I chose to build my career around providing ABA services specifically in a home environment, where many of the most socially significant skills are present and often most challenging, where I can help support families through their hardest moments, and where I can see the greatest lasting changes for the families I serve. When I first read the proposed changes to our Medicaid regs in the state of Virginia, I was floored, because it truly seems like the goal is to eradicate the possibility of providing home-based treatment for our consumers/clients.  Because of the way the draft regs are written, which look nice and lucrative if you are providing a clinic-based model, my fear is that more and more LBAs will choose to drift away from home-based work and move more toward clinic-based work only (or that companies' survival will be dependent on clinic-based work, thus eradicating home-based treatment altogether). As the draft regs have made clear, without an available supervisor/LBA/LMHP, services cannot occur, thus creating major limitations in the state of Virginia for the populations we serve.

I do see a few specific and major limitations that I would like to highlight: 

• A clinic setting may provide a highly controlled environment in order to teach skills, however clients may not have a higher rate of generalization to their more natural home or community environments. I have seen this play out MANY times with clients transitioning from residential/center-based models to help with significant behavior reduction. In a center/clinic, the challenging behavior may have been reduced to near-zero rates, however upon re-entry into the home, the behavior change had not adequately generalized and the challenging behavior ends up re-emerging (at often dangerous rates). Home-based ABA is imperative to creating lasting, life-long behavior change in the most socially significant environment.
• Home-based services allow for parent training opportunities to occur in the most natural environment. Part of the program description is to provide quality parent training opportunities. Quality, in my mind, should be in the most socially significant environment for the family, with the opportunity to provide the most trials available as well. This cannot adequately happen in the confines of a center program where you are limited to your time slot for parent training. However, home-based services allow parent training opportunities to happen at a higher frequency (think of using BST & coaching throughout an ENTIRE afternoon with a family -- game changer!) AND within the exact same environment where the behavior occurs (again...generalizable opportunities!). 
• Families in more rural environments or those with a lower socioeconomic status may be limited in their ability to access center-based treatment. They may not have the ability to travel to appointments, or have to be dependent upon Medicaid or public funded transportation, which we all know is in very short supply right now. This creates an unnecessary barrier to treatment and may have accidental impacts on certain populations. I think of the radius I serve in - 1 hour from our home office - and how many families I serve without a car, driver's license, available transportation, or even basic self-advocacy skills, and I KNOW they will be the ones suffering at the hands of these Medicaid changes. If we can't provide home-based ABA in the state of Virginia, and they are unable to travel to a clinic that is an hour away, how do they get the help they need? 

Thank you for considering these comments for the future of home-based ABA in light of the proposed Medicaid regulation changes.