Ethical Service Delivery Models in the Time of COVID-19: A Risk/Benefit Analysis Tool

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Learning Objectives

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1. Participants will analyze a systematic tool to determine the risk vs. benefit related to medical necessity and service provision during COVID-19; participants will determine actionable next steps to apply tool utilization in respective practices.

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• Participants will discuss and determine ethical considerations surrounding decisions based in medical necessity, continuity of care, essential service provision, and environmental conditions during with the COVID-19 pandemic.

Continuing Education Units (CEUs)

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• First 100 Zoom registrations will receive a 1 free Ethics CE from SC ABA.
• Please email the 3 code words with your full name and BACB certification number to southcarolinaaba@gmail.com by Monday, March 30, 2020.
• Zoom will send out an automatic reminder to do this.

Panelists

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Zahra Hajiaghamohseni, PhD, BCBA; SC ABA Immediate Past President

Sarah Duarte, M.Ed., BCBA, LBA; Arion Care

Jennifer Sweeney, PhD, BCBA-D, COBA; Ohio ABA President

Mary Caruso-Anderson, PhD, BCBA-D, LBA; DC ABA President

Disclaimer

As you are using the tool, refer back to the BACB PECC: Ethics Guidance for ABA Providers During COVID-19 Pandemic.

This screener does NOT constitute legal or medical advice.

This is just an example of a process for ethical decision making to determine continuum of care needs to handle COVID-19 service disruptions.

Opening Remarks

• State Associations developed Ad Hoc Committee to address risk versus benefit for continued direct services
• Thank you Shaune Langston, Esquire for reviewing this screener
• Joint effort to help each other during unprecedented global crisis
• Risk Mitigation is a specific process that most of us did not get trained in during our graduate coursework.
• Please be compassionate and kind with any comments in the chat box
• Ethical decision making is complex and uncomfortable
• * We may not be able to answer all Questions during this live Webinar*

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BACB Guidance

• Released on Thursday, March 19th & revised on March 20th
• Suggest a systematic assessment to determine the continuum of placement options for each individual client
• This means that decisions on how to continue care for your clients is not a one-size fits all formula
• Professional and Ethical Compliance Code (PECC)
• Section 1.0
• Section 2.0
• Section 4.0

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PECC 1.04

Additional Considerations

• Follow all National, State, or Local mandates
• Example: Charleston County shut down on Thursday but the surrounding counties did not do a shelter in place.
• Essential personnel is Legal designation determined by each state

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Additional Considerations ...

• ABA services are healthcare services, the medical necessity of which must be determined on a case-by-case basis
• Council for Autism Service Providers (CASP) has some great resources on this if you are looking for more information on these two terms.
• For your current clients, going through a risk-benefit assessment allows you to determine what is necessary for us to provide when we are responding to a major crisis and how to safely delivery what the client needs.
• Decision making on a case-by-case basis
• Ex: Medical Model (Triage a situation)
• Elective
• Urgent
• Emergency

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Medical Model Example

COVID-19 response plan: An example

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PECC 4.07

Social Distancing Protocol

This is a nationwide intervention to slow the spread of COVID-19 so the national health care system is able to handle the more severe cases that will continue to need intensive care.

• This is nationwide; it is a well documented barrier at this point

PECC 2.15

Systematic Assessments

Behavioral Health Center of Excellence

(BHCOE)

Risk-Benefit Assessment: COVID-19

Continuum of Care Screener

• Organized into 5 sections
• Take 20-30 minutes to do with a parent or caretaker
• Coordinate a time with fewest distractions for caretaker
• May mean doing the call earlier in the morning, at nap times, or after client goes to bed
• Use the process or assessment on some regular intervals to determine if parent/caretaker/client needs are changing during this crisis

Section I: Family Issues / Family Coping

SECTION I: Family Issues/Family Coping

1. How have your household/residential dynamics changed in the last FEW weeks (e.g., siblings fighting more, marital stressors, homeschooling/occupying free time)? Is your household prepared in terms of supplies for a possible shelter-in-place for 2 or more weeks?

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• How are you coping with this change (e.g.,do you Facetime/phone with family/friends/exercise)? Do you have social support? Do you have regular tutorial, educational, or church support services?

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Section II: Family Social Behaviors

SECTION II: Family Social Behaviors

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1. Are you engaging in social distancing per the CDC and WHO (e.g., staying self-quarantined with your original group, staying 6 feet away from anyone, limiting any unnecessary exposure in grocery stores, telework from home). 
1. Self-quarantined with the original group?
1. Do you monitor the child/adult social distance from other members outside of the family?
2. Have you been teleworking if possible?
• If going onsite at work, what are the precautions that an adult takes before entering home?
• If working outside of the home, what are the precautions at work?

Section II: Family Social Behaviors

1. Are you going into grocery stores and maintaining at least 6 feet at all times from others?
2. Are you going anywhere else in public other than work/grocery store?
1. List:
3. COVID-19 symptom check:

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*Secondarily: vomiting, diarrhea, stuffy nose?

Section III: Client Behaviors

SECTION III: Client Behaviors

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1. What is your client’s daily schedule like? When are they most successful in the day? When are they least successful in the day?
2. What is the client currently doing during downtime?
3. Is the client engaging in a routine including but not limited to routine/scheduled hygiene/eating/sleeping, playtime, and recess times daily?
4. Any changes in severe, moderate, or mild interfering behaviors?  (this could be increase or decrease)
5. Has caretaker completed training/ or is participated in sessions regularly?

Section III: Client Behaviors

The interviewer asks herself/himself:

• Do you need to develop a crisis plan that involves calling 911?
• Can the parent safely manage the problem behavior with Telehealth support from BCBA?
• If it is severe, do you have a fitted mask and gloves and thermometer (fever check) to take personal protection measures if you need to go onsite to assess? * We have a responsibility to the people we are asking to go into the field*
1. If NO, do you have high risk people in your personal home?
2. If NO, what medical symptoms have you had/have those in your family had?
3. If NO, have your family members been following social distancing guidelines?
4. If NO, assess risk-benefit continuum is the benefit of going greater than the risk of going (e.g., meaning COVID-19 exposure)
5. If YES, assess risk-benefit continuum if patient or yourself are high risk (kids with autism are high risk)

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Section III: Client Behaviors

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1. Any changes in the use of essential communication for basic wants/needs (we are not talking about social skills)

• Anything else that will help us help you/your child? By way of example, or suggestion do you think it would be helpful for client to hear patient’s regular ABA team via phone/Facetime or some other technology during the regularly scheduled session time?

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Interviewer considers these:

• Determine if we need to make any antecedent or consequent interventions (e.g., visual supports and drop off outside house or email to them; model through telehealth).
• Can technology include support for emails, or live video conferencing that can share videos or demonstrate certain suggestions or training/measures to help caretakers better understand how to understand non-emergent situations?

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• Determine if we need to develop a family-friendly version of generalization or maintenance plan for essential communication skills (e.g., visual supports and drop off outside house or email to them; model through telehealth)?

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Section IV: State or National Climate

Section IV: State or National Climate

Are there any National, State, or Local mandates that would prevent non emergency or non essential outpatient services?

• Essential and Emergency services are determined state by state
• If yes, follow all mandates for your area or state

Section V: Evaluating the Course of Action

SECTION V: Evaluating the course of action: (Telehealth Screener) * Telehealth is recommended as the safest option*

Client Demographics

• Age: ______
• Comorbid Intellectual disability: ______Y/N
• How many direct hours: _____ (Comprehensive 15+ hours; focused 14 or fewer hours); hours of 97153 (____), 97155 (____), 97156 (____)
• Instructional control (if NO, will need to default to caretaker model): ______Y/N
• Client barriers (screen, interfering behaviors, attention; if YES, will need to default to caretaker model): ______Y/N
• Parent barriers: ______Y/N (e.g., marital stressor, siblings, physical/mental health (> if YES, please default to a Risk vs Benefit assessment)
• Risk vs Benefit assessment
• Will direct face to face intervention benefit outweigh the risk of client/client’s family being exposed to COVID-19 or a serious illness from COVID-19 exposure

____ (Y/N) Proceed to Section V: Direct Service Considerations

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Section V: Evaluating the Course of Action

Technology Check: these could present barriers that would require additional evaluation to determine if these could be removed

• Reliable Internet: ______Y/N
• What device would be available for the patient or parent during Telehealth ____(e.g., laptop, phone, ipad, tablet)
• If doing with parent as RBT- does parent have Earbuds ______Y/N
• Distraction-free environment: ______Y/N
• Time of day that would be best: _____Y/N
• Which Technology do you prefer: ________(audio-only on telephone, Facetime, Skype, Doxy, Google Hangout, Zoom

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• For example, if a parent does not have a device other than smartphone. Do you have a loaner iPad you could drop off on doorstep.

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Section V: Evaluating the Course of Action

Telehealth options

ABA Provider providing direct services to client

ABA Provider providing direct services to Client with parents delivering as the “hands”

ABA Provider providing family training and coaching to caregiver

ABA Provider(s) providing group services to group of clients

Most intensive

Least intensive

Section V: Evaluating the Course of Action

ABA provider to client

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To be used when you have instructional control, and few barriers

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Examples:

97153: RBT

97155: BCBA (with program modifications)

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ABA Provider providing direct services to client

Section V: Evaluating the Course of Action

ABA provider to client with parent directing/delivering as RBT

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There are increased barriers with this model

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Examples:

97153: RBT

97155: BCBA (with program modifications)

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ABA Provider providing direct services to Client with parents delivering as the “hands”

Section V: Evaluating the Course of Action

BCBA / BCaBA to parent

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Focus is on managing environmental stressors (including homeschooling and other unique transitions/situations) and skill development

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Examples:

97155: coaching/modeling (daily, smaller

units) and observations

97156: training parents (twice weekly, l

onger units); Q&A

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ABA Provider providing family training and coaching to caregiver

Section V: Evaluating the Course of Action

ABA provider(s) to group

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Such as virtual social groups

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Examples:

97153: RBT

97155: BCBA / BCaBA

• This is based on what each insurance allows for group codes
• Could consider do non billable if this would help your client access peers
• (determined by your organizational policies)

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ABA Provider(s) providing group services to group of clients

Section V: Direct Service Considerations

After risk-benefit assessment, if direct outweighs the risk of COVID exposure: consider these items

1. Medical and Social Distancing Attestations
1. Temperature checks: (every member of house and every member of providers house)
2. Form attestation example
3. Check CDC for environmental cleaning and disinfection (CALABA JOB AID HERE)

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• Direct Onsite Considerations
1. One client per a provider (this reduced COVID exposure and cross contamination)
2. If not possible, consider changing clothes between patients
3. Do home based, if possible (see why here)

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Section V: Direct Service Considerations

Home considerations: (CALaba Webinar)

1. Only work with client 1:1 in home
2. Remain in a different room than other members of the family
3. Do not provide food or snacks to client
1. Have caretaker provide food
2. No hand over hand prompts/reduced physical prompts
3. Have provider use bandaids on fingertips or wrist bracelet with a bell (this reminds provider not to touch face) (Nicole Gravina Behavior Based Safety Article here)

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Section V: Direct Service Considerations

Clinic considerations:

• 1:1 in clinic or in different rooms
• Check CDC for environmental cleaning and disinfection
• Consider a decrease in physical prompting
• Consider not feeding client food/have parent/caretaker provide food (use gloves)

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Putting it all Together: a Client-Specific Example

• Client:
• Child is 8 year old; Initial Diagnostic has child at F84.0-Level 2. Client receives 12 hours of 97153 a week after school during normal routines. I have 10 broad goals and 30 teaching objectives across social communicative deficits and restricted and repetitive behaviors across a 6 month treatment plan.
• Family:
• Family I work with has significant parental stressors with multiple siblings in the house.
• Family is concerned about having enough money to buy groceries for another 2 weeks if shelter in place in ordered
• The family has been engaging in social distancing and no COVID symptoms reported
• Client Behaviors:
• Client has had increase of mild to moderate behavior with siblings during downtime throughout the day. This includes trying to hit a 17 year old sibling, refusing to do chores, increase in ‘whining’ during the day. Need to develop some antecedent and consequence strategies to address these. Need new materials developed for parent. Parent has completed parent training and met criterion for parent goals. Parent participates in regular sessions 2-4 times a week for at least 15 minutes each contact.
• Telehealth considerations:
• Child has too many barriers with the use of the Technology for BCBA or BCaBA or RBT to deliver the services directly through Telehealth to child.
• Parent indicated she does not have any protected time to do consistent Telehealth because of the demands of other children. Parent would do 1-2 a week check in via the Telephone if I scheduled day of with her.
• My clinical decision: Safety First (Do no harm to client, family ,staff, community)
• I will place 8 goals on hold. I will modify 2 goals to address the downtime and interfering behaviors.
• Can I manage the urgent issues through Telehealth with parent 1-2 times a week? YES, I will try for 1 week and reassess to determine effectiveness of my modifications.
• Does the benefit of direct ABA outweigh the risk of COVID exposure? For this client, not at this time with the current information coupled with the social distancing protocols
• I will proceed with 2X week checks in with parent and determine a time of day based on her schedule.

Make a Continuum of Care Decision

• Triage individual client behaviors into emergent, urgent, and required
• Consider the family coping/stressors and social behaviors
• Use the safest delivery method possible that accounts for your client, client’s family, your staff, and will provide therapeutic benefit to clients
• Each decision is case by case
• Some clients will need face to face care during this crisis due to the immediate benefit of ABA outweighing a COVID-19 exposure
• Some clients plan will need to change if behaviors change (e.g, you may start with Telehealth and need to adjust to direct)
• Consider essential skills that may be lost without direct. How quickly could you regain them once you go back to direct?
• Has parent received training on essential skills already
• This is a global crisis.
• We may temporarily adjust what behaviors we target depending on the risk-benefit assessment.
• We may place some goals/objectives on hold for the social distancing period to focus on emergent and urgent

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An example of how Zahra is Documenting

Telehealth Webinar: Tuesday, March 31

Closing Thoughts

• PLEASE Take care of yourselves!
• Reach out to your state association
• Confer with a mentor
• Panelist contact:
• Email Zahra @ southcarolinaaba@gmail.com
• Email Jen @ president@ohaba.com
• Email Mary @ districtaba@gmail.com
• Email Sarah @ SDuarte@arioncare.com
• Behind the Scenes SHOUT OUTS
• CASP (Lorri Unumb), Christy Evanko, David S. Green, Langston Law Firm, PLLC

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COVID-19 Resources

• SC ABA Website > Resources > COVID-19
• https://www.sc-aba.org/covid-19-resources.html
• This webinar recording will be there
• A brief video model of Sarah and Zahra conducting a risk-benefit assessment and staffing the case to determine how to proceed
• A graphic version of the tool described in this presentation
• A word document version of the tool described in this presentation
• Two additional examples of Risk-Benefit tools

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References

Behavior Analyst Certification Board. (2020). COVID-19 Update from the BACB. Retrieved on March 20, 2020 from https://www.bacb.com/bacb-covid-19-updates

Behavioral Health Center of Excellence (2020). Why we are temporarily transitioning to home-based therapy graphic.

Centers for Disease Control and Prevention. Implementation of Mitigation Strategies for Communities with Local COVID-19 Transmission. Retrieved on March 19, 2020 from https://www.cdc.gov/phlp/publications/social_distancing.html.

Gravina, N., (2020). Behavior Science Strategies For Reducing the Spread of Illnesses in Organizations. Retrieved on March 16, 2020 from https://science.abainternational.org/behavioral-science-strategies-for-reducing-the-spread-of-illnesses-in-organizations/ngravinaufl-edu/.

Keene Perspectives. (2020). COVID-Screening Tool.

Miller, M. (2020). Telehealth in ABA: Practical Applications with Dr.Megan Miller Retrieved on March 24, 2020 from https://zoom.us/rec/play/v5Ipfu-prW83HIaV5gSDUPd-W9W8e_2s1iZMrvteyR7gVXYHZAajN7IbY-XcGgSdGA5UNOTJjorgoi6t

World Health Organization. Coronavirus Disease (COVID-19) Pandemic https://www.who.int/emergencies/diseases/novel-coronavirus-2019

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Q & A with Panelists