Regional Autism Assistance Program Expert Panel Meeting Minutes Monday, March 24, 2014, 9:00am to 10:30 am GoToWebinar

Transcription

1 Regional Autism Assistance Program Expert Panel Meeting Minutes Monday, March 24, 2014, 9:00am to 10:30 am GoToWebinar Facilitators: Barbara Khal / Debra Waldron Opened with roll call (See table below) Regional Autism Assistance Program Expert Panel Members Name Organization Represented Present 3/24/14 Theresa Armstrong Department of Human Services Alyson Beytien (Bobbie Schell) Mercy Service Club Autism Center Josh Cobbs Pier Center X James Curry Iowa Autism Council/Family Member Peter Daniolos UI Hospital and Clinics Child Psychiatrist George Estle Barbara Guy (Sean Casey) Gretchen Hageman Tanager Place Department of Education Iowa Department of Public Health Barbara Khal Child Health Specialty Clinics - Regional Autism Assistance Program X Laura Larkin Department of Human Services X Scott Lindgren UI Children s Hospital Autism Center X Marilyn Seemann Toni Fuller Merfeld Steve Muller Nathan Noble Tracey Page Kristine Steinmetz Debra Waldron MHDS Commission Member/Service Area Manager MetroWest Learning Center The Homestead Blank Children s Hospital/Unity Point Health- Developmental Pediatrician ChildServe Autism Society of Iowa/Family Member Child Health Specialty Clinics - Regional Autism Assistance Program X X X X X

2 Other Attendees Name Dr. Chuck Wadle Tim Curry Melissa Havig Steve Johnson Peggy Swails Leslie Huber Erika Hertel Organization Represented Magellan Health Services Medical Director Magellan Health Services National ABA Director Magellan Health Services Manager, Member Services and Community Programs Magellan Health Services Clinical Director Child Health Specialty Clinics - Regional Autism Assistance Program Child Health Specialty Clinics - Regional Autism Assistance Program Child Health Specialty Clinics - Regional Autism Assistance Program Update on Regional Autism Support Program Administrative Rules The administrative rules have been finalized and approved for the Autism Support Program (ASP). The rules will go into effect on April 1, The final version of the rules is available on the legislative website and on the Department of Human Services (DHS) website by searching for the title Chapter 22, Autism Support Program under Human Services Section [441] of the administrative code. Fund Administrator Magellan Behavioral Health was chosen as the Fund administrator. The application for the ASP is on Magellan s website along with other pertinent information. Magellan will participate in future Expert Panel meetings. Children Who Are Undocumented A review of the rules and the law requires that children need to have legal status to access the Fund. Update: Legislative Funding for Draft legislation allocated two million dollars for Fiscal year (FY) This funds the program at the same level as FY Carry Forward of FY2014 Funding FY 2014 funds may not be carried forward into FY The panel expressed that there is not enough experience yet to know funding is necessary to meet the need for a full year. Information regarding funding will be collected and shared with legislators. 2 P a g e

3 Baseline Standardized Assessment Score / Tools to Evaluate Progress Per the RFP and the administrative rules, the administrator has the responsibility of selecting a baseline assessment tool. The tool selected must be approved by DHS. Magellan noted the industry is moving toward selecting a uniform national method for measurement. They expressed the need for a comprehensive, cohesive and uniform system for progress measurement. Magellan recommended the SKILLS ASSESSMENT developed by the Center for Autism and Related Disorders (CARD) to provide the Baseline Standardized Assessment Score. It is an online data collection system that allows Magellan to collect data and produce reports. The data is used to interpret and make authorization decisions for families. The raw data collected can also be reviewed at a national level to understand how effective ABA programs are. Magellan has purchased a subscription for this tool and would allow each provider agency access. The SKILLS tool was recently presented to DHS and has not yet been approved. Autism Treatment Evaluation Checklist (ATEC) was submitted and approved by DHS in Magellan s original application as the tool to evaluate progress. Discussion Panel members expressed concerns about adopting the SKILLS ASSESSMENT. Nationally, there has not been agreement by providers on a single tool. The Panel is in favor of using a technique better than what is currently used (ATEC) for tracking children served, and has the goal of utilizing an overall tool for the baseline assessment score. The Panel was extremely concerned as the ASP Fund begins April 1, They do not want the requirement of a new tool to cause delays in getting services to families of children with ASD. The SKILLS tool is relatively new. Panel members need additional information regarding the reliability and validity of the tool compared to other tools, such as the ATEC. The Panel would like to review evidence demonstrating that SKILLS is an improvement over the ATEC. Magellan will share more information with the Iowa team on the tool s reliability and validity. There were other questions discussed that will need to be addressed regarding the SKILLS tool: When is the SKILLS tool performed? Is it completed prior to the condition of authorization? How are providers reimbursed to conduct the SKILLS tool? Duplication of data entry for providers is another problem that will need to be addressed. Panel members were concerned that SKILLS is tied to a curriculum-based program. It was noted that providers utilize different tools to address the domains that affect children with ASD and are treated by ABA. The tool will need to address the various domains such as communication, socialization, language, academics, etc. It would be ideal if a single tool could be identified for use in ABA for general skill acquisition and for ABA used to reduce challenging behaviors. 3 P a g e

4 Another concern expressed by the Panel was that utilizing the SKILLS tool will create training Issues for Iowa providers. Many providers currently do not have experience utilizing the SKILLS tool. ABA providers will need time to train their staff to use the tool and may need to adapt their processes as well. Magellan made assurances that they will review the SKILLS tool with each ABA provider to ensure they are comfortable administering the clinical tool and that the new tool is compatible with their current processes. Summary While the Panel agreed that the ATEC tool has flaws, most members of the Panel supported proceeding with the ATEC as most providers are familiar with this tool. Magellan agreed with this as a temporary strategy. A pilot of the SKILLS tool could be undertaken to compare SKILLS currently used by Iowa providers. Members of the Panel will submit additional questions on this topic after the meeting, which will be compiled by CHSC and added as an attachment to the March 24, 2014 minutes (see Attachment 1). Family Engagement and Participation: Measurement Tool and Evaluation Family participation is mandated by the ASP per administrative rules. The treatment plan must identify the specific activities and responsibilities of the parents. The goal is to ensure that the family or other significant caregivers are also being trained on the interventions utilized by the ABA provider. Discussion Family participation is necessary to maximize child outcomes. It is a requirement of the program and should be integrated into the treatment plan. Magellan has developed forms specific to the Autism Fund for the initial eligibility determination and for the continuing review process. The forms were recently approved and information on the Regional Autism Assistance Program are listed on Magellan s website, along with the application to the Autism Support Program fund. Magellan has a process in place to inform and document the family s involvement during the care management calls. The purpose of care management calls is to review and, if necessary, clarify the information that was submitted by the ABA provider. An authorization for service delivery is also made during the call. Participants will include: Magellan, the family member, and the agency providing ABA services. Magellan agreed to coordinate and include the family s care coordination team in these calls. Family members commented that the process is important as family members are an integral part of their child s care. The RAP leaders met with Magellan representatives on March 14, They discussed collaboration efforts between RAP and Magellan. Magellan offered to host a webinar with RAP leaders prior to April 1 4 P a g e

5 to assure a smooth implementation of the ASP. CHSC has developed materials to help publicize both RAP and the Fund. Magellan has requested collaboration with publicity efforts and will work with CHSC RAP leaders to coordinate. Both Magellan and CHSC will ensure that family members know about ASP and the application guidelines. Families can choose whether they want care coordination services from the RAP and/or the Pediatric Integrated Health Home. Summary Family participation is a requirement of the program mandated by the legislation. Family Participation will be integrated into the treatment plan. Magellan has tools in place to inform and document family participation. This will be reviewed during the care management calls. School Engagement by ABA Provider: Measurement Tool and Evaluation Provider engagement with the schools is mandated by the ASP per administrative rules. The treatment plan must identify the specific activities taken by the ASP service provider to engage the eligible individual s school. The goal is to coordinate the interventions for the child in all settings, including school and outside of school. Discussion Both family participation, as discussed previously and provider engagement with the schools will be integrated into the treatment plan. Per Magellan, the care management call will address what coordination is occurring and pertinent to the schools. Panel members noted that school engagement becomes especially important during the transition to discharge. The ABA provider is not responsible for the actions of the school. Concerns were noted as schools in Iowa have local control. For instance, if a child has an Individualized Education Plan (IEP), the IEP team has to consider recommended interventions, but the IEP team is not required to implement the suggested intervention. The requirement for the ASP in this regard is that the treatment plan must identify specific activities taken by the ASD service provider to engage the eligible individual s school and the results of such action. The intent of the legislation was to have meaningful involvement with the school. The legislation specifically mandated that efforts be made to involve the schools. The Panel noted that when outcomes are evaluated, progress monitoring should indicate whether schools are implementing the recommended interventions made by the ABA provider. The most effective course is to have the recommendations implemented in both settings, in and outside of school. 5 P a g e

6 Concerns were expressed that schools throughout Iowa need training about the ASP. CHSC, DE and Magellan will communicate and coordinate efforts to design communications at the schools. The DE has hired an Autism Consultant, Wendy Trotter. She will begin in May She comes from Easter Seals in Illinois. Sean Casey will provide additional information in the future. It was noted that families are also trying to learn about the ASP. CHSC s RAP teams are available to assist families and publicize the ASP. Thirteen RAP teams have been created. At each site, CHSC has delegated a portion of the time of an Advanced Registered Nurse Practitioner (ARNP), a Registered Nurse (RN) and a Family Navigator (FN). CHSC has also developed public relations materials regarding the RAP. Peggy Swails, RAP Coordinator, works under CHSC s contract with the DE. Peggy will be developing relationships with the staff at the DE and other stakeholders. Although there will not be any training provided by the DE before April 1 st regarding ASP, Peggy Swails will meet with Sean Casey and Barb Guy to assist and coordinate outreach efforts. Summary Provider engagement with the schools is mandated by the ASP legislation. The goal is that meaningful attempts are made to provide interventions in the school and ABA settings. Magellan has tools in place to document the ABA providers engagement with the schools. Specific activities will be listed in the treatment plan for ABA services. Telehealth Infrastructure for ABA Services Iowa is a rural state with limited access to ABA services. There is nothing in the code or rules that would restrict the use of telehealth services in the ASP. Discussion Iowa has approximately 50 credentialed ABA providers, but not all providers work with children with ASD. The rural nature of the state also creates a need to explore the use of telehealth more broadly. Panel members cautioned that providers utilizing telehealth for their front line therapists must be held to the same requirements outlined in the statute. The panel was assured that there are requirements to become a provider for the network to ensure the quality of services. The credentialing of providers is Magellan s responsibility. Reimbursement for ABA via telehealth should be paid at the same rate as direct ABA services. On Magellan s website is a list of current providers who have signed a contract to be an approved provider. As the network expands, this list will be updated. Two examples of acceptable situations for the use of telehealth were for contacting the family or contacting the schools. 6 P a g e

7 The Panel questioned if telehealth could be utilized for both styles of ABA delivery: ABA with the aim of reducing challenging behaviors; and ABA focused on general skill acquisition, e.g., the Lovaas style. One suggestion for direct ABA provision using telehealth was BCaBA s supervision of a paraprofessional who is working directly with the child. It was expressed that ABA is very hands-on and requires direct contact in the immediate environment. It is less clear how telehealth can be used for the direct provision of ABA service. An expert in the use of telehealth may be required to train providers on using telehealth effectively. The University of Iowa has several federally funded projects which primarily focus on challenging behavior. They have used telehealth to train parents, either from a clinic to clinic connection utilizing CHSC s regional centers or to provide services from their clinics to families in their homes. They have been successful in reducing challenging behaviors by over 90% and have several publications on the subject (see Attachment 2). Magellan cautioned the Panel that measurement and outcomes of ABA have some universality but it is important to ensure that proximity to the network remains. For example, it would not be advisable to implement telehealth which would permit ABA providers far removed from Iowa to provide services without ever directly having personal contact with the child or family. Summary The Panel recommends that the delivery of ABA services via telehealth be implemented as part of the ASP as is described in the law that authorizes the design and funding of the program. Reimbursement for ABA via telehealth should be provided to any individual provider or organization that is included in Magellan s provider network for the ASP and has appropriate expertise in the delivery of ABA through telehealth (see Attachment 2). Note that the attachment was previously distributed to all Iowa legislators by Rep. Heaton and Sen. Beall. Public Comment Clarity was requested as to whether exceptions to qualify for the Fund can be made for children who cannot locate a BHIS provider in their geographic region (e.g., Is a 5 year old child who receives Medicaid and lives in an area that does not have access to a BHIS provider eligible for the fund?). The response from DHS was no. The ASP Fund needs to be preserved for children who do not have access to ABA services in any other way. Pier Center noted it is eligible to provide services for the ASP, but not for BHIS funding. No new providers are being accepted into the network of BHIS providers. The Pier Center noted that they have requested an ad hoc exception but until they are approved as part of the network, they cannot serve families with Medicaid. Pier Center reports they have started a waiting list. Magellan stated that there have been some discussions about IME revisiting ABA as part of Medicaid. 7 P a g e

8 Discussion ensued regarding necessity of funding and obstacles that may create barriers for Iowa to attract quality providers. Many Panel members signed off at the regularly scheduled meeting end time of 10:30 am, including the representatives from Magellan. However, several Panel members remained on the call and discussed additional issues relating to clinical and billing processes. During these discussions, the consensus was that there needs to be further discussion between Magellan representatives and the Panel members. Several providers indicated their contracts have yet to be signed due to these issues and questions. The group is hoping to clarify these unresolved issues prior to April 1, 2014, when the applications for the ASP can be submitted to Magellan. Summary Update: Barb Khal contacted Steve Johnson following the conference call to address contractual concerns between providers and Magellan. Steve reports that Magellan will conduct phone calls with provider agencies on an individual basis to discuss their specific questions and concerns. Given the importance of this information and the time constraints, it was decided to submit all specific questions directly related to Magellan s role as the Administrator to a representative with the CHSC team. CHSC will then compile and submit the questions accordingly to Magellan so they can prepare their responses. In a follow-up to the Panel, CHSC requested that questions be submitted to Peggy Swails at peggy-swails@uiowa.edu by the end of business day on Tuesday, March 25. Attachments to the Minutes Attachment 1: Questions submitted to Magellan from the Expert Panel Members Attachment 2: Telehealth ABA Service Delivery in Iowa 8 P a g e

9 Recommended Statements from the Expert Panel to Magellan and DHS 1. Assessment: The Expert Panel strongly recommends the need for further review to determine the most valid and efficient methods for evaluating the progress and outcomes for individual children receiving ABA services through the Autism Support Program. The SKILLS assessment tool proposed by Magellan is intimately tied to an intervention curriculum developed and used by the CARD Center in California. This curriculum lacks sufficient scientific evidence to support its widespread use. The SKILLS assessment was not designed to be used independently from the curriculum, and this curriculum is not being used by any of the ABA providers in the Magellan network in Iowa and is not backed by sufficient evidence of effectiveness to support its use in Iowa in the future. Despite the significant concerns of the Expert Panel regarding the use of the ATEC as an ABA outcome tool, the panel recommends continuing to use the ATEC until a better evidence-based outcome tool (or tools) can be selected through collaborative discussions between Magellan and the Expert Panel. 2. ABA Telehealth: The Expert Panel recommends that the delivery of ABA services via telehealth be implemented as part of the Autism Support Program as is described in the law that authorizes the design and funding of the program. Reimbursement for ABA via telehealth should be provided to any individual provider or organization that is included in Magellan s provider network for the Autism Support Program and has appropriate expertise in the delivery of ABA through telehealth. (Additional background information on ABA telehealth in Iowa is provided in the separate document attached entitled, Telehealth ABA Service Delivery in Iowa 2-14.pdf, from the UI Children s Hospital. This information has already been distributed to all Iowa legislators by Rep. Heaton and Sen. Beall.) Contractual Questions Assessment (1) What is included in assessment? a) Psychological testing? b) Formal Functional Behavior Analysis? c) Informal functional assessment? d) Preference assessments? e) Skills assessment? VB-Mapp, ABLLS f) ATEC? g) Other standardized assessments such as Vineland? (2) Do we need prior authorization to conduct the assessment? a) Submission of treatment plan and outcomes tool to Magellan within 15 days of first visit (3) Do we have 15 days to do the assessment and then submit? Oversight (4) What is included in supervision? a) Direct oversight of staff working with child? b) Video oversight? c) Team trainings in group? If child specific? Not child specific? d) Team/Individual trainings in role play and in live environments? e) Is it to be billed to specific child s code? 1 P age

10 (5) Can you supervise more than one program/child/staff at a time? a) Supervision of a social skills group? b) Does social skills group require the same oversight by BCBA (2:10 hours provided)? c) Is this specifically supervision of child s program or staff supervision? (6) What else is included in oversight and management? a) Writing or revising the treatment plan? b) Data review and compilation? c) Program/procedure/data collection system development for goals for specific child s program? d) Overview of effectiveness of a strategy (e.g., comparison of video modeling vs direct instruction for a specific child) e) Review of other documentation of the service (e.g., reviewing service notes written about a child s sessions this week) f) Probing for new targets g) Development of instructional materials? h) Collaboration with other professionals involved in the child s learning (SLP, School staff, etc.)? (7) If a BCBA is providing training during a session with the college-degreed front-line professional, are both contact units billable? a) The contract documents include wording under criteria for support staff that says supervision can be by a BCaBA. There is no rate allocation for this service in the rate schedule. b) Is there a maximum number of hours that can be billed in a single day? If so, does this include both BCBA and front-line hours? Parent Training (8) Is parent training still a required component? a) Are we limited by location for parent training? (Home is used in the code as a descriptor) b) Is all parenting training done one-on-one? c) Confirm that parent training can be done by the support staff and the BCaBA as well as the behavior analyst. (9) Define Home Care Training to Client The Role of the BCaBA (10) Should be able to conduct anything that the BCBA can do, with the possible exception of assessments, as long as adequate supervision is being provided by the behavior analyst. a) If we want to develop more BCBA s in Iowa,it would be important to offer a stepping stone that encourages people to work toward that status by recognizing the value of a BCaBA. Site based vs. other settings (11) Are there any rule requirements for the physical location where the service is provided? a) Is there any oversight regarding the location? b) Is there a process which authorizes the location? 2 P age

11 Determining Eligibility (12) Describe ways to assist families in determining eligibility a) In what way(s) must a child demonstrate they are not eligible for Medicaid services? b) If a parent has not accessed waiver service for the child, would the child be eligible? c) If a child is on a wait list for waiver, is the child eligible? Questions about processes (13) Will there be a 30-day plan and then 6-month plan? a) Will the assessment be part of the 30 days? (14) School engagement is a required component. a) Where does that go in the billing process? b) Does the provider bill for oversight when working with the school? c) Are there restrictions as to what content can be taught through this service? d) What are the rules for documentation? Assessment tool(s) (15) When is the assessment initiated? a) How frequently is the assessment conducted? b) What is the cost of the assessment and who pays for the assessment cost? c) Who is responsible for training staff on how to use the assessment? d) What is the cost of the training? e) If this is part of the payment under ASP, who collects the co-pay portion of this service? 3 P age

12 Telehealth is Needed to Increase Access to Behavioral Services Statewide for Children with Autism Prevalence of Autism Spectrum Disorders 1 in 88 children have an autism spectrum disorder, with the prevalence rates higher for boys (1:54) than girls (1:252) More than 8,200 Iowa children under the age of 18 are estimated to have autism Why is There a Problem in Obtaining Behavioral Services? Applied Behavior Analysis (ABA) is the most effective evidence-based treatment for autism. However, There are currently only 52 Board Certified Behavior Analysts (BCBAs) and Board Certified Assistant Behavior Analysts (BCaBAs) in Iowa. 42 of the 52 providers (80%) are located in urban areas (Cedar Rapids/Iowa City, Des Moines, Davenport, Dubuque, and Sioux City). 36% of the Iowa population resides in rural areas. Lack of access to service providers for children in rural areas often results in long delays in receiving needed services, families being foreced to absorb significant costs to obtain services from out-of-state providers, or children going without needed services (Baker et al., 2003; Wacker et al., 2013) Telehealth Services Can Help Solve the Problem Community-based, person-centered services that are delivered locally form the foundation of Iowa s MHDS re-design and the requirements of the Olmstead v. L.C. Supreme Court decision. However, local ABA services are not available in most parts of the state. Section 225D.2 of the Iowa Code creates the Iowa Autism Support Program and establishes that telehealth may be used in delivering and coordinating interventions with appropriate providers for children and families. However, access to behavioral telehealth requires overcoming barriers related to lack of trained providers and inconsistent reimbursement for care by psychologists and BCBAs. Fast Facts about Behavioral Telehealth What is telehealth? o Use of electronic information and telecommunications technologies to support long-distance clinical health care, patient and professional health-related education, public health and health administration ( For applied behavior analysis for autism, how has telehealth been used? o Research conducted by several research teams has evaluated the effects of conducting ABA procedures (specifically functional analyses and functional communication training) via telehealth (Barretto et al., 2006; Gibson et al., 2010; Machalicek et al., 2009; Suess et al., 2013; Wacker et al., 2013a; Wacker et al., 2013b) What are the results of ABA telehealth research? o Studies show that behavioral assessment and treatment can be conducted effectively via a telehealth system to reduce severe challenging behavior and increase social communication. o The Wacker et al. studies compared the effects of ABA procedures conducted directly in the home versus via telehealth and showed comparable results. This makes telehealth a practical option for providing urgently needed behavioral services.

13 What are the major benefits of providing services via telehealth? o Increased Access In the Wacker et al. studies, participants in the telehealth group lived within a 50-mile radius of a Child Health Specialty Clinic spread throughout the state of Iowa while the inhome group lived within a 100-mile radius of the behavior consultant s office o Cost-effectiveness According to the Wacker et al. studies, conducting behavioral services via telehealth saved substantial costs by reducing travel time and consultant time. These cost savings can be achieved using telehealth to provide behavior training to parents either in a local clinic or in the family home. Costs Service In Person Service Via Telehealth Parent s Time Per Week 1 hour 1.5 hours Behavior Consultant s Time Per Week 8 hours 1 hour Family Assistant s Time Per Week (at CHSC clinic) N/A 1.5 hours Cost Per Child Per Week (for direct care staff) $291 $60 Cost Per Child for 6 Months of Weekly Behavioral $6,984 $1,440 Services What are other states doing in relation to providing services via telehealth? o 44 states have some form of reimbursement for telehealth in Medicaid, Iowa is NOT one of them (Center for Connected Health Policy, 2013) o 21 states have some form of reimbursement for telehealth via private coverage, Iowa is NOT one of them (American Telemedicine Association, 2014) How have other states worded telehealth legislation? ( o Example from Missouri: Each health carrier or health benefit plan that offers or issues health benefit plans which are delivered, issued for delivery, continued, or renewed in this state on or after January 1, 2014, shall not deny coverage for a health care service on the basis that the health service is provided through telehealth if the same service would be covered if provided through face-to-face diagnosis, consultation, or treatment. o Example from Missouri: A health carrier shall not be required to reimburse a telehealth provider or a consulting provider for site origination fees or costs for the provision of telehealth services; however, subject to correct coding, a health carrier shall reimburse a health care provider for the diagnosis, consultation, or treatment of an insured or enrollee when the health care service is delivered through telehealth on the same basis that the health carrier covers the service when it is delivered in person. For additional information about behavioral telehealth, please contact: Dr. Kelly Schieltz, Postdoctoral Fellow at the University of Iowa Children s Hospital kelly-schieltz@uiowa.edu