Positive Approaches Journal, Volume 8, Issue 4

Volume 8 ► Issue 4 ► 2020

Innovative Approaches to Gather Community-Based Service Data

Deborah Todd

Abstract

Data collection is an essential expectation of service grounded in Applied Behavioral Analysis (ABA). The Behavior Analyst Certification Board (BACB), 4th Edition Task List H-01, indicates, “select a measurement system to obtain representative data given the dimensions of the behavior and the logistics of observing and recording.”1 The need to collect data in community-based settings to report progress on goals can create some challenges including how to collect data while providing treatment in a setting where safety must also be ensured and having some mechanism to communicate the data collected efficiently. This article will describe one provider’s approach to collecting data in the community while addressing the aforementioned and other challenges.

Focus Behavioral Health is a community-based provider, providing supports to adults with Autism and or an Intellectual Disability in the state of Pennsylvania. One of our organizational objectives is to use data efficiently and effectively to help individuals to reach their fullest potential. Initial concerns related to meeting this objective involved the lag in time that data were collected and shared to ensure data integrity and accuracy. Existing data-based platforms did not meet our needs nor were they specifically aligned with the regulations of the programs we are enrolled in; therefore, we developed our own platform, Reliable, to meet all of the data collection and progress reporting requirements of the waiver programs and to address potential barriers we identified in our evaluation of other platforms. Key features of our program include the use of iPads, pre-populated objectives for easy tracking, safeguards embedded within the program to help prevent fraud and errors, easy submission of notes through electronic synchronization of the clinical documents, and a two-step passcode protection process to ensure HIPPA compliance.

Staff training is critical to the success of this model. Staff are trained to the chosen objective. They are taught how to break the objectives down so that they know what replacement behavior or targeted skill they are collecting data on. Additionally, the training focuses on forms of data measurement systems and creating opportunities to address the objective. The interventions outlined in the participant’s plans are described for the staff so that they understand how to implement the intervention and record the participant’s response to the intervention. During the training, staff are presented with sample scenarios and are tested on the ability to create a documentation note based on a scenario so that the trainer can assess basic understanding of their data collection skills. Staff also shadow a Behavior Support Specialist, Skill Building Specialist, or a Program Supervisor to ensure that they understand how to create opportunities to work on the objectives, how to implement the interventions within the community setting, how to complete the data collection tool correctly, and how to translate this into the clinical documentation captured in Reliable.

Ongoing supervision and support are also included in this model. It is expected that the Behavior Support Specialist or the Skill Building Specialist provide consultation with all staff responsible for collecting data at a minimum of twice per month. They provide consultation regarding how the objectives the participant selected to work on are being addressed within the natural environment, they observe the staff implementing the objectives outlined in the participant’s plan, they provide training if an intervention is not being utilized as designed, and they may take their own data as a sample of interrater reliability, and address any discrepancies in data collection. The Behavior Specialist or Skill Building Specialist are integral to ensuring that all staff working with the participant are identifying the targeted behaviors and replacement behaviors/skills and are collecting data in a consistent manner.

There were initial concerns about how the participant would respond to this data tracking system. To alleviate these concerns, the participants are introduced to the iPad system at their initial intake meeting to review expectations and answer any questions. The participant is involved in the development of their goals and objectives, and once they are established, they are reviewed on the iPad with the participant so that they are aware of what appears on the forms. As the parameters about the data collection system have been reviewed from the beginning, staff remain open with participants about the need to collect data during sessions. Since the bulk of the clinical documentation and data are collected within the session, staff review the data and any other observations, concerns, and next steps with the participant before leaving for the day. As the objectives are reviewed within each session, the participant becomes familiar with their objectives, making it easier to maintain treatment integrity in the community setting.

Barriers and Solutions

A project workgroup began by identifying common barriers to community-based data collection systems, and a review of the requirements of the waiver programs.

The first barrier identified was treatment planning with unclear or vague definition of behavior(s) or targeted skill(s). If staff were not clear on what data to measure, data could not be reliably gathered. For example, a vaguely written objective such as “will increase social skills” is not clear, not defined and subjective to the staff’s interpretation of the behavior. To avoid this problem, supervisory staff, with supporting information from the Functional Behavioral Assessment (FBA) Processes and Behavior Support Plan (BSP) and input from the participant and his/her family, are responsible for developing the objectives and uploading them into Reliable.

The second barrier identified was the need to collect data in the community setting while balancing the need to focus on the participant. To ensure easy access, all staff are provided with an iPad. The iPad has two layers of security within it to keep participant’s information private, requiring passcodes at both the home screen and the entry point to Reliable. The forms are structured within our Reliable server and are released only to the participant’s direct staff by an administrator. Reliable lists each participant they are supporting and the clinical document form that contains pre-populated goals and objectives. When supporting a participant, the staff are encouraged to review the objectives with the participant identifying priorities for the day and how the participant would like to address the objectives (for example, cleaning can mean many different things- cleaning their kitchen, the bedroom, the car); this way the staff are already thinking as to how to create opportunities to work on the objectives. Since iPads are a common piece of technology in community settings, staff are taught to casually use their iPad to capture data so that the data is reliable as it is being recorded in close proximal time within the time spent with the participant. If not done this way, staff may not remember the exact number of opportunities that were presented to work on the skill or replacement behavior and the number of successes, as well as the number of prompting that was needed.

The third barrier we identified was the need for data to be easily accessible for analysis. Too often in paper pen systems there is a delay with staff sharing their notes and we had experienced many staff who did not meet timelines. The delay impacts the ability to review the data as they have to physically come to an office during hours when they are commonly actively working with participants. With our Reliable system, staff are encouraged to complete the note that evening and sync it to the server. At minimum, it is mandatory they sync the iPad on Wednesdays and Sundays of each week. Therefore, the maximum number of days that would lag between a session and the submission of the clinical documentation is three days. Once it is synced, administrative staff have immediate access to the data. This allows data to be summarized in a timely manner to provide data based instructional decisions on next steps in supports for the participant. It also allows for immediate follow up with the staff if they do not submit their notes by the established deadline, as administrative staff can easily view who has and who has not submitted clinical documents on time. This timely submission can quickly identify simple errors, such as a note missing a section by labeling them as “incomplete” and puts the color of the note in red. Identifying these errors in data collection errors early allows for quick correction and staff training, if necessary.

Results

Initially Focus’s administrative team had much discussion regarding the cost of developing the program and providing iPads for staff. While there was a significant upfront cost, the administrative team was able to see immediate outcomes within the first year of implementation. First, administrators were able to track utilization on a weekly basis and follow up with direct staff if a participant’s hours were not utilized according to their Individual Support Plan. Second, because notes are submitted consistently twice a week, the billing is kept up to date and submitted within a timely manner, preventing lags in reimbursement. Specifically, the claims submitted for payment under the Reliable system are submitted 80% quicker than in the past. Third, the paybacks Focus had at audit due to billing errors were reduced by 90% and we have increased revenue due to the reduction in amount of claims that we could not submit for billing, either because we did not receive the clinical documentation in a timely manner, it was submitted incompletely, or there was an over utilization of units.

A primary reason we wanted to our data collection to be technology based was because of the potential impact for participants. For example, one participant had an objective regarding reducing socially inappropriate behaviors (i.e., purposefully belching, passing gas, touching other’s food), as well as reducing self-harm behaviors (i.e., threats to cut self, expression of suicidal ideations). We found, through easy data analysis of this data collection system, a correlation between socially inappropriate behaviors and an increase in self-harm behaviors. We were able to use this information to help the treatment team look closer at socially inappropriate behaviors as an indicator of impulse control issues, and start to put additional strategies in place to reduce the risk of self-harm, having the potential to make a huge impact in the everyday life of this individual.

Reliable lends itself to a higher level of consistency in communication with staff. For example, if a staff member calls off, a supervisor can see from the clinical documentation of the session last provided and communicate the information to the substitute staff. Efficiencies in managing staff and streamlined services and supports while acknowledging staff turnover and need for substitute staff are also positive outcomes related to the adoption of this system.

Discussion

As Focus is preparing to expand this model to the services we provide in other waivers, several things were considered. First, given the number of employees we have, the anticipated growth rate needs to be factored in the budget based on the number of iPads to be purchased. Second, programmers were consulted regarding the cost of modifications to the Reliable program for the purpose of meeting the expectations of other waivers. Third, a pilot of the Reliable program is important to provide staff an opportunity to try the system and provide feedback to make this a system that is relevant to their programs.

Overall, the use of technology has improved our operations and the services and supports we provide to participants. Not only are staff and participants more cognizant of the objectives contained within the support plans but data has been recorded more accurately, in general. This system has also improved the ability to control for timelines in which clinical documents are received and can be reviewed by a supervisor and it has prevented common errors in billing, reducing payback at audit from occurring. Reliable has assisted in making staff training more efficient and streamlined through enabling a more efficient analysis of data that is used to support programmatic changes for participants and our programs. A model such as Reliable can be easily adapted for other service provider’s needs and operations.

References

1. BCBA/BCaBA Task List Fourth Edition. BACB.com. https://www.bacb.com/bcba-bcaba-task-list/.