Academic journal article The Behavior Analyst Today

Revamping Therapeutic Staff Support Practices

Academic journal article The Behavior Analyst Today

Revamping Therapeutic Staff Support Practices

Article excerpt

Therapeutic Staff Support (TSS) provide proactive child management, time structuring, positive behavioral support, and crisis intervention to children with serious mental health diagnoses via a federal entitlement program, Early Periodic Screening Diagnosis and Treatment (EPSDT). For those of us who work daily in the behavioral health rehabilitation field, having this position filled by well trained and supervised staff is critically important. However, despite the real and potential benefits of the TSS in the context of "wrap around services," most stakeholders in the state of PA, (where this type of service is more extensively developed than most other states), agree that the current system for TSS must change. Almost all are concerned and complaining. Parents and agencies have filed suit against the Commonwealth for failure to provide medically necessary services in a timely fashion, as in the precedent setting Kirk T. litigation. Parents and provider agencies are also concerned about the quality of services, particularly when they hear that "treatment" involves trips to McDonald's or the arcade. Teachers complain that TSS in their classrooms are often nonproductive and sometimes a hindrance. Managed care companies and agencies complain that TSS services decay into "glorified babysitting." Finally the state of PA is overwhelmed with the over utilization of the TSS service, usually the most costly aspect of EPSDT service provision.


The above problems can be grouped into the following areas: a) insufficient number of TSS to fill child needs as assessed by psychologists and psychiatrists evaluating children brought to the attention of the system (see Kirk T. et al. vs. Houston, 2001 circuit 3rd); b) poor learning history and insufficient training of the TSS (e.g., TSS no-shows, TSS who become embroiled in the same power struggles with children as parents and teachers, thus offering no increased professional benefit, and agency failure to staff--see Kellner vs. Philadelphia School District); and c) almost exponential growth of TSS costs since 1994. Each of the above concerns can be addressed with a radical job restructuring of the TSS position in which service prescriptions are based on objective measures, thereby increasing the focus on clear goals established through empirical assessment practices. This paper presents the nuts and bolts of how to place the TSS position in a new light in order to solve the problems commonly raised.

Creating a Five Tier System Based on Need

Ideally, a provider agency's program manager should begin, with the psychological evaluation (including the results of formalized behavioral assessment instruments) to create treatment goals in collaboration with the family. Once goal analysis is done, the treatment team leader (either the Behavior Specialist Consultant or Mobile Therapist) develops a treatment plan with an individualized task analysis of the skills and strategies need for each individual. This task analysis should result in an hour-by-hour breakdown of expected TSS activity. Then, in the following revised system, TSS skills are matched with the level of service needed by each child receiving services (see Table 1). The TSS position can be fruitfully divided into five separate levels of care, depending on the child's needs. The training level for the TSS can vary. Since there will be stratification of job levels, there will be an increased pool of potential TSS applicants to select from as well as pay/cost differentials that will help address the high cost of services to state. Additionally, improved access and quality of TSS are addressed.

Table 1. Experience Requirements for a Five Tier TSS System

TSS level 1: TSS Aide requires High-school diploma and three years of

TSS level 2: TSS Associate requires Associates Degree and two years
experience working with children or 60 college credits and two years
experience working with children. … 
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