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    Sharon Wilkes is the Director of Residential Options Inc. (ROI) in Lansing, Michigan. ROI specializes in evidence-based practices and therapeutic interventions for people with Autism Spectrum Disorder and related developmental disabilities. Since the passage of PA 99 and PA 100, ROI has also been a provider of Applied Behavior Analysis (ABA). Mrs. Wilkes was able to take sometime out of her day to discuss her reaction to the proposed Medicaid expansion of ABA coverage. 
     
    . I’d like to start by asking if you’re familiar with the plan to expand Medicaid’s coverage of ABA from age six to age 21.
     
    I certainly am. 
     
    Great. What kind of effect do you think this change will have on ROI and how you operate?
     
    Things are definitely going to change, because I think a program for the older kids, especially when you get in the teenage years, is going to have to be more functional. You won’t see as much discrete trial teaching as you will experiential type teaching and natural environment learning. One of the things we’ve been talking about is developing almost a virtual community; where you’ve got a building that has a grocery store, a bank, health club, a doctor’s office and such; and you take a client, who may not be successful at those places in the community right now, teach them to have job skills in those kind of settings, and transfer them back to the community. So, there are a lot of ideas floating around, but it’s going to be a whole different look than what we do for the really little kids. 
     
    With the increased Medicaid eligibility for ABA, how many more clients do you anticipate taking on? 
     
    Well, we’ve been told that there are roughly 18,000 kids with autism in Michigan. If you look at that population by county, you’ll realize there’s going to be way more business than we can do. We currently serve about 120 kids between here (Lansing) and Jackson. We should be able to, in the new facility, double our capacity. Not to mention we’re still thinking about something else for the older clients. So, we could possibly serve even more people than that, depending on the needs of the families. However, a lot will depend on how fast we can hire BCBAs (Board Certified Behavior Analysts who oversee client programming). They’re (BCBAs) not easy to come by. 
     
    So, there will be an increased demand for BCBAs, and more people trying to become certified? 
     
    Oh, there definitely will. I think it will catch up eventually, and that there are a lot of people going down that path right now. But, you’re looking at a two or even three-year lag before the supply catches up with the demand. We’ve done a pretty good job of keeping up with the zero through six age, but if you multiply that by the number of kids six to 21…I don’t know. 
     
    What is the normal BCBA caseload currently?
     
    A typical caseload is about 12-14 clients per BCBA. 
     
    How many BCBAs are there currently at ROI?
     
    There are six board certified behavior analysts and four tier-two supervisors, who are qualified to supervise a client’s program. 
     
    Assuming you double your clientele or even more, how many BCBAs do you anticipate hiring?
     
    Well, we have another one coming on at the end of August, and we’re short now…so I’d say we could add six to 10 in the next year. I honestly don’t think we’ll be able to hire that many, though, both financially and marketing-wise. 
     
    Do you think expanding coverage from age six to 21 is too big of a leap too soon?
     
    Yes
     
    Why do you think that? 
     
    Well, we’ve barely been able to keep up with the demand from zero to six. And, I think the older age group is going to be harder, because it’s going to have to be more community based. Those kinds of programs take more task analysis…you can’t take the curriculums we have right now that are very well spelled out and apply them. For instance, if you take someone to do laundry, you have to task analyze that; work on every step individually. Not to mention you have to drive them to the laundry mat. The whole process is going to be much more labor intensive than what we do for the little kids. I don’t know what caseloads will look like with that older group. The other side of that is: the older you get, and the less developed a client’s communication is, most often you’re going to see more challenging behaviors. You’ll have head-bangers, people that bite, scratch and run out in traffic, and they’re not little kids, where you can just grab their arms. There’s much more risk, danger, and you have to compound that with how many years of learning experience the client has. It’s going to take a lot longer to undo troublesome behavior with a 15 year-old, who is used to getting their way, than with our current population. 
     
    Would you have preferred this expansion to be phased in?
     
    Yes, I sure would have. I don’t think anybody is prepared for this. I feel fortunate that our company has experience working with more challenging behaviors, because a lot of places don’t know what that’s like. It’s going to be a rude awakening for a lot of places. 
     
    Thank you for your time; I know you’re busy.
     
    You’re welcome. Thank you. 
     
     
    Additional comments from Michael:
     
    I have worked as an ABA technician for the past two years at ROI. My clients include a wide array of severities and ages. I’d like to use this opportunity to comment on the proposed Medicaid expansion from the perspective of a technician; someone who works in the trenches, so to speak. 
     
    In my experience, the programming for children is very rigid and spelled out. To illustrate this, let me give an example of a normal ABA session with a client age three to six: The client’s therapist has designed a specific program of goals, which we review electronically. Said goals might include matching items, repeating words or phrases, filling in phrases and repeating motor movements. The technician presents the task and records data on whether the client was able to complete it independently. This process is repeated periodically within the client’s session, along with allotted periods of breaks in a “playroom”. 
     
    As mentioned by Mrs. Wilkes, these goals change drastically as the client grows older. To contrast the two programs, let me give an example of a session with a client in his teenage years. Our goal as technicians working with older clients is to help them live as independently as possible. Therefore, our trials take place in the community. The session starts by driving to the client’s house. Our first stop is at the library, where the client must return books, pick a topic/book to learn about and read for at least 10 minutes quietly. They also work on maintaining a quiet voice and learning to tolerate others who may not be as considerate. Next, we go to a grocery store and shop for items on a list. There are many actions to consider and take data on in this setting. For instance, using a shopping cart appropriately, saying excuse me while passing by others, comparing prices and paying with the correct amount of money. Although this is not the full extent of the client’s program, it becomes clear how much more involved these sessions are compared to the previous example. 
     
    From the standpoint of a technician, the skill level required to run each of these two programs is quite distinct. While working with younger children, your tasks are being conducted in a very controlled environment. If any problem behaviors occur, therapists and other technicians are on site to assist you. Working in the community, on the other hand, there is much more at risk. If your client has a problem behavior in a grocery store for example, not only do you have to ensure their own safety, you have tens of citizens to worry about, as well as any damages to merchandise that must be paid for. Scariest of all is the possibility of elopement, where a client runs out of a store and, God forbid, into the street. Unfortunately, the ability to avoid such a situation can’t necessarily be taught; but learned. It takes experience to understand a client’s triggers and how to defuse the situation. 
    Therein lies a major concern I have with the extent of this proposed expansion: the experience of Michigan’s current behavioral technicians. Given the relatively recent rise of ABA therapy in Michigan after the passage of PA 99 and PA 100, many of Michigan’s behavioral technicians have at most two years experience working with Medicaid clients ages zero to six. As the expansion takes effect, centers will be flooded with eligible older clients, and programs for them will look similar to the one previously laid out. The demand for new technicians will skyrocket, and you will most likely see these new employees running community-based programs. Thus, in my opinion, it will take a significant amount of time for the experience of Michigan’s technicians to catch up with the needs of the clients, which may lead to some risky situations in the meantime.
     
     A phase-in, as Mrs. Wilkes discussed in the interview, may have been a better option, slowly increasing the older clients eligible for services. This would allow centers and technicians to gain experience with this population before opening them up to such a vast group. Although I am ecstatic that so many new Michiganders will receive the autism treatment they so rightly deserve, I don’t expect our ABA centers will be operating as effectively as possible for quite some time.            
     
    Resources:
     
    https://www.michigan.gov/documents/budget/Budget_all_together_2016_final_481096_7.pdf
     
    https://www.michigan.gov/documents/autism/ASDStatePlan_2_19_13_Final_414143_7.pdf
     
    http://www.roi-mi.com

     

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