Leading ABA Software Provider CentralReach Names Health Tech Veteran, Cheryl Michael as Chief Product Officer

Despite the many social strides that have been made in 2018, it’s still far too difficult for adults with autism to find work. With prevalence rates now showing 1 in 40 people with autism, only 16 percent are in full-time paid positions, and those people can face criticism, isolation, and discrimination in the workplace.

People with autism deserve more opportunity for employment and fair treatment when they are employed. Furthermore, it’s possible that in minimizing employment opportunities for those with autism, we miss out on the benefits of a neurodiverse workforce, in which the range of differences in individual brain function and behavioral traits are regarded as part of a normal variation in the human population, and squander their unique talent.

In 2018, we have finally begun to see a national conversation budding around advocacy for adults with autism spectrum disorder (ASD) in the workplace, but simply put, adults with autism want and deserve more opportunities to exercise their strengths and feel engaged in the workplace.

At CentralReach, we’re working to create those opportunities through our ReachOut Program. While our clients support the lifespan of needs of children and adults with intellectual, developmental and physical disabilities, we saw the incredible need of creating employment opportunities for adults on the autism spectrum. CentralReach now employs an inclusive team that includes adults on the autism spectrum.

Beyond how the program proudly seeks to address the need for greater neurodiversity in the professional world, we are excited to see how it is making a significant difference in the everyday morale not only for the adults in the program, but for their families who have witnessed a major change in their adult children and have entirely new outlooks on what is possible for them in their adult lives.

Family members of participants in the ReachOut Program report that they have seen huge improvements in the quality of life of their adult children as a result of the program.

“My son was incredibly bored, disengaged, and longed for a job,” said one mother. It was difficult for her to imagine an independent future for him where so few job opportunities existed. After just six months in the program, he has a newfound sense of responsibility, a better relationship with his family, is helping to pay bills and opening up more. Another program participant has learned to drive and bought his own car since joining the program, and many more examples exist.

These individuals bring remarkable talent and work ethic to the team at CentralReach. We’re excited to continue to grow the ReachOut program in the coming year, and to advocate for the equal opportunity and treatment of adults with autism in the workplace.

Get ready for the 2019 CPT® codes for Adaptive Behavior Analysis. On September 5, 2018 the American Medical Association CPT Editorial Panel announced new CPT codes, including 10 new codes for ABA billing. These codes will take effect and be available for use effective January 1, 2019, but payors may implement them over various time schedules.

These new billing codes matter — especially since reimbursement for your hard work with clients depends on correct billing procedures. At CentralReach, we want to support you through this transition so you can continue to deliver superior ABA services. The following FAQs and resources were developed to jumpstart your preparation efforts and help you successfully adopt these new CPT codes.

Let’s get started!

What are CPT codes?

The Current Procedural Terminology (CPT) is a listing of terms and identifying codes used to report services and bill medical insurance providers. The CPT codes are issued, maintained, and copyrighted by the American Medical Association (AMA). Category I codes are permanent, and Category III codes are temporary (to allow for data collection in emerging fields).

What are the key differences between the new and old CPT codes for ABA?

• The set of codes is smaller (10 new versus 16 old)
• All codes are timed (minimum 15 minute increments)
• There are NO codes for indirect services. However, there may be allowance under code 97151 to “analyze and interpret” and to “prepare.”

How might my practice benefit from the new CPT codes?

The ABA codes previously fell under Category III (temporary). Now, most will be elevated to Category I (permanent). Status as Category I codes should lead to fewer denials of coverage due to rationale such as “experimental” or “unproven” or “not medically necessary.”

Also, HIPAA requires the implementation and use of Category I codes, so reimbursement may be easier.

How might the new CPT codes affect my revenue stream?

Implementation of the new codes may take a quarter or longer, depending on the payor. Your revenue stream may be disrupted. Additionally, you may need to negotiate new rates with your payors, since the codes do not cover indirect services.

How should I prepare for CPT code implementation?

It may take several months for your payor to adapt the new CPT codes, but you can get a jumpstart by taking the following steps:

1. Read the codes. While we recommend reading the full AMA CPT codes, the BACB provides a helpful crosswalk between the old and new codes. All 16 old codes were Category III codes, which were temporary. The 10 new codes include Category I codes (8 permanent codes) and Category III codes (2 temporary codes).
2. Attend a local or online training. Ensure your billing and clinical teams understand the services included under each code. Consider external trainings and resources such as Q&A sessions by the Association for Professional Behavior Analysis, and this recorded webinar by the Behavioral Health Center of Excellence.
3. Get in constant contact with your payors. Your provider network reps will be the most valuable point of contact, as they are employed by the insurance carriers and will have access to information specific to that carrier. Use CentralReach’s CPT Payor Checklist, a resource designed to help you get prepared to discuss key information about your payors’ timelines, authorizations, and new unit rates.
4. Continue to read your CentralReach emails. Look for a future webinar, implementation guide, and other aids to assist you with setting up the new CPT codes in your CentralReach account.  

Even though the implementation of the new CPT codes may create some challenges, CentralReach cares about your success and wants to see your practice thrive. Our platform has the flexibility and tools needed for you to smoothly implement these codes based on each of your payors’ specific requirements and timelines. Stay tuned for more information and resources on setting up your practice for 2019 CPT billing success!

Data functions as the lifeblood of behavior analysis. How does a practicing behavior analyst know if a particular intervention worked? Data. By what means do behavior analytic journals evaluate the effectiveness of experiments? Data. And in what manner do insurance companies assess the medical necessity for behavior analytic services? If you said data, right again!

Saying that data pervades behavior analysis would evoke nods of agreement from fellow behavior analysts (and maybe get you a beer at the conference if you said it enthusiastically). From Skinner to contemporary behavior analysis, data plays a pivotal role in basic research and applied practice.

Yet the sheer amount of data, along with questions about how to use it properly, can pose an overwhelming task for those entering the field. Functional assessment, single case design, and social validity all require data. And each of these behavioral applications uses data in significantly different ways.

Practitioners of the science of behavior (i.e., BCBAs and RBTs) often work directly with individuals. The BCBA conducts an assessment to determine areas of client needs and strengths. From the assessment data, a behavioral plan or program emerges. The behavior analyst or some other person (e.g., parent, registered behavioral technician, teacher) applies the intervention. Someone collects data and evaluates the intervention. However, collecting intervention data and analyzing assessment data sometimes get mixed up.

IVs and DVs

What people examine in science can vary considerably. But all scientific experiments share commonalities, including the concept of variables. Behavior analysis qualifies as a science and has several variables: independent variables, dependent variables, extraneous variables, confounding variables, and controlled variables.

The independent variable (IV) and the dependent variable (DV) form the basis of understanding a functional relation (i.e., one variable operates in a specific manner as a function of another variable).

The IV represents the event or variable the behavior analyst attempts to control. In applied practice, those IVs go by the name of “interventions.”

On the other hand, the DV constitutes a variable measured or tested. The DV will show what, if any, effects the IV has. Some example IVs and DVs in behavioral experiments include:

• A person may smoke fewer cigarettes (DV) when exposed to negative images portraying the terrible health effects of smoking (IV).
• A child may raise her hand more often in class (DV) when the teacher praises her for hand raising (IV).
• A telemarketer may keep a potential customer on the phone longer (DV) when he compliments the customer (IV).

The above examples illustrate the ease with which people can identify IVs and DVs. Yet, sometimes BCBAs have so much intervention and assessment data collected the lines between the two can blur.

Accuracy Building Interventions

Many behavioral interventions help learners acquire or become accurate with content: Discrete Trial Instruction (also called Discrete Trial Training, and Discrete Trial Teaching), Natural Environment Teaching, or Pivotal Response Treatment, to name a few.

Discrete Trial Instruction (DTI) has become a very popular accuracy building intervention, especially for those working with children with autism. With DTI the behavior analyst implements five components: 1. Presenting the discriminative stimulus; 2. Providing a temporary prompt if necessary; 3. Waiting for the behavior to occur; 4. Providing a reinforcer; and 5. Finishing with a brief pause before beginning the next trial (Mayer, Sulzer-Azaroff, & Wallace, 2012). One discrete trial would capture the application of steps 1 through 5.

A behavior analyst working with a client would have a goal for DTI. The intervention may target color identification, gross motor imitation, or matching kitchen utensils. The behavior analyst would use DTI to help the client attain the goal (often expressed in percent correct such as “The child will imitate 25 two-step chains of motor behavior with 80% accuracy on 2 out of 3 sessions across a variety of trainers”).

The question becomes, what data should the BCBA chart? A review of program books or program binders reveals at least two practices.

1. Some BCBAs will chart prompt levels. The prompt levels display prompt level data. Did the BCBA or RBT use physical (full or partial), modeling, gestural, verbal, or visual prompts?
2. BCBAs also record plus/minus (i.e., plus for a correct, a minus for incorrect response). The plus/minus data then convert to a percentage. For example, for five trials of matching yield 3 + (pluses) and 2 – (minuses). The data transform to 60% correct (3 correct out of 5 trials).

In both of the previous cases, the data tell a story. For the prompt levels, the data speak to BCBA or RBT behavior. Prompts come from the behavior analyst or behavior technician, and the data communicate what the adult did, not what the client did.

In the second example, the percent correct reports the accuracy of the client’s behavior. Specifically, how well or how accurately did the client perform with the set of discrete trials. The client participated in 5 discrete trials and correctly completed 3 of them (60% correct).

The recorded data on a graph will show trend, level, and variability of the data. But does any of the data answer the question, “Did the client meet his performance goal?” In other words, if a behavior analyst set a goal for a client that involved matching the five primary colors, do the recorded and graphed data answer the question?

The discrete trial data reflect progress with the accuracy building intervention itself, not necessary an independent assessment of client behavior.

Prompt data certainly do not get at how well a client can match the colors. And the discrete trial data reflect progress with the accuracy building intervention itself, not necessary an independent assessment of client behavior. What better options exist for data-scrupulous BCBAs and RBTs?

Data Options

The behavior analyst must first decide what data to chart. A review of the IVs and DVs may help. Imagine the following experimental question:

Will the accuracy building intervention discrete trial instruction improve a client’s ability to label five primary color swatches?

The previous experimental question offers options. The behavior analyst could record data on the IV (DTI), the DV (labeling the five primary colors), or both. Monitoring data on the DV or IV provides the behavior analyst and behavior tech with different information.

Table 1. Difference between data monitoring and analyzing the DV and IV

Table 1 does indicate advantages to recording, graphing, and analyzing data on the intervention (IV). And while the behavior analyst can learn about the intervention, not having any data on the DV means not knowing or understanding the effects on a client’s behavior. The behavior analyst must decide when, on what, and how much data to collect.

The decision to collect data doesn’t end with a data binder. In Precision Teaching, and embedded in Chartlytics software, several options for displaying data exist. The data display choices include Geometric Mean, First, Last, Stacked, Median, Summative, Best, and Worst. Each will provide different information for the DV and IV.

What does each option mean and when should a behavior analyst use each? Table 2 provides the answers. Deciding whether to use First, Best, or Geometric resides with the BCBA, RBT, and in some cases the client. Part of the data process involves different people looking at the data. The options for focusing in on one particular aspect of data display will depend on clinical circumstances.

Table 2. Definition of different points to display with advantages for each

Some other considerations include the following:

1. Many Precision Teachers use Best when employing “celeration aims.” Using First may also work best with setting daily improvement goals or aims.
2. Summative may help guard against multiple observers who pass data sheets around. Summative, as with duration data, have great utility when collected across more than one observer.
3. Remember, none of the previously mentioned data options matter if the BCBA or RBT collects only one data point per day.

The options for displaying intervention or measurement data make for different narratives. An example of multifaceted data appears in Figure 1. In one session an RBT ran six discrete trials that produced six sets of data points.

The data come from Chartlytics and show the accel and decel data for each trial, as well as the date, time, and person collecting the data. The recorded time provides an account of the pace with which the discrete trials occurred.

Figure 1. Data collected from one day of DTI

As shown in Figure 2 below, the BCBA can inspect the data with any of the previously mentioned options from Table 2. The graphical embodiment of the different “Points to Display” bring into focus the advantages listed in Table 2. Each chart segment has a Count Per Day vertical axis and Successive Calendar Days horizontal axis. The yellow aim bands convey the aim or goal for the intervention data (i.e., corrects = 20 and incorrects = 1 to 0).

Figure 2. Data represented with different options

Contrast the First and Last data displays. The First discrete trial had more incorrects than corrects while the Last flips the interpretation. The Geometric Mean and Median look very similar suggesting the mean or average for the data set lie at 4 or 5 corrects with 4 incorrects. The Best and Worst also drastically differ from each other, demonstrating the margins of improvement in the overall session. And Stacked paints a picture of all performance data on one view. The dispersal of corrects and incorrects reveal the variability and accuracy of discrete trials.

The data views in Figure 2 all speak to the IV or intervention (DTI) and not an independent assessment of the skill (labeling five primary colors). The ability to see all of the different displays and Points to Display contextualize the data. A behavior analyst gains understanding and insight when inspecting the data with different options.

Conclusion

Focusing on intervention data communicates how special conditions arranged by the behavior analyst may affect client behavior. The answer to how much client behavior does change becomes visible with an independent assessment of target behavior outside of the intervention. Having different options to display IV and DV data lead a data analyst (e.g., BCBA, RBT, client, stakeholder) down a fruitful path — discovering functional relations and what works best for each client.

Rick Kubina, Ph.D., BCBA-D
Director or Research, CentralReach
Professor, The Pennsylvania State University

References

Mayer, G. R., Sulzer-Azaroff, B., & Wallace, M. (2012). Behavior analysis for lasting change (2nd ed.). Cornwall-on-Hudson, NY: Sloan.

How do people achieve fluency, or true mastery with content area knowledge? For example, subjects like biology, statistics, physics, and history all possess their own vocabulary and concepts. Mastering abstract information such as the Linnaean Taxonomy (biology), probability (statistics), velocity (physics), or the branches of the government (American history) pose challenges to all students.

Many self-study methods exist which help students, or anyone, learn content. Researchers surveyed college students and discovered 11 different study strategies. After (1) rereading notes or the textbook and (2) engaging with practice problems, students used (3) flashcards (Karpicke, Buttler, & Roediger, 2009).

Many studies examine flashcards and their benefits. For instance, flashcards have helped young children learn to read better, aided medical students acquisition of terms, increased university students psychology exam scores, and even heightened patients understanding of diabetes and medication adherence.

Flashcards continue to attract the interest of researchers and practitioners due to their effectiveness, adaptability, and portability. Yet even with the previously stated benefits and popularity of flashcards, several factors limit their potential.

1. Almost all flashcard practice trials have no set timed practice interval. In other words, students will practice in an untimed manner.
2. No uniform performance goals exist. Students may practice to any accuracy criteria (e.g., 80%, 90%, or 100%).
3. Flashcards lack instructional design. Creating flashcards comes with no set of rules and each deck may contain widely discrepant methods for presenting target content.

The previously stated limitations make flashcards less effective. Students using the popular instructional tool may not learn content as effectively or efficiently as they like. Furthermore, retaining information and moving forward with more complicated content may occur at slower place or not at all. Fortunately, a method exists that addresses the flashcard limitations and has research demonstrating accelerated performance gains and learning.

Flashcards Morph into SAFMEDS

In 1978 Ogden Lindsley and Steve Graf pioneered a practice and assessment procedure called SAFMEDS (Potts, Eshleman, & Cooper, 1993). SAFMEDS stands for Say All Fast, a Minute Every Day, Shuffled. In other words, learners would:

• See the front of the card and Say the answer.
• Practice with the entire set or All of the content in the deck
• Go through the content Fast instead of slow to produce steeper celerations (faster learning).
• Practice with timed units such as a Minute or other consistent interval (e.g., 20 seconds).
• Assess progress and practice content Every Day instead of weekly or some other protracted time interval.
• Shuffle the deck instead of practicing the cards in order.

A host of studies demonstrate the superiority of SAFMEDS over flashcards and other self-study practices. Research indicates that SAFMEDS form an effective instructional and assessment method in many domains (View some examples under Resources at the bottom of this article).

A study conducted by your friendly blog author demonstrates how SAFMEDS can help behavior change agents improve understanding of important Precision Teaching concepts such as movement cycles.

SAFMEDS and Movement Cycles Study

Staff who work with people with disabilities such as autism, intellectual disabilities, and learning disabilities can employ Precision Teaching to enhance measurement, decision making, and communication of data among team members and stakeholders. Precision Teaching has four steps:Pinpoint, Record, Change, Try Again.

The first step consists of creating a pinpoint. And at the core of the pinpoint exists a movement cycle. Movement cycles contain two parts, an observable action described by an active verb and the object involved with the action.

The essence of every behavior originates in a movement cycle. Composing an essay would translate to “writes essay” (action verb + object involved with the action). “Aggression” could include several movement cycles: hits staff, slaps face, or scratches arm. And complex behavior such as “joint attention” may encompass aims gaze, points finger, or follows gaze.

Behavior change agents can profit from Precision Teaching knowledge such as movement cycles. A study, for example, demonstrated a 94% difference in detection accuracy when comparing movement cycles with operational definitions (i.e., 35% detection accuracy for operational definitions and 68% for movement cycles). Another experiment examined how behavior analysts and special education teachers working with students with autism would learn movement cycles with SAFMEDS.

In the Kubina, Yurich, Durica, & Healy (2016) study, the experimenters crafted two SAFMEDS decks with pictures depicting students behaving. The picture on the front of the card had a corresponding movement cycle (i.e., two words = active verb in the simple present tense + object receiving action) on the back of the card.

Figure 1 came from one of the decks. The student had a specific behavior participants needed to translate into a movement cycle. In the picture circles and arrows focused precision and indicated movement. The larger circle showed a hand while the smaller circle centered on two fingers. The arrow portrayed downward motion. Therefore, if the participant said “presses toy” the experimenters would score the response as correct.

Figure 1. A picture of a card taken from a movement cycle deck.

The participants made many competing, incorrect responses to the SAFMEDS cards at the beginning of the study. Participants might say the incorrect active verb (push instead of press), use the incorrect verb tense (pressing – present progressive tense – instead of presses – simple present tense), choose an incorrect object receiving the action (piano instead of key), or not use the proper format of action + object involved with the action (saying “He is hitting the doll”)

Additionally, the participants initially performed the assessment task slowly, with hesitations, or skipped answers outright. The following clip came from one participant’s baseline. The X’s in the video represent incorrect responses.

Across time the participants increased their frequency. The students practiced saying their answers and self-correcting their responses. The participants also practiced on the whole deck each day and shuffled it before a practice trial.

Figure 2 illustrates skill progress. In baseline, all of the participants made more incorrect (x) than correct (dot) answers. Furthermore, incorrect responses accelerated in baseline, a worsening condition for saying movement cycles.

Figure 2. A multiple baseline design for group 2 using Deck A movement cycles.

The experimenters applied the SAFMEDS intervention and the same learning pictures emerged: correct responses grew rapidly while incorrect responses decelerated quickly.

The transformation appeared remarkable. The following video captures one of the performances of a participant toward the end of the SAFMEDS intervention. The dots on the video mark each instance of a correct response made in time.

The SAFMEDS study had several important findings:

1. SAFMEDS offers a reliable method to help adult learners quickly gain competency with the targeted content (e.g., movement cycles);
2. Participants retained information across time;
3. SAFMEDS facilitates extension of content to novel content (i.e., Participants performed very well on a novel deck demonstrating transfer of learning);
4. A performance criterion or frequency aim can signal how fast and accurate participants must respond in order to achieve their goal; and
5. Analyzing performance results on a Standard Celeration Chart provides a wealth of visual and statistical information.

Conclusion

SAFMEDS supports the learning of simple and complex content for young and older learners. SAFMEDS also gives rise to important learning outcomes such as long-term retention and maintenance, application or extension of content to novel material, and social validity seen in meaningful participant behavior change and stakeholder satisfaction (see references below and in article).

Rick Kubina, Ph.D., BCBA-D

Director of Research, CentralReach

Professor of Special Education, The Pennsylvania State University

References

Karpicke, J. D., Butler, A. C., & Roediger III, H. L.(2009). Metacognitive strategies in student learning: Do students practice retrieval when they study on their own? Memory, 17, 471-479.

Kubina, R. M., Yurich, K. L., Durica, K. C., & Healy, N. M. (2016). Developing behavioral fluency with movement cycles using SAFMEDS. Journal of Behavioral Education, 25, 120-141.

Potts, L., Eshleman, J. W., & Cooper, J. O. (1993). Ogden R. Lindsley and the historical development of precision teaching. The Behavior Analyst, 16(2),177-189.

Resources

Branch, A., Hastings, R. P., Beverley, M. & Hughes, J. C. (2018). Increasing support staff fluency with the content of behaviour support plans: An application of precision teaching. Journal of Intellectual & Developmental Disability, 43, 213-222.

Chapman, S. S., Ewing, C. B., & Mozzoni, M. P. (2005). Precision teaching and fluency training across cognitive, physical, and academic tasks in children with traumatic brain injury: A multiple baseline study. Behavioral Interventions, 20, 37-49.

Mason, L. L., Rivera, C. J., & Arriaga, A. (2018). The effects of an avoidance contingency on postsecondary student SAFMEDS performance. European Journal of Behavior Analysis, 19, 62-71.

Peladeau, N., Forget, J., & Gagne, F. (2003). Effect of paced and unpaced practice on skill application and retention: How much is enough? American Educational Research Journal, 40, 769-801.