Are Universities Doing Their Part? With Dr. Ellie Kazemi And Dr. Lusineh Gharapetian

Are Universities Doing Their Part? With Dr. Ellie Kazemi And Dr. Lusineh Gharapetian

Welcome to episode four of the show.

There are so many updates and much going on. I will start by saying we wrapped the Autism Investor Summit, which was so much fun. Anna, you were there. We had a lot of the BHCOE team there. I’m curious if you have any takeaways from that event.

It was an amazing event. That was my first time attending in person. My first attendance at AIS was when it was virtual because of COVID. First of all, it’s an amazing job choosing the venue. It was wonderful. The weather was perfect. That’s all I kept hearing. People were like, “The weather is perfect.”

There were some important takeaways that helped everyone understand how to begin to address the staffing issue. That may be my biggest takeaway. I felt like everyone was hugely important in where we are, even on the payers’ side. You heard payers talking and saying, “How are you going to figure this out?” There was a lot of good information and data to help everyone do that.

For those of you who have never been, it’s our fourth year doing this conference. Usually, the day before the Investor Summit, we do a Payer Summit, which is an invitation-only payer meeting. That’s a great conversation for payers to talk and collaborate in a safe space. This is our second year doing that. That was great to see some of those conversations.

With the Investor Summit, people get nervous with the word investment because people feel multiple ways about investment coming into the industry. When we think about investment, I think of it as, “How are you investing in your business, growth, and innovation?” A lot of people came up to me and were like, “I thought this was all about money.” This is the Autism Innovation Summit or the Autism Impact Summit. That was cool to hear too.

There’s a focus on that financial aspect of the industry and the market dynamics, which we don’t talk about in some of the clinical conferences. It’s focused on the C-level or executive leadership board members and investor side of the community to look at the trends in the market. It was cool to see such a diverse group of people. I’m curious what yours is, Anna. My favorite talk is the first one, Jim Hogan, who works for Google. He is an autistic individual who shared his story about how he found his way into Corporate America. He was amazing and so insightful.

Dexter Braff, who’s the Head of The Braff Group, gives us an incredible market dynamic analysis of transactions going on in the space, patterns, multiples, and evaluations. That was super fascinating because I haven’t seen that data shared anywhere. You can view all of those presentations on the AIS Learning Management System. They are prerecorded. Anna, what was your favorite talk?

I thought the payer panel was fascinating. I say that because I don’t know if I have ever seen a panel where three payers were having a conversation about improving quality and access to quality services. Sara led the panel. It was about innovating on value-based pay. It was so interesting. Everyone in the room was watching the uniqueness of it unfold.

 

There was a representative from Aetna, Optum, and Magellan. Their views on it and how they were looking at approaching value-based pay to improve quality, patient outcomes, and access to their members were fascinating to me. I don’t know if I expected more alignment but they all had very individual unique ways that they looked at that. Sara, you moderated that panel. What were your thoughts about it?

That was such a tough panel to moderate because there are so many unknowns across value-based care like where are we going with it? It’s probably a nice segue to talk about some of the value-based care partnerships we have announced. It was tough because we hadn’t announced all of those partnerships. I had to moderate it in a way that wasn’t speaking to those relationships that we had been working on.

Also, all three of them had such unique perspectives about whether there’s even a world for alternative payments in ABA and had all very different sensibilities. They are the three representatives of the five-largest insurance carriers in the United States. It was a great conversation. It was tough and hard to have a conversation around a topic where there were so many unknowns and differing opinions.

I thought you did great on bringing out key factors. Everyone was interested in that payer perspective. I wanted to give a huge shout-out to David Cox, who is one of our own. I thought his presentation was insightful. It also worked very nicely in answering a lot of the questions that everyone had around turnover, addressing that, and understanding what are the real reasons. Maybe not to many people’s surprise, it’s not all about money. Everyone was pretty blown away. There were lots of cameras and phones up taking pictures.

You have a good presentation when half the audience has their phone up taking photos.

That happened with The Braff Group presentation as well.

In other highlights, Sarah Trautman from the Defy Community did a great presentation. I wasn’t able to listen to it live but I went on and listened to the recording. She was so funny and had many great things to say. Your panel, Anna, was great on market growth and expansion strategies. I love that. We also did a Q&A with Darren Sush from Cigna about the partnership that we had announced. That was a fun thing to share with the community at that point.

There were lots of good and exciting stuff. I enjoyed it. It was so nice to be back in person. If you have never been, I hope you join us in 2023. It’s always great to welcome people but it was also cool to see when I asked, “How many of you were at the first Autism Investor Summit?” Half the people raised their hands. It’s cool that so many have stuck with us over the years.

We’ve got many topics, so that we will move on. Sara, kudos to you because I feel like we were talking about this at work. There are a lot of conferences. For me, it was so awesome that I walked away feeling like, “That’s a lot of information I have not heard.” That’s valuable for us to bring something that the field can feel like, “I’m not hearing the same thing over and over.” It’s a different take as you described. It’s awesome. I’m super excited for 2023.

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We do have a conference-heavy industry. We were joking that every city, sub-city, or state has its ABA chapter. They all do a conference, and it feels like you have to be at every single one of them. It’s tough to figure out how to prioritize. There are a couple that I always keep on my radar. We are going to talk about Pepperdine but before we talk about that, I wanted to share a couple of industry updates that I thought might be meaningful if you haven’t heard about them. Anna, did you see this press release that came out from Central Reach?

You mentioned that to me but I did not see the press release yet.

They released a press release that essentially said that there was a new brand around Central Reach and some new initiatives. I will summarize both of them. I thought this was interesting. The first was that they unveiled a new look and feel to more closely align with their mission, their commitment to autism and IDD, and some of the customers who are working with that community. The rebrand went live on May 11th, 2022. It should appear in all of their products in the coming weeks. That didn’t change any functionality or solutions but gave a better representation of what they do.

The second thing that they did was they put a stake in the ground to say that it’s time for a new software category that supports the lifelong care journey of individuals diagnosed with autism and related intellectual disabilities like ASD and IDD. They found that based on the trends they have seen, ABA and ABA similar services are being delivered across the entire lifespan. There’s no specific technology category for these providers. They have put their stake in the ground as the leader of ABA in the software market. They are essentially trying to carve out this market as being something that they are specialized in again. I thought that was an interesting update.

That sounds very exciting. I’m always interested in the life cycle, the patient journey, and the patient mapping. We have conversations about that. We love innovation at BHCOE. That sounds like it’s going to be a great opportunity for providers to engage on multiple levels.

In other news, we announced two initiatives at BHCOE that I’m personally excited about. The first is with Cigna or Evernorth. We are working with them to define and measure the quality of care standards or health outcomes for autism treatment. That’s something that is the first of its kind that I’m aware of in which we will be working as a partner of Evernorth to establish foundational measures for ABA treatment that can be done at a national level and help organizations, providers, and patients identify the overall quality of care delivered.

We announced on May 10th, 2022, a similar partnership with Centene. If you are not familiar with Centene, it’s one of the big five insurance carriers. They purchased Magellan. The partnership, similarly, will work with Centene to develop these foundational measures for quality care. Those are some two initiatives that we are so excited about, not only developing those measures but also launching the value-based care program itself.

In both of those partnerships, accreditation is something that will be required to participate in the value-based care program as a base factor of, “Have you ever been sanctioned by Medicaid? Have you been accused of a healthcare-related crime?” Those are some things we are checking on the accreditation side. Those will be requirements to participate in a broader value-based care program with both of those entities. I’m very excited about them. We will likely do a whole separate episode on this topic alone because it’s a dense and exciting topic but I wanted to share that because it’s a significant BHCOE update.

It’s huge, Sara. I’m super excited because it’s an opportunity to bring everyone to the table and collaborate. That’s one of the most meaningful pieces. This is not BHCOE or a payer saying, “We have all this figured out.” It’s like, “Let’s figure this out.” I’m thrilled that we get to partner with these organizations and make something real and meaningful happen for everyone. I know providers, and we have gotten a lot of great feedback about participating. You can go to our website and fill out a form.

 

Participate in the workgroup. Thank you for mentioning that. For both of those projects, we will have a Centene and a Cigna-specific workgroup. If you are interested in being part of that conversation, we would encourage you to apply for the workgroup as a provider or if you are a parent, we will have both two workgroups that will represent both of those stakeholder groups. We will be very transparent through the entire process as we work through it.

We are going to have a public comment on the measure. A lot of what we are going to be doing is going to be communicated front and center to many of you reading. We are excited about it. Our next update is what we are here to talk about, which is an announcement we made with Pepperdine. We recorded a nice conversation with Ellie Kazemi and Lusineh Gharapetian. I’m excited to share this with all of you. Anna, do you have anything to add to the Pepperdine piece before we dive in?

I would love for you to do a quick overview for all of our readers who may not know what Pepperdine is or who may not know what our accreditation for a training site is going to look like. The big picture to me of what this episode is leaning into is about ensuring that clinicians are being trained at places that have standards. We are going to have accreditation for that. If you are a new BCBA coming into the field, there are ways that you can ensure where you are getting your training that their standards are being held to.

Sara, I sometimes don’t say all the right things because I’m not involved in all of that accreditation process and how it’s laid out. Standards may not be the right word but I’m excited because going back quickly to turnover, training was one of the top three. This is going to be valuable in addressing some of the reasons that we see a lot of staff turnover. It might be helpful because a lot of our readers may not even have context around the university training site collaboration.

I’m happy to give a quick overview before we dive in. I will start by saying Pepperdine University is one of the universities on the national level that trains and pumps out qualified individuals to sit for their BCBA exam. They are local to Los Angeles but also have an online program. They also work with an organization called 2U. It’s a publicly-traded company that essentially does online program management partnerships. They help place students with training sites for not just ABA but all types of programs that require experiential learning like psychology, social work, and things like that.

Our original conversation started with 2U and Pepperdine to identify how we could help 2U in placing their students with qualified sites. At BHCOE, our mission is around quality. What we found was that no matter how much important work we were doing trying to increase quality at the organization level, if universities aren’t ensuring that their students are getting proper training and oversight at the academic level, then you are still dealing with a job market that comes into an organization quite green without the right training or experience.

The organization tends to take on the burden of training those people even though they should have ideally gotten that training during graduate school. What we were able to do was come up with a partnership first and foremost in which we were trying to drive students to enter the job market and essentially earn their BCBA. Pepperdine is offering a 10% tuition discount to any RBT or technician. Anyone who works for a BHCOE-accredited organization can earn a 10% discount on their tuition if they choose to apply for the program. That’s the first exciting thing.

The second piece is that Pepperdine is moving forward with requiring that all of their students obtain their supervised fieldwork through a BHCOE-accredited training site. For those of you who aren’t familiar, you have to accrue a certain number of hours as you get your coursework before you can sit for your BCBA exam. Oftentimes this happens during the two years you are in your Master’s program. Sometimes it happens afterward. For Pepperdine, they will be requiring organizations that supervise their students either seek accreditation or they will no longer be able to supervise their students. There are some exception policies that are in place.

For example, the student already works at the organization. They have been with them a certain number of times. It wouldn’t make sense for that student to have to switch organizations. There will be a separate vetting process for that organization. Another exception is if they are in the middle of some type of audit or natural disaster. That would be a time-limited exception. There are some exceptions for those organizations to make sure we don’t cause any undue burden or anything like that. That’s the basis of the partnership. I don’t want to give too much away because we are about to talk about all of this with Ellie and Lusineh. Does that all sound good?

Pepperdine is one of the universities on the national level that trains and pumps out qualified individuals to sit for the BCB exam. Click To Tweet

That sounds amazing. It’s super exciting. Let’s dive in.

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I am so excited. We have two great people with us to talk a little bit about whether universities are doing their part in improving quality across Applied Behavior Analysis. We have Dr. Ellie Kazemi.

Thanks for having me.

Thanks for joining. We have Dr. Lusineh Gharapetian. I know both of you very well but I don’t know how many of our readers do. Ellie, do you want to do a quick intro? Who are you? What are you doing here? Lusi, you are next.

“Who am I?” That’s a question I’m not sure I can take on during one episode but relevant to this episode, I am the Chief Science Officer at Behavioral Health Center of Excellence. I get the pleasure of being able to interpret our science and talk to the public about all the good work we are doing here. I’m excited because the training site is very close and near to my heart because, as a full-time faculty member at Cal State, Northridge, I started the program in behavior analysis. We launched an entire practica coursework as well as a handbook. I have done a lot of work in supervision. This is an area that I’m super excited about being able to help. That’s me.

Lusi, I am so happy to have you here. I don’t want to date us but we met a very long time ago. You will have to fill in the gaps here but if I recall, I interviewed you for your first technician position when you were entering the field. That was the most random thing that happened.

That pretty much takes us back to the very beginning, when I was looking for behavior technician positions. As a brand new person in the field, I had started my Master’s program without having any experience or even knowing about what ABA was. Halfway through, I was like, “I’ve got to get some practical experience.” Where we were was the agency that I applied to. That takes us all the way back.

What a small world. I never knew that.

 

That’s the ABA geography that everyone can do. It’s like, “How do you know everyone?”

I’m going to take you back a little bit further. I’m always interested in how someone got into the autism field. Everyone’s story is so unique. I would love to hear a quick version of how you got into ABA.

I fell into it, not knowing that was the career path that I was going to take. I was working in a research lab doing neuroimaging work at UCSD, where I did my undergrad. I was applying to grad schools to go to PhD programs. I happened to come across this Master’s program in ABA. I was like, “It’s science-based and data-driven. I like it. I’m going to give this a shot to make myself a better PhD candidate.” I entered the program not knowing anything about anything. I fell in love with it within a year. It was like I drank the Kool-Aid. It changed my outlook on life.

I discovered autism treatment through falling into the field of ABA. I had previously been very passionate about ABA. All the work I had done in my undergrad was like, “This is how we diagnose autism but there’s a lack of treatments other than behavioral treatment for autism.” It was always this disheartening thing in my undergrad like, “What are the options for someone who ends up being diagnosed with autism?” I was young and naive back in the day. My outlook on this topic is different now than it was a long time ago.

I was thinking of the last couple of episodes of the show. We have talked so much about the job market, running an ABA organization or some of the stuff that’s happening within ABA but we haven’t talked about the university’s role in the ABA landscape. I’m excited to have both you, Ellie, and Lusi here because you both have this rich history in what the training and university programs have looked like for Applied Behavior Analysis. Before we do that, Lusi, tell us what’s your role at Pepperdine University. How did you get there? Give us a little bit of understanding as to what your day-to-day is at the organization so people know that context.

I am an Assistant Professor and the MS ABA Associate Program Director at Pepperdine for our Behavior Analysis program. I have been there for several years. Beyond that, I started working in the field clinically. I transitioned from clinical work to doing some organizational behavior management type of work. From that, I transitioned into teaching. I was an adjunct for several years across several universities. I became full-time at Pepperdine with this position.

I have that experience of starting from being the person who’s creating the behavior change on the level of an individual to transitioning to training individuals who are going to be providing that behavior change to moving towards that higher-level model, “What do I need to teach these folks?” We are going to go out there and do to do the day-to-day work.

Ellie, I have heard stories over the years. You started the program at Cal State University, Northridge. That was years ago when there was no program at all for Applied Behavior Analysis in Los Angeles.

It was the first thing they asked me to do. It was the position of Cal State Northridge. What they were looking for at the time was someone who would join their clinical psychology team and help the students who were completing their Clinical Psych degrees to get the BCBA coursework so that they could become certificants. At the time, they were looking for finding a way for those individuals to be able to practice because otherwise, they would have had to go on to Doctoral programs.

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That allowed me an avenue to begin the coursework and eventually separate our program from them. We went ahead and separated in 2008 and established the first Master’s program in Applied Behavior Analysis program in CSU Northridge at least. Cassatt, Los Angeles, had a concurrent program with special education, which we learned a lot from too.

For those who are not in California, California has had a pretty rich history of funding Applied Behavior Analysis for a long time. There’s a regional center system here in California. There has been a robust amount of funding available for ABA before most states ever had a mandate. Training for ABA was necessary years ago because of how much funding was available for that. It has been a great service to at least the State of California.

I’m curious. Everything at BHCOE that we do revolves around quality. Sometimes we forget about the universities and the big-picture role that they play in quality and production Board Certified Behavior Analysts. I want to pose a question to both of you. What role do you think that the universities have in the quality of our field? The loaded question is, how do you think it has been going?

There are a couple of different things. Universities’ roles on the basic level it’s to establish what are the concepts and principles of behavior, what is the science of behavior, and how do we go about studying it. More deeply and hopefully later on in someone’s curriculum, they understand what the foundations are for the philosophy that guides the practice and science of behavior analysis.

If a person can understand that philosophical orientation and has a solid understanding of the behavioral principles, hopefully, they will develop the critical thinking skills to think like scientists and be able to solve problems when they are working clinically. The role that universities should take on is to give this scientific orientation and teach this philosophical position. Ultimately, what we end up doing in graduate programs is maybe some of this, hopefully.

What happens at different programs? I don’t know but this is what we are aiming for. Ultimately, we are giving a lot of information to students that we hope they take out and use appropriately and effectively in the field. We hope that they apply these strategies and things that we teach them in ethical and high-quality ways but we can’t control that because that’s a realm that we have very little control and oversight over.

I have met many of your students. I work closely with some of them. You target and accomplish a lot of those because they are wonderful and competent people. My history was different from Lusi’s in that when I entered behavior analysis, there were no nearby programs that I could enroll in to get that strong training.

Quality control for me in our field first began with trying to assure that we have competent behavior analysts to create a strong program that was holistic and included assessments, interventions, and that scientific thinking that Lusi spoke about but also to have some control over the type of supervision experiences that our students got.

The first thing we were hearing was that there was this tremendous discrepancy between what we were teaching in the classroom and what people were being asked to do in the field. I was very young. I thought I could take it all on at the time. We decided to put forth a lot of ways to try to control that. It was fulfilling. We learned a lot about the nearby community partners but it was difficult to take on at the university.

 

I taught adjunct when Pepperdine’s program first started. I was teaching a couple of courses. I remember each university does it differently for those who are not familiar with it. In some cases, when I was at Pepperdine, we would have a class called the Practical class where the students could get group supervision during that time. They were ideally working externally at an agency to accrue hours towards their BCBAs.

In some cases, some universities don’t have that training or Practical class at all. They just say, “You figure it out and get your hours externally.” In some cases, they say, “You can work on campus. There’s an on-campus clinic.” Out of those three hybrids, is there anything else I’m missing for people who are not familiar with how most universities are structured?

Back in the day, we may have had some programs that required you to get all of your hours while you were enrolled with the university but nowadays, with the move to 2,000 hours, that’s becoming less frequent.

The next question is this. When I think about universities, you say you figured out your hours on your own. I think about programs when I was at Pepperdine where we took a vested interest in getting students to get their hours during the years that they were getting their Master’s. What are the pros and cons of both? Why would a university choose to go one route versus the other?

Pepperdine has moved away from that model of offering group supervision because of the ethical concerns. We are not in the field of supervising individuals, and also because of the BACB’s requirements that anyone who’s providing supervision to students has to meet the minimum supervision requirements. We can’t provide individual supervision to students. Therefore, we cannot offer them the group supervision portion of what we are offering.

We have moved away from that model, unfortunately. If we were in that position to be able to offer them all of their supervision, that would be ideal because we could make sure that we are connecting the academic piece to the application piece. Unfortunately, we don’t have that luxury anymore. The limitation of that model, on the other hand, is that students are restricted in where they can work, the type of work that they can do, the hours that they need to put into accomplishing that, and the number of hours that they need to work while they are enrolled in a graduate program.

In allowing students the opportunity to work at their fieldwork sites, we have an application process for the agencies and the supervisors but beyond that, students are allowed to select their sites as long as they complete this process with us. There’s a little bit less oversight and control on the university’s side but there’s more flexibility for the student.

Our requirement is for them to do their minimum requirements every month for what the BACB requires for them to be doing fieldwork. In that context, that additional flexibility helps the students but the limitation of that is that if they are not working enough hours, that could be a limitation or not getting the same quality of supervision because we have less oversight. That hurts them.

It’s a very interesting question you have put forth, Sara, because when it comes to quality, universities have not had a way to assess or report on the quality of their program outside of assuring that they are embedding the tasklist items that the BACB, for example, requires. We can assure you that we have those in our syllabi. The rest of the responsibility has fallen upon us.

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Erick Dubuque and I did a review. We found that ABAI has accredited programs. You have had to be around for at least five years and have historically had the data. CSUN would have become eligible for that because our Master’s program was newer than those. I’m sure Pepperdine is becoming eligible soon to do that. The difference that we could do in looking at quality was exam pass rates.

Us universities, all we have is the exam pass rates as a quality indicator for ourselves at this time, which we know is not the best quality indication at all, and gaining some understanding of what’s happening when our students are placed out in the community. Whether we have practica or not, the big issue that Lusi is mentioning here is putting our eyes and ears out there as our students are working with people. The type of supervision we received has been a challenge for all of us.

It sounds like the burden has fallen on the organization. That’s why I thought this conversation was important because when you think about training, anyone can pick up a book and read. Anyone can sit in a classroom and learn from a professor but with the hands-on practical experience that I and all of us received when we were in graduate school sounds like that model is rare to find now.

You are in this unique situation where students are coming and learning the knowledge from the textbook but then they are going elsewhere externally to a lot of the providers that we work with.  With all that in mind, I’m excited to share that we announced that Pepperdine University Graduate School of Education and Psychology and BHCOE, along with your placement partner, 2U, have formed a partnership to help expand and enhance the training for Applied Behavior Analysis students. I’m excited about it. Lusi, do you want to share a little bit about what that means for your students?

We are very excited about this partnership with BHCOE. What it means for us is that we are going to be requiring our students to attend practica sites that have achieved the BHCOE Practica Accreditation. This is something that we will be rolling out in the next couple of years. Ultimately, the idea is that we are going to be utilizing the strengths of BHCOE to have them come in and provide that level of oversight and assessment, “Is this agency providing the quality of clinical training that we would like to see within our field?” As Ellie was mentioning, we are going to have these eyes and ears out in the field, making sure that these things are happening the way that they should be happening.

In addition, these clinical sites are going to benefit from having access to these resources that are going to help to strengthen their agency-wide practices. They are going to produce better practitioners, and those practitioners are going to be more likely to stay within those organizations due to the quality of training that they are receiving. Ultimately, it’s going to strengthen our field in a lot of different ways. In addition, this partnership means for our students that if they come in already working at the BHCOE site, they will qualify for a scholarship to attend our program. Those details are in the works. We are very thrilled about this partnership.

I am excited because we do have the scholarship details. It is a significant scholarship. It applies to fifteen of the GSEP academic programs, which is great. It applies on-ground, hybrid, and online. It’s 10% off of your tuition. If you work for an accredited site and you choose to pursue your Master’s degree, then you will get 10% off your tuition at Pepperdine, which is amazing. The reason I’m excited about this partnership is because, I don’t know if you all remember this but maybe a couple of years ago, this is pre-Ellie joining BHCOE, Ellie, Lusineh, Adel Najdowski, and I were sitting at lunch, and talking about the pain points across universities.

Lusi, you were at Cal State LA at the time. All three universities approved training sites independently. All three universities that were within a 50-mile radius were sitting there and saying, “We think George’s ABA company is great. They can accept our students.” That, George’s ABA was going through and having to prove to Cal State LA, Pepperdine, and CSUN that they were appropriate to receive students. We saw this as a big inefficiency.

I’m excited about the fact that this will also reduce the burden on the providers who are trying to create these in-network partnerships with universities because they are trying to get students and make sure that they’re providing that training. Also, it will reduce the burden on the universities who are doing double work across a lot of these sites. As BHCOE, we are already out there doing those observations and vetting these providers. It makes sense to keep that back-and-forth in line of communication quite open with the university partners that we have.

Sara, you bring up such an important point. I will give you my personal example. A lot of times, the agencies that are applying to become approved agencies with us will say, “You have this super long comprehensive process. It takes so long. You have so many questions and supplemental documents that you need to submit.”

 

I can see how that’s unnecessary for them because they are like, “This person happened to work here and go to your program. Now we have to do all of this other leg work so that they can accrue their supervision with us or we have to worry about losing the staff member.” What you are describing is going to eliminate that because they are only going to have to go through that process this one time. It’s going to apply to all of their students, hopefully.

Lusi, I have a secret for you. I’m responsible for a lot of the long process that you see because Adel had reached out to me for our practica process because we were one of the first universities to put one in place. That long process you speak of has also been very laborious for us at the university. There is no additional pay for all of that review and time that we put in. The universities don’t have a system of that level of a comprehensive review to assure that your student is at a place where they are getting the type of supervision they need.

We, as faculty, had historically taken that on, among many other things. It can lead to some burnout on our part, and how often can we keep it up. I remember for sure a big conversation we were having, Sara, because Adel and I would constantly talk about the letters like, “What are some of the ways you respond to people if they are not quite there yet?” She was constantly asking for all these templates that I was sending her way saying, “Neither of us should be doing this anymore.”

I remember as you were complaining about that, I was like, “We are evaluating these providers. We can add some questions around training.” Ellie, that’s a nice segue. Do you want to tell us a little bit about the training site accreditation? How was it created? What are some of the sections there? If you are familiar with our accreditation process, there’s the full accreditation, which is quite comprehensive. There’s a training site accreditation that can get added on or be used as a standalone as well.

Before you start on that, I also think this is beneficial for our students because, from the students’ perspective, they come into a program thinking their site is going to work. If we end up saying, “This doesn’t work or see these red flags,” it puts them in a very precarious situation to be like, “No, I want to stay here because of my relationship with the company or yes, I do need to leave this place.” They have to find a new site, which delays when they can start their practicum.

The other is some of the literature we see that has been published about how should they seek out good ethical organizations. I’m thinking, “These poor students, how are they to know what to look for? They have not quite mastered the skills yet to go out there and figure it out.” A lot of these conversations were the reasons that I originally joined BHCOE. I have always been interested in quality but this was this incredible opportunity to help set some standards and move us forward in these areas.

I was excited when Sara shared with me that this is an area she wants to continue to help with because we had felt it at the university. Our training site accreditation is developed very similarly to the way we do other accreditation. We take on representatives. We had providers who have been providing some good supervision for some time. We also had university faculties and coordinators who all serve as subject matter experts and came together to tell us about what they expected to see as quality outcomes for their students and in good supervision.

We also collaborated with other organizations like ABAI because we knew that they were putting out some language around practica. I worked closely with Ashley Shayter, who then put together some of this based on some of the things that she was also doing at the time at her university. We put out, did some public comments, asked individuals what they thought about our standards, and took the approach of, “We are starting this. What are some organizations we can rely on? We know APA has been doing this for some time for psychologists.”

You are completely right, Lusi. It seems to me like that’s a win-win. The organizations get an individual invested in their career. They want to be at an accredited site where they can get the most. The universities can trust that their placements mean something and get good experience. The student can then be free of harm. It’s less probable that they will be in an organization that does not provide them with the type of supervision that they need. To me, it seems like a win-win. I hope I have answered your question there, Sara.

I don’t want to put you on the spot because you probably don’t have this off the top of your head. What are some of the things that we look at in the training site accreditation? I will caveat by saying there was a time where I would know every single standard. I am well beyond knowing that off the top of my head, so I don’t expect you to at all.

Create clear guidelines about what are the best practices and standards to follow. Click To Tweet

That’s because you also have that freakish memory that I can’t seem to have at all where you remember everything. I have to make contact with the recent material at all times. What we are looking for, in addition to what we typically do in evaluation, is the quality of therapy, onboarding, training, and the type of outcome data that individuals have been collecting. What are they doing with patients? What are the types of responses patients give us when we ask them about the type of quality services that they are getting?

All of those things we borrowed from what we understand in the general evaluation and made this unique to training sites by including the supervisors. We ask questions to the supervisors about the type of experiences they get to provide, support, and resources they have. We also interview the trainees at the site so that we can learn about their experiences. Those who have graduated as trainees have a lot to provide as direction about what the organization was like before they went out into the real world and started to practice.

The other things we look for are, “Are they adhering to what we understand as best practice and supervision?” We look to see, “Are they able to provide behavior skills training for some of the things that the individual needs to learn? Are they getting the experience to provide parent training? Are they getting the experience to train behavior technicians? If they are, is someone watching them do that and providing them with feedback to do that?” Those are the type of things we will look for.

We have a high volume of these new career professionals coming into the space. You mentioned turnover before, Anna. I think about the fact that these people are impressionable. It’s important that they get that first experience right and that their voice is also heard. Sometimes I feel like their voice is dismissed a little bit because who are they to share their experiences? They don’t know what good training looks like. It goes back to the social validity piece.

As a field, we have to move towards the idea of listening to patients and saying, “We may be doing everything perfectly but patients don’t feel that way.” It’s the same thing with students. We may be doing everything perfectly but we need to make sure that students feel that their best interest is in mind and that they are getting the training that they want. I’m excited about that, especially considering it’s the biggest workforce in our field. I don’t feel like we listen to their voice enough.

We are all behavior analysts. We know that no one intends to be a bad supervisor. I don’t know any organization that’s like, “I’m going to take on these young students and do a crappy job of putting them out.” At least I don’t think anyone comes in ever thinking that way. The contingencies set it up such that people do get overwhelmed and over-busy. They might get much more engaged with administrative work rather than have the time for some of the clinical oversight or provide feedback on professional conduct.

Having a structure and clear guidelines about what’s the best practice and standards to follow but also having us as outsiders as a source to provide that feedback adds the contingency that’s missing. Otherwise, we know what’s going to happen in any environment. If you put a good or excellent person in a bad environment, that’s what you are going to get out of them.

If I can add to that, what we are talking about here is the demand on agencies. BCBAs don’t all sign up to be fieldwork supervisors, and yet they are assigned this role, whether or not they feel confident in doing that task or not.

That resonates with me so much. To Ellie’s point, we all have our reasons of why we joined BHCOE. I joined BHCOE because I have spent the last decade advocating for access to care through insurance and Medicaid and helping track your families. One thing that I began to realize over the past few years was that all ABA doesn’t look the same. The critical piece that quality plays in ensuring this benefit can continue. That is not something that I take lightly, and that is why I came to be a part of this incredible team here.

I’m thinking, Lusi, from your perspective. We are talking a lot about California. What you are doing here is so incredible. For all our readers across the United States, how can this translate maybe to help other universities? What would you say to those who are maybe considering becoming a training site that could help them understand? What are the next steps to do this? How do you feel about that?

 

The first thing that an agency needs to establish is, “Am I capable of allocating resources for clinical training of people who are going to go on to become BCBAs?” If an organization is brand new and they are working on building up their caseload, they have maybe 1 or 2 BCBAs who have 15 to 20 cases each, they probably don’t have the bandwidth to also provide clinical supervision. We need to first identify, “Are you someone who wants to be doing this? Are you doing it because you think you have to be doing it?”

Once we identify that, then it’s about, “How you can ensure that you are doing a good job for our field.” That’s where BHCOE comes in. Why not seek external support from an organization that wants to come in and give you the resources and tools to allow you to be successful? Why not allow this organization to come in and do that initial assessment of giving you the thumbs up, “You are doing things the way that is going to represent our field in the right way?” Organizations have to have that willingness to embrace change, be assessed and want to improve themselves.

The willingness to embrace change is a valuable piece in this because it’s easy to get stuck doing the same thing. It’s what I was mentioning earlier. The other reason I’m so excited about this is that training seems to be a primary pain point in our industry. Staff feeling a lack of training said, “This is so exciting because it resolves and brings some answers to that and some support.” I’m so excited about what you are doing.

I will also add that there are agencies out there that are doing fantastic work. Why not have that work be recognized? You are doing great but it’s not just about you. Accept the recognition, that’s fantastic for you, and set the bar for other agencies to follow in your footsteps.

I’m getting so excited just learning. Many universities might be worried about ABA organizations not being happy with this type of requirement. Do you have any advice for them?

It ultimately goes back to being open to embracing change. It is not easy. It requires a lot of additional planning for universities, students, and organizations. It may be an additional thing that they have to allocate time to when they already have very limited time in their schedule. At least on our level, hopefully, this rollout will happen in a way that will give agencies appropriate time to get to that point. It’s like going to the dentist. Nobody likes it but you got to do it.

I hate the dentist. That’s my least favorite thing to do. That’s a great example.

That’s better than another analogy I have heard accreditation referred to.

That was Jonathan Mueller’s comment. I was like, “Holy cow.”

At the Investor Summit, he gave a presentation and called accreditation a colonoscopy. I like dentists better.

Accreditation ensures there is equal performance and equal opportunities. Click To Tweet

Lusi, correct me if you don’t feel that this is true at all. I felt that the organizations around us were super excited at the time when we set standards. Some of that is because they were historically used to maybe being the providers that are doing an excellent job providing good services but the quality was not as noticed as if they knew university faculty members had relationships with certain individuals or potentially even graduated from the program. Universities did not have a third-party objective system to be able to go to.

My experience when I entered the field, and the reason I immediately moved to set some standards, was that I felt that there would not be equal opportunities for all organizations to recruit new students that are coming into the fields. Instead, people were trying to take me out to lunch and figure out ways to get themselves known. I worried very much about that because that wouldn’t tell me about quality necessarily. I don’t know how you feel about that but I feel like this provides that equal opportunity to say, “My quality is good. I do this.”

That’s such a good point because I have heard providers complain to me saying, “We provide great supervision,” but there’s someone who’s very business savvy, is able to connect with someone at the administrative level at a university, and gets the first right of refusal relationship on students. The fact that students are turning into a marketplace is what we want to avoid. Lusi, go ahead.

That’s exactly what my experience was. I didn’t know the first thing about applying to ABA agencies when I was in my graduate program. I was looking to my professors to give me recommendations. Everything happens through word of mouth. Even nowadays, that trend continues. I have had terrible experiences at some of the places I have been referred to. Word of mouth is something like you trust this person to give you a good recommendation but nobody knows the quality of your experience.

Within organizations, you can fall under a great BCBA who’s going to give you excellent supervision, and you can fall under a terrible BCBA. If the organization hasn’t accounted for the quality across the board, then it is the luck of the draw of who you end up being paired with. What accreditation is going to help to fix is ensuring that across the board within an organization, you have equal performance and opportunities. That’s also going to allow those equal opportunities for organizations that are looking for students in graduate programs.

It’s a good segue talking about accreditation. I wanted to talk about the BACB’s newsletter in which they announced that universities have ten years, which is a long timeline but a timeline nonetheless, to obtain ABAI Accreditation as a prerequisite to provide approved hours for certificants. I wanted to know what you thought about this decision. How does that affect your program? How do you think that’s affecting universities in general? How do you think it will impact quality?

I’m very rigid in this way, and I love it. I will put that out there. Personally, it’s fantastic. We should have done this a long time ago. It’s going to help to improve the quality of the university-based training that we are offering. It’s going to help standardize things that are not standardized and hold everybody who earns this degree to that standard. My point is that it’s a valuable thing that we are doing.

That it will impact some universities more than other universities and some programs more than others but that’s a good thing. For those universities that had an impact more, it should be a wake-up call for them, “Are you engaging in the best practices that are going to move our field forward?” I’m not naming any names. “Are you a degree mill?” We don’t want degree mills in behavior analysis. What we do is so nuanced. We need people to get what they are doing or else we are going to find ourselves in the situations that we are finding ourselves in.

I want to caveat because I want to make sure we don’t get in trouble. These are just opinions here about what we all think. I do think there’s a movement in our society about the commoditization of education. When you think about the technical schools, the online programs, and some of the fast-food types of approaches to education, one thing I will say is that the good news is that education is innovating.

Education is one of the slowest innovators I have found across industries. I love the idea that education is shifting its model of how people get educated but I do agree that we need to continue evolving and pushing the envelope to make sure the outcomes and successes are there of the students who obtain those educational degrees from these unique programs that may not be the traditional method.

 

I want to add that every program should have the opportunity to improve its practices to this degree. I also want to highlight that, on the other hand, I see that this is going to create barriers to access for members from diverse cultural backgrounds who may not have access to traditional education. We have these unique, educational, and innovative practices that are happening.

If the program doesn’t evolve and adopt those practices and take into consideration these standards, then I see there is a larger impact on individuals from marginalized backgrounds with moving to accreditation because it’s going to make them attending these programs and graduating from these programs potentially more difficult. While I love this idea in the theory of, “We do need to move towards standardization and ABAI Accreditation for our university programs,” we do need to factor in what can we do to make that process accessible for all members of our community.

I was thinking about the single mom or the person who’s making a career change, midlife who doesn’t have the luxury of attending a 9:00 to 5:00 program where they don’t have to work.

It’s the idea of continually innovating because I think about the human life component of a child with autism. I have a child with autism. When I think about that piece of this, for me as a parent, it makes total sense. I want the field to continue to improve, evolve, and ensure that whoever is going out to see our kids that have autism has the best training to help our kids have the best outcomes.

That is so important. I think about how that has evolved over time in medicine and other fields. New technology comes out. You’ve got to learn how to use new equipment. I think about surgeons in general and all the new things from a technology standpoint. For me, behavioral health shouldn’t look any different.

We should be focused on accessibility without giving up quality. No one is going to go to a heart surgeon that’s like, “I went to the school that only makes you go for five years, and you don’t even have to go in-person. I’m going to do your heart surgery.” I would be like, “That’s okay.” Raising the standards and thinking about how it impacts the patient is important.

If we were to also notice some of the numbers in our field, it’s very much telling. More than 50% of BCBAs have graduated within the last few years. We are dealing with an influx of coming away of many individuals who are graduating from these programs. In the paper Erick and I did, and this is where I know, Sara, and your memory is so much better than mine. We found that the majority of the students, something like 50% or so, came from two schools that were not putting out the best exam pass rates. It is concerning to know that we need some quality control over the universities. If we have such an influx or a need and get many students coming out, we have some quality control over it.

I’m with Lusi on this. When I developed the program at Cal State Northridge, we began by thinking that we were going to become accredited. We designed coursework and everything else to be prepared for that process. We have been collecting self-assessment data for that reason. Standardization is excellent. We certainly see a difference between those organizations and schools that have that standardization and a third party looking at them. I’m about accreditation because it provides that oversight. It’s hard for me then to say, “I’m really all about quality control and accreditation,” but as a university faculty, I don’t want this because it’s going to be pain and suffering.

We covered a lot but maybe I will pose a final question here. Do you have any advice for the university department chairs or professors who are worried about the state of the field and are trying to tackle this issue quality? I will caveat by saying at BHCOE, no matter how much we were trying to stop the bleed of the quality issue at the provider level, we realized we couldn’t do it without universities.

I remember one time posting about something like that on LinkedIn. A couple of professors reached out to me like, “What are you talking about? We are doing our part.” The idea of collaboration between the university and the provider was a newer concept. That would be my two cents to the answer. Are the providers and the universities collaborating on what does the university want out of the providers they are partnering with to make sure their students have a stellar experience? That’s the gap that I hope this partnership will fill. I’m curious. What advice you might give, Lusineh or Ellie?

First of all, I also wanted to say that Pepperdine’s program is not yet accredited. We have started the process of working towards that. My perspective on accreditation for universities is coming from a place of, “This is something I want to do for our programs.”

You are only five years old in 2022. You don’t think you were eligible.

We started in 2016. That’s one thing. Before I say what I would offer to universities, I also want to say that we are all people in a system and working within that system. Depending on which school system you work in, whether it’s a private or public university, you are dealing with the bureaucracy that’s going to potentially prevent you from doing the things that you consider ideal for your program. It is up to us to advocate for our field because we are such a small field and in high demand. We have to make our voices heard and set that standard for our universities to tell them what is expected from us.

What accreditation does is that it gives us the foundation to stand on because when a program goes to the administration and asks to make these changes, a lot of times, they are like, “Why would we make these changes? Things are going fine the way they are. You are talking about taking time away and more release units to do these things that the programs find the way that it is.”

When you come in with this requirement for accreditation, now you have that leg to stand on where you tell your administration, “These are the requirements that we must meet if we want to continue to operate.” Universities or faculty members within universities need to look to this as an advantage to help us be able to advocate for moving our field forward.

That was brilliant. I’m not sure if I can add anything to that because she’s 100% right on.

Thank you so much, Lusi, for joining us. Thank you, Ellie, for taking time out to join us as well. It was a great conversation. We can’t wait to maybe give a recap of some of the follow-ups from the partnership in a couple of months here. Pepperdine was the first to dive in. We have a couple of other universities who have also agreed to take on this path as well. We can’t wait to share more with all of you as those announcements come out. Thank you all so much. Have a great rest of your day.

 

Important Links

• Autism Investor Summit
• BHCOE
• Jim Hogan – AIS Learning Management System
• Google
• The Braff Group
• Dexter Braff – AIS Learning Management System
• AIS Learning Management System
• Aetna
• Optum
• Magellan
• David Cox – LinkedIn
• Defy Community
• Cigna
• Central Reach
• Evernorth
• Centene
• Ellie Kazemi – LinkedIn
• Lusineh Gharapetian – LinkedIn
• 2U
• Erick Dubuque – LinkedIn
• ABAI
• Partnership – Pepperdine University Graduate School of Education and Psychology (GSEP), 2U and Behavioral Health Center of Excellence Form Innovative Partnership to Expand and Enhance Training for Applied Behavior Analysis Students
• Adel Najdowski – LinkedIn
• APA
• Jonathan Mueller – LinkedIn
• BACB’s newsletter
• https://www.BHCOE.org/2022/05/bhcoe-centene-partnership/
• https://www.BHCOE.org/2022/04/bhcoe-evernorth-partnership/