Abstract
Although research shows early intensive behavioral intervention is efficacious when delivered in university or private intervention centers, little is known about effectiveness or feasibility of disseminating early intensive behavioral intervention to larger communities. The Michigan State University Early Learning Institute was developed to address gaps in distribution of early intensive behavioral intervention to community settings, with an emphasis of serving children and families on Medicaid. This short report describes the Early Learning Institute’s approach and preliminary utilization data among Medicaid families. Results suggest the model has potential for dissemination within community settings and promote utilization among Medicaid children.
Lay abstract
Although research shows early intensive behavioral intervention can be very beneficial for children with autism spectrum disorder when delivered in university or private intervention centers, little is known about the best way to provide early intensive behavioral intervention within the broader community. The Michigan State University Early Learning Institute was developed to address challenges with providing early intensive behavioral intervention in community settings, with an emphasis on serving children and families on Medicaid. This short report describes the approach taken by the Early Learning Institute and reports data regarding enrollment and utilization among Medicaid families. Results suggest the model has potential to be used within community settings and that children on Medicaid are likely to consistently attend their treatment sessions.
Early intensive behavioral intervention (EIBI) is an empirically supported comprehensive treatment for children with autism spectrum disorders (ASDs; Reichow, 2012). EIBI is delivered for 25–40 h/week, for at least 1 year, often beginning before a child turns 4 (Smith et al., 2015). Although EIBI is efficacious when delivered in university or private intervention centers, little is known about the effectiveness or feasibility of implementing EIBI when it is disseminated to larger communities (Caron et al., 2017).
Recent insurance legislation across the United States has increased accessibility of EIBI for children with ASD by requiring Medicaid and commercial insurers to pay for EIBI services (Kelly, 2015). However, there are inequities in treatment utilization among children on Medicaid; for example, Yingling et al. (2019) investigated utilization rates among a sample of Medicaid children with ASD in South Carolina. They found participants in their sample utilized only 37% (range: 30%–44%) of allocated EIBI services in their first year of treatment. Because lower dosages of EIBI are less effective for promoting behavioral and cognitive gains (Linstead et al., 2017), implementation strategies are needed to ensure all eligible children receive the necessary treatment dose.
The Michigan State University Early Learning Institute (ELI) was developed to address gaps in distribution of EIBI to Medicaid families. The purpose of this short report is to describe the approach taken by the ELI to serve Medicaid families and to report preliminary utilization data among those families.
Michigan State University ELI
The ELI seeks to deliver EIBI in a manner that is replicable by community providers. Although affiliated with a university, the ELI is a financially independent collective of EIBI centers that serves children with ASD within or very near their home communities. The ELI is a unique EIBI program because it emphasizes services for diverse, low-income children and families.
The ELI began as a single center serving eight children within the University’s Child Development Laboratory Preschool. The ELI was placed within an existing preschool to ensure children with ASD had social learning opportunities with typically developing peers at a young age and from the onset of EIBI programming. Programming consists of an individualized mix of discrete trial instruction, natural environment training, Picture Exchange Communication System®, video modeling, activity schedules, and inclusive therapeutic programming (see Wong et al., 2015, for review and descriptions). The child’s performance data inform the amount of each therapeutic approach, with social interactions with peers as the primary target skill. Board Certified Behavior Analysts (BCBAs) collect weekly procedural integrity data of individual Behavior Technicians, while site directors assess the fidelity with which BCBAs carry out core components of the ELI approach. The ELI was replicated by adding a community-based center in each of the following 2 years, one within an urban Head Start preschool and another within a suburban early childhood collaborative.
The ELI was founded on three core principles that continue to drive delivery of services: (a) community integration, (b) consistency of treatment, and (c) proactive and strategic planning. The following sections describe each core principle, and how those principles relate to the ELI’s mission of delivering EIBI to underserved families.
Community integration
Each ELI site was collaboratively designed by faculty and local early childhood centers to embed EIBI treatment sites within existing community infrastructure. This process shaped the policies and procedures of the ELI in a manner that aligns with the needs of community agencies. In addition, the ELI paid rent and tuition to the early childhood centers for use of physical space and to reserve seats for inclusion opportunities within classrooms. Although we do not have sustainment data, we hypothesize that collaborative arrangements, such as monetary reimbursement for space, increased the value of the ELI to community stakeholders and supported the sustainability of the ELI within community settings.
The distribution of ELI centers across multiple communities in one county offers several potential advantages over a centralized approach in which all participants come to one location. Treatment centers in families’ home communities may reduce barriers associated with transporting children to treatment. In addition, partnerships with local educational service providers lead to familiarity between families and school systems, which can benefit the child when they later attend those schools.
The ELI’s enrollment, staffing, and financial model prioritizes community-based intervention to support replication outside a university environment. A BCBA is hired at each location to provide oversight and supervision of children’s programs at that location. BCBAs are fully employed by the ELI and have salaries paid by the ELI revenue as opposed to grants or other university funds. The majority of Behavior Technicians are hired from within the community and receive training primarily from the aforementioned supervisor, as opposed to being undergraduate or graduate students under faculty supervision. Finally, the ELI is fully self-sustaining based on revenue generated from services provided. All costs including staff, administration, rent, and materials are paid for by insurance revenue.
Consistency of treatment
The ELI delivers consistent EIBI in two ways. First, children enrolled at ELI attend the center and receive therapeutic services every Monday to Thursday, from 8:30 in the morning until 4:00 in the afternoon. This schedule was selected to support families who needed direct care for children during the typical workday and who required consistent scheduling to integrate ELI’s treatment hours into their lives with minimal disruption. Families use the open treatment day (i.e. Friday) to schedule other services for their children (e.g. speech and occupational therapy, medical appointments) without missing behavioral therapy sessions.
A second advantage of the ELI weekly schedule is that Fridays allow for professional development for staff and time for data analysis and program review. Although staff training and data analysis without the child present are not billable services, research indicates they are essential features of effective EIBI programs that substantially strengthen the therapeutic services administered to children (Eikeseth et al., 2009). Child-level outcomes are beyond the scope of this initial report, though the ELI tracks child progress using annual standardized assessments, semi-annual formative assessments, and daily behavioral data tracking.
Consistency is further maintained by ensuring the BCBA’s caseload remains small and in one location, creating supervision and training opportunities for staff throughout the day. A small and centrally located caseload can be a distinct advantage to a distributed caseload, such as home-based EIBI programming, where a supervisor visits each client once or twice per week.
Proactive and strategic planning
Since Lovaas’ (1987) first report of EIBI outcomes, school readiness is a critical outcome measure of EIBI. Although studies differ from Lovaas’ estimation that 47% of children could attend kindergarten with no supports following EIBI (Howard et al., 2005), a measure of school attendance remains an important policy indicator for EIBI. A primary argument in favor of EIBI is the reduction in overall cost of care over time (Peters-Scheffer et al., 2013), though savings can only be maximized if children transition from expensive behavioral health treatment into less costly public education while maintaining positive EIBI outcomes. Therefore, many features of the ELI were designed with transition to kindergarten in mind.
Each ELI location resembles a typical preschool classroom with individual and small-group learning spaces. Children receive therapy in a classroom-like environment instead of individual offices or cubicles. The ELI schedule and treatment goals incorporate group sessions, recess and play opportunities, and snack and lunch times to replicate conditions children will see upon their transition to kindergarten.
Transition to school services is incorporated into parent training at the ELI. Parents receive bi-monthly family training as a billable component of treatment. In addition, beginning 6 months before the child transitions to kindergarten, the ELI provides non-billable parent advocacy training and transition preparation for school-based services. The 8-week advocacy training prepares parents to collaborate with school professionals, describe their child’s strengths in observable and measurable terms, and develop individualized education plan (IEP) goals that transfer their child’s current level of performance within the EIBI setting into school. The child’s BCBA attends educational planning meetings with the parents and actively participates in the school team’s IEP meeting. Finally, a clinical representative from the ELI works with the school team to ensure continuity of services and to address re-emergence of behaviors that had previously been addressed in the ELI.
Service utilization
The Michigan State University Institutional Review Board approved the research conducted at the ELI. Parents of all participants provided informed written permission and consent for involvement in this research, and for the data shared in this report. Although aspects of the ELI are hypothesized to support low-income families, an initial question was whether the ELI would be accessible to and utilized by low-income families. The ELI provides available spaces to families on Medicaid prior to offering spaces to private insurance children. Twenty two of the 28 children (17 males, 5 females) enrolled at the ELI for at least one full year during our first 3 years in operation were on Medicaid and were therefore eligible for participation in this preliminary analysis. Parents of these children reported household incomes that placed them in the low to extremely low range of the US Department of Housing and Urban Development guidelines based on family income, number of family members, and zip code. Thirteen families identified as White, five as Biracial, two as Hispanic, one as Indian, and one as Middle Eastern.
We calculated utilization using the same procedures described by Yingling et al. (2019). Annual treatment hours were divided by annual authorized hours and multiplied by 100 to obtain a percentage. During the first 3 years of the ELI, the 22 children from low-income households reliably attended therapy sessions with a mean utilization of 85% (range: 72%–94%); all but one child exceeded 80% utilization during their first year of services (see Figure 1). Although additional data are needed to further examine effectiveness of the model, preliminary implementation data suggest low-income families enroll children in the ELI and those children have high attendance when compared with prior studies examining utilization among low-income families (Caron et al., 2017; Yingling et al., 2019).
This figure depicts the percentage of utilization for each Medicaid participant during their first year of treatment at the Michigan State University Early Learning Institute. The dashed red line depicts the 80% utilization threshold.
We also calculated utilization for parent attendance at parent advocacy sessions pertaining to transition of their child from the ELI to public school settings. The parent advocacy sessions were non-billable services and therefore not part of the mandated treatment program for the child and family. Mean utilization of non-billable services was 78% (range: 50%–100%).
The preliminary results suggest the ELI model might support dissemination of EIBI to under-treated children with ASD and their families, though several barriers must be considered in scaling such a model to additional communities. First, funding structures vary across states and countries, which might mean that some locations could not support a similar model. Second, it might be difficult to create and administer a model like the ELI in rural communities where individual sites cannot recruit enough children or staff. Third, the values that control business operations of some agencies might sometimes conflict with delivering optimal services to children and families. Although these barriers require careful and systematic implementation research, the integration of the ELI treatment centers into existing community infrastructure, and utilization by families on Medicaid offers the possibility of delivering EIBI at a scale that meets the needs and financial resources of communities.
Footnotes
Authors’ note
M.Y.S.B. is now at the Department of Educational Psychology, University of Minnesota, and A.D.D. is now at the Department of Education and Human Services, Lehigh University.
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was supported in part by grants from the Michigan Department of Health and Human Services and the Blue Cross Blue Shield Foundation of Michigan.
