For people with brain injury and their families, cognitive problems may be the greatest barrier to returning to “normal” life. These difficulties involve memory, attention, social behavior, safety judgment, and planning and carrying out future actions. They affect a person’s ability to care for himself, keep appointments, complete tasks, or interact with people appropriately. At stake is the person’s ability to succeed at work, school, or home. Without treatment for cognitive problems, the long-term effects can be devastating.
What is CRT?
Cognitive Rehabilitation Therapy (CRT) is a broad term used to describe treatments that address the cognitive problems that can arise after a brain injury. Given the wide range of symptoms and severity of cognitive problems in individuals with brain injury, CRT does not refer to a specific approach to treatment. Although physical injuries, or speech or swallowing problems are typically covered by insurance, some health insurers deny coverage for CRT. Struggles with reimbursement may be due in part to the “invisible” nature of cognitive problems, but also to a lack of understanding about what CRT is.
The Institute of Medicine (IOM)’s 2011 report1 provides the following broad definition: “Cognitive rehabilitation attempts to enhance functioning and independence in patients with cognitive impairments as a result of brain damage or disease, most commonly following TBI or stroke.” (IOM, 2011, p. 76). It clarifies that CRT is different from cognitive behavioral therapy, a treatment approach for emotional and psychiatric problems. The IOM describes two broad approaches to CRT:
- Restorative treatment, whose goal is to improve the cognitive system to function in a wide range of activities;
- Compensatory treatment, which trains solutions to specific problem areas such as using memory notebooks or learning self-cuing strategies.
CRT has many variables: providers, settings, focus, and treatment formats. Many different types of professionals deliver services described as CRT. These providers are typically credentialed and licensed by their professions and state boards. They include, but may not be limited to:
- speech-language pathologists
- occupational therapists
- physical therapists
- vocational rehabilitation counselors
CRT services are provided in different settings, such as
- Inpatient rehabilitation units
- Outpatient departments
- Community brain injury rehabilitation centers
Treatment may also be delivered in a variety of formats (individual, group therapy, day treatment program), and intensities (intensive inpatient rehabilitation, daily outpatient, or weekly).
Ideally, cognitive assessment to evaluate level of alertness, orientation to surroundings, and memory of recent events begins from the moment someone with a brain injury is admitted to the hospital. With moderate or severe cognitive impairments, individuals may receive CRT during an inpatient rehabilitation program and then be discharged to an outpatient setting for further treatment. The treatment team and discharge coordinator typically make recommendations about the treatment setting and type of provider that will be most effective in working with the kinds of cognitive problems that the individual displays.
For example, someone with a moderate degree of cognitive impairment may benefit from a comprehensive outpatient CRT program that includes individual treatment as well as group therapy for social/behavioral goals. The program may include functional activities such as planning outings into the community, or work or school re-entry. Comprehensive programs like this may be staffed by providers from multiple disciplines.
More targeted therapy may be delivered by a single provider. For example, a person with cognitive issues related to language processing (following directions, using written strategies for memory and organization) may focus on speech-language pathology services. Someone working on the cognitive skills for driving or home management may receive occupational therapy. The professional who delivers the service may describe the treatment as CRT or in terms unique to that profession.
People who sustain a concussion or mild TBI without being hospitalized may have a more difficult time being referred for CRT and having treatment covered by insurance. Often the Emergency Room report doesn’t describe cognitive problems, or the person doesn’t notice difficulty concentrating or remembering until she returns to work or school. Without medical documentation of the problem, insurers may decline to make referrals or pay for CRT.
Challenging Insurance Denials for CRT
Because of the variability in patients and the CRT they may receive, research studies, to date, have not identified a single most effective treatment. In some cases, reports of limited research about CRT has led private health plans to deny CRT. The IOM report calls for more research on CRT, but recognizes the difficulty in obtaining conclusive results. The report states in italics “In fact, the committee supports the ongoing clinical application of CRT interventions for individuals with cognitive and behavioral deficits due to TBI.” (IOM, 2011, p. 257).
Families and providers can work together to challenge insurance denials if they occur. Families can appeal denials, and ask the professional to provide detailed reports of functional progress made by the patient or articles demonstrating the effectiveness of the technique being used. Professional associations such as the American Speech-Language-Hearing Association provide assistance to speech-language pathologists and their patients by writing letters supporting CRT. Finally, appeals can be made to the state’s Insurance Commission, where a review will take place at a level beyond the health plan.
Cognitive rehabilitation therapy may be like the proverbial elephant — it feels different to different people depending on their circumstances and perspective. But, as patients and families will attest, CRT is as fundamental a need in TBI recovery as physical rehabilitation — and for some, even more essential to their quality of life.
Institute of Medicine. 2011. Cognitive Rehabilitation Therapy for Traumatic Brain Injury: Evaluating the Evidence. The National Academies Press.
Written exclusively for BrainLine by Janet Brown, MA CCC-SLP, director, Health Care Services in Speech-Language Pathology, American Speech-Language-Hearing Association. www.asha.org.