HIPPOTHERAPY STANDARDS

H1 MANDATORY

Is there written evidence that the therapist who provides direct treatment services in a hippotherapy program meets the following qualifications:

• Is licensed, registered or certified to practice a nationally recognized health care profession in accordance with their state practice acts.
• Maintains current professional liability insurance.
• Is a NARHA Registered Therapist or Hippotherapy Clinical Specialist (HPCS) and if not, there is a policy in practice that a NARHA Registered Therapist or HPCS supervises the treatment sessions conducted by non-NARHA Registered Therapists.
• Has received training in the principles of hippotherapy, equine movement and equine psychology.

Yes / No Interpretation: In part A, therapists practicing hippotherapy have traditionally been occupational or physical therapists. However, hippotherapy may also be practiced by other licensed, registered or certified health professionals with a strong treatment background in posture and movement, neuromotor function and sensory processing.

In part C, it is the NARHA Registered Therapist or HPCS’ responsibility to evaluate the skills of the therapist in the program and provide appropriate supervision and training. A NARHA Registered Therapist or HPCS does not need to be present during the hippotherapy treatment sessions performed by non-NARHA Registered Therapist or HPCS. However, the supervising therapist must be available on a regular basis for consultation and education.

In part D, the intent of the standard is to insure that a non-NARHA Registered Therapist or HPCS has adequate training in order to carry out a safe and effective hippotherapy treatment. This information and training should be provided by a NARHA Registered Therapist, a HPCS, a NARHA Certified Instructor and other horse and therapy professional available to the program.

Compliance Demonstration: Visitor observation of therapist's licenses/registrations/certifications; professional liability insurance certificates; NARHA registration certificates or board certification, or log of therapist training by the program; director description of therapist training process.

*H2 MANDATORY

DNA (does not apply): If center does not have a PTA and/or COTA providing treatment services.

Is there written evidence that the physical therapist assistant (PTA) and/or certified occupational therapy assistant (COTA) who provides treatment services in a hippotherapy program meets the following qualifications:

• Is certified, registered, or licensed to practice as a physical therapist assistant or certified occupational therapy assistant in accordance with the state/provincial regulations governing his/her respective practices.
• Maintains current professional liability insurance.
• Is a North American Riding for the Handicapped, (NARHA) Registered COTA/PTA, and if not, the COTA/PTA has received training in the principles of hippotherapy, equine movement and equine physiology.
• Has a written policy in practice at the center stating that a NARHA Registered Therapist or Hippotherapy Clinical Specialist (HPCS) of the respective field evaluates, develops the treatment plan and supervises the COTA/PTA in accordance with the regulatory laws of their respective states/provinces.

Yes / No / DNA

Interpretation: In Part A. Therapists practicing hippotherapy have traditionally been occupational, physical therapists and speech therapists with a strong movement background. However, hippotherapy may also be practiced by PTAs and COTA's under the supervision of licensed or registered therapists of their respective fields, and in accordance with the state regulations governing the practice of occupational therapy and physical therapy. The requirement that PTAs and COTA's be licensed, registered or certified in the particular state or province in which they practice reflects that they are practicing their profession based on the standard of practice established in the particular state/province in which they reside.

In Part C. The intent of the standard is to insure that a PTA and/or COTA has adequate training in order to carry out a safe and effective hippotherapy treatment. This can be achieved by meeting the requirements delineated by the NARHA registration process, or by specific training under the direction of an NARHA Registered Therapist or HPCS.

In Part D. It is the responsibility of the supervising AHA Registered physical and/or occupational therapist or HPCS to develop the treatment plan of any patients that receive treatment from a PTA and/or COTA. It is the responsibility of the PTA and/or COTA and the respective supervising therapist to adhere to state regulations. Requirements for documentation and frequency of supervision may vary according to state law.

It is critical for personnel to realize that the supervising therapist is ultimately responsible for the provision of occupational and physical therapy services within the hippotherapy session.

Compliance Demonstration: Visitor observation of PTA's and/or COTA's licenses/registrations/certifications; professional liability insurance certificates; log of PTAs and/or COTA's professional training; the WRITTEN policy on PTA and/or COTA supervision by an NARHA Registered Therapist or HPCS of the same profession.

H3

DNA (does not apply) if the therapist is a volunteer and not paid for services rendered.

Is there a written contractual agreement between the Therapist/Health Care Provider/Contracting agent and the center?

Yes / No / DNA

Interpretation: The employee contract may include salary or wages (if applicable), length of employment, benefits, who is responsible for provision of professional and general liability insurance coverage, termination standards (such as "at will"), and reference to job description and other personnel policies.

The independent contractor agreement should include: terms of payment, length of contract, who is responsible for professional liability and general liability coverage, who is responsible for paying the various taxes, services to be performed. Legal counsel should be consulted in regard to these and other possible provisions, such as releases of liability and indemnification language.

Compliance Demonstration: Visitor observation of randomly selected WRITTEN contracts.

H4

DNA (does not apply) if facility does not bill for services.

Is there written evidence of billing policies and procedures?

Yes / No / DNA

Interpretation: The fees should be reflective of the local treatment fee schedules.

Compliance Demonstration: Visitor observation of WRITTEN policies and procedures.

H5

Is there a written policy in practice on the number of hours that each equine can be worked in a hippotherapy program:

• Per working session?
• Per day?
• Per week?

Yes / No

Interpretation: A "working session" is a period of continuous use without any lengthy break. Special consideration should be given to equines that are only used for hippotherapy versus equines that are used in other ways throughout the rest of the week. The rationale for the use of each equine should be based on the size and type of patients served; size, age and environment.

Compliance Demonstration: Visitor observation of WRITTEN documentation and personnel description of scheduling procedures.

H6

Is there written evidence of a system in practice for training the therapist/health professional and hippotherapy team members which includes the following:

• Orientation to the hippotherapy program' s policies and procedures?
• Hands-on training:
  1. Rehearse emergency procedures?
  2. Rehearse safety procedures?
  3. Transitions on and off equine?
  4. Practice equine handling techniques?
  5. Practice patient handling techniques?
  6. Rehearse a mock therapy session to insure a coordinated team approach prior to patient participation?

Interpretation: In Part A, HPOT program policies and procedures may include: philosophy of the program vision statement, intake and discharge criteria, fee schedules, cancellations, weight and size limits of patients, behavior management issues, administrative structure/lines of communication.

In Part B.1, emergency procedures may include: a fall from an equine, seizures, an injury from a kick, acute illness, fire and emergency dismounts in all treatment situations such as leading/long lining.

In Part B.2, safety procedures may include: approaching equines, restraining equines for grooming/tacking, working around the equines, checking condition of equipment, checking the fit and security of the equipment on the equine, transitioning patients on and off equines, stabilizing the patient on the equine, introducing extraneous pieces of equipment to the equine/patient during the session (eg. balls, rings, towels, etc.).

In Part B.3, horse handling techniques relevant to hippotherapy may include: leading by halter or bridle, therapeutic lunging, long lining, lunging.

In Part B.5 patient handling techniques may include: lifting and carrying, transitioning on and off the equine including ‘handing off’ to an already astride Therapist/TA for T-HPOT session,, stabilizing the patient on the equine, therapeutic handling techniques to the T/A when the therapist cannot be the person the behind the patient in a T-HPOT session, facilitating and inhibiting techniques, and other treatment techniques.

Compliance Demonstration: Visitor observation of WRITTEN training documents and materials.

H7

Are there training and conditioning methods specific to hippotherapy in practice for the equines used in hippotherapy?

Yes / No

Interpretation: It is understood that the quality of the results achieved in hippotherapy are directly related to the quality of movement of the hippotherapy equine. Therefore, it is important to maintain the suppleness and strength of the hippotherapy equine through training and conditioning.

In T-HPOT, due to increased stress, it is particularly important that the conditioning emphasize the elevation of the topline through strength and flexibility training. The equine has to be gradually accustomed to the distribution of weight behind the center of gravity and desensitized to the input of the additional leg pressure near the flank.

Compliance Demonstration: Visitor interview and personnel description of training and conditioning methods.

H8

Are the following documents available on site for each patient?

• Prescription from a physician IF required by the therapist's state practice act.
• Treatment plan which includes long and short term goals.
• Progress notes, completed on a regular basis, which reflect the treatment and its modifications based on the response of the patient.
• Re-evaluations, completed on a regular basis, which update the goals and plan, make recommendations for further treatment, discharge or transition into another program.

Yes / No

Interpretation: Patient documentation will reflect the Practice Acts of the therapist's respective profession. The areas of evaluation, long- and short-term goals, and the implementation of the principles of hippotherapy may differ based on the educational background of the therapist

Compliance Demonstration: Visitor observation of randomly selected patient files of each therapist involved in hippotherapy.

*H9 MANDATORY

Is there a system in practice to insure that the equine handler during all hippotherapy sessions has received training specific to the needs of a hippotherapy session?

Yes / No

Interpretation: In this instance the horse handler is the person in charge of the handling of the equine during the hippotherapy treatment. The person should have extra training in handling horses specifically for hippotherapy and recognizing signs of stress in horses.

Compliance Demonstration: Personnel description of training and conditioning methods.

H10

Is there a system in practice that requires the hippotherapy team to select the following prior to each patient treatment session:

• Equine?
• Equipment for equine?
• Equipment for patient?
• Number and role of volunteers/staff?

Yes / No

Interpretation: The system in practice should include a written list of the required information that is readily available to the team at the treatment site and posted.

In Part B, the equipment for the equine may include: various saddles and surcingles, stirrups, halter, bridles and bits, various pads, side reins, leads, long lines, lunging equipment, boots or bandages for horse's legs, various types of whips.

In Part C, the equipment for the patient may include belts, rings, balls, neck straps on the equine, etc.

Compliance Demonstration: Visitor observation and personnel explanation of the selection system.

H11

DNA (does not apply): if not offering T-HPOT.
Is there written documentation of:

• The rationale for the use of T-HPOT rather than HPOT to address specific treatment goals?
• Periodic re-assessment of the ongoing need for T-HPOT?

Interpretation: T-HPOT has potential for increased stress on the equine and increased risk for the patient and Therapist or TA. There needs to be written justification that T-HPOT is the only option for treatment and that the potential benefit will outweigh the potential risk. In addition, significant patient progress is essential to justify the ongoing use of T-HPOT.

H12

DNA (does not apply): if not offering T-HPOT.
Is there a written policy in practice for patients who are deemed clinically appropriate for T-HPOT, which includes the following:

• The combined weight of the equipment, patient and Therapist or TA does not exceed 20% of the equine's weight?
• The patient participating in T-HPOT with helmet is not taller than the chin of the Therapist or TA's when mounted?
• The patient does not exceed the weight of the Therapist or TA?
• The patient demonstrates physical behaviors (voluntary or involuntary) that can be safely managed by the Therapist or TA?
• The patient or parent/guardian signs an informed consent acknowledging the inherent risk of a T-HPOT session?

Interpretation: As the combined weight and positions of the patient and Therapist or TA greatly increases stress on the equine's back and loin area, there should be a determined limit based on the equine's conformation, condition and the generally accepted figure of 20% of the equine's weight. A 1000 pound horse, for example, should not carry more than 200 pounds of combined weight, assuming good conformation and conditioning. The height limitation for the patient helps to prevent injury to the Therapist or TA's face and head should the patient's head move quickly backwards. This also helps to ensure that the size and weight of the patient is within the ability of the Therapist or TA to safely handle. Physical movements and behaviors, such as extensor thrust, tantrums, flailing, etc. that are unable to be managed safely by the Therapist or TA would be a contraindication for the use of T-HPOT. The patient's family and treatment team needs to make an informed decision about participation in T-HPOT due to the increased risk of this activity.

Compliance Demonstration: Visitor observation of WRITTEN policy and signed forms, personnel description, and visitor observation of T-HPOT session.

H13 MANDATORY

DNA (does not apply): if not offering T-HPOT.
Is there written evidence of a procedure in practice to determine the duration and frequency of the T-HPOT equine's schedule, including:

• Maximum of 30 minutes per session inclusive of transitioning onto and off the equine?
• Sessions scheduled on non-consecutive days?
• No greater than 2 sessions per day in non-consecutive sessions?
• Limited involvement in other equine assisted activities on the same day in which the equine is involved in T-HPOT?

Interpretation: A record should be kept of the number of times the equine works in T-HPOT and in other capacities. Given that T-HPOT is a stressful activity for the equine, consideration should be given to a lighter schedule for that equine on a T-HPOT day.

Compliance Demonstration: Visitor observation of written documentation.

H14

DNA (does not apply): if not offering T-HPOT.
Is there written evidence of the competence of the Therapist or TA on the equine, demonstrating a well-aligned, secure seat and position at all times, during the following:

• Riding at a walk, trot, and canter with and without stirrups?
• Sitting at a walk in the T-HPOT position (behind the equine's center of gravity) while being led or long lined during changes of pace, serpentines, figure of 8 and transitions to and from halt?

Interpretation: Evidence of riding ability may include, but is not limited to, NARHA Certification at the Advanced level; Pony Club C-level or higher; Comparable CHA certification; a letter from another instructor who has NARHA Advanced certification, Pony Club C-level status or CHA comparable certification who has observed the Therapist or TA demonstrate the above listed skills, in person or by video.

Compliance Demonstration: Visitor observation of WRITTEN documentation.

Compliance Demonstration: Visitor Observation of WRITTEN documentation and interview of personnel.

H15

DNA (does not apply): if not offering T-HPOT and the individual providing the patient handling is the licensed therapist. If the person providing the patient handling is the Therapist's Aide (TA) and is not the therapist, is there written evidence that s/he has been trained in the use of therapeutic handling and is under the direct supervision of the therapist during all sessions?

Yes / No / DNA

Interpretation: In order for treatment to be effective, the individual providing the patient handling should have sufficient knowledge and skill to facilitate the patient's progress according to the treatment plan. The therapist must directly supervise this individual during all T-HPOT sessions in accordance with their state practice act.

Compliance Demonstration: Interview of personnel; and visitor observation of WRITTEN evidence of competence.

H16

DNA (does not apply): if not offering T-HPOT.
Is there a procedure in practice for the use of tack that ensures the following:

• The pad used to protect the equine's back is large and long enough to accommodate both the patient and the Therapist or TA on the equine?
• The pad is safely secured to the equine?
• There is a handle/handhold accessible to the Therapist or TA on the equine?

Interpretation: Saddles, English or Western, are inappropriate for T-HPOT due to the displacement of the weight of the Therapist or TA on the equine over the equine's loin area, and the interference and possible cause for injury to the Therapist or TA on the equine by the cantle of the saddle. In T-HPOT the protection of the equine's back is of prime importance. Size and length of the pads should cover the equine's back and sides so that the patient and the Therapist or TA on the equine sit comfortably on the pads and not onto the equine's back. The pad should be of a material sufficient to protect the equine's back with shock absorbing and weight distributing properties with consideration given to the balance and position of the patient. For safety, the pad must be secured so that it does not slide. In an emergency, the Therapist or TA on the equine should have easy access to a secure handle, for balance, not to control the equine. Examples may be the handle of a surcingle, a properly fitting neck strap or other reliable tack.

Compliance Demonstration: Visitor observation and interview of personnel.

Glossary of Hippotherapy Terms

Hippotherapy: a term that refers to the use of the movement of the horse as a strategy by Physical Therapists, Occupational Therapists, and Speech-Language Pathologists to address impairments, functional limitations, and disabilities in patients with neuromusculoskeletal dysfunction. This strategy is used as part of an integrated treatment program to achieve functional outcomes.

Hippotherapy Team Members: those involved in the provision of hippotherapy services. The team will be the NARHA Registered Therapist or HPCS Therapist, NARHA Certified Instructor (if the therapist is not a NARHA Certified Instructor) and a horse and horse handler trained specially for hippotherapy. During the hippotherapy session, the hippotherapy team may include side walkers for safety and, of course, the patient. The therapist is in charge of the hippotherapy session with the main focus on the patient responses to the horse's movement and maintains direct communication with the horse handler and other team members.

Horse Handler: The person in charge of the handling of the hippotherapy horse during the treatment session. This person should have extra training in handling horses specifically for hippotherapy.