ABA Therapy Treatment Planning Overview

ABA Therapy Treatment Planning

• The presentation is about ABA therapy treatment planning, dosage, duration, and discharge.
• The agenda includes a 3D view of treatment planning, a 3D review process, case examples, and critical conversations and managing disputes.
• The 3D view involves dosage, duration, and discharge.

Treatment Planning the Kyo Way

• Services are prescribed based on each client's profile.
• Treatment dosage is continuously tuned.
• Services are provided until medically necessary.
• Technology monitors patient progress at individual, regional, and company levels.

Conscientious 3D Treatment Planning

• Thoughtful and iterative treatment planning is essential for optimized outcomes.
• Patient progress is optimized.
• Family time and priorities are respected.
• Health plan and member costs are considered.
• Access is ensured for children who need treatment.
• Kids, families, payers, agencies, and society all benefit.

Definition of Applied Behavior Analysis (ABA)

• ABA is a science that systematically applies behavioral analysis principles to improve socially significant behaviors.
• Experimented-based analysis is used to identify the factors that influence behavior change.
• The process involves 6 components, one of which is meaningful improvements to crucial behaviors.

Definition of Medical Necessity

• Guidelines vary by payer but share common principles.
• Standardized assessments must demonstrate measurable and ongoing improvement in targeted behaviors and skills.
• Continued improvement in behavior and skills are expected.
• Cessation of treatment should result in a decline in progress.

BACB Code of Ethics for Behavior Analysts

• Behavior analysts consider factors such as risks, benefits, side effects, and client preferences when developing interventions.
• Interventions are designed and implemented with the goal of maintaining positive results under typical conditions.
• Appropriate levels of oversight and behavioral service provision should be provided to reach client goals.

Dosage: Individualized, Tuned Approach to "How Much"

• The amount of ABA therapy should be individualized based on client needs
• Guidelines suggest a range of 10-25 hours per week (focused model) to 30-40 hours per week (comprehensive model) for children with autism spectrum disorder (ASD).
• Dosage research indicates that more hours doesn't always equal more progress

Dosage Research

• In fee-for-service (FFS) models, more therapy hours often lead to greater reimbursement for agencies.
• There is contemporary research that indicates that higher hours doesn't necessarily equate to better outcomes.
• Standardized measures have shown that more hours doesn't always lead to better progress.

JAMA Pediatrics Article on ABA Dosage

• A meta-analysis found that the research on ABA doesn't support more than 20 hours/week of treatment being effective.
• There are limitations to the study.
• Clinicians need to carefully assess which of their clients would benefit from intensive services (20+ hours/week).

Understanding Evidence-Based Interventions

• Evidence-based interventions include ABA delivered by therapists or parents, Speech Language Pathologists (SLPs), Physical Therapists (PTs), Occupational Therapists (OTs), and social skills groups.
• There is a wide range of evidence-based interventions available for children.

Kyo's Clinical Culture Aligns with Recent Research

• Kyo prioritizes clinical recommendations that respect family time, payer dollars, and patient outcomes.
• Children require comprehensive support services, including appropriate education and least restrictive settings possible.
• High-dose ABA therapy is exceptional, not the norm, at Kyo.

Dosage Considerations: Sweet Spot of Therapy

• Common dosage ranges for ABA in Kyo are 12-21 hours/week for all but advanced cases.

Additional Dosage Considerations

• Factors that can impact dosage include age, language/imitation skills, potential barriers to treatment, co-occurring diagnoses, other therapies involved, and caregiver commitment.

Dosage Considerations

• The factors that may influence the dosage of therapy for a patient include the child's age, their language/imitation skills, potential treatment barriers, co-occurring diagnoses, other therapies being used, and the caregiver's input.
• Research shows a correlation between pre-treatment language skills and imitation skills and the outcome of the ABA therapy.
• Some factors that can impede learning include severe tantrums, aggression, limited communication skills, and a lack of motivation for social interaction.

What other programs and activities is the child involved in?

• What activities and programs are the child engaged in?
• Are these activities evidence-based interventions?
• Do the activities align with the child's special interests or bring them joy?

How Might a Clinician Prepare a Family for Discharge?

• Conversations about discharge should occur at the start of therapy.
• Discharge should be treated as a celebration of the child's accomplishments.
• Connect the family to other local resources.

Resources for Families/Coordination of Care

• Kyo provides specialized BCBA parent training.
• Kyo offers behavior consults through CA Regional Centers.
• The program provides support for transitioning from intensive ABA to other therapies.
• Other agencies may also provide services.

How Might a BCBA Respond to a Dispute?

• Behavior analysts should prioritize patient care above everything else.
• Conflict resolution should attempt to align with the best interest of the patient.
• If conflict cannot be resolved, services may be terminated.

When Disputes Arise Over Medical Necessity

• It is crucial to turn to the research, looking at the current evidence for the specific level of service.
• Seek guidance from regional clinical consultants or directors.
• It is important to ascertain if other senior BCBA colleagues would concur with the recommended treatment.

###ABA Treatment Cycle

• Dosage, duration, and discharge are all part of the larger treatment cycle.
• BCBAs continuously monitor and adjust their approach to treatment, similar to skill teaching processes.

How might the following recommendations conflict with Kyo’s clinical values?

• Recommendations for extremely high doses of ABA therapy may conflict with Kyo’s values if the child already receives additional support.
• Recommendations for high-dose ABA therapy may conflict with the family's choice of homeschooling if other therapies could better serve a child.

Age at the Start of Treatment

• Some studies show that starting ABA therapy earlier, before the age of seven, is associated with more positive and successful outcomes.

Which baseline skills predict outcomes?

• Pre-treatment verbal skills, imitation ability, and low severity of ABA symptoms (lack of self-injurious behavior, repetitive behaviors, and stereotypes) are predictive of positive outcomes.

3D Review Process

• The 3D review process has three levels.
• Level 1 triggers when there's limited progress.
• Level 2 involves a joint review of the treatment plan, potentially with a superior therapist involved.
• Level 3 involves requesting a consultation with the Board to clarify the plan of action.

Example Health Plan Criteria for Discharge

• Criteria for discharge include showing improvement in targeted areas, caregiver refusal of treatment recommendations, exacerbation of behavioral issues from treatment, lack of progress after a certain point, and when care may be primarily for convenience and not benefit.

Duration: Personalized, Outcomes Based Decision for "How Long"

• The decision on how long treatment should continue should be based on individualized patient outcomes.

Outcomes are Essential to Duration Decisions

• Consistent progress as measured by standardized assessments, such as the Vineland, is essential for continued treatment.
• Clinically significant progress (at least a two-point improvement) every six months, should be seen as the gold standard for ongoing ABA therapy.

Some Patients will Not Demonstrate Meaningful Progress

• Not all patients who receive ABA will demonstrate significant progress on standardized measures.
• Some patients may transition to a less intensive method of care.

Discharge: A Data-Based Approach

• The process of discharge should be carefully documented with established criteria and timelines.
• The clinical team must work closely with families and other professionals to facilitate the transition.
• This process must follow specific guidelines.

Kyo Also Provides Guidance on Discharge

• Detailed discharge policies can be found in the clinical policy manual.
• Services funded through insurance must meet the guidelines of the payer's criteria for medical necessity for continued treatment.
• Patients must continue to show progress in socially significant areas, with specific criteria in mind.

Discharge Conversations

• Discharge discussions should start early in the treatment process.
• Discuss the criteria for discharge up-front and often.
• Use available data from standardized measures for guidance.

How Might a Clinician Prepare a Family for Discharge?

• Start dialog early in treatment about discharge criteria.
• Treat discharge as positive and celebrate progress.
• Connect families with community resources for potential continued care.