The current draft for ABA service focuses on improving services to a standard of quality care, which is certainly needed. However there are other factors and variables when providing in home services, especially in rural areas, that impact the ability to meet some of these expectations. When required components of quality services, like supervision in the absence of individuals, treatment planning, data analysis, are considered "in kind" they begin to lose their priority, when productivity standards are in place to ensure the service is sustainable.  This puts service providers in a state of burn out attempting to meet productivity standards (to keep service viable in areas) while providing the quality of standards they are held to in certification, licensure, other regulatory bodies and standard of care. Rural areas are effected by the ability to maintain theses services with longer than average drive times and lack of other resources, making it difficult for providers to provide most of their case requirements in the presence of individuals supported.  LBA's having the ability to analyze data, treatment plan, and provide supervision and support in the absence of individuals being supported is essential component of quality service.

When services are clinic based and the LBA's, direct care staff, and individuals are all on site with no travel time and ease of access, but with the intended location of service delivery being in home and community settings it has a huge impact on service delivery and quality of service, especially when provided in rural settings.

Providing all aspects of ABA in the presence of the individual supported, like data analysis and supervision, is not always the most effective use of time. Often when on site other needs arise and the purpose of the meeting is not met, leaving the data analysis or supervision to be provided outside of the billing times. Requiring weekly supervision of unlicensed staff, but only allowing billing of supervision if in the presence of the individual supported will affect the quality of supervision provided, which is a key component of ensuring treatment plans are understood and will be implemented with fidelity (which is where the onsite supervisions are key in quality services and is supported- but should not be the only allowable / billable form of supervision).

Making these services in kind effects suitability because there is not a set time it takes for these duties. Each individual supported requires a varied level of support and intensities and making an average time it should take weekly is not reflective of the individualized nature of treatment support required by LBA's or other supervising physician acting within their scope. The individualized nature of ABA requires LBA's to spend time outside of the home analyzing data, treatment planning and modifications, as well as supporting staff in supervision. 

It seems a little conflicting that the intended location for services in the in home setting, yet the allowable activities and structure of billing seems to only be sustainable in a clinic setting.