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3 Medicare Proposes 2012 Home Health Care Rates

5 AUDIOLOGY
Audiologists and lEPs; the effects of secondhand smoke on tiearing; improved telephone speech perception; new treatment for Usher syndrome. 1 0 How to Fit RTI Into a Heavy Workload 1 4 Universal Design for Learning: Meeting the Needs of AI I Students 1 8 Capitalizing on Communication: 2011 Schools Conference 2 4 From the President: Mentorship 26 SLP Establishes School to Focus on Language Intervention

2 7 Memories of 9/11
28 The Role of Educational Audiologists 3 2 A Collaborative Approach to Emotional/Behavioral Disorders 3 8 Internet: Interactive Whiteboards 4 0 Limelight: Julie West 411 Classifieds 4 4 People on the Move 4 7 First Person on the Last Page: P. K. Harrison

Laws Protect Young Athletes
Growing Number of States Pass Concussion-Related Legislation by Bess Sirmon Fjordbak

Mentoring Programs Open Check out information about online programs for new faculty (p. 35) and students (p. 46).

return to play? There is no conports-related concussion among pre-participation baseline assessment of sensus on the best course of action school-aged athletes in the United (Duff, 2009). Physicians, coaches, ) States is an issue of increased cognitive-linguistic function. and trainers often use individualvisibility in the media, in clinical ized, graduated retum-to-play protocols based on neuropsycho• settings, and in legislative capitols across the country (Duff, 2009; logical testing and other factors. Salvatore & Sirmon Fjordbak, 2011). Estimates of concussion Some states have laws that mandate these protocols, while incidence range as high as 3.8 million other states have rejected or never introduced such legislation. A per year (CDC, 2007), translating into an average rate of about 10% of athletes careful review of federal and state legislation governing concussion management plans, based on information gathered from texts sustaining a concussion during any of bills and laws from each state's governmental website (see season, either during practice or play. online sidebar for state websites), reveals the variability. When is it safe for a student-athlete who has sustained a concussion to See Concussion page 8

The component missing from most of the bills is the requirement for

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Concussion from page 1

Concussion Legislation Summary State Legislation
At this point in the year, most states have cc eluded their regular legislative sessions. Bills th passed through the legislative branch of govemm^ have either been signed into law or await a gover signature (see chart at right). As of July 29, 2011: ' • 31 states and the District of Columbia have passl bills related to concussion management into law 1 have bills awaiting the governor's signature. • Seven other states have legislation pending. • Six states have introduced no legislation relative this issue. • Five states had bills introduced into the legislature that were unsuccessful. Many states have followed the lead of the National Collegiate Athletic Association (NCAA). In April 2010, the NCAA adopted policies that require a concussion management plan specifying that collegiate athletes who sustain a concussion should be removed from the current contest and may not return to practice or play until receiving clearance by a team physician or désignée. Further, student-athletes should be presented with information on concussion and must sign a statement accepting responsibility for reporting injuries and illnesses, including concussion symptoms, to medical staff (NCAA, 2010). The wording of legislation introduced across the country includes some recurrent themes. Most of the bills embrace some form of the following language: • Coaches and trainers must receive training in concussion management, including recognizing the signs and symptoms of concussion. They must follow return-to-play protocols that involve graduated levels of activity. • Concussion-management training for coaches and trainers must be reviewed annually, with periodic recertification of skills. • Athletes and parents must receive information on • concussion signs and symptoms prior to the start of each season, and must sign informed consent allowing the student to play. • Athletes who sustain a concussion may not return to play in the same game. • Athletes must receive written clearance from a physician or other licensed health care professional before returning to play or practice. Federal law H.R. 469 (introduced) States with at least one concussion management law (*pendingslgnature of governor) Alabama Illinois Nebraska Rhode Island Alaska Indiana Nevada South Dakota Arizona Iowa New Jersey Texas Arkansas Louisiana New Mexico Utah Colorado Maryland North Carolina Vermont Connecticut Massachusetts North Dakota Virginia District of Columbia Minnesota Oklahoma Washington Idatio Missouri* Oregon Wyoming States with pending 2011 legislation (in committee) California Michigan Ohio Delaware New York Pennsylvania

South Carolina

States with no concussion legislation rbills introduced but died in 2011) Florida** Kansas** Montana West Virginia Georgia Kentucky New Hampshire** Wisconsin Hawaii** Mississippi Tennessee** Other states Maine—passed two laws establistiing a study commission on tlie feasibility of instituting testing for sports-related tiead injuries, and a working group to investigate concussive head injuries in student-athletes. New Hampshire—legislation similar to that of Maine was introduced, but withdrawn.

establish regulations for the prevention and treatment of concussions. The bill institutes minimum state requirements, including the establishment of a concussion safety and management plan. It would mandate education for athletes, parents, and school personnel about the nature of concussion; support for students recovering from concussion, including academic accommodations; and best practices to ensure uniform safety standards, treatment, and management. Consistent with most state laws and the NCAA regulations, the bill requires parent notification of injury and also requires that a student who sustains a concussion be removed from play and prohibited from returning to athletic or academic activities until he or she receives written release from a health care professional. The release may also require the student to follow a graduated return to normal activities based on the student's symptoms.

Limitations
One critical component missing from niost of the bills is the requirement for a pre-participation baseline assessment of cognitive-linguistic function. A number of instruments are appropriate for this type of data collection (including traditional pencil-and-paper tests and batteries). In addition, technology-based applications measure response speed and accuracy and a range of cognitive functions such as verbal memory, attention to task, sequencing, and visuospatial
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Federal Legislation
"Protecting Student Athletes from Concussions . Act of 2011" (H.R. 469) was introduced into the House of Representatives in January 2011 by Sen. Timothy Bishop (D-N.Y.) and has been referred to the Subcommittee on Early Childhood, Elementary, and Secondary Education. The bill, which has garnered 24 co-sponsors, would require school districts receiving Elementary and Secondary Education Act funding to

processing. The availability of this kind of baseline data allows more accurate measurement of some of the subtle—yet significant^—deficits that can occur post-concussion but that are not readily observable on traditional imaging studies (e.g., CT, MRI). Bills with a baseline assessment requirement (e.g., H.B. 677 in Texas) have faced opposition for a number of reasons, related primarily to the cost of the baseline assessment. In the current budget climate, both at the state and federal level, limited resources are available for new programs, and unfunded mandates carry little weight. However, states willing to shoulder the burden of the expense would be recognizing the benefit of prevention, rather than paying the associated costs in cases of catastrophic injuries for which local schools could be found liable. Of the state laws reviewed, only Rhode Island has passed a law mandating baseline cognitive assessment. In NewYork, A.B. 5188, which mandates baseline testing, is pending. Similar measures failed in Texas and Hawaii. Other states are approaching the issue from the perspective of non-binding resolutions, rather than statutes. New Jersey, for example, has resolutions pending in committee in both the General Assembly (A.R. 85) and in the Senate (identical companion bill S.R. 74). This measure urges schools to implement baseline cognitive assessment of school-aged athletes for the purpose of objective measurement, appropriate management, and safe return to play. This resolution does not have the force of law, nor does it address

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the fiscal implications of this type of assessment, but it does serve to increase legislators' and educators' awareness of the potential impact of concussion in the school-aged population. A further limitation is that speech-language pathologists are not typically included in the definition of licensed health care providers. Some states, as well as the federal bill, define "health care professional" as individuals licensed, certified, or otherwise recognized by states who are experienced in identification and management of concussive injuries. Although retumto-play decisions should not rely solely on one opinion (SLP or otherwise), the collection and analysis of cognitive-linguistic data, both at baseline and postconcussion, is within the scope of practice of speechlanguage pathology. The addition of such information gathered by SLPs can contribute to the formulation of appropriate return-to-play protocols and management decisions. The increased awareness of concussion incidence, prevalence, and recovery sequelae is being addressed at state and federal levels. Importantly, SLPs need to be aware of the effects of concussion on communicative and academic function. In the past three years, 29 states (plus two more pending approval by their respective executive branches) have enacted legislation that specifically addresses the prevention

The collection and analysis of cognitivelinguistic data, both at baseline and post-concussion, is within the scope of practice of speech-language pathology. References
Centers for Disease Control and Prevention. (2007). Nonfatal traumatic brain injuries from sports and recreation activities—United States, 2001-2005. Morbidity and Mortality Weekly Report, 56(29), 733-737 Duff, M. C. (2009). Management of sports-related concussion in children and adolescents. The ASHA Leader, 14(9), 10-13. National Collegiate Athletic Association. (2010). NCAA Sports Medicine Handbook (21st ed.). Indianapolis, IN: Author. Salvatore, A. P., & Sirmon Fjordbak, B. (2011). Concussion management: Speech-language pathologist's role. Journal of Medical SpeechLanguage Pathology, 79(1), 1-12.

and management of sports-related concussion in school-aged athletes. None of the bills specifies SLPs as members of the concussion management team. However, as legislation is enacted and policies change, SLPs can be recognized as licensed health care providers, well-positioned and well-prepared to be a part of the nationwide efforts to prevent and manage concussion, ii^ .Bess Sirmon Fjordbak, PhD, CCCSLP, assistant professor of speechlanguage pathology in the Department of Rehabilitation Sciences at the University of Texas at El Paso, is also associate director of the UTEP Concussion Management Clinic. She served as vice president for social and governmental policy of the Texas Speech-Language-Hearing Association. Contact her at bsfjordbak@utep.edu.

Additional resources for this article can be found at The Leader Online. Search on the title of the article www.asha.org/ leader.aspx..

Home Care from page 3

CMS proposes a payment reduction for high-therapy episodes (i.e., more than 20 therapy visits in 60 days) because payments have consistently surpassed costs by higher margins than those for low-visit episodes. Conversely, episodes that comprise only three to five therapy visits have been underpaid and will be adjusted. The CMS proposal redistributes payments from high-therapy episodes to low-therapy episodes.

The reference to the "plan of care" refers to the overall HHA plan of care approved by a physician. As described in regulations, the patient's function must be periodically reassessed by a qualified therapist, of the corresponding discipline for the type of therapy being provided, using a method that would include "objective measurement."

Fixed Payments
If a home health episode includes fewer than five home health visits, the PPS payment is replaced by a fixed payment per visit. The proposed 2012 per-visit rates are $134.25 for speech-language pathology, $123.50 for physical therapy, and $124.40 for occupational therapy (geographically adjusted). These figures represent a 1.5% increase for each discipline. The 2012 proposal also includes a revision to the 2011 requirement that a physician meet face-to-face with the patient prior to HHA admission. HHAs strongly protested this requirement; the proposal allows a physician who treated the patient in an acute or post-acute setting to inform the HHA's certifying physician of the patient's qualifying conditions. W Mark Kander, director of health care regulatory analysis, can be reached at mkander@asha. org.

Reassessment
Confusion over changes in the 2011 regulations regarding scheduled reassessments—including when they are to be performed and by whom, especially when a patient is receiving more than one type of therapy—should be resolved with the proposed 2012 regulation (see The ASHA Leader, Nov. 3, 2010, www-asba-org/Publications/leader/lOll/llOSlS/Home-Care-Rule-Will-TakeEffect-on-April-l.htm). The proposed regulation more clearly identifies that "Where more than one discipline of therapy is being provided, the qualified therapist from each discipline must provide the therapy service and functionally reassess the patient [in accordance with regulations] during the visit which would occur close to but not later than the 19th visit per the plan of care." The reassessment must occur during a regularly scheduled visit and must also meet the CMS rule that patients be reassessed at a minimum of every 30 days. After each discipline's reassessment is conducted, a new 30-day reassessment window begins.

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