Leveraging Technology to Create Access to High- Quality ABA Treatment Options Joy S. Pollard, Ph.D., BCBA-D, LBA Behavior Change Institute Stanford University School of Medicine New Model of Care - Telehealth Delivery of health-related services and information via telecommunication technologies Overcome provider shortages Increase access to specialty providers Reduce health care costs Enhance continuity of care Promote consistency Tele-mentoring/capacity building Reduce isolation experienced by rural providers ABA Applications Participants Teachers Parents Technicians Teaching Method FCT DTT Preference Assessments Setting Clinic Home School 1
Telehealth Practice Guidelines Purpose Education tool to support behavior analytic organizations Overview Telehealth Service Models Ethical telehealth development plan Protect consumers and reduce liability Enhance family care TeleHealth Delivery Mechanisms Synchronous Live, two-way interaction Immediate feedback Modify treatment protocols Asynchronous Recorded Feedback delayed Capture low-frequency behaviors Time to upload and transmit videos Mobile Health Mobile Communication Devices Generalization Self-reporting 2
3-months 9-months Clinical Infrastructure: Targeted Education & Training Practitioner training Telehealth competence Software Troubleshooting equipment 3
Clinical Infrastructure: Targeted Education & Training Technology Placement Placed high location (e.g., Bookshelf) Corner of Room Targeted Education & Training - Family Experience Practitioner rapport building Smile Introductions Laugh! Learn Names Eye Contact 4
Targeted Education & Training - Family Experience Screen configuration Camera position Lighting Background Privacy & Confidentiality Targeted Education & Training Family Experience Screen configuration Camera position Targeted Education & Training Family Experience Lighting Background 5
Privacy & Confidentiality - Telehealth Home Office TeleHealth Home Office Lock office door Computer screen face away door White noise machine Clinician headsets Videoconference security Informed Consent Targeted Education & Training Privacy & Confidentiality Policies & Safeguards - Determining Appropriate Clients Clinically appropriate to accept client Therapeutically beneficial environment Therapeutic materials inventory Systems of support available within community 6
Policies & Safeguards - Determining Appropriate Clients Clinically appropriate to accept client Child size and severity of challenging behavior Environmental safety checklist On-site support staff Policies & Safeguards - Determining Appropriate Clients Patient Safety Pre-established crisis plan Local Crisis Intervention Emergency response numbers Emergency response time Protocols for terminating telehealth and referring to local services Policies & Safeguards - Determining Appropriate Clients 7
Sociocultural Considerations - Rural Communities Financial Barriers Transportation Barriers Treatment Monitoring Community-Based Services Increased risk for pre-existing relationships Limited services (e.g., family therapy, respite) Sociocultural Considerations - Rural Communities Sociocultural Considerations - Rural Communities 8
Telehealth mitigate barriers Family Therapy Sibling Therapy Bilingual clinicians Improve communication accuracy Clinician Accessibility Toilet Training Sleeping Protocols Severe Challenging Behavior Toilet Training Age: 4 VB-MAPP: Level 3 Challenge: Recognized when needed have bowl movements Corner of room when needed to have a BM and say Please don t look Constipation 9
Toilet Training Challenging behavior Screaming Hitting Running away/hiding under bed Additional Challenges: High levels parent stress Inconsistent implementation protocol Disagreement between caregivers Variable parent work schedule Toilet Training Telehealth Benefits Clinician scheduled support 7:00pm every evening No travel/commute: Available any hour of the evening between 6:00-9:00pm when client typically voided Improved parent comfort Improved parent implementation Toilet Training If not for Telehealth, I wouldn't have been able to provide this level of accessibility. I was able to be on the video conference with a moment's notice to support the family through crisis moments 10
Sleep Protocols Age: 5 VB-MAPP: Level 3 Challenge: Child not falling asleep by himself at night or during nap Would wake anytime caregiver moved and tantrum Sleep Protocols Challenging Behavior: High pitched screaming Tipping over furniture Climbing on furniture Low treatment fidelity Sleep Protocols High levels of caregiver stress Mother: difficult work schedule as a nurse Grandmother: main daytime caregiver had difficulty implementing protocols Father: not participating in treatment 11
Sleep Protocols Protocol Selected a week to focus on sleep protocol Each night required modifications based on progress night before Parent coaching available during most challenging times (11:00pm-3:00am) Sleep Protocols Telehealth Benefits Family Improved parent comfort & support Parent coaching used once during week Observe environmental modifications that would not have been able to identify over the phone Accessibility not been possible without overnight stays Utilize chat feature minimize noise Child successfully sleeping on his own within 10 days Sleep Protocols Telehealth Benefits Clinician Improved satisfaction with ability to impact treatment outcomes High level of support without impacting own quality of life 12
Sleep Protocols Something I'd also like to highlight is that it was really reinforcing, as a clinician, to be able to support the family in this manner. Prior to working via telehealth, I wasn't able to implement sleep protocols that were this effective. I'm also now more empowered through my ability to provide high levels of treatment via telehealth. Summary Telehealth offers opportunities to enhance care for families in rural/underserved areas Opportunity enhance care urban areas Strategies for enhancing the family experience immediately applied in practice Research Family Experience/Continued Needs Clinician rapport building and parent involvement via telehealth Systems monitoring quality of care References 1. American Psychological Association. (2013). Guidelines for the Practice of Telepsychology. Retrieved from http://www.apa.org/practice/guidelines/telepsychology.aspx 2. American Telemedicine Association. (2014). Core operational guidelines for telehealth services involving provider-patient interactions. Retrieved from http://www.americantelemed.org/docs/default-source/standards/core-operational-guidelinesfortelehealthservices.pdf?sfvrsn!6 3. Behavior Analyst Certification Board (BACB). (2014b). Professional and ethical compliance code for behavior analysts. Retrieved from http:// bacb.com/wp-content/uploads/2015/08/150 824- compliance-code-english.pdf 4. Bolin, J. N., Bellamy, G. R., Ferdinand, A. O.,Vuong, A. M., Kash, B. A., Schulze, A., & Helduser, J. W. (2015). Rural Healthy People 2020: New decade, same challenges. The Journal of Rural Health, 31, 326 333. 5. Health Resources and Services Administration (HRSA): Bureau of Health Professionals. 6. World Health Organization. (2007). Global re- sources for persons with intellectual disabilities. Retrieved on March 15, 2013, http://www.who.int/ mental_health/evidence/atlas_id_2007.pdf 13
Joy Pollard, Ph.D., BCBA-D joyp8@stanford.edu jpollard@behaviorchangeinstitute.com 14