CARF standards address Disorders of Consciousness

Transdisciplinary, field-driven, and person-centered accreditation standards

CARF International develops and releases transdisciplinary, field-driven accreditation standards for the Disorders of Consciousness (DoC) Specialty Program. The new accreditation standards demonstrate a person- and family-centered approach to support the need for persons with DoC to have better access to timely and specialized rehabilitation.

DoC encompasses a wide spectrum of clinical syndromes—which include persons presenting in a state of coma, vegetative or unresponsive wakefulness, minimally conscious, post-traumatic, or acute confusion—resulting from traumatic brain injury (TBI) and other causes. Access to rehabilitation in inpatient settings remains limited for many individuals recovering from moderate and severe traumatic and atraumatic brain injuries.

“Recent guidance and published research has supported the need to create specialized teams with the competencies and skills necessary to work with this very unique population of individuals,” said Terrence Carolan, Managing Director of Medical Rehabilitation and Aging Services, CARF International. “With improved recognition and referral across the continuum of care, these individuals can find the highly skilled care that will give them the greatest chances of recovery. The number of individuals with DoC is also anticipated to grow over time, particularly following new guidance from the American College of Surgeons (ACS) in collaboration with the American Congress of Rehabilitation Medicine (ACRM).”

These ACS/ACRM best practice guidelines acknowledge that ending aggressive care after only 72 hours of a TBI diagnosis is arbitrary and not recommended. A period of treatment and observation for 28 days is needed to increase certainty regarding prognosis. The ACS/ACRM guidelines also indicate that functional outcomes acceptable to the patient and/or family can occur in up to 20% of patients who do not regain consciousness in the first four weeks after injury.

Standards rationale

DoC programs deliver services that focus on the assessment, treatment, and care of individuals with DoC and may be located in a hospital, skilled nursing facility, or long-term care hospital in the U.S.; acute hospital or hospital with transitional rehabilitation beds in Canada; or, in other countries, a setting that is comparably licensed.

“Individuals with DoC are already present across the continuum of care, from ICU to long term care,” said Carolan. “The problem is many healthcare settings are either unfamiliar with DoC or are unable to recognize it. We anticipate and are already seeing an increase in the number of individuals with DoC, and this increase will continue with time as more healthcare systems in the United States, Canada, and around the world improve the diagnosis, treatment, and medical management of those with DoC.”

Before deciding to create the DoC Specialty Program standards in Medical Rehabilitation, CARF collected information that included 12 months of interviews with stakeholders (individuals and family members) which were recorded and analyzed for themes; related efforts across the field of rehabilitation; and recently published literature and resources. This groundwork showed strong signals supporting the creation of standards to be used in the peer-led accreditation survey of DoC programs through the Medical Rehabilitation Standards Manual.

Standards created

The standards address the essential components of a DoC specialty program, which include:

• An efficient pre-admission process that facilitates entry to the DoC program by collaboration with acute care providers for appropriate referrals and informed communications with the families/support systems of the person served.
• Admission decisions based on the clinical status of the person served and independent of social, psychological, or demographic characteristics.
• Use of a transdisciplinary approach to provide a complete and clear understanding of a person’s condition where the team works together to assess consciousness using tools specific to this population and setting. They also use treatments that support emergence, manage medical issues, and improve function. This approach supports identifying an accurate diagnosis and guides effective, evidence-based care for people with complex medical and rehabilitation needs.
• Families/support systems are partners in decision-making, receive education and support to effectively care and advocate for their loved ones, navigate fluctuations in the clinical status of the persons served, and balance prognostic uncertainty and hope.
• Personnel receive competency-based training on the unique aspects of persons with DoC.
• Personnel also receive ongoing support for their own well-being.
• The program advocates for the needs of persons served and their families/support systems.
• The program demonstrates the commitment, capabilities, and resources to comprehensively address the needs of persons with DoC.

CARF standards process

CARF’s process for creating new standards includes convening an International Standards Advisory Committee (ISAC) to develop the standards, then a review of the proposed standards, and gaining expert insight from the CARF International Advisory Council before conducting a public field review. The Disorders of Consciousness ISAC and public field review involved 139 stakeholders, including individuals with lived experience and their family members.

Carolan and the ISAC members used input from the reviews and a consensus-driven process to finalize the standards published in the 2026 Medical Rehabilitation Standards Manual, which goes into effect July 1, 2026.

“This is about awareness, access, and advocacy,” said Carolan. “We’re at a point where healthcare providers are not always able to identify individuals that have DoC. There’s still a need for improved awareness of what DoC is—not just by the public, but by healthcare providers at all levels of care. This is a very specific part of rehabilitation and there is a profound lack of access to specialized care. There is a tremendous need to support DoC care and support across the continuum of care.”