Initial Assessment

Pre-approval letters from the Arkansas Department of Health, Division of Developmental Disabilities are required on all new cases

          * Arkansas Department of Health contact person for pre-approval letters:

                     * Rhonda Stewart: rhonda.stewart@dhs.arkansas.gov

          * Pre-approval letters are not required for requests for continuation of services, every 6 months

          * DMS-693 EPSDT Referral/Prescription

          * Needs to be completed by the PCP

          * Needs to be signed within a year of the request start date

          * Medicaid recipients, covered by ArKids B are not eligible for ABA services

Individualized Treatment Plan Required Content

Demographics and background information

          * Child name, DOB, age

          * Psychosocial information

                    * Who lives in the home

                    * Languages spoken

                    * Family dynamics

                    * Recent stressors or major changes

          * Diagnosis, date of diagnosis, relevant medical history

          * Reason for referral

          * Previous ABA providers and dates of service (if applicable)

          * Date services began with current provider

 

Current and previous services:

          * School attendance and related services

          * Behavioral Health

          * Therapies (OT/PT/ST)

          * Community

          * Note coordination of care with other providers

 

Signature and date

          * Parent/Caregiver: Indicating acknowledgement of the treatment plan

          * Supervising BCBA: Indicating review and approval of the treatment plan

 

Facility and supervising BCBA contact information

Skills-Based Assessment

At least one skill-based assessment

          * Visual representation of both previous and current assessment results

          * Include child's name, color codes, and date of assessment

 

Written summary of treatment-focused symptoms present (based on file review, parent interview, observation, and assessment results) across the following domains:

          * Communication

          * Social

          * Independent play and leisure

          * Adaptive

          * Sleeping and feeding

          * Community

          * Safety

          * Restricted or repetitive behaviors

          * Learning rediness/foundational skills

          * Maladaptive/challenging behaviors (if present, Functional Behavior Assessment should be completed)

                    * Significantly interfere with learning

                    * Limit access to social and community opportunities

                    * Result in harm to self or property

Functional Behavior Assessment

Intensity level of identified behaviors

          * Biting self or others, leaving a mark

          * Leaving the house without permission and wandering the neighborhood

          * Getting up from the table during discrete trial teaching, but not leaving the room

 

Clear operation definition of challenging behavior

 

Assessment conducted to identify function of behavior, with at least one of the following

          * Indirect assessment

                    * Collection of ABC and direct observation data

          * Functional analysis or IISCA

          * Hypotheses and summary statements describing the maladaptive behavior(s) and their functions

          * Analysis of assessment data that supports the summary statements

Clinical Recommendations

Recommended number of hours for treatment and reassessment

          * Treatment hours/units should be requested per week for 26 weeks

          * Assessment hours/units should be requested in total and the same end date of treatment

          * Note if there is an increate, decreate, or no change in hours requested

          * Provide clinical rationale for requests to increase hours

 

Note any gaps in care or barriers to progress

 

Location of treatement

          * Home

          * School

          * Clinic

          * Other

 

List of the evidense-based interventions to be used as outlined

          * See Phase 2 of the National Standards Project (National Autism Center, 2015)

 

Interventions for behavior reduction are directly connected to the function(s) of behavior

 

Positive Interventions are recommended and exhausted before aversive or punitive procedures are considered

Skill Acquisition Goals and Progress Reporting

Skill Acquisition Goals

          * Derived from skills-based assessment, caregiver interview, direct observation, and/or functional behavior assessment

          * Contain measurable mastery criteria (e.g. 80% of trials, across 3 consecutive data, for 10 different examples)

          * Attainable by the end of the 26-week treatment request

          * Baseline data and date obtained for the specific skill being targeted (e.g. responded correctly to 0/3 examples)

 

Progress Reporting

          * Date goal was introduced

          * Written summary of current skill level (e.g. child has met 14/20 targets)

          * Goal status (e.g. mastered, continued, not yet targeted, on hold, discontinued) and rationale

          * Rationale should include explanation for the goal status and treatment modifications to address lack of progress

          * Only submit progress on goals that were targeted during the previous authorization period and new goals that will be targeted during the next authorization period

Behavior Reduction Goals and progress reporting

Behavior Reduction Goals

          * Hypothesized function of behavior derived from functional behavior assessment

          * Contain measurable mastery criteria (e.g. 3 or less instances across 10 consecutife data days OR 80% reduction in daily instances across 15 consecutive data days)

          * Attainable by the end of the 26-week treatment request

          * Baseline data and date obtained for the behavior targeted for reduction (baseline data should include repeated measures over time)

          * Function based specific replacement behaviors should be identified with corresponding skill acquisition goals (e.g. waiting for preferred items, requesting a break from instruction)

 

Progress Reporting

          * Date goal was introduced

          * Written summary of current skill level (e.g. engaged in an average of 5 [range 1-10] instances per day across the last 10 consecutive data days)

          * Goal status (e.g. mastered, continued, not yet targeted, on hold, discontinued) and rationale

          * Rationale should include explanation for the goal status and treatment modifications to address lack of progress

Parent/Caregiver Goals and progress reporting

Goals

          * Contain measurable mastery criteria (e.g. 80% of steps across 3/3 observations)

          * Attainable by the end of the 26-week treatment request

          * Baseline data and date obtained

          * Individualized for the family

 

Progress Reporting

          * Date goal was introduced

          * Written summary of current skill level (e.g. completed an average of 65% [range 45-80%] of steps independently over the last 3 observations)

          * Goal status (e.g. mastered, continued, not yet targeted, on hold, discontinued) and rationale

          * Rationale should include explanation for the goal status and treatment modifications to address lack of progress

Accepted Signatures

*Accepted signatures include those that are digitally signed using a third–party electronic signature service (e.g., Adobe Sign, DocuSign, HelloSign) or any type of electronic signature (e.g., Adobe Fill & Sign, JPEG of a signature) provided the document is signed by the appropriate party with the intent of signing the document. *Accepted signatures include those that are digitally signed using a third–party electronic signature service (e.g., Adobe Sign, DocuSign, HelloSign) or any type of electronic signature (e.g., Adobe Fill & Sign, JPEG of a signature) provided the document is signed by the appropriate party with the intent of signing the document.