Michigan Department of Health and Human Services (MDHHS) Behavioral Health and Developmental Disabilities Administration Wraparound Annual Conference: June 2017
2 Overview Autism Program Overview Insurance Reform Autism Spectrum Disorder Medicaid Autism ABA Policy and Services Applied Behavior Analysis
3 MDHHS Autism Program Established in 2013 as part of the Behavioral Health and Developmental Disabilities Administration Section consists of behavior specialists, data and supports analysts, administrative assistant, and manager Support autism services throughout Michigan
4 MDHHS Autism Program Manage and provide oversight of Medicaid covered ABA services for individuals with autism Liaison to external stakeholders including Michigan Departments, advocacy organizations and universities Support families and agencies in their challenges related to services
5 MDHHS Autism Program Manage MDHHS autism contracts Autism Alliance of Michigan Michigan universities Coordinate and provide state and regional autism trainings for providers, specialty organizations and conferences Provide support to the Autism Council
6 MDHHS Autism Program 2017 University Autism Contracts $1M CMU, MSU, Oakland, U of M-Dearborn, Wayne State, and WMU 2017 Autism Services Contract Autism Alliance of Michigan Autism Safety Training MI Navigator Call (877)-463-AAOM or email navigator@aaomi.org
7 Michigan ABA Degree Programs $1M in autism university contracts for FY17 Michigan now has 10 universities offering ABA degree programs (up from 2 in 2012) 150 students in Michigan ABA university programs
8 Community Collaborations & Outreach Families Physician practices Speech, Occupational and Physical Therapy providers Local Public Health Local Department of Health and Human Services Local advocacy networks Early On Daycare centers Schools / ISDs Vocational Technical Centers/Programs Emergency responders Community leaders Universities and Community Colleges PIHP/CMH agency staff
9 Autism Insurance Reform Pre - 2012 Autism Legislation: It was very challenging to obtain insurance approval for services to assist children and adolescents with autism. There were parents reporting they did not want to have an autism diagnosis for their child because it may mean not receiving services. Physicians struggled with recommendations for treatment because of the lack of insurance benefits and resources to assist families. Applied Behavior Analysis was an unknown service and/or not an option for many families.
10 Autism Insurance Reform 2012 Autism Legislation mandated for-profit, commercial, HMO, and non-profit health insurance companies regulated by the state of Michigan to cover services related to the diagnosis and treatment of autism spectrum disorders (ASD) to its insured members through 18 years of age. Treatment must be evidenced-based and include the following care as determined by a licensed physician or a licensed psychologist: Behavioral health treatment (applied behavior analysis) Therapeutic care (speech therapy, occupational therapy) Pharmacy care Psychiatric care Psychological care
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12 Autism Facts Fastest growing developmental disability in the US CDC reports 1:68 children diagnosed with ASD
13 Autism Facts 65 percent of students with autism are involved in bullying situations Autism may or may not be physically obvious 50 percent of those with autism are non-verbal Little to no vocal speech May communicate by non-vocal means such as using pictures or communication device/app May have very little to no appropriate communication all together
Michigan Autism Facts 2016 2017 school year: 19,632 children in Michigan with an IEP related to autism (increase of 886 from previous school year)
15 Autism Spectrum Disorder DSM-5 examines abilities in two categories: 1. Substantial functional impairments in social communication and social interaction 2. Substantial restricted, repetitive and stereotyped patterns of behavior, interests, and activities
16 Autism Spectrum Disorder Functional impairments in social communication and social interaction: Lack of social interest in others Minimal to no appropriate play skills Poor eye contact Deficits in verbal language and communication Lack of shared interests and emotions Difficulty developing, maintaining and understanding relationships Challenge understanding social norms
17 Autism Spectrum Disorder Restricted, repetitive patterns of behavior: Difficulty with flexibility, rigid behavior Ritualized patterns of behavior Minor changes in the environment result in extreme distress Fixated interests Stereotyped motor movements or speech patterns Hyper- or hypo- reactivity to sensory input Pain, temperature, sounds, textures, smell, touch, visual
18 Autism Spectrum Disorder Often co-existing concerns or diagnoses: Mental Health or Psychiatric Disorders, such as: Anxiety or Stress Disorder Mood Disorder Obsessive-Compulsive Disorder ADHD Depression
19 Autism Spectrum Disorder Co-existing concerns or diagnoses, cont d: Impairments with fine and/or gross motor skills Intellectual disability Attention difficulties Sleep difficulties Seizure disorder Feeding disorder
Autism in the Media 20
21 Medicaid Applied Behavior Analysis Centers for Medicare & Medicaid Services (CMS) issued an informational bulletin on July 7, 2014 to clarify Medicaid coverage of services for children with Autism Spectrum Disorder (ASD) under the Early Periodic Screening Diagnosis and Treatment (EPSDT) benefit MDHHS submitted a request to amend the current state plan on August 19, 2015 This State Plan Amendment (SPA) to include ABA as a EPSDT benefit was approved by CMS effective January 1, 2016
22 Children and Adults with ASD Section Michigan Department of Health and Human Services No mandated insurance coverage for diagnosis and treatment of ASD Michigan s Autism Insurance Reform effective MDHHS Children and Adults with ASD Section established Medicaid Autism ABA coverage for kids 18 mos. 5 yrs. policy effective Medicaid Autism ABA coverage for kids birth 20 yrs. policy effective Pre - 2012 October 15, 2012 February 2013 April 1, 2013 January 1, 2016
23 Michigan Medicaid System Mental health and developmental disability services in Michigan are delivered through Prepaid Inpatient Health Plans (PIHP) and/or contracted providers of Community Mental Health Service Programs (CMHSPs) 10 Regional PIHPs 46 CMHSPs Covering all 83 counties
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25 Michigan Medicaid System: Autism Services Medicaid Health Plans Medical/physical evaluations Screening for ASD Speech, occupational and physical therapy Prepaid Inpatient Health Plan (PIHP) Comprehensive diagnostic evaluations Applied Behavior Analysis (ABA) services Medically necessary mental health specialty services (respite, community living supports, supports coordination, supported employment)
26 Michigan Medicaid ABA Services by Region 4,685 Total Enrolled (6/26/17) 1000 800 550 600 555 569 400 200 0 225 507 216 187 180 198 137 276 295 178 42 109 117 97 95 134 33 Region 1 Region 2 Region 3 Region 4 Region 5 Region 6 Region 7 Region 8 Region 9 Region 10 Age 0-5 Age 6-20
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28 Michigan Medicaid ABA Services ABA Service Steps 1. Screening for ASD 2. Comprehensive Diagnostic Evaluation 3. Development of the Individual Plan of Service 4. Start ABA
29 Michigan Medicaid ABA Services Step 4: Begin ABA services working 1:1 or in a small group with the goals outlined in the individual's plan. Services are provided by trained Behavior Technicians, and are supervised by Board Certified Behavior Analysts (BCBA) or other qualified provider with a minimum of a master s degree and who is pursuing BCBA certification by 9/30/2020
30 ABA Service Structure Board Certified Behavior Analyst (BCBA or BCBA-D) Board Certified Assistant Behavior Analyst (BCaBA) Licensed Psychologist (LP) Limited Licensed Psychologist (LLP) Qualified Behavioral Health Professional (QBHP) Behavior Technician (BT) BCBA or other qualified professional
31 ABA Services: Behavioral Intervention ABA services include a variety of behavioral interventions which have been identified as evidence-based by nationally recognized research reviews and/or other nationally recognized scientific and clinical evidence
32 ABA Services: Behavioral Intervention BCBA or other qualified provider selects and adapts one or more interventions as appropriate for each individual Interventions selected based on goals identified by the family in person-centered planning process, behavioral assessment, behavioral plan of care, and ongoing analysis of data collected by the BCBA or other qualified provider Behavior Technician: Direct intervention with individual receiving services May be 1:1, or small group format Some individuals may require 2:1 BT-to-child ratio Implement ABA treatment plan with oversight from BCBA or other qualified provider
33 ABA Service Providers BCBA additional responsibilities: Family training Collaboration with other service providers Make clinical data-based recommendations May supervise other BCBAs, BCaBAs, or qualified providers
34 Michigan Medicaid ABA Services: Provider Capacity Michigan:602 total Board Certified Behavior Analysts (BCBA/ BCBA-D) and Board Certified Assistant Behavior Analysts (BCaBA) Michigan Medicaid: 239 BCBAs, 26 BCaBAs (January 2017) BCBAs may also be providing some services within CMH/PIHP network outside of ABA policy 59 agencies contracting with 37 CMHs 25 CMH centers for ABA
35 Michigan BCBA & BCaBA Provider Capacity #11
36 Applied Behavior Analysis (ABA) Applied Behavior Analysis, or ABA, is the science of behavior change in relation to socially significant behavior Uses the principles of science to examine the relationship between behavior and the environment What happens prior to occurrence of behavior What happens immediately following occurrence of behavior Focus on function of behavior
37 Applied Behavior Analysis (ABA): Key Points Concepts date back as far as 1913 ABA founded by B.F. Skinner in 1938 More widely examined and formally defined in 1968
38 Applied Behavior Analysis (ABA): Key Points Change environment to change behavior Consequences shape behavior Overall goal is to help each learner develop skills that will enable them to live their most independent and successful life Breaks down larger, more complex skills into smaller teachable steps Increase or decrease frequency/ duration/ intensity of a certain behavior Program and goals are different for each individual Is delivered by parents, behavior technicians, friends, peers, siblings, etc. in one-on-one or group formats Can be provided in a center, daycare, home, community, clinic, etc.
39 Applied Behavior Analysis (ABA): Key Points While ABA is not isolated for use with persons diagnosed with ASD, it has been identified as the most effective evidence-based practice for this population Behavior of living, learning organisms, not just individuals with autism Can be highly effective at any age Utilizes only those interventions supported by years of repeated scientific research Endorsed by U.S. Surgeon General and a number of other state and federal agencies
40 Applied Behavior Analysis (ABA): Key Points Interventions focus on principles related to learning and their use to bring about meaningful change Primarily utilizes positive support strategies: Positive reinforcement Imitation training Task analysis Functional analysis Visual supports PECS Video modeling Antecedent-based interventions Differential reinforcement
41 Applied Behavior Analysis (ABA) Possible goal areas: Appropriate and functional communication skills Daily living skills Following routines School readiness Imitation Social skills/ social relationships Employability skills Safety awareness Self-monitoring/ downtime skills Tolerating denial/ disappointment Should be specific to the learner and focus on generalizing skills learned to other people, stimuli, and environments
What does ABA look like? 42
43 Michigan Medicaid ABA Services June 26, 2017: 4,685 total individuals enrolled Age range: 1 year, 3 mos. 20 years, 11 months 2,859 individuals age 6 and older (61% of total enrolled) Ended November 2015 with 1,414 total enrolled individuals Increase in age range of those eligible for services equates to an increased need for: Collaboration with other providers and entities involved with the child and family (e.g. Wraparound coordinators, schools, speech/ot, hospitals, MRS) Coordination of services Flexibility in service options (location of service, hours, etc.) Increase in quantity and variety of training options for providers
44 ABA Services: Children age 6 and Older Often more significant rate and intensity of challenging behavior History of reinforcement Increased likelihood of history of trauma, including as a family unit May not have previously received any services, or not a robust option of services, in the past
A Mother s Journey 45
46 ABA Services: Children age 6 and Older Preparing for transitions: school, home, work, Hawthorn, hospital Relationships/puberty/sexuality May show more significant gap between the child s development and that of typical peers Functional daily living skills critical! Healthy lifestyle choices Family/caregiver involvement continues to be essential to success
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48 Michigan Medicaid ABA Goals: FY17 Continue to collaborate with other internal and external options regarding all appropriate and medically necessary services and supports for individuals with ASD Children s Waiver Program (CWP) Currently 45% have ASD diagnosis Habilitation (HAB) Supports Wavier Parent Support Partners Wraparound Family Support Subsidy Program 69% have ASD diagnosis Schools Hospitals Other agencies
49 Trainings and Resources Dr. Amanda Kelly, PhD, BCBA-D: Behaviorbabe www.behaviorbabe.com www.behaviorbabe.com/aba-videos
Quality ABA Programs 50
51 Resources Autism Alliance of Michigan www.autismallianceofmichigan.org Autism Society of Michigan www.autism-mi.org, 1-800-223-6722 Autism Speaks www.autismspeaks.org, 1-888-288-4762 Michigan Alliance for Families www.michiganallianceforfamilies.org, 1-800-552-4821 Michigan Department of Education www.michigan.gov/mde, www.michigan.gov/greatstart, 1-517-373-0485-Great Start 1-888-320-8384-Office of Special Education Michigan Department of Health and Human Services www.michigan.gov/mdhhs National Autism Center www.nationalautismcenter.org
www.michigan.gov/autism 52
Questions? 53
54 Thank you! Brie Elsasser, BCBA, Autism Transition Specialist elsasserb@michigan.gov James Grant, Autism Program Data Analyst grantj4@michigan.gov Lisa Grost, Autism Section Manager grostl@michigan.gov Kara Hart, Family Services and Supports Analyst hartk2@michigan.gov Morgan VanDenBerg, BCBA, Autism Behavioral Specialist vandenbergm@michigan.gov For additional information, please visit www.michigan.gov/autism