Case Study: How a Concussion Rehabilitation Program Achieved CARF Three-Year Accreditation
Last updated: April 2026
Client details are presented in anonymized form consistent with IHS confidentiality obligations. Bracket placeholders indicate where client-specific data will be inserted prior to publication.
Client Overview
- Organization type: [Hospital-based concussion clinic / Sports medicine concussion program / Outpatient neurorehabilitation program with concussion specialty]
- Location: [State]
- Programs in scope: [e.g., Concussion Rehabilitation — Outpatient]
- Annual volume — concussion/mTBI cases: [X]
- Primary populations served: [e.g., Student athletes / Adult workers / Military veterans / Mixed general population]
- Interdisciplinary team disciplines: [e.g., Physiatry, Neuropsychology, Vestibular PT, Visual Therapy, Psychology]
- Reason for pursuing CARF: [e.g., VA community care contracting / hospital referral network development / sports medicine market differentiation / MCO specialty network application]
- Prior accreditation status: [None / General Medical Rehabilitation / First-time specialty applicant]
- Engagement start date: [Month, Year]
- Survey date: [Month, Year]
- Outcome: CARF Three-Year Accreditation — Concussion Rehabilitation awarded
The Challenge
[Organization name] had built a clinically strong concussion program over [X years], assembling a genuinely interdisciplinary team and developing clinical protocols that reflected current evidence. The program had excellent clinical outcomes. The documentation infrastructure had not kept pace with clinical development — and three specific gaps created significant accreditation risk.
1. Return-to-Activity Protocols: Clinical Knowledge Without Documentation Infrastructure
The program's physiatrist and athletic trainers were applying the Concussion in Sport Group's graduated return-to-sport protocol and an adapted return-to-learn protocol based on current evidence. But these protocols existed in the clinicians' heads and in informal clinical notes — not in documented policy, not in a standardized clinical record format, and not in a way that demonstrated consistent application across all providers. When IHS reviewed [X] randomly selected clinical records, return-to-activity staging was documented in [X%] of files; protocol identification was documented in [X%] of files; modification rationale was documented in [X%] of files where modifications had been made.
CARF requires that return-to-activity protocols be documented, evidence-based, and consistently applied. The gap between clinical practice and documentation was the program's single highest-priority remediation item.
2. Symptom Monitoring: Multiple Tools, No System
Different providers in the program were using different symptom monitoring tools — the SCAT6 in the sports medicine component, the PCSS in the neuropsychology component, and informal symptom inquiry in physical therapy — with results documented in separate sections of the clinical record with no longitudinal tracking mechanism. There was no defined administration schedule, no systematic comparison of symptom scores across time, and no documented use of symptom data in return-to-activity progression decisions.
3. Interdisciplinary Coordination: Parallel Assessments Without Documented Joint Planning
The program's providers knew each other, communicated informally, and delivered genuinely coordinated care for complex cases. Routine cases, however, were managed within individual discipline silos — physical therapy, neuropsychology, and sports medicine each addressing their domain without documented cross-discipline communication or joint treatment planning. CARF requires evidence of interdisciplinary coordination as a systematic program feature — not a case-by-case exception for complex patients.
IHS's Approach
Phase 1: Gap Assessment (Weeks 1–3)
IHS conducted a comprehensive gap analysis identifying [X] deficiency categories. The return-to-activity protocol documentation gap was classified as critical — it required policy development, clinical record format redesign, and staff training before the six-month operational data clock could start generating clean documentation. The symptom monitoring fragmentation was classified as significant — it required tool standardization and a longitudinal tracking system. The interdisciplinary coordination gap was classified as significant — it required a systematic coordination protocol for all cases, not just complex ones.
Phase 2: Return-to-Activity Protocol Documentation System (Weeks 4–10)
IHS developed a comprehensive RTA Documentation Framework:
- Protocol policies: Formal documentation of the program's evidence-based RTA protocols for sport, school, and work — citing the Concussion in Sport Group 6th Consensus Statement and CDC HEADS UP framework as primary evidence sources. Protocols formalized in policy with version control and annual review requirement.
- Clinical record format: Standardized RTA staging section added to all clinical encounter notes — documenting: current protocol, current stage, criteria met for current stage, criteria for next stage advancement, and modification rationale where applicable.
- Protocol training: [X]-hour training for all providers on the formal protocol documentation requirements, including case-based exercises applying the documentation format to common clinical scenarios.
Phase 3: Symptom Monitoring System Standardization (Weeks 6–14)
IHS designed a unified symptom monitoring system:
- Standardized on the PCSS as the primary longitudinal symptom tracking tool for all providers, supplemented by the SCAT6 for sideline and initial acute assessment in the sports medicine component
- Defined administration schedule: acute assessment, weekly during active treatment, at return-to-activity milestone transitions, and at discharge
- Longitudinal symptom tracking template embedded in the clinical record — graphing total symptom burden score over time and flagging scores above defined thresholds for clinical review
- Documented link between symptom scores and RTA staging decisions: clinical record format requires documentation of current symptom score at every staging decision
Phase 4: Interdisciplinary Coordination Protocol (Weeks 8–16)
IHS designed a tiered interdisciplinary coordination protocol that systematized coordination without creating unsustainable meeting burdens:
- Routine cases: Weekly cross-discipline case review using a standardized one-page case summary format — each provider documenting assessment findings and treatment plan in a shared format reviewed asynchronously by all disciplines before the next session
- Complex cases: Synchronous interdisciplinary case conference with documented minutes and joint treatment plan update
- Thresholds for escalation to complex protocol: Defined and documented — symptom duration exceeding [X weeks], [specific symptom patterns], referral for neuroimaging, or provider request
Phase 5: Mock Survey and Final Preparation
IHS conducted a [X]-day mock survey with [X] record audits applying RTA protocol documentation criteria, symptom monitoring consistency review, and interdisciplinary coordination evidence audit. Written deficiency report identified [X] remaining items remediated before application submission.
Outcome
CARF Three-Year Accreditation — Concussion Rehabilitation awarded following a [X]-day survey. [X] commendations noted including specific recognition of [e.g., the RTA documentation framework, the longitudinal symptom tracking system]. [X] minor recommendations addressed in post-survey QIP.
Market Impact
- VA community care contract: [Program] qualified for VA community care contract for concussion/mTBI services within [X months] of accreditation
- Sports medicine referrals: [X] new team physician and athletic trainer referral relationships established within [X months] of CARF announcement
- Managed care network: [X] MCO specialty network applications accepted, citing CARF accreditation
- Documentation quality: RTA protocol documentation rate rose from [X%] to [X%] of clinical records within [X months] of implementation
Key Lessons for Concussion Rehabilitation Programs
Clinical Knowledge Must Become Policy
Experienced concussion clinicians often have the protocol knowledge internalized — they are applying evidence-based approaches without needing to reference a document. CARF requires the documentation to exist even when the clinical knowledge does not. Converting clinical expertise into formal policy documentation is the foundational step for any concussion program pursuing CARF accreditation.
Tool Standardization Enables Longitudinal Tracking
Multiple validated symptom tools in use across disciplines creates fragmented data that cannot be longitudinally tracked. Standardizing on a primary longitudinal tool — while preserving specialty-specific supplementation — enables the systematic symptom tracking CARF requires. The clinical value of longitudinal symptom data is significant independent of accreditation; CARF simply makes it mandatory.
Systematic Coordination Requires a Default Process — Not Just Expert Judgment
Interdisciplinary coordination for complex cases is common in strong concussion programs. CARF requires it for all cases. Building a lightweight, sustainable coordination process for routine cases — a weekly case summary format rather than a full team meeting — achieves CARF compliance without creating operational burden.