Working for a company that provides Applied Behavior Analysis (ABA) services, we were always tied to insurance companies’ untouchable rule: if you are not with the client face to face, you are not entitled to reimbursement and your time is not valid as service delivery. As Executive Director of Clinical Services of ABA Services of Connecticut, I was always one of the “enforcers” of the concept. However, as a consultant for many international projects (some of which were developed through coaching sessions), I always wondered why these remote approaches could not be utilized here in the United States.
Over the last ten years, several studies were published to address this possibility. Telehealth-based interventions for Autism Spectrum Disorder (ASD) have been studied with ABA programing/strategies with acceptable reliability and effective treatment of behavior problems (Suess et al., 2013; Lindgren et al., 2016). Further, telehealth IEP consultations for ASD have been noted to improve IEP quality and educational results (Ruble et al., 2013). Additionally, a recent pilot study used telehealth to deliver an adapted manualized CBT (Cognitive Behavior Therapy) for co-occurring anxiety with ASD (“Facing Your Fears”) that seems to be effective in reducing anxiety symptoms (Reaven et al., 2012). Researchers also found satisfactory feasibility rates as noted by the high session attendance (94%), and mean satisfaction ratings for both parents (93%) and children (89%), and adequate fidelity from clinicians (92%).
In the field of ABA, utilizing a telehealth format could help with remote service delivery, but there are many variables to take into consideration. For example, ensuring clinical programs are set up accurately and securely as well as guaranteeing that providers are compensated despite the change in delivery format.
The Coronavirus pandemic caused many insurance companies to change regulations and requirements (including remote service delivery). However, providing ethical services with a high standard of care became a business challenge and a clinical nightmare, including unpredictable circumstances and unclear expectations, for many providers.
Our company enacted the following strategies to confront the challenges presented to us:
Prior to starting the remote service delivery model, we established approval by the insurance companies with which we worked.
Once approval was established, we conducted interviews with all our clients/families to determine if they are open to a telehealth delivery format. A special consent form was designed and then signed by the families that were willing to utilize remote ABA therapy. Out of 41 active cases involving clients with ASD, 25 families were willing and able to receive remote services.
After the number of families that required services was established, the amount of certified and non-certified personnel needed to fill those hours was clear. In addition, the training needed to prepare the staff became evident. These staff required a new set of skills to provide remote services, and therefore immediate and intense training was conducted.
Next, the development of “the blueprint” of how programming would be modified to fit a new format was established for our clinicians (5 BCBAs – 3 full-time and 2 part-time, 1 BCaBA). Each staff member needed to sort through each of their client’s programs and establish which needed to be prioritized and/or modified. Prioritization took into account which behavior goals and associated protocols were not suitable for remote delivery. The following steps were used in this process:
- Can the program be delivered visually? If not, could it be modified to deliver essential assessment-based skills?
- Do we need to change mastery criteria as a result of proposed modifications? To what extend? Will it still bring the client to the desirable results?
- How much time will our modifications require? Will they impact data collection? Will we have to redesign our data collection paperwork?
- How much training will our therapists and caregivers need to implement these changes? How fast and effective could our training be provided?
We spent almost ten full days resolving these questions, evaluating results, and shaping the new structure for our telehealth services. Most cases required modifications and some additional material development. Data collection was changed minimally with a couple of new forms added. Training took little time for the therapists and certified personnel who had a lot of experience in utilizing different learning software. For less computer-savvy staff, training took a longer time, but the overall level of clinical skills kept all our active cases afloat.
One meaningful finding during this analysis/preparation time was a clear understanding that we needed to develop a company protocol with spelled-out, step-by-step directions for remote services delivery. We also understood that this additional knowledge would need to become an essential part of our standard employee training in the future so that all staff could provide remote services when necessary.
Once staff was trained and programs were modified, sessions needed to start remotely. Although our company incurred expenses during this “trial and error period” (reimbursement for the time our employees spent putting structures in place for our clients), it was a valuable investment into understanding this process.
Because we were utilizing a new format, we decided to start cautiously to ensure small successes that we could build upon. We wanted to test how our clients (and caregivers) would respond to the new learning format, regarding medium and endurance. We started with evaluating fifteen-minute sessions for the first couple of days. The evaluation included asking the following questions:
- How do we evaluate if a session was successful?
- How do we adjust the session times based on the client/caregiver behavior?
- How should we manage billing if insurance reimbursement for some companies is in 30-minute intervals?
Criteria for success was established individually for each client, and based on that criteria, session time was gradually increased. Frequent and ongoing communication with staff and caregivers was essential for successful increases in time. In the few cases that required small increases in time (less than thirty minutes), a combination of direct services with a child were provided for 15-20 minutes (with a caregiver involved), and a coaching/discussion time with that caregiver as a follow-up completed the 30-minute block.
Essential to the development of successful remote sessions were the following components:
- Certified personnel trained our staff to recognize clients’ tiredness and frustration before problem behavior surfaced.
- Staff encouraged therapists and caregivers to ask for additional training or coaching sessions when needed.
- Observations of online sessions were scheduled frequently.
- In tough behavior situations, our certified clinicians did not hesitate to take a lead if they felt that therapist was losing control of the session.
- Equipment was tested prior to use.
- Utilization of “gamer headset” for privacy and confidentiality. Furthermore, these headsets significantly reduce feedback.
- Staff were positioned in a private room where work was not interrupted and/or overheard.
- Because of the time delay in communication over a remote platform, staff was taught to talk slowly and allow longer pauses between sentences.
- Staff was encouraged to use the mute button to reduce extraneous noise in the sessions, especially when in a supervisory role.
We have been utilizing this model for two full months now. We are collecting data and planning to do more analysis moving forward. However, our clinicians are seeing skills acquisition happening, mastery criteria being reached, and (according to all our BCBAs) much higher level of parental involvement and understanding.
So, hopefully, readers will benefit from our learning experiences as well.
The COVID-19 pandemic has led to considerable amount of problems for ABA services consumers. It also effectively demonstrated that under the pressure of overwhelming consumer needs, no “carved in stone” rules of insurance reimbursement can stay untouched. We faced challenges that we were not prepared for. Nevertheless, these challenges helped us to learn and build new set of clinical skills, new capabilities for problem solving, new repertoire of strategies for effective service delivery.
Marina A. Azimova, EdM, MSW, BCBA, LBA, is Executive Director of Clinical Services at ABA Services of Connecticut, LLC. For more information, please visit www.abaservicesofct.com.