Therapeutic Consultation Behavioral Services: 2021 Updates - DBHDS Vision: A life of possibilities for all Virginians
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Therapeutic Consultation Behavioral
Services:
2021 Updates
DBHDS Vision: A life of possibilities for all VirginiansLearning goals
• Understand related compliance indicators from DOJ SA
• Understand key changes to associated regulations
– Expectations for service authorizations—effective 7/1
– Short term grace period until 6/30
• Understand next steps
– quality reviews from DBHDS’ LBA team
– Practice Guidelines
– Training for SC’s
Slide 2Housekeeping
• All attendees will be muted throughout
– Please use chat/comment box for questions
• Recording of training to capture questions
– DBHDS will provide answers to the chat in subsequent FAQ
– This webinar has slides that address most frequent comments
on Town Hall (end of training)
• ASRs throughout (learning goals checks)
• Quick intros & contact information
– Amy Braswell: amy.braswell@dbhds.virginia.gov
– Barry Seaver: barry.seaver@dbhds.virginia.gov
– Nathan Habel: nathan.habel@dbhds.virginia.gov
– Sharon Bonaventura: sharon.bonaventura@dbhds.virginia.gov
• Training also provided to SCs and service authorization team
Slide 3DOJ Compliance Indicators
• January 2020:
– Parties agreed upon 328 compliance indicators (CI’s)
– CI’s roll up to associated original SA provisions
– Several CI’s are specific to therapeutic consultation
behavioral services
https://dbhds.virginia.gov/assets/doc/settlement/indreview
/joint-filing-of-complete-set-of-agreed-compliance-
indicators-as-filed-01.14.20.pdf
Slide 4Most relevant indicators
• The Commonwealth will provide practice guidelines for behavior consultants on the minimum
elements that constitute an adequately designed behavioral program, the use of positive
behavior support practices, trauma informed care, and person centered practices.
• The permanent DD waiver regulations will include expectations for behavioral programming
and the structure of behavioral plans.
• 86% of individuals authorized for Therapeutic Consultation Services (behavioral supports)
receive, in accordance with the time frames set forth in the DD Waiver Regulations, A) a
functional behavior assessment; B) a plan for supports; C) training of family members and
providers providing care to the individual in implementing the plan for supports; and D)
monitoring of the plan for supports that includes data review and plan revision as necessary
until the Personal Support Team determines that the Therapeutic Consultation Service is no
longer needed
• The Commonwealth will provide the practice guidelines and a training program for case
managers regarding the minimum elements that constitute an adequately designed
behavioral program and what can be observed to determine whether the plan is
appropriately implemented.
• DBHDS will implement a quality review and improvement process that tracks authorization
for therapeutic consultation services provided by behavior consultants and assesses:
– 4) whether behavioral services are adhering to the practice guidelines issued by DBHDS
CI’s for behavioral services largely focus on aligning expectations for behavior
plans with industry standards, increasing access to services, and quality reviews to
ensure adequacy
Slide 5Learning goals check
The compliance indicators for behavioral services focus on:
a. Increasing access to behaviorists only
b. Technical assistance provided by DBHDS
c. Aligning expectations for BSPs with industry
standards, increasing access to services, and
quality assurance
d. Quality reviews and technical assistance from DBHDS
Slide 6Regulations
• Some minor changes
– (e.g. change BCBA to “Licensed Behavior Analyst), change “associate” to “assistant”
behavior analyst
– Change “behavioral” analysis to “behavior analysis”
• B.2. Criteria and allowable activities, allowable activities for this service shall include:
– i. Consulting related to person centered therapeutic outcomes, in person, over the
phone or via video feed consistent with in accordance with the requirements of the
Health Insurance Portability and Accountability Act (HIPAA)
• C. Service units and limits.
3. Travel time [ , and ] written preparation [ , and telephone communication ] shall be
considered as in-kind expenses within therapeutic consultation service and shall not be
reimbursed as separate items.
5. [ Behavioral consultation. ]
[ a. ] Only behavioral consultation in the therapeutic consultation service may be offered
in the absence of any other waiver service.
[ b. Initial requests for behavioral consultation may not be authorized for more than 180
days.
c. Behavioral support plans will be submitted with subsequent authorizations as well as
baseline data for the initial request after assessment and then an annual summary of
quarterly data for re-renewals. ]
Slide 7Regulations
• E. Service documentation and requirements.
• [ (1) Behavior support plans will contain the following information, at a
minimum: (i) demographic information; (ii) person-centered
information; (iii) history and rationale ; (iv) functional behavior
assessment; (v) behaviors targeted for decrease; (vi) hypothesized
functions of behavior; (vii) proactive strategies/antecedent
interventions; (viii) replacement behaviors/behaviors targeted for
increase; (ix) consequence interventions (when indicated); (x) safety
and crisis guidelines (when indicated) ; (xi) any additional
recommendations (linkages, etc.); (xii) appropriate signatures and plan
for training. ]
• 2d: d. Ongoing progress note documentation of rendered consultative
service that may be in the form of contact-by-contact or monthly notes
that must be contemporaneously signed and dated, that identify each
contact [ including location and recipient of training activities ] , the
amount of time spent on the activity, what was accomplished, and the
professional who made the contact and rendered the service.
Slide 8Regulations
• 2e.
• [ (1) For behavioral therapeutic consultation, the
quarterly review shall include graphed data and a
summary of this data.
• (2) For behavioral therapeutic consultation, the annual
review shall include graphed or tabled data that is
trended across the first three quarters. ]
Slide 9Telehealth
• Telehealth may be utilized for all person-centered outcome
activities--other than direct therapy
• Consider telehealth in the following ways:
– Increase access for people in need in rural areas
• Increase the reach of your agency to parts of the state you haven’t
served
– Increase your effectiveness, e.g. assess and train in moments
of need
– Connect with CSBs and/or with DBHDS to indicate your
availability to accept via telehealth
• Consider where you can provide face to face and where you can
provide telehealth
• It is most desirable to have some schedule of face to face (post-
pandemic)
Slide 10Types of authorizations for t.c. behavioral services
• Initial request
• Second request
• Annual Plan Renewal requests (follow the initial and
secondary)
Slide 11Authorizations, timeframes, required documents
Authorization Timeframe Required documentation for authorization
Type
Initial Up to 180 days Part V must outline the following:
Authorization o that a Functional Behavioral Assessment (FBA) will be conducted
o that a BSP will be created
o the plan for data collection during this period
Second Post 180 days of Behavior Support Plan
authorization the initial FBA (the FBA may be within the BSP or a separate document).
authorization Any baseline data or treatment data collected used in formulating the plan
period until the ISP Part V must outline the following:
annual date o Request for/description of training for stakeholders must be included and parallel what is included
in the training section of the BSP.
o Measurable benchmarks for behaviors targeted for increase and decrease in the BSP, which must
be included in the “ I no longer want/need supports when…” area of the Part V
ISP Update Annual ISP date to Graphical displays with progress summary covering at least the current review period.
(Annual renewal annual ISP date Current BSP
or when Current FBA (FBA can be incorporated into the BSP or on a separate document)
needed) o In preparation for the shared planning meeting, the most recent FBA and treatment data must be reviewed
by the behaviorist. A reference of this review and the behaviorist’s determination of the continued validity or
need for re-assessment must be included in the FBA. See Part V requirements below if re-assessment is
determined.
Documentation of any training completed within the timeframe of the most recent review period
Part V must outline the following:
o Request for/description of training for stakeholders must be included and parallel what is included
in the training section of the BSP.
o If the behaviorist determines re-assessment is needed, request re-assessment in Part V. If
behaviorist determines previous FBA is still valid, re-assessment does not need to be include in the
Part V.
Slide 12Exceptions
• It is understood that there will be exceptions to the
rules
– Communicate exceptions that you believe are impactful
to service authorization staff
– Feel free to reach out to Sharon or Nathan if you need
assistance
• Grace period for these changes to regs (5/1/21-6/30/21)
• An exceptions document will be created based upon
grace period data and initial launch data
Slide 13Learning check
How many authorization types are there for this service?
a. 1
b. 2
c. 3
d. 4
Slide 14Key regulatory updates—Initial auth request
Initial requests for behavioral consultation may not
be authorized for more than 180 days.
– The request must include the Part V, which must outline
that a Functional Behavioral Assessment (FBA) will be
completed, that the creation of the behavior support plan
will occur, and the plan for data collection
Slide 15Learning goals check
The initial request for authorization may not be authorized
for more than…
a. 45 days
b. 90 days
c. 180 days
d. 365 days
Slide 16Learning goals check
For initial authorization request, the Part V must minimally
outline the following:
a. That a BSP will be created
b. That data will be collected
c. That a FBA will be conducted
d. The completion of the Functional Behavioral
Assessment (FBA), creation of the behavior
support plan (BSP), and the plan for data
collection
Slide 17Key regulatory updates—Second auth request
For the second authorization request (after the initial, 180 day
maximum authorization request), the following are required to
be submitted by the behaviorist:
– Part V with request for/description of training for stakeholders
– Part V needs to include measureable benchmarks for
behaviors targeted for increase and decrease in the ““I no
longer want/need supports when…” area
– “John will engage in no more than 3 instances of aggression per
month for 3 consecutive months”
– “Sue will communicate her desire for preferred items at least 50 times
per month for 2 consecutive months”
– Behavior support plan
– FBA information/results
– Any baseline or treatment data gathered thus far
Slide 18Learning goals check
For the second authorization request, the following will be
required for the behaviorist to submit:
a. Part V with request for/description of training for the
person’s support system, measurable benchmarks
related to behaviors in the BSP, the BSP, the FBA, and
any baseline or treatment data
b. Part V with plan for training
c. The BSP, the FBA, and the Part V
d. Only the Part V and the BSP
Slide 19Key regulatory updates—ongoing auth requests
• For any authorization requests following the initial and
secondary, the behaviorist will need to submit the following:
– Part V with plan for training & measurable benchmarks for all
behaviors in the BSP
– Summary of data in an acceptable format (e.g. line graph display)
– Current BSP (with FBA results)
– Documentation of any training completed within the most recent
review period
Note: As a part of the shared planning meeting the behaviorist must
review the FBA and treatment data and determine if the functions
are still valid. A reassessment of the functions of behavior is
required when data suggest treatment expectations are not being
met or there has been a significant change in status of the individual
that is negatively impacting outcomes. The review of the continued
validity of the FBA must be documented in the BSP. If reassessment
is needed, this must be requested in the Part V.
Slide 20Learning goals check
For any annual plan renewal or subsequent authorization
requests (after the second authorization), the following are
needed from the behaviorist:
a. The BSP
b. The FBA
c. Part V with plan for training and measurable
benchmarks related to behaviors in the BSP,
graphed data, BSP (with FBA results), and
documentation of any training completed
within the most recent review period
d. Only documentation of training provided to stakeholders
Slide 21Learning goals check
Telehealth through HIPAA compliant platforms is
acceptable for:
a. Direct therapy only
b. Person centered therapeutic outcomes
c. Person centered therapeutic outcomes and direct
therapy
d. Only for training stakeholders
Slide 22Grace period until 6/30/2021
Existing Authorizations – Grace Period:
Any re-authorization submitted between the dates of 5/1/21 though 6/30/21 may be given a new
authorization for up to 90 days to come into compliance with the new regulation requirements. If the
documents submitted are in compliance with the regulations, then the authorization can be approved up to
the deadline of the next annual ISP.
Example 1:
Jane B. submitted a request for a re-renewal (annual) for JJ on 6/1/21. The documents submitted included a
current BSP and a graphical display and analysis of the data. No FBA or training records were provided.
Authorization decision: Authorization given until 8/31/21 upon which the resubmission must
include a completed FBA and training records.
Example 2:
Joe D. submitted a request for re-authorization on 6/29/2021 due to an annual ISP deadline on 7/15/21. The
documents submitted included a completed FBA, graphed data, BSP, and plan for training and evidence that
some training had occurred in previous auth year. All required docs for new regs were present.
Authorization decision: Request approved until next annual ISP date.
Example 3:
Charles B. submitted a request for a re-renewal (annual) for RB on 7/6/21. The documents submitted
included a BSP inclusive of a FBA. There were no graphical displays, no plan for training in BSP or Part V, and
no evidence that training occurred.
Authorization decision: Pend until required documentation is provided
Slide 23Learning goals check
The grace period is until ______. After the grace period,
documentation must adhere to _______.
a. 8/31/2021, new regulations
b. 6/30/2021, regulations based on when the individual
first received services
c. 6/30/2021, new regulations
d. 8/31/2021, regulations based on when the individual
first received services
Slide 24Learning goals check
If documentation does not adhere to the new regulations
during the grace period, which of the following may occur?
a. The request will be denied
b. The request may be approved for up to 90
days; at the next authorization request,
required documentation must be submitted
c. The request will be pended for 90 days
d. The request will be approved for the entire ISP year
regardless of presence or absence of documentation
Slide 25Practice Guidelines for BSPs
DBHDS has created draft Practice Guidelines for BSPs:
– These are basic guidelines on the minimum elements that
constitute an adequately designed behavior support plan
(behavioral treatment plan) for individuals receiving
therapeutic consultation behavioral services under the DD
waivers in Virginia.
– Inclusive of supplemental information on the use the least
restrictive and most effective treatment philosophy and
positive behavior supports, utilizing person-centered thinking
and planning, and incorporating a trauma informed approach
as it relates to behavior support planning
– Behaviorists must review the practice guidelines and minimum
elements to ensure their BSPs are in adherence
– Please always consider the audience that is delivering front
line services (e.g. copious technical jargon in BSPs)
Slide 26Minimum Required BSP Content Areas
• Demographic information
• Person centered information
• History and rationale for services
• Functional behavior assessment (FBA)
• Hypothesized functions of behavior
• Behaviors targeted for decrease
• Behaviors targeted for increase (replacement behaviors)
• Antecedent strategies
• Consequence strategies
• Safety or crisis guidelines (if applicable)
• Plan for training
• Appropriate signatures (consent)
• Practice Guidelines will be posted on Town Hall under DMAS on
5/24/21
– https://townhall.virginia.gov/
Slide 27Quality reviews on minimal BSP elements
• DBHDS behaviorists will review a randomized sample of
all behavior support plans that are authorized
– DBHDS will provide quality feedback on the presence or
absence of required elements to behaviorists via a
documented quality review process
• Adherence to the spirit of the elements is important for
multiple reasons
– Quality services for individuals
– Consistency across providers
– Field of behavioral services in VA through publicly funded
system
Slide 28Learning goals check
The Practice Guidelines for Behavior Support Plans...
a. Are currently available and will be used for peer reviews by
DBHDS
b. Will be posted on Town Hall in May 2021, are
guidance on the minimum required BSP
elements, and will be used for quality reviews
of BSPs by DBHDS LBAs
c. Will be posted on Town Hall in May 2021 and will be used
by DBHDS service authorization for authorization reviews
d. Are currently available and will be used by DBHDS service
authorization effective 7/1/21
Slide 29FAQ
• What about changing billing units to 15 minutes?
– Nature of regulations
– CMS applications on Town Hall, include request for this
change there
• Can t.c. be added to the BI waiver?
– CMS applications on Town Hall
Slide 30FAQ
• Are quarterlies based on the ISP date or based on the
date that services began?
– Quarterlies align with ISP dates, not when behavioral
services began
• What if you are requesting an initial authorization one
month before the ISP date? Example: ISP date is
8/1/2021, and you request initial auth on 7/1/2021?
– Request the auth for the one month
– Complete another similar request for the remaining 5
months
Slide 31FAQ
• What is “in kind” paperwork?
– Refer to regulations for “allowable activities” for what is
permissible
– Example of “in kind” written paperwork
• What about obtaining the SIS? Is the FBA an age-
appropriate assessment?
– Request the SIS from the SC and document the request
– The FBA is an age-appropriate assessment
Slide 32FAQ
• Why are data and graphs required? We will have
significant problems obtaining data…
– Suggestions…
• Ensure families and providers understand your responsibility as a
behaviorist and what is required for this service
• Select appropriate data collection methods/measurement
system
– Consider if need to be integrated into other current data systems
(e.g. sleep, toileting, etc.)
• Target the right amount of behaviors given the needs and
resources available
• Utilize telehealth for in vivo data collection which you take to
supplement data taken in the home or community
Slide 33FAQ
• Why are data required, suggestions cont.…
• Provide appropriate training
• Frequent reinforcement for data collection and corrective
feedback when lacking
• Emphasis on data collection yielding better decisions results
• Incorporate data review and graphing into your sessions
• Data collection buy in for staff & families…
– Increase control by longer term positive reinforcers and
decrease control by shorter term negative reinforcers
(Tarbox, 2017)
Slide 34FAQ
Slide 35Resources & next steps
• ABA Snippets articles in OIH Newsletter
– Began June 2020
– Navigate to “Newsletters” tab
• https://dbhds.virginia.gov/office-of-integrated-health#
• Practice Guidelines for BSPs on Town Hall
• Training for support coordinators
• Upcoming training opportunities
• Exceptions information
• BSP template for optional use
• Responses to questions in chat via FAQ
Slide 36You can also read
