State Education Department or be supervised by an individual with these educational credentials;
- Specialized training in the disabilities that result in cognitive deficits (such as head injury) and in the delivery of cognitive remediation services; and
- At least two years of experience in the provision of cognitive remediation services.
Specialized training should include course work, workshops, etc., in cognitive remediation and the nature of traumatic neurological impairments so that they have the background to provide effective services. Resumes of staff that meet the three above criteria, must be secured to review their knowledge, skills and experience. All vendors must be approved by the Bureau of Provider Review. The district office medical/psychological consultant may be able to provide interpretive information or assist in reviewing providers at the local level before requesting central office approval.
Cognitive remediation service providers will be reimbursed at a rate of up to $25.00 per hour. No IPE's or combination of original IPE's and amendments may exceed $6500 for this service. All other sources of reimbursement or similar benefits should be used before ACCES-VR case service funds are expended. Often funding is available through third party insurance, Medicaid and Medicare.
Cognitive remediation services will be authorized using case service code 350. Cognitive remediation is a restoration/treatment service and is based upon economic need.