Best Practices for the Administration of Behavioral Health Rehabilitation Services (Wrap around) in Pennsylvania: Six Basic Problems and Their Solutions

By Cautilli, Joseph D.; Rosenwasser, Beth et al. | The Behavior Analyst Today, Spring 2000 | Go to article overview

Best Practices for the Administration of Behavioral Health Rehabilitation Services (Wrap around) in Pennsylvania: Six Basic Problems and Their Solutions


Cautilli, Joseph D., Rosenwasser, Beth, Clarke, Karen, The Behavior Analyst Today


Many behavior analysts in Pennsylvania currently work as Behavior Specialists in early periodic screening diagnosis and treatment (EPSDT) funded Behavioral Health Rehabilitation Programs (BHRP). These services were devised originally to serve low income children's medical needs within their local communities. Over time these services have been expanded to mental health diagnoses and have the potential to help prevent many of the dire consequences typically found for children with untreated or undertreated disruptive disorders and developmental disabilities. For a variety of reasons BHRPs, commonly referred to as "wrap around" services, are often chaotic and poorly organized. Many programs fold within the first five years of their existence. However, rather than a problem with the constraints of EPSDT-funded programs, we see this as a program management issue. This paper introduces ways to improve BHRPs from a behavioral systems perspective.

The Problems with BHRPs

The development of Behavioral Health Rehabilitation Services (BHRS) for children and adolescents followed from the Scott vs. Snider decision (1991) critiquing the adequacy of then current services. In 1994, request for particular services, namely the Behavior Specialist Consultant, the Mobile Therapist, and the Therapeutic Staff support services, to be offered in home, school, and community, were requested so many times, that the PA Office of Medical Assistance Programs (OMAP) decided to place the services on the medical assistance fee schedule. This led to the beneficial effect of services being offered to a greater number of children more quickly. On the other hand, having structured positions on the fee schedule, each with limited roles and functions, has hurt innovation in service design.

While the funded positions became more structured, the general call, at the state level, for programs to be innovative led many agencies to be lulled into a sense that 'anything goes' with little preference given to interventions demonstrated to be effective for the various children being served. Even worse, many agencies were attracted to the flexibility of programming because of the range of services for which they could bill; wrap around has become known as a "cash cow" which can support other agency programs and larger salaries. In addition, many agencies opened their doors without adequate institutional support. Finally, the positions specified in the OMAP regulations are beyond the present skills of many among available pool of potential staff. Unfortunately, rigorous training in the interventions shown to be effective for the types of problems that children being served is severely lacking, as attested to, in part, by the complaints of numerous schools who interact with these staff. All of these problems have led to generally poor quality services and the poor image that BHRPs have developed.

Thus BHRPs suffer from a host of problems from program quality to integrity. Despite these problems, we argue that simple structural and functional solutions can achieve the goal of setting community-based BHRPs back on track.. As the reader will see many of these suggestions are critical to the development of any successful program. The six major problems that BHRPS suffer from are: (1) lack of qualified personnel and specificity of role and daily functions; (2) Poor training and supervision of staff; (3) lack of consumer knowledge of the program and informed consent; (4) lack of institutional support (i.e., lack of needed functional roles and staffing of those support roles) (5) poor forecasting of incoming clients and management of intake; and (6) economic contingencies from institutions to increase growth before proper institutional supports exist. This paper analyzes each of these problems and offers simple management techniques to these eliminate problems, restoring quality and integrity to most programs. Lack of qualified personnel and specificity of role and daily functions

BHRPS in Pennsylvania have three primary positions: Behavior Specialist Consultant (BSC); Mobile Therapists (MT); and Therapeutic Staff Support (TSS). …

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