ABA Therapy Treatment Planning_ Dosage, Duration and Discharge PDF

ABA Therapy Treatment Planning Dosage, Duration & Discharge  1 A 3D View of Treatment Planning Agenda 2 3D Review Process 3 Case Examples 4 Critical Conversations and Managing Disputes 2  Treatment...

ABA Therapy Treatment Planning Dosage, Duration & Discharge  1 A 3D View of Treatment Planning Agenda 2 3D Review Process 3 Case Examples 4 Critical Conversations and Managing Disputes 2  Treatment Planning the Kyo Way: Taking a 3D View Dosage Duration Discharge 3  Treatment Planning the Kyo Way: Conscientious, Iterative, Tech-Enabled We prescribe the right amount of ABA for each client based on the patientʼs profile We continuously tune each patientʼs treatment dosage We provide services for as long as it is medically necessary for the patient, but not longer We use technology to help monitor patient progress at the individual client, regional, and company levels 4  Conscientious 3D Treatment Planning is a Win for ALL When we are thoughtful and iterative with treatment planning we: – Optimize patient progress – Respect family time and priorities – Respect health plan / member $$ – Do our part towards ensuring access to the kids for whom treatment is medically necessary Who wins? → Kids and families, payers, agency, society 5  3D View Enabler 1: Definition of ABA Definition of Applied Behavior Analysis – ABA is the science in which the principles of the analysis of behavior are applied systematically to improve socially significant behavior and experimentation is used to identify the variables responsible for behavior change (Cooper, Heron, Heward, 2007) – ABA involves 6 components, one of which is meaningful improvement in important behavior 6  3D View Enabler 2: Definition of Medical Necessity Medical necessity guidelines vary by payer, but the principals are generally the same: 1. Standardized assessment instruments indicate that measurable and ongoing improvement in targeted behaviors/skills is being made 2. Reasonable expectation that the patientʼs behavior and skill deficits will continue to improve in a meaningful and measurable manner 3. Reasonable expectation that withdrawal of treatment will result in loss of progress made 7  3D View Enabler 3: BACB Code of Ethics BACBʼs Ethics Code for Behavior Analysts 1. 2.14…Behavior analysts also consider relevant factors (e.g., risks, benefits and side effects; client and stakeholder preference; implementation efficacy; cost effectiveness) and design and implement behavior change interventions to produce outcomes likely to maintain under naturalistic conditions. 2. 3.12 Behavior analysts…also advocate for the appropriate amount and level of behavioral service and provision oversight required to meet defined client goals. 8  Dosage: An Individualized, Tuned Approach to “How Much” 9  How Much ABA Should a Patient Receive? CASPʼs Practice Guidelines for ASD: 30-40 Hours per week Comprehensive Model Skills targeted across a number of domains 10-25 Hours per week Focused Model Skills targeted limited to a few domains 10  Dosage Research In a FFS payment model, more hours = more $ for agencies. But is it really better for patients? The greater the intensity of hours, the more progress a child will make Conventional View More is Better The studies that support this view are based on the # of goals achieved ‒ Why might this be problematic? Studies using standardized measures have found more hours doesnʼt always mean more Contemporary progress Moderate Doses Understanding Can Be Equally ‒ Sandbank et al, 2024 Effective ‒ Rogers et al, 2021 ‒ Sallows & Graupner, 2005 ‒ Ostrovsky, Willa, Howard, Davitian, 2022 11  JAMA Pediatrics Article on ABA Dosage A large-scale meta-analysis conducted by Sandbanks et al, published in June 2024 in JAMA, is worth of clinician attention and reflection. The analysis looked at over 9000 children with autism across 140 studies on ABA and concluded that the corpus of ABA research does not support the effectiveness of ABA treatment >20hr/wk. The study had some limitations – Grouped caregiver delivered interventions w/ those by BTs – Some of the studies showed negative effects while some showed solid effects Clinicians should be thoughtful about which clients are recommended to receive 20+ hours. 12 https://sfparents.org/ What Does Evidence-based Intervention Look Like? SLP PT Social skills Parent Teacher group delivered OT Parent delivered ABA delivered SLP ABA ABA Parent OT Teacher delivered delivered ABA SLP ABA Parent Therapist Therapist delivered delivered delivered Therapist ABA SLP ABA ABA delivered Therapist Parent delivered ABA ABA delivered Therapist Therapist ABA delivered delivered ABA ABA We must understand our treatment in the bigger picture of the full suite of evidence-based interventions available to a child. 13  Kyo’s Clinical Culture Aligns with Recent Research We pride ourselves on clinical recommendations that optimize for a patientʼs outcomes and that respect family time and payer dollars. We believe that school-aged children should receive a free and appropriate education, including the necessary supports, in school, in the least restrictive environment, to the greatest extent possible. There are very few patients that seek services at Kyo that need 20+ hours/week therapy for optimal progress. At Kyo patients receiving this level of therapy are the exception, not the norm. Make Every Moment Count 14 Dosage Considerations: The Sweet Spot 9 12 15 18 21 Initial recommendations at Kyo are 12+ and rarely exceed 21 hours/week. 15  Additional Dosage Considerations Patientʼs Maladaptive Other Language & Co-occurring Caregiver Age Behaviors / Therapies, Imitation Diagnoses Commitment Barriers Activities Skills 16  Dosage Considerations Patientʼs Maladaptive Other Language & Co-occurring Caregiver Age Behaviors / Therapies, Imitation Diagnoses Commitment Barriers Activities Skills Our youngest patients may not have other interventions available or started yet (school, SLP, etc) Neural circuits have been found to be most adaptable during a childʼs first 3 years of life* Older patients may have a history of plateauing with ABA therapy Overall treatment goal for young patients may be to dramatically change the childʼs developmental trajectory (close the gap) while for older patients the goal may be to address a finite number of functional skills Age does not always correlate to outcomes** *Centers for Disease Control and Prevention **Chenausky et all, 2018 17  Dosage Considerations Patientʼs Maladaptive Other Language & Co-occurring Caregiver Age Behaviors / Therapies, Imitation Diagnoses Commitment Barriers Activities Skills Research has demonstrated that a correlation between pre-treatment language skills and imitation skills and patient response to ABA therapy* *Chenausky et all, 2018; Pitett et al, 2022; Sandbank et al, 2020 18  Dosage Considerations Patientʼs Maladaptive Other Language & Co-occurring Caregiver Age Behaviors / Therapies, Imitation Diagnoses Commitment Barriers Activities Skills What may impede learning?* – Strong, persistent negative behaviors (e.g. tantrums, aggression) – Weak or impaired verbal operants (echolalia) – Social behavior (limited motivation for social interaction) *Sundberg, VB-MAPP Barriers Assessment 19  Dosage Considerations Patientʼs Maladaptive Other Language & Co-occurring Caregiver Age Behaviors / Therapies, Imitation Diagnoses Commitment Barriers Activities Skills “Children with ASD and intellectual disability have the most difficulty developing social competence.”* What other co-occurring conditions might have an impact on a patientʼs treatment outcomes? *Bennet et al, 2014 20  Dosage Considerations Patientʼs Maladaptive Other Language & Co-occurring Caregiver Age Behaviors / Therapies, Imitation Diagnoses Commitment Barriers Activities Skills What other programs and activities is the child involved in? – Which activities are evidence-based interventions? – Which activities are important for the childʼs special interests/ bring joy? *Bennet et al, 2014 21  Dosage Considerations Patientʼs Maladaptive Other Language & Co-occurring Caregiver Age Behaviors / Therapies, Imitation Diagnoses Commitment Barriers Activities Skills Are parents available to observe a portion of sessions on a consistent basis and are they willing and able to meet with the clinical supervisor for ongoing parent training? Are other primary caregivers available for coaching and observation of sessions? Do parents seem open to the principles associated with ABA therapy? (e.g., Repetition, reinforcement, extinction) *Bennet et al, 2014 22  At Kyo We Personalize Patient Prescriptions We do not We DO – Prescribe the same level of hours – Look at each child and consider the for every child of a certain age likelihood of progress based on their profile, the research literature, the – Prescribe the same level of hours patientʼs preferences and family time for every child who has significant maladaptive behaviors – Ask patients to drop all other therapies and hobbies to enable ABA 23  The Intersection of Business & Clinical: An Ethical Approach to 3Ds Itʼs ok for companies to set requirements for patients that they can serve Itʼs not ok for companies to use their business requirements to drive clinical recommendations – Example: A company CAN set a minimum # hours / patient profile that they are able to serve (e.g., 30 hours/week in a center, 10 hours/week, etc.) or a maximum # hours/week. A company SHOULD NOT recommend that min or max number of hours for every patient who seeks an evaluation. Patients who do not require that level of therapy should be referred to another provider. 24  What’s the Minimum Hours/Week of Treatment at Kyo? We require 12+ hours/week of treatment initially. (The family must be available for 12 hours.) Exceptions include clients who are in the final stage of fading out services (hours should not be at or below 9 hours/week for more than one authorization period) and clients in Kyoʼs ABA Optimized program. Clients who would benefit from direct instruction from a BT less than 12 hours/week should be referred to another provider 25 What Steps Can We Take to Ensure That Our Clients Receive the Optimal Therapy Dosage? Follow Kyo policy (Clinical Policy Manual) and research literature in treatment recommendations Engage in critical conversations with families regarding their availability Support and retain BTs 26  Dosage Decisions are Data-based Over time, a clinician may recommend an increase or decrease in hours based on a patientʼs response to ABA therapy An objective, standardized outcome measure (e.g., Vineland) is an important part of the data-based decision Goals and other measures of patient progress and satisfaction are also analyzed 27 Case Examples: Dosage 28  Note: The following examples pertain to Kyoʼs customary ABA therapy services. Dosage recommendations for patients in Kyoʼs ABA Optimized Program may differ. 29  Max Max is a 2 year old who was recently diagnosed with ASD and intellectual disability. He presents with speech, fine motor and gross motor delays. Max currently attends a nanny share with another child Mon-Fri, 9am - 5pm. He communicates by hand-leading and vocal protests. He does not engage in gross motor imitation nor vocal verbal imitation. He engages in daily tantrums that last an average of 20 minutes, up to 50 minutes and which include crying and throwing objects. Max likes watch balls drop from a ledge. He does not engage in joint attention and receives no other targeted interventions. Parents and nanny are open to learning ABA methods and to being present for caregiver training. Clinical Recommendation? Age, language/imitation skills, potential barriers to treatment, other therapies, co-occuring conditions, parent commitment… Range 12-15 hours/week 30  Sebastian Sebastian is a 4 year old who was recently diagnosed with ASD. Sebastian currently attends a private preschool Mon-Fri, 9am - 1pm and he naps 1-3pm. He communicates vocally in 1-2 word phrases. He is able to imitate gross motor movements and vocal utterances. He engages in some stereotypy including toe-walking and shuffling of objects. Sebastian has emerging joint attention and receives speech therapy twice/week for 45 minutes and OT once/week for 60 minutes. Parents are open to learning ABA methods and to being present for afternoon sessions and parent training. Clinical Recommendation? Age, language/imitation skills, potential barriers to treatment, other therapies, co-occuring conditions, parent commitment… Range 15-30 hours/week 31  Amara Amara is a 6 year old who was diagnosed with autism at the age of 3. Amara is currently home-schooled. She communicates vocally in 3-4 word phrases. She is able to imitate gross motor movements and vocal utterances. She engages in occasional hand flapping. Amara receives speech therapy twice/week for 30 minutes. Parents are open to learning ABA methods and to being present for sessions and parent training. Clinical Recommendation? Age, language/imitation skills, potential barriers to treatment, other therapies, co-occuring conditions, parent commitment… Range 12-20 hours/week 32  Carlos Carlos is a 9 year old with autism, seizure disorder, and intellectual disability. He attends a special day class for students with moderate-severe disabilities, 7 hrs/day M-F. He receives SLP, OT, and AAC consult services at school. He communicates with an electronic device. He engages in self-injurious behavior including banging his head with his fist and aggressive behavior towards others including biting. He is toilet trained and is able to dress himself, brush his teeth and wash his hands when provided with gesture and verbal prompts. At home and at school he sometimes leaves his desk and the dining room table and wanders around the classroom/house during instruction and meal times. Parents are receptive to being involved w/ ABA therapy. Clinical Recommendation? Age, language/imitation skills, potential barriers to treatment, other therapies, co-occuring conditions, parent commitment… Range 12-15 hours/week 33  Daniella Daniella is a 12 year old with autism. She is fully included at her school where she receives 1:1 support from a district para. Daniella communicates in several word phrases and sentences. She engages in high-pitched screaming multiple times/day when presented with non-preferred tasks. She engages in weekly tantrums at home and at school that including screaming, crying, hitting others, and toppling heavy furniture. She engages in parallel play w/ peers and her sibling but rarely engages in cooperative play nor back-and-forth conversations. Parents have concerns about ABA strategies and work with a Floortime consultant. Clinical Recommendation? Age, language/imitation skills, potential barriers to treatment, other therapies, co-occuring conditions, parent commitment… Range 12-15 hours/week 34  Anton Anton is a 15 year old with autism. He is in the general education program at his local school and has never received behavioral support there. Recently he was diagnosed with Level 1 ASD. He has difficulty making and keeping friends and he presents with executive functioning challenges. It is often hard for Anton to understand other peopleʼs perspectives and during class discussions he makes remarks that others interpret as being rude. He is performing above grade level in all academic areas except for writing, for which he receives standard accommodations. Clinical Recommendation? Age, language/imitation skills, potential barriers to treatment, other therapies, co-occuring conditions, parent commitment… Range 3-6 hours/week (refer out, unless ABA optimized) 35  Steven Steven is a 13 year old with autism. He is in a special day class at his local middle school and he received ABA therapy for a number of years when he was in preschool and elementary school. He communicates in sentences and has good imitation skills. Steven has a secondary diagnosis of schizophrenia. Approximately once every six weeks Stephen has a behavioral outburst that requires the police to come to his home or school. Steven weighs 130 pounds and when he becomes distraught, he puts adults in a choke-hold and tackles them. He also flips furniture, threatens adults with knives, ties a rope around his neck, and runs into the street when agitated. Clinical Recommendation? Age, language/imitation skills, potential barriers to treatment, other therapies, co-occuring conditions, parent commitment… Likely need to refer out 36  How Might the Following Recommendations Conflict with Kyo’s Clinical Values? A five year old has a recommendation for 40 hours/week of ABA. He attends a special day class 30 hours/week where ABA techniques are used and he receives speech and OT at school. He has no severe maladaptive behaviors. A six year old has a recommendation for 30 hours/week ABA. His parents have chosen to home-school him and he is receiving no other intervention services. 37  Duration: A Personalized, Outcomes Based Decision for “How Long” 38  3D View Enablers The same enablers of smart dosage decisions can help to guide our decisions surrounding duration of treatment Definition Definition BACB Code of Medical of ABA of Ethics Necessity 39  Outcomes are Essential to Duration Decisions Consider the patientʼs progress on the Vineland – As a standardized tool, it provides a way to objectively measure progress – Clinically significant progress is a minimum of an average 2 point improvement every 6 months – A 2 point improvement indicates that treatment is helping to close the developmental gap We anticipate that health plans will increasingly require standardized assessments to justify treatment continuation 40  Some Patients Will Not Demonstrate Meaningful Progress on the Vineland Most patients who do not demonstrate clinically significant progress on a standardized measure will be discharged after being provided with an opportunity to receive ABA for a minimum period of time (e.g., 2 years) Some patients who do not show progress on the Vineland but who make meaningful progress on skills that are essential for living, may continue to receive treatment - these are exceptions, not the norm. – When might continued treatment be justified? Goals, PSI, VB-MAPP, Other? To measure our effectiveness at a macro level, we look at outcomes across clients (at a supervisor level and regional level) 41  Discharge: A Data-Based Approach 42  The BACB Provides General Guidance on Fading Specify desired outcomes at initiation of services Involve parents and other professionals in planning Design a gradual step-down in services Include a plan for monitoring and follow-up in written discharge plan 43  Kyo Also Provides Guidance on Discharge Detailed information about Kyoʼs policies related to discharge can be found in the Clinical Policy Manual – Services funded through insurance must continue to meet the payerʼs medical necessity guidelines While these vary by payer, they generally require evidence of continued progress as measured by a standardized assessment tool – Patients must continue to make meaningful progress on socially significant goals – Discharge criteria must be individualized for the patient Consider language such as “functioning at the same level as peers”; this may not be a realistic criteria for all clients 44  Dosage, Duration, and Discharge are Like Other Parts of the Treatment Cycle BCBAs continuously monitor a clientʼs progress and adjust the behavioral principles and tactics used The same scientific process that BCBAs use to determine next steps with teaching a skill should be applied when considering overall treatment continuation or discharge. 45  Example Health Plan Criteria for Discharge The recipient shows improvement from baseline in targeted skill deficits and problematic behaviors such that goals are achieved or maximum benefit has been reached Caregivers have refused treatment recommendations Behavioral issues are exacerbated by the treatment Recipient is unlikely to continue to benefit or maintain gains from continued care The client does not demonstrate progress towards goals for two or more successive authorization periods Continued care would be provided primarily for the convenience of the child or caregivers 46 3D Review Process 47  Timeline for Intervention or Discharge: 3D Review Process Level 1 – BCBA recognizes limited progress (no improvement on any Vineland domain or less than 50% goals achieved) and reaches out to Clinical Consultant for support – BCBA and CC dialogue about potential clinical interventions, goal adjustments or changes to treatment recommendation → Level 1 may also be initiated by Clinical Integrity team 48  3D Review Process Level 2 – Lead Record Consultant alerts senior member of Clinical Integrity Team when a client makes little progress for 2 authorized periods – CC and VP Clinical (or designee) conduct a joint review of the clientʼs treatment plan and make recommendations – CC holds follow-up conversation with BCBA 49  3D Review Process Level 3 – When recommended course of action during a Level 2 review is unclear, VP Clinical may request review and guidance from Kyoʼs Scientific Advisory Board 50  Case Examples: Duration & Discharge 51  Tyrell Age: 7 Time in Treatment: 5 years BX goal(s): Task refusal (occurs at low levels; no notable progress over the last 4 years) Skill Acquisition: Only 1 out of 11 goals mastered in the last reporting period Vineland: Small improvement in scores, but flat compared to 2 Vinelands ago Clinical Recommendation: 10 hours/week 52  Leo Age: 21 Time in Treatment: 6 years (also had ABA for two years in preschool) BX goal(s): Throwing objects, elopement Skill Acquisition: Functional goals, some progress during therapy sessions, unclear generalization and independence Vineland: Flat scores Clinical Recommendation: 12 hours/week 53  Chloe Age: 10 Time in Treatment: 1.5 years BX goal(s): Crying, interrupting, tantrums-low rates, low intensity Skill Acquisition: Daily living goals-limited opportunity to target in sessions Vineland: Increase since last administration, but inconsistent progress when compared to previous scores Clinical Recommendation: 6 hours/week 54 Critical Conversations & Managing Disputes 55  When are ‘Critical Conversations’ Needed? Family does not provide enough availability for child to receive minimum treatment dosage Patient is no longer making meaningful progress or needs no longer meet definition of medical necessity 56  Conversations about Discharge Start at the Beginning, Not the End Before starting services (final stages of assessment) – Reference research literature that supports either focused treatment minimum (10 hrs) or comprehensive program minimum (30 hrs) and cite Kyoʼs minimum (10 hrs) – Discuss clinical recco and ensure families have enough availability in their preferred time blocks. – Discuss how services will be faded over time as goals are achieved. – Include discharge criteria in the initial assessment. – Include parent in conversation about ultimate treatment outcome. – Typically clients must be greater than one standard deviation below the norm on a standardized assessment to qualify for ongoing treatment. 57  Conversations about Discharge Continue During Treatment Provide data! – Vineland scores -flat or decreasing – Graphs that show goals continuing for long periods of time – Return to conversation about research lit and BACB guidelines Reference initial discharge criteria – Have goals been achieved? 58  How Might a Clinician Prepare a Family for Discharge? Begin the conversation early on and revisit each authorization cycle – At each TPU period, spend some time reviewing the discharge criteria that has been established, and how close the patient is to meeting it Treat discharge as a celebration! – Plan a graduation party Celebrate gains the child and family made through the course of treatment Connect the family to other local resources 59  Resources for Families/Coordination of Care BCBAs who specializes in parent training (vs. tiered intervention model) – Kyo TH only BCBA/program – CA Regional Centers offer funding 6 hrs/month behavior consult by a BCBA for a 6 month authorization period Consider conversing with the family and their case manager to explore vendors to aide with the transition from a more intensive model to PT only Other interventions/providers – Agency that specializes in SSGs 60  How Might a BCBA Respond to a Dispute? BACB Code 2.04D: Behavior analysts put the clientʼs care above all others and, should the third party make requirements for services that are contraindicated by the behavior analystʼs recommendations, behavior analysts are obligated to resolve such conflicts in the best interest of the client. If said conflict cannot be resolved, that behavior analystʼs services to the client may be discontinued following appropriate transition. 61  When Disputes Arise Over Medical Necessity How to resolve conflicts: Turn to the research – What evidence exists for continuation of services at the specified level? Seek guidance from your regional Clinical Consultant or Director of Clinical Integrity – Does a senior BCBA colleague confirm or question your recommendations? 62 Q&A 63 Appendix 64  Age at the Start of Treatment Predicts Success in Some Areas Some studies show treatment should start prior to age 7 to have significant impact closing developmental gaps In a retrospective cohort study, Kyo found that our clients make clinically significant process regardless of the age at which they start treatment (Fenske et al., 1985;Granpeesheh et al., 2009; Harris & Handleman, 2000) 65  Which Baseline Skills Predict Outcomes? Pre-treatment verbal skills, including verbal imitation and non-verbal imitation Pre-treatment ability to imitate Lower severity of ABA symptoms (lack of SIB, repetitive behaviors, stereotype) (Sallows and Graupner (2005), Dixon et al. 2016) 66