Harla B. Frank, M.S., BCBA
bSci21 Contributing Writer
That’s going to be the story for the next year or so: [digital health] moving from a curiosity, to a research tool, to an actual mainstream, accepted clinical tool. I think it’s very exciting. — Corey Bridges
Telehealth, the new frontier! Exploring the unknown can be scary: what dangers await those who enter the new landscape? The fear of logistical, ethical, and legal snares hidden behind the altruistic desire to help those in remote regions is enough to prevent exploration. However, there are a few intrepid explorers who overcame their fears and ventured in. They have blazed the trail for us and have tested the value of exploiting the resources of telehealth practice and found, via research, that the value is worth pioneering this new frontier in Applied Behavior Analysis (ABA) service provision!
What is “Telehealth?”
Medicaid defines “telemedicine” as a procedure that “seeks to improve a patient’s health” using “two-way, real time interactive communication between the patient and the physician or practitioners at the distant site” (Medicaid.gov, n.d. para. 1). This “two-way, real time” interaction requires “telecommunications equipment that includes . . . audio and video equipment” (Medicaid.gov, n.d., para. 1). In the early days of excursions into telehealth, more elaborate measures were often used to support such interactions, but with the rapid advance in technology, it is now easier, and more cost-effective than ever before, to use computer technology to provide ABA services to those living in remote/rural areas who do not have easy access to service providers.
Using technology to provide ABA services remotely was reported in the fall 2006 issue of the Journal of Applied Behavior Analysis (JABA). Barretto, Wacker, Harding, Lee, and Berg (2006) described the successful application of telehealth by experienced behavior analysts to facilitate brief functional analyses in their work at Biobehavioral Service at the University of Iowa. This study not only supported the efficacy of the brief functional analysis but also the efficacy of using telecommunication systems to train local consultants and significant others in the administration of the brief functional analysis (Barretto et al., 2006).
In 2015 and 2016, Dr. Todd Ward, President and Founder of Behavioral Science in the 21st Century (bSci21Media, LLC) reported several uses of telehealth in service delivery. In his first article, he described Virtual Parent Training (VPT) – a program that “connects behavior analysts with parents to provide services via webcam and Bluetooth technologies” (Ward, 2015a, para. 2). Dr. Ward’s July 21, 2015, article, “Building Children’s Communication Skills Via Telehealth,” describes a study conducted by David Wacker in which parents were trained remotely to implement Functional Communication Training (FCT) to 17 children (Ward, 2015b). The children’s problem behaviors were able to be replaced by alternative communication “by 93.5% across all participants” within “an average of 21 weeks” (Ward, 2015b, para. 5). Ward also reports the cost-effectiveness of the telehealth approach. Cost per child per week using the telehealth approach was approximately $58.00, while in-person therapy would have been approximately $335.00 (Ward, 2015b). In “Social Skills and Staff Training in a Limousine: Using Telehealth to Implement OBM,” Dr. Ward describes Brett DiNovi & Associates’ approach to teaching social skills using very “tricked out” limousines! In addition to increasing the social skills of clients in the controlled atmosphere of the limousine, and in less structured community settings, the limousines are also the setting for front line staff training in the form of coaching and verbal feedback via Bluetooth headsets and cameras. The training then increases in complexity by adding “graphical feedback” and “goal setting” (Ward, 2016, para. 7).
The growing body of research supports the efficacy of using telecommunications systems for ABA service delivery. Studies to date have focused on the successful training of parents and parent assistants in the administration of functional analyses (FA) (Wacker et al., 2013; Suess, Wacker, Schwartz, Lustig, & Detrick, 2016); training parents to implement FCT (Suess et al., 2016); training college students and special education teachers to correctly implement Discrete Trial Training (DTT) (Higbee et al., 2016); training therapists to effectively deliver commands and positive reinforcement during mand training in an early intervention program in Georgia-Sakartvelo (Barkaia, Stokes, & Mikiashvili, 2017); and training direct-care staff to administer a multiple-stimulus-without-replacement preference assessment (Higgins, Luczynski, Carroll, Fisher, & Mudford, 2017). While the majority of the studies focus on training local caregivers/therapists or parents to administer FAs, the growing body of research speaks to the versatility of telecommunications systems as effective modes of service delivery.
The advantages to clients and their families of utilizing a telehealth service delivery model are many! Individuals in remote regions of our country – and the world – can access ABA services via telecommunications systems. Regional service providers, teachers, parents – and more, can be trained to administer FAs and function-based, behavior intervention plans. Using a telehealth approach, one can provide needed services more quickly and reduce the long wait lists so prevalent in remote areas that may not have trained behavior analysts to deliver in-person therapy (Applied Behavior Analysis Edu.org, n.d.).
There are also advantages for the behavior analyst. The analyst can add to the number of clients served by eliminating the need to travel to service delivery sites (Applied Behavior Analysis Edu.org, n.d.). The high customer satisfaction with the training and results also adds to the behavior analyst’s self-esteem (Applied Behavior Analysis Edu.org, n.d.).
Show Me the Money!
In 2017, the Federal Employees Health Benefits Program (FEHBP) mandated that its insurance carriers cover ABA services for those diagnosed with autism (Lunney, 2016). In addition to this mandate, the Office of Personnel Management (OPM) encouraged “insurance carriers to offer telehealth” services (Lunney, 2016, para. 5).
Medicaid currently provides state-specific reimbursement for telehealth services in 48 states and Washington, D.C. (WebABA, n.d.). In fact, Medicaid and Medicare have been providing coverage for telehealth services for over 10 years (Griswold, n.d.). Private payer laws have been enacted in 32 states and Washington, D.C., but the laws vary from state-to-state (Blackman, 2016). While more and more insurance carriers are moving toward reimbursement of telehealth services, in large part due to the Affordable Care Act and the push for lower costs, the justification for this type of service delivery usually depends upon difficulty of access to a provider based upon the client’s remote location (Griswold, n.d.).
It is important that the behavior analyst thoroughly research state laws and client insurance requirements regarding provision of telehealth services. While 35 states currently have parity laws that require private insurance carriers to provide reimbursement for telehealth services equal to in-person service delivery, many states do not have parity laws that specifically spell out reimbursement rates (American Telemedicine Association, n.d.). Caution is advised!
Interested? A Few Things to Keep in Mind
Telehealth regulations vary from state-to-state, but there are some common threads:
- States that authorize telehealth services for ABA therapy/training, may require “telehealth licensing.” Some states provide inter-state licenses so you can provide services across state lines (U.S. Department of Health and Human Services Health Resources and Services Administration [HRSA], 2013). It is important that you check the requirements for your state and the state in which your client receives services – not necessarily where he/she resides (HRSA, 2013).
- Your telecommunications equipment must comply with the Health Information Portability and Accountability Act (HIPAA), and the system used to store and transfer records must meet the regulations of the Health Information Technology for Economic and Clinical Health Act (HITECH) (HRSA, 2013).
- You will want to check with your insurance provider to determine the insurance requirements for telehealth provision (HRSA, 2013).
Telehealth is an exciting new frontier! There are a few intrepid explorers blazing the trail before us, but there are dangers along the path – primarily issues of insurance coverage of telecommunication systems service delivery. The uncertainties regarding pay for telehealth services versus in-person service delivery is being addressed and strides were made with the enacting of parity laws in many states; however, much remains to be done. Ethical issues surrounding the quality of virtual service delivery is also an important consideration. The quality of the service must meet the high standards of our profession.
One must always contemplate the dangers ahead before setting out on any journey. It wasn’t so long ago that supervision of BCaBA and BCBA candidates was made possible to those in remote regions via telecommunications approaches. Distance supervision has worked out quite well. Perhaps this new behavioral frontier is worth further exploration. As Robert Brault said, “The road to success is not a path you find, but a trail you blaze.” Behavior analysts have always been trail blazers!
It is not the strongest of the species that survives, nor the most intelligent, but the one most responsive to change. — Charles Darwin
American Telemedicine Association. (n.d.). States with parity laws for private insurance coverage of telemedicine (2018). Retrieved from http://www.americantelemed.org/policy-page/state-policy-resource-center
Aporta, A. P., Resende, A., Nogueira, M., Goyo, C., & Pollard, J. S. (2016). Interactive computer training to teach discrete-trial instruction to undergraduates and special educators in Brazil: A replication and extension. Journal of Applied Behavior Analysis, 49, 780-793.
Barkaia, A., Stokes, T. F., & Mikiashvili, T. (2017). Intercontinental telehealth coaching of therapists to improve verbalizations by children with autism. Journal of Applied Behavior Analysis, 50, 582-589.
Barretto, A., Wacker, D. P., Harding, J., Lee, J., & Berg, W. K. (2006). Using telemedicine to conduct behavioral assessments. Journal of Applied Behavior Analysis, 39, 333-340.
Blackman, K. (2016). Covering and reimbursing telehealth services. Retrieved from http://www.ncsl.org/documents/health/lb_2404.pdf
Griswold, B. (n.d.). Will insurance cover video and phone sessions? Retrieved from https://pro.psychcentral.com/will-insurance-cover-video-and-phone-sessions/
Higbee, T. S., Aporta, A. P., Resende, A., Nogueira, M., Goyos, C., & Pollard, J. S. (2016). Interactive computer training to teach discrete-trial instruction to undergraduates and special educators in Brazil: A replication and extension. Journal of Applied Behavior Analysis, 49, 780-793.
Higgins, W. J., Luczynski, K. C., Carroll, R. A., Fisher, W. W., & Mudford, O. C. (2017). Evaluation of a telehealth training package to remotely train staff to conduct a preference assessment. Journal of Applied Behavior Analysis, 50, 238-251.
Lunney, K. (2016). FEHBP insurance carriers must cover autism treatment beginning in 2017. Retrieved from http://www.govexec.com/pay-benefits/2016/02/fehbp-insurance-carriers-must-cover-autism-treatment-beginning-2017/126275/
Medicaid.gov. (n.d.). Telemedicine. Retrieved from https://www.medicaid.gov/medicaid/benefits/telemed/index.html
Suess, A. N., Wacker, D. P., Schwartz, J. E., Lustig, N., & Detrick, J. (2016). Preliminary evidence on the use of telehealth in an outpatient behavior clinic. Journal of Applied Behavior Analysis, 49, 686-692.
U.S. Department of Health and Human ServicesHealth Resources and Services Administration. (2013). Increasing access to behavioral health care through technology. Retrieved from https://www.hrsa.gov/sites/default/files/publichealth/guidelines/BehavioralHealth/behavioralhealthcareaccess.pdf
Wacker, D. P., Lee, J. F., Padilla Dalmau, Y. C., Kopelman, T. G., Lindren, S. D., Kuhle, J., Pelzel, K. E., & Waldron, D. B. (2013). Conducting functional analyses of problem behavior via telehealth. Journal of Applied Behavior Analysis, 46, 31-46.
Ward, T. A. (2015a, July 16). Virtual autism treatment. Retrieved from https://www.bsci21.org/virtual-autism-treatment/
Ward, T. A. (2015b, July 21). Building children’s communication skills via telehealth. Retrieved from https://www.bsci21.org/building-childrens-communication-skills-via-telehealth/
Ward, T. A. (2016, October 18). Social skills and staff training in a limousine: Using telehealth to implement OBM. Retrieved from https://www.bsci21.org/social-skills-and-staff-training-in-a-limousine-using-telehealth-to-implement-obm/
Harla Frank, M.S., BCBA earned her Master’s degree in Psychology, with an emphasis in Applied Behavior Analysis, from Florida State University. Since receiving her certification as a Board Certified Behavior Analyst (BCBA) in 2007, she has worked primarily with children and young adults on the Autism Spectrum, but has also worked with adults with a variety of diagnoses and needs. She has served as an expert witness for Applied Behavior Analysis (ABA) in the Colorado court system and has had the privilege of providing “ABA approaches” training to foster care staff and families.
Since 2010, Harla has taught ABA course sequences, as well as general psychology courses, for Kaplan University. Currently, she also contracts with a pediatric home healthcare company in Denver to provide ABA therapy to children with a variety of diagnoses. You can contact her at firstname.lastname@example.org.