RBT--Person or Service?

Continuity of quality service might be one of the most important aspects of treatment with successful outcomes. Quality can refer to a number of variables including a strong rapport between client (and family) and clinicians, built over time with a steady progression of engaging and reinforcing sessions. While case managers are part of this quality service, it is inevitably the registered behavior technicians (RBTs) who share the most time and encounters with client and family. often in the family home. Hence, the reality of turnover of staff, or perhaps the necessity for 'time-off,' can create a semblance of discontinuity in service all on its own. In this episode, Dan and Mike revisit a 'company line' oft used to promote parameters like 'sub' clinicians when assigned staff is unavailable for a session and client as usual--the RBT is 'a service, not a person.' All the while, Mike splits time between being a 'sub' of sorts himself, caring for his 2-year-old while 'mama' is away, as Dan and he analyze the pros and cons of seeing the RBT as a service, and not a person.

Lots to analyze in this tasty brew--a hint of bitterness, perhaps a bit sour at times, but it promises a smooth finish. Enjoy all the layers, and always analyze responsibly.

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Transcript

SPEAKER_00: 0:00

Welcome to ABA on Tap, where our goal is to find the best recipe to brew the smoothest, coldest, and best tasting ABA around. I'm Dan Lowry with Mike Rubio, and join us on our journey as we look back into the ingredients to form the best concoction of ABA on tap. In this podcast, we will talk about the history of the ABA brew, how much to consume to achieve the optimum buzz while not getting too drunk, and the recommended pairings to bring to the table. So without further ado, sit back, relax, and always analyze responsibly.

SPEAKER_03: 0:52

All right, and welcome to another installment of ABA on Tap. I am your co-host, Mike Rubio, along with Daniel Lowry. Good to see you, Mike. It's been a little while, but glad to be back at it, man. It seems that we front-loaded this season and done kind of a couple of episodes, and then life happens and we have to take a break. But I'm glad to say that I believe this is our eighth episode of the fourth season, which is usually our maximum for the first three seasons. We've achieved eight episodes, and we're well on our way to do 12, one a month, and hopefully we can scale up next season. So we appreciate all the listenership. We appreciate all the support, even some of the negative commentary, which

SPEAKER_02: 1:32

is...

SPEAKER_03: 1:33

helped us realize we've got attention out there, even if it's negative. But those are all good things, and we're all glad for it.

SPEAKER_00: 1:43

Yep, that's the thing. When you do this kind of on the side, you've got work, and then you've got family, and then you've got health, and a lot of other things kind of come in the way, but glad to be back at it. Shout out to a company called 3Pi Squared that reached out to us. Very excited to join them on the podcast streets. They do ABA podcast as well, so I wanted to give them a little bit of a shout out. They'll be coming on to our podcast. We'll be coming on to their podcast as well, and really just encouraging and want to throw it out there. Anybody who agrees or disagrees with our stances on anything, please reach out to us. We'd love to have you on the podcast or work out some sort of arrangement where we create a discussion that hopefully just betters the field. So very much looking forward to that.

SPEAKER_03: 2:27

As I like to say, we appreciate... Good disagreements, good healthy disagreements. However, we stay away from argument. We're not trying to be right other than do right by our clients. That's the important part. So you can have an anti-ABA stance. We want to hear from you. We want to hear from you. We want to understand why. And we want to offer our own perspective. So yes, please, please do reach out. Again, we welcome healthy disagreement here.

SPEAKER_00: 2:52

In fact, our next few podcasts, we'll be, again, revisiting some of the detractors and Yeah, we'll be talking about that. The potential is ABA in crisis will be a multi-part series coming soon. But without further ado, let's get to the topic at hand today.

SPEAKER_03: 3:13

So sometimes we... concoct a title as we think of the theme for the day, and I think you've nailed the one for today. This is going to be called RBT Person or Service. Yes. And the reason we've had to revisit this topic is we're actually professionally going through a transition and joining another group, and in looking at different reimbursement rates, we often have to consider things like session length and... cancellations and the idea of substitutes specifically which is something we talked a lot about over the past two weeks and trying to ensure client service continuity so if your regular rbt or even your supervisor isn't available for a visit can somebody else on your staff can it can appear fill in adequately and what does that look like right now in the old days when we Well, I say the old days for us because I think we've left the cookie cutter templates way behind. Maybe that was a little easier, right? Because everybody was doing the same thing. In fact, we insisted on people doing the same thing as though We are the same person across people, which often led or was maybe at the heart of our generality crisis or challenges. Sure. Okay. A little bit interesting, kind of a personal anecdote. I'm a little bit of a substitute today, personally, as I watch my two-year-old daughter here on the screen who's trying to nap very diligently and follow my instructions as we try to record. And her mom's not around today. Her mom is away at a work conference. So I am dad. flying solo for the next three days, and that's a bit unusual. As much as I know the routine, I'm gonna implement it a little bit differently. I'm gonna speak a little bit differently. My timing's gonna be a little different. And that could work to cause a little bit of distress in my daughter, who's accustomed to a very strong routine, because her mother's fantastic. It could also serve to get me accustomed, get her accustomed to a new way of doing things without completely deviating from the routine. And I think that's what a lot of our families face, right? So the same thing could happen to you or me in terms of seeing our doctor or our dentist or our physical therapist, the idea that you get accustomed to one person who's delivering the service, and then at some point they go, hey, that person's not going to be here. Would you like to keep your appointment with this other physical therapist, this other doctor, or do you want to reschedule and cancel. Now for us, again, given continuity of service as well as fiscal health, the idea that we can maintain the integrity and the consistency of those sessions is of great importance, which then leads us to try to find the best way to look at an RBT, especially a very skilled one, and when they're not around, what is the replacement solution? What are the options? What do we tell parents about that? How do we encourage them to realize that, well, if we're not using a cookie cutter recipe, then they're going to be doing something a little bit different with your child. And that might not look as good. It may not sound as good. There may be a little bit of distress from your child, just like maybe my daughter is experiencing right now. But the idea that It's good to get accustomed to that as a fact of life or a factor in life is also another part of the discussion. And then yet the third part of the discussion, which I mentioned, is the fiscal health. The idea that too many cancellations, well, that doesn't bode well for us in terms of being able to deliver the service in a cost-effective manner. So covered a lot of ground there, as I usually do at the beginning. I'm going to pass it over to you to let you unpack it all and sort some of this out for us. And then again, to reiterate, this is going to lead into maybe two, three-part series on the notion of rates and fiscal health and other discussions that are very relevant and current in the ABA news in terms of not just detractors of ABA, but the things that maybe we've done to ourselves or that... things like equity firms are currently doing to the landscape of ABA treatment. So, Mr. Dan, talk to us. What are you thinking? I know you've gone down the rabbit hole recently, so illuminate us, educate us. What you got on your mind?

SPEAKER_00: 7:28

You always do cover a lot of ground. I make some mental notes and then there's a lot of ground to cover a lot of great points. Don't worry, I'll come back. The first thing, like you mentioned about you playing mom today and relating it to the RBT situation is that while putting your or certain things that she's used to doing with her mom may not look as idyllic as they do with the... The parent that they're more, you know, the habit is trained with. Sure. But you're trading some ease or I don't know how. You're making it. Consistency, ease. Consistency for generalization. So same thing with the RBT situation, right? You're trading some, hey, I know this person. And when this person comes in my house, they know where everything is and they know the routine and everything's good. Whereas a new person may not know these kind of things. So you're trading that ease. for the generalization. Because at the end of the day, our goal in ABA is designed obsolescence. If we do our job, we fade out. So at the end of the day, we want anybody to come in and that child to be able to respond to anyone. And that's kind of where that term is RBT, a service or a person. That actually came from our previous employer. And they said it in a context which I Don't know if I 100% agreed with at the time, but I think there's some validity to it because they were talking about it more in the concept of turnover. And they had a whole lot of turnover. Now, our company, fortunately, knock on wood, doesn't really have a whole lot of turnover. So... Our parents have been very accustomed to seeing the same very consistent RBT for years and years because we don't have a lot of turnover, whereas most companies do. But as you're talking about trying to increase efficiency and things like that, when on the rare chances our RBTs do call out, our parents are just more accustomed to cancel because they're so used to the consistency, which kind of shoots us in the foot there because we may have another RBT that can go out and provide a service. Again, may not... be the exact service that they're used to in the same exact habits, but they can provide the service. So going back to the originator of that concept, my previous employer, when they were talking about it, In the context of turnover, to some extent, theoretically, an RBT should be interchangeable because they're just implementing the plan that the BCBA has written for them. Again, obviously, with some nuances, a BCBA can't say, this is what you're going to do every second of every day. You're going to have to be able to figure some of these things out. But for the most part, an RBT... They're not developing anything. They're implementing things. So at the end of the day, it kind of is a service with a person, and it's hard to kind of differentiate those things. So just kind of reiterating what I said earlier, with the service and a new person, you're gaining generality while losing a little bit of ease or consistency. At some point, that's probably something that's worthwhile and a worthwhile endeavor to an extent.

SPEAKER_03: 10:44

So as you discuss all this, I'm going to pause this for just a second because I'm supposed to be providing a service to my daughter as a different person here. And I forgot to turn on the sound machine.

SPEAKER_02: 10:57

So

SPEAKER_03: 10:57

I'm going to pause this for a second. Be right back. And we're back. Thank you for that slight pause there, Dan. We're watching the monitor here. She's not napping, which could make me extremely frustrated, but... We were just talking here off the air. If I get frustrated, that doesn't necessarily help. And it's oddly enough, we were just talking about this theme on Friday with some of our parent education group. Yeah, anyway.

SPEAKER_00: 11:24

So you were literally bringing ABA from the lab to the living room or the bedroom.

SPEAKER_03: 11:27

The bedroom, yeah. Seriously, or the recording studio, right? So we'll see. I mean, if she can't nap, maybe we'll do an experiment and bring her in here, and I'm sure it would be very, very cute voice recordings that our listeners might enjoy, or it could be a complete disaster Two and a half year olds certainly have a mind of their own. Anyway, so you were alluding to a prior company that we've both worked for. And I want to say one of the concerns when you're an employee and you're talking about RBT, a service, not a person, which, again, has a lot of merit, that statement. But when you spend your... supervision or clinical meetings only talking about hours and optimizing, maximizing whatever verb people want to use for hours and all your discussion is just focused on the money, the fiscal part of it. And somebody says, RBT, it's a service, not a person. There's a great deal of skepticism that comes from that as opposed to our current situation where there's a much stronger balance. In fact, I would say that The clinical discussion largely outweighs the fiscal discussion, but we keep a healthy portion of fiscal discussion in mind because it's necessary. Without fiscal health, we're not able to deliver our best we need you need both yes uh but again i don't know what your thought is knowing that you know we've both we've been in both camps and yeah some some you know some situations they're talking about this idea of service not a person and i'm going yeah whatever you're just lining your pockets you just want to see more money and again that's not completely illogical because without that funding then we can't buy materials we can't give raises. So it's a really interesting balance that we're trying to strike.

SPEAKER_00: 13:16

Yes. Yeah, I agree 100%. And I think the context is so important because I was the trainer for this company. And so I saw all these people that delivered the service. So it's really easy for a higher up person who doesn't know these people from anybody to say it's a person and not a service where I look at them in the face and train them. And even fiscally, if you're training people and spending a lot of money non-billable to And then there's a huge turnover, then fiscally that doesn't make sense either, much less on a personal level. So that was an issue that we were facing. And additionally, I also saw clients as well and did some support. This was before I got my BCBA, but I did some supervision support as well as kind of like an interim at that time. And I would see the families and the child, you know, individuals on the spectrum do sometimes struggle building rapport. And if they're constantly having to go through that again and again and again, that can be very challenging and very counterproductive because the individual, you know, you're having to spend two, three weeks. for that individual to finally start to build rapport with the staff. And then two weeks after that, the staff changes. So you've got 50% of the service delivery just on building rapport. And again, highlighting back to older ABA methods, there was building rapport and then work. Now it's kind of more intertwined here. It's a lot less work. But in terms of the productivity of sessions, that was greatly decreased because of looking at RBTs as a service and not a person. So with that company, the pendulum was swung very far to the service, not the person. On our end, it swung, I think, probably too far as the person and not the service because the families will not be comfortable with anybody else on the event that happens. You know, we have somebody to cover a session when their RBT is out, sick or whatever. We're good. Thank you. Thank you for

SPEAKER_03: 15:24

that

SPEAKER_00: 15:24

pause. Just a quick baby check.

SPEAKER_03: 15:27

So just to, again, highlight or give a visual for everybody listening out there, we've got a monitor here next to the mixing board, and we're watching my two-and-a-half-year-old roll around the bed and not take a nap. She's not crying, which means we will continue our recording. But we might have to pause again. And, again, fits right into the discussion today as I am the substitute parent in many ways. I am the substitute nap time. guy today because I don't put her down for a nap.

SPEAKER_00: 15:55

Is parenthood a person or a service?

SPEAKER_03: 15:58

It's two people, ideally. Sometimes it takes a village. So when we're talking about building rapport, that's an important concept, right? Because you can say this statement, again, we're going to keep repeating this, it's a service, not a person, but yet we talk about building rapport. So the idea that a child, for example, is going to perform exactly the same way for someone they've never met as they would for somebody they've been working with for now, say, eight weeks, who's built a routine, who's developed rapport, built a routine, and now can implement services on a schedule, meaning we're doing this first, and then this next, and then this third, and this fourth, and this fifth. So as I outline that, that by itself renders that statement Pretty ridiculous, right? Absolutely. I don't know you. I'm a child. Hey, we like to teach things like stranger danger, which is something that I'll tear apart in a future episode. Just because it rhymes, we tend to overuse it. But the idea that we're working with kids who are maybe dealing with a little bit of... you know, some social idiosyncrasies, maybe not having a lot of social interest. They've developed a social interest. Now we're going to introduce you to somebody who you've never met. And just because they have the same exact materials or toys, we expect you to perform exactly the same way.

UNKNOWN: 17:26

Yep.

SPEAKER_00: 17:26

Which is not, I mean, you wouldn't want your daughter to go through the same sleep routine with a complete stranger off the street. That wouldn't be desirable. So there is certainly nuance, like you're saying.

SPEAKER_03: 17:38

Well, and the idea that, for example, my daughter right now, or when we do groups, the idea that a strange environment, new people, and then that child maybe demonstrates what's commonly known in the developmental world is strange. separation anxiety and they cry. Well, but now they're having a tantrum because they

SPEAKER_00: 17:54

have autism. Got to ignore them.

SPEAKER_03: 17:56

Well, ignore them because, so not soothe them. No. So the idea that they're thinking about their parent being elsewhere. And they're only doing it because they have autism. And they're upset about it. Right, exactly. So again, we start unpacking the confusion here in terms of sort of our fiscal drive. to preserve those sessions, knowing that we talk about rapport building and we talk about generality and the variation that's required to build generality, but we're going to convince a parent that if we send this sub, hey, this is the same exact service. Well, it's based on the same principles, this service, but it's a different person. So their bedside manner, to use that from a medical perspective, totally different now. And we want some of that. But some of that is probably not going to– or likely not going to look the same. Absolutely. The flow, the pacing, the rhythm of your session will now change.

SPEAKER_01: 18:51

Sure.

SPEAKER_03: 18:51

And, again, we want some of that. But if your child's now crying because the person they're accustomed to isn't there, as a parent, you're likely to quickly go– oh, this is worthless. This is no longer, we can't have subs. This is, what a loss. What a terrible session. Now, we don't want kids crying.

SPEAKER_01: 19:11

Sure.

SPEAKER_03: 19:11

But again, the idea that this child's going, hey, this isn't my usual person. This is weird. There's value in that, even though the expression of that is likely going to make the rest of us, the adults, the parents, go, oh, this isn't working out so well. What I like to say, right, good session or bad session? Well, the child cried a little bit. It's a bad session. Are we sure it's a bad session just because they cried? Or do kids cry routinely? And not that we want to make them cry, but the idea that we want to resolve that is the value of having a sub-RBT is what we're saying.

SPEAKER_00: 19:43

And one of the things that I think you're alluding to that is– is a valid point of the ABA detractors in that how sometimes ABA is disempowering to the client is kind of like you alluded to. If a new subperson comes and the session isn't successful for whatever reason, however that wants to be defined by the parent, then we always look at the child. The child had a bad day. Well, Isn't it on the new person who came to that individual's house to build rapport with the... I mean, we're coming into the child's house. The child doesn't need to build rapport with us. We need to build rapport with them. So why isn't it ever like, hey, we failed in that situation. Hey, and we'll try again. We need to do better. But it's always, no, we come in with our stuff, and if it doesn't work, the child needs to do better.

SPEAKER_03: 20:37

So again, expecting the child to do the exact same thing they do with... a familiar person that they've had several weeks to build rapport with, and we're expecting that to be replicated immediately. So we're rendering that completely illogical. Now, for our purposes, in terms of putting the fiscal health aside, but the continuity of service, right? The idea that, okay, if you don't have ABA on our schedule based on what we determined was a good allotment of hours, then the consistency falls apart, which means overall, Our service is less valuable. Knowing that if we provide a sub, it's not going to look the same, but at least the continuity was present.

SPEAKER_00: 21:21

There you go. Yeah, absolutely. And the thing is, if the session doesn't go well, then that's just probably a precursor that when that child was presented with a new school teacher or something like that, it wouldn't have gone well. So let's work on teaching that child to be able to be tolerant to... First of all, figure out who they should listen to and who they shouldn't. So if somebody comes to their house, maybe they should reference their parent to be like, who is this person? Because if they're too friendly with everyone, then I get the parent coming and saying, well, now they just run off with anybody at the park. Well, because anybody who comes to the door, you want them to be super friendly with. So, yeah, I think... At the end of the day, there is a lot of validity in having that new person there because if it was unsuccessful, then it would have been unsuccessful when we presented it in the future. Let's present it with trained people who should know how to deal with that situation, should make it as minimally unsuccessful as possible, and then report back to the BCBA so we can work on a plan to increase that generality. Because at the end of the day, there are going to be people outside of mom, dad, whoever's in that house, and the one or two rbts that that person has that they probably are going to have to take directions from whether it's an extended family or not even directions just interact with whether it's an extended family school teacher substitutes teacher aid in the classroom so we do want that individual with you know referencing the parent or referencing a trusted person to be able to listen or respond to other people without having a tantrum and that is so when we have that sub like you said and it doesn't look like we planned and they had the quote-unquote bad session No, that's actually a productive session because we did a lot of teaching there, even if it didn't look like we thought teaching was going to look like. Again, the last thing I'll say here is that it's not the result of the situation that creates frustration. It's our violation of an expectation. So if we thought the individual was going to be presented with a bunch of instructions and respond a certain way and they didn't do that, that's when we become frustrated.

SPEAKER_03: 23:27

Yeah. And again, there's a lot to unpack here in terms of how to do this successfully, right? So in the past, one way that people approached this was we're going to have our programs, we have our set materials, which means that that's part of the service, and as long as this substitute person goes in with the exact same plan, goes in with the exact same materials, then who cares about rapport, right? Let's just run this because this is discrete trial training, ABA

SPEAKER_02: 24:00

101. And

SPEAKER_03: 24:03

as long as you can say, do this and good job, and you've got your folders and your Velcro, you should be cool, right? Absolutely. But to your point, this is a whole different person.

SPEAKER_02: 24:16

We

SPEAKER_03: 24:17

would want the child to resist that a little bit. But when they do, we're... often unprepared for that meaning either the parent or the staff is going this child is crying this can't be good and again we don't want children in distress but then in response to that crying what would you say is the value of working through that let's say the child cries the entire session right what are we explaining to the parent what are we explaining to that rbt in terms of the success that is available during that session.

SPEAKER_00: 24:50

That hopefully the RBT could have tried various different things and tried to work with the child instead of just ignoring the child for crying or looking at the child like they shouldn't be crying. Let's figure out how the RBT can problem solve that. I think you had a really good... At the last case manager meeting that we talked about, you really kind of opened my eyes to comparing what we do to the medical field as ABA does become more and more medical and less educational, I guess, per se. And that... I think we can look at the RBTs much more like medical assistants or nurses. And I'm going to use some generalizations from my understanding of the medical field. If somebody wants to come in and clarify and say, no, that's not exactly what the nurse or the medical assistant does, please do. But so the doctor is going to be like the BCBA, right? The doctor is the one who gets the information and creates the plan. So short of that, The nurses, or at least the medical assistants, they're kind of a service. They're going through the general things where they're collecting the data, they're running the vitals, they're doing the testing, and then that testing is reported back to the doctor. They make the decisions. So realistically, the medical assistants or whoever know how to conduct a lot of the tests, right? They know how... probably trained in phlebotomy. They know how to draw blood. They know how to take blood pressure. They know how to do all of those things. So I should be able to see a different medical assistant and be able to... That medical assistant... with, you know, with proper training, should be able to run the test and report back to the doctor. That being stated, let's say I have, you know, a collapsed vein or I have, in my specific situation, I have an issue on my right arm for taking blood pressure. So they always have to take it to the left. So if it's a new medical assistant, hey, they're not going to know those things, right? So maybe it's going to take a little bit longer. But With problem solving, it can probably get done. Now, it's not the theoretical medical assistant or the nurse who knows me very well and knows, okay, Dan's here. This is exactly where I poke and prod and how I take the blood pressure. But it can probably get done. Now, if you're seeing a different medical assistant every single day and having to explain yourself, at that point, it becomes a little tedious as the consumer. Like, hey, man, like... I'm tired of every single day coming in. Now, for most medical procedures, you don't come in every day. You come in every week, every month, probably not even that, right? Every six months. So it's not that big of a deal. In fact, for my six-month checkups, for my remission, almost every time I see a different medical assistant, and it's totally fine. But the doctor's the same. So it kind of gets into that piece, I feel like, and I will talk about the fiscal piece because I do think that's important, but I want to just pass it back to you on that analogy between the RBT and the nurse and the BCBA and the doctor.

SPEAKER_03: 27:55

Well, to go a little further with that analogy, I do feel like in that sense the doctor in terms of practice, right? So the idea that I'm going to go into a case that I know, a situation where I've observed the RBT on various occasions, and that I'm going to somehow replicate their session, even at my level of training and experience. That's likely not going to happen. And I bet a lot of doctors, to your point, feel the same way. The idea that they're going to administer the vaccine, that they're going to somehow do the blood draw, I doubt that. I mean, yes, they could. As you said, they're trained. They're capable. They're out of practice. Sure, sure. Now, they're well-versed and well-practiced at diagnosing, at examining, at all those things that they're trying, that the medical assistants, the nurse practitioners are gleaning from them. But even for me, the idea that I'm going to step in as a substitute, whether it's at home here today or for any of my RBTs, that's going to be a difficult session for me, too, in terms of pacing, in terms of rhythm, because I'm not... It's not something I'm doing every day, right? So on the other hand, there's been situations where I start casework because we're a little bit behind on staffing or we're a little short on staffing and somebody's been on a waiting list. Yep. And in that situation, that can also be unfair to a lot of our staff because now parents are expecting my... As I develop this case, they're expecting my pacing, my level, and my experience... to be replaced by somebody who's coming in as an RBT. And no disparagement to RBTs. So many of them are certainly younger than me, certainly much more enthusiastic, maybe much more engaging or interesting to the child. But they come in, and then parents go, well, they just don't seem as experienced as you. Well, right. I'm starting my 27th year of practice. This person just got trained six months ago, and while we might tot ourselves and say they got trained well, they're still developing their chops. Absolutely. So that's really, really difficult, and again, sort of thinking of myself as a parent today, but myself as a parent, hypothetically, who's receiving services, ABA services, and I'm accustomed to somebody, so is my child, and then here comes somebody new who might be super skilled, doesn't know my situation. Suddenly my child is now saying, I don't want to work with this person. They're crying, but you did the right thing as a parent to try and maintain, I should say, quote unquote, the right thing. Sure. To try and maintain continuity of service, to try and promote generality. These are all things that we don't necessarily talk to parents about up front. We're getting better at it and saying, this is going to be your schedule based on your availability and based on your need. And guess what? Sometimes this person that we're assigning to you may not be available. So before you even meet them, before we even implement services, we should start talking to you about this possibility of a substitute. And we should be very honest about the fact that this session might not look, at that point in time when this comes up, might not look as good, or better yet, we're early on in services, this is your second day of service, and now we're facing the question of a sub. At that point in time, do we scratch it or do we still provide continuity given that we don't have any continuity to begin with? So there's a lot to answer here. This is a finely tuned dance we're trying to figure out with a lot of different steps. Sure. Trying to put continuity and treatment integrity first and then somewhere in a backseat, but still a very important backseat, the idea of fiscal health. Yes,

SPEAKER_00: 31:30

and I do want to get into that. But just wrapping up on the doctor piece, I think there's one thing that can probably... keep you out of the doctor's office or make you visit the doctor's office less. Any thoughts on that? How to keep yourself mentally sharp without having to see the doctor? So I

SPEAKER_03: 31:47

don't know what that does. I don't know if this is like an apple a day keeps the doctor away, but I do appreciate the opportunity to talk about something called Magic Mind that I know makes a difference for me mentally when we do this podcast. So we're going to chat a little bit more about human behavior and daily efforts to get the day started well, to boost performance, to energize, to stay alert. As you know, Historically, coffee has been a staple as a source of caffeination, a little pick-me-up to start the day and keep it all going later in the day. I love my morning cup of coffee. I had one today, and it works, no doubt. But sometimes I need a bit extra. Not just energy or wakefulness, but true mind-boosting, brain-surging action. This is where Magic Mind does the trick, especially when preparing for the podcast. Magic Mind is what I keep on tap. The secret is three days, and more is better. But three days prior to our recording, I start my Magic Mind routine daily. Nice and cold out of the refrigerator, deliciously invigorating, little green shot, Paired with my morning coffee, I feel it kick right in. Fresh and earthy, mild and cool in my stomach, and a noticeable increase in my mental acuity. If I'm feeling a bit tired, Magic Mind launches me into action. If I'm feeling a bit sluggish, Magic Mind is a sudden increase in mental power such that I can continue to generate and innovate with new ideas, whether it's first thing in the morning or later in the day. Given the basic ingredients, I can consume Magic Mind without worry. We're talking about adaptogens, herbs, roots, and other plant substances like mushrooms that help our bodies manage stress and restore balance after a stressful situation. Nootropics, non-prescriptional Thank you. is a naturally occurring non-protein amino acid that promotes relaxation by reducing stress and anxiety levels. Vitamin D3 for strengthening bones, strengthening the immune system, improving brain function, boosting your mood, helping lower your blood pressure, fighting inflammation, on and on and on. And finally, a nice little touch of agave for some sweetening, where some energy drinks on the market include up to nine cubes of sugar in each serving. Magic Mind uses three-fourths of one cube of sugar per shot, and this is not refined sugar but derived from agave. This means delightful sweetness with less than 10% of the sugar found in most energy drinks that just give you energy but don't do anything for your mental acuity. So, if you want to boost your brain performance, memory, mental acuity, alertness, try Magic Mind today. In fact, please do look at the episode description to find a link with a discount toward your prospective purchase. I hope you try Magic Mind and enjoy the benefit Right back to it, sir. Thank you for those two minutes.

SPEAKER_00: 34:35

Thank you for doing that, because that has a lot of big words that I think the Stanford education has you much more prepared for than I'd be ready for. That's a lot of big words.

SPEAKER_03: 34:44

Nootropics or nootropics? I'm not sure how to pronounce it. I'm going to have to correct it for the next mention.

SPEAKER_00: 34:51

But the doctor situation, so you mentioned that sometimes you'll start a session, start sessions for... Yeah, start of the whole service. Service, that's the word I'm looking for. And then maybe within a couple sessions, the RBT calls out and now we have a decision. Do we send a sub or do we cancel the session? And I think a lot of that also depends as like, you know, going back to the doctor analogy, if you as the BCBA or the doctor there, also depending on the client's profile, depending on the RBT's experience, so if the rbt's got you know five years experience and they've probably seen a lot of different kids and can can adequately work through the session. If the client has a very specific profile, like you've worked with some clients that have some comorbidities, some even I think had, you worked with a couple of clients that had cancer and things like that. So in those situations, you probably wouldn't want to send an RBT out or a medical assistant in this example, or a nurse without the doctor there to thoroughly debrief the person. So there's a lot of variables in there. And I think an additional variable, I want to talk about it a I'll chew into the weeds on it because I think the next three, four, five episodes, however long our next series about the fiscal ABA, the fiscal parts of ABA and is ABA in a crisis, is going to be on, as you mentioned, the financial impact of the subbing. So in that situation, I want to relate it. There's not a lot of... In my understanding, medical situations where you go regularly, like daily or something, to go see the doctor, it's more discontinuous than that. But when I went through chemo and stuff like that, I was seeing the doctor fairly regularly. And that's where I think the situation is a little bit different when we compare the medical model to the ABA model. Because in ABA, we are seeing the client regularly. typically multiple times per week. You know, in our company, it might be once or twice. In a lot of other companies, it might be every day that they're seeing this person. That's not as common in the medical field where you're going and seeing somebody every day. And I'm thinking about it, you know, relating back to my medical situation is you have the discussion of is the loss of potential service by waiting out for your specific nurse medical assistant, RBT, worth... So is that loss of service and also the financial aspect worth the potential of putting in a sub? And what I mean by that is if you have a child that gets five days of service and they've gotten four days this week and their person calls out the fifth day, you hypothetically might not be losing a lot. clinically by not having that fifth day. If they only go once a week or maybe they, for whatever reason, they really need the service. maybe they are going to lose a lot. So maybe clinically, it makes sense to have a sub. That's on the clinical side. Then you have the financial side, which is even more challenging. And I think the impetus for a lot of companies, again, we'll talk about this a lot in the upcoming episodes, to really, really push these subs. Not only do parents not necessarily have the relationship with their therapist because their therapists are so interchangeable and there's so much turnover there, but also... If the client is not able to have that session, then the company loses out on the potential revenue, especially if they have another RBT that could have provided that service. Most RBT's... excuse me, most companies aren't going to pay their RBTs for non-client time. So if they have an RBT that could have provided the sub that the family did not want to have the sub, then that RBT is going to lose out on hours and just lose out on flat income, which is going to increase the turnover rate. Or on the very rare chance, I don't know of any other company that does it, but our company does where we offer guaranteed hours and paid cancellations. Then that company is essentially eating the fee of that cancellation because The RBT is now getting paid to not work, even though they could have worked to provide the sub, but per refusal of the parent, they're not able to work. So the company is eating that RBT's hourly wage without reimbursement because we only get reimbursed for the hour. Now, that all comes down to the margins. If your margins are very small... then if you're paying for that RBT to not work, you're going to become insolvent very quickly. So again, it's a huge dynamic. It's a lot of different moving parts here that we're trying to balance the clinical aspect with the financial aspect. A lot of ground there. Let me pass it back to you.

SPEAKER_03: 39:41

A lot of ground indeed. So now just to decipher that a little further, if you are a company, and there's many out there with good reason, client cancels, Now that RBT is out those hours, we're not going to pay those hours. That RBT goes home or goes wherever it is they go. They're not going to be compelled to go back to the office. No. Why would I go back to work? You're not paying me. Correct. In our case, we've been very fortunate on many levels. Okay, they just canceled on you. Come back to the office. At least pre-COVID, it was much more common and we're trying to get back to that culture. Come back to the office. Now, I can't generate any revenue based on your client face-to-face time, but at least I can generate value towards your training and experience. Yes. Or prepare you better for that client next time you see them. Or figure out why that client is canceling so much. Or figure out who in the office might be available as a future sub during that same time slot, because they happen to be in the office too, given their cancellation. Now we can exchange information. Something as simple as a subsheet, which I think... something we use daily, the idea that I'm not going to tell you play-by-play what the session looks like because, in fact, we've moved away from that cookie-cutter approach. Session's going to be dynamic. We know what the program goals are. We know what some of those procedures are, but they're not necessarily going to look the same way every time. So now I can write down some ideas, what the kid likes, what they like to play, some of the things that are triggers, some of the things to stay away from, and we can share that information. So we're not generating value from you billing the client service but we're generating value towards some future such that you might be better equipped for your client, somebody else might be better equipped to sub for you on that client, and then maybe we reduce the impact on the parent's perspective of, well, I don't think I want to sub. It doesn't look so well. Now, we'd be foolish to think that that by itself is going to take care of it. We still have to go back to the idea that A sub-session might be rough. I like to say it might be a lesson in negation because all the child is doing no, a saying is no, and all we're saying is acknowledging it. That's an important skill, though. That's a great skill. And it's a great skill for RBTs, too, to say, well, I'm not your usual person. You're rejecting me. And every time you say that, I'm going to show you that I'm listening by backing up a little bit. And then within reason and respectfully trying again. Or better yet... Your parents are prepared for this because we adequately prepare them during intake about this possibility. So we're actually going to sit and have the child watch us get comfortable, parent and RBT, because if the child's referencing, or even if they're not noticeably referencing, they're listening, there's a certain tension and familiarity that's you know, being produced or relayed there. And even that might be a value. It might not look the same. It might be hard to convince the consumer that that is a value. Sure. But it is a value towards some prospective subbing opportunity where now you're not unfamiliar. Now we demonstrated to our child that we're familiar, that we're getting comfortable, and that should make the child much more comfortable in the future. So, again, these are all things that we haven't necessarily developed a good... We haven't personally, but we're trying to... in terms of preparing parent and RBT and ourselves for this idea of a future sub. It could look awesome. It could be somebody, it could be a perfect fit. It could be the novelty could work in your favor and the lack of familiarity could also work to your disadvantage. Sure. But no matter what, we're ready for it. Yep.

SPEAKER_00: 43:18

And you're kind of battling three things at once. Let me just take one step back. Especially this episode, I'm not criticizing any ABA company that doesn't do paid cancellations. We get it. No, we understand. We get it. It's a lose-lose either way when there's a cancellation. Fiscally. I'm just speaking fiscally now. We'll talk clinically in a second.

SPEAKER_03: 43:39

And even in terms of continuity.

SPEAKER_00: 43:41

Exactly. Fiscally, either the RBT is going to lose out on the income, which is... not ideal because they obviously need it even probably more than the company or the company's going to lose out on the income. Somebody's losing out on income because of the way that insurance reimbursement is organized right now when somebody cancels. That's why a lot of companies will have late fees. Doctors' offices typically have less than 24-hour cancellation fees, trying to find some way to make up that lost revenue when you get canceled late notice and you're not able to adequately plan. So I do just want to highlight that fiscally. Again, I acknowledge that the rates that we have Allow us certain perks. So I don't want to sound like I'm on my high horse here coming down on other outfits or anything like that. That's not the point here. The point is to say, fiscally, when somebody... gets canceled on, it's going to hurt somebody. Now let's look clinically. There's a loss, no matter what. Fiscally, there's a loss. Now let's look clinically because we're going to be balancing three things, right? We're balancing the person, we're balancing the service, and we're balancing the compensation for that, right? So going back to the chemo example, taking kind of out of the ABA situation, you've got the person, the person who's going to deliver it, who may know everything about me and the best way to do it to make my life easier. You have the service, which is the actual chemo, and then you have the fiscal reimbursement that they will receive for doing that. Now, in that situation, we have to figure out the level of emergency and the level of how impactfulness missing or delaying one of those service deliveries is going to be. And I don't know that we've done the best job of necessarily evaluating that in ABA. And I don't even know, for example, with Chemo, for example, if moving it up one day or moving it back one day, I'm pretty sure that happened from time to time. If me as the client could say, hey, let's... Okay, my nurse is going to be out this day. Can I move it up one day or move it back one day? Looking at the service, is the service going to be equally as effective? And that's one thing that could be evaluated at the ABA level, right? So... to maintain the fiscal situation? What if the RBT increased session 15 or 20 minutes for five or six sessions? Is that going to be the same? Do they even have the ability to do that in the schedule? A lot of them don't because, as we'll talk about in future episodes, people are scheduled so jam-packed because we have to look at that fiscal solvency. So you've kind of got those three things going at once. Yes, as the patient, I I do want the person who knows me best. That's going to make my life easier. But what am I willing to sacrifice? And if the doctor comes and says, hey, if you don't have this medication on this day, you're going to have a severe adverse effect of that. Well, I'm probably willing to sacrifice the person who knows me while delivering it. Because the service is that important. And that's what we're kind of talking about now is the service of ABA. How impactful is the person delivering it, the RBT? And there's obviously not going to be one answer. There's so many variables in there. But it does definitely lead to an interesting discussion. So let me pass it back to you on that.

SPEAKER_03: 46:59

So in terms of us missing a session, taking a negative or having a negative impact on ABA, let's kind of break that down a little bit. So that could be maybe... The idea that there's a family who's leaning on us desperately to come in and provide a second set of hands, a third set of hands, four set of hands, given maybe a client that's very challenging physically with aggression, whatever it is. Maybe we're coming in at a time that's during mealtime and there's a lot of concern about that. So the idea that we miss, whether it's a familiar person or not, To your point, that could be a time where we say, ooh, do we have somebody skilled enough, who's ready, who's trained enough, experienced enough to deal with the weight of that circumstance such that the continuity is of greater importance? And in that case, then we take care of continuity clinically, and we take care of the fiscal health as well. Yes. On the other side, I can think of at least one client on my caseload who's come a long way. But to your point... To date, if the current staff is not available, I will likely not recommend a sub, only because walking into the situation, a lot of nuance, there's a lot of skill to be learned, there's a lot of experience to be had directly with that client. Otherwise, somebody might find themselves in trouble. somewhat of a risky, if not highly uncomfortable situation based on some of the behaviors that are occurring. So in that case, I'm going to be hard-pressed and say, no, you're citing yet another situation. The idea that we've got a routine service going on. We've had a good amount of consistency. We've seen some progress. And now... we have a sub, we think the situation's ready for a sub, sub comes in, but the way that session looks, despite us being there providing continuity, the session outcome does not seem to provide any continuity. And I think that's the one that I'm most interested in overall because we might have good control or good influence over that variable if we prepare ahead of time, if we can actually educate parents and somehow quickly and reasonably and succinctly talk about all these things without necessarily lending too much information, but really highlight the importance of continuity based on generality, based on just meeting somebody new, based on the power of novelty and liking somebody new immediately versus the power of unfamiliarity and helping your child say, hey, I don't know this person. I don't feel comfortable. And I'm going to start expressing that. And by expressing that, We don't want to think that this whole situation is a wash. It just means that everybody, parent, child, and RBT alike, have to be ready for that circumstance. I go back to my analogy with the smoke alarm. That smoke alarm is going to be going off. It's going to be in your ear. You're going to be fanning it, and it's not going to work. And what are you going to do? Are you going to lose

SPEAKER_00: 50:02

your cool? As frustrated as you want.

SPEAKER_03: 50:04

Right. You can get as frustrated as you want. You're going to have to work around that smoke alarm. You're going to have to talk to the parents while that smoke alarm is blaring. You're going to have to try and make that smoke alarm turn on. turn off, whatever it is, there's a skill to be learned in that circumstance as to what do you do for an hour and a half, two hours, when you're a sub and the child is not taking to you. The idea that you show up for continuity and maybe you end a little early because we don't want to belabor the point, or if it's not belaboring the point, the idea that you stick it out and you try to arrive at some attenuation, some level of resolution such that you don't end up leaving as a result of some high-level escalation because we always worry about the reinforcement value of that situation. So, again, I could probably go on and on and on. I won't. But there's so many permutations to this that I think we need to consider where it often just boils down to the, hey, we've got to pick up the rate or the reimbursement for that session, send somebody out. Hey, we've already got a ton of turnover, so who cares? They're seeing new people anyway, in which case this is just a service, And we don't really care about rapport. Like you, not putting anybody on the spot, knowing that some outfits put more weight on the physical health just by default than the clinical integrity, and knowing that we are erring on the side of clinical integrity, but trying to look at ways to maintain optimal physical health so that we can increase our clinical integrity. Sure.

SPEAKER_00: 51:47

Yeah. I think if somebody were to just flat out ask me, is RBT a person or a service, I'd probably give the answer that you always give me, which Whenever I give you, hey, do you like this or this? And what would the answer be, Mike? Both. He would say

SPEAKER_03: 52:01

yes. The answer is yes.

SPEAKER_00: 52:03

Is RBT a person or a service? Yes. Mike would say yes. Because I do think, and my opinion has actually changed, honestly, since we started talking about it. I was leaning more towards service, and now I'm kind of 50-50. Because, again, going back to the medical analogy, like the service of chemo, As long as the chemo gets in my veins, that's the service, right? That's the service. Now, the person delivering it is going to affect, it could affect my mood and could have an effect on my experience getting it. But as long as that gets in my veins, then I've received the service. The thing with the RBT and ABA is the service is the person, right? So there's not like an external stimuli. There's not a medication or something like that. So they're kind of one in the same. Now, I will say that trying to get a little bit more nuanced here, that if your ABA service delivery is more trial based, then you can separate the service from the person easier because you're saying that I want you to run. It's so funny that I think about it and we're even guilty of this when you're when you're You're prepping somebody to sub. Historically, what would we do? We'd give them the trial-by-trial sheet and say, well, here. Here's going to be the trial-by-trial sheet. Here's going to be the programs I want you to run. So if that is your methodology, again, we've been victim of this too, not attacking anyone. then I think then the ABA delivery is more of a service and the person who delivers it can be interchangeable because they have their thing that they need to run their 10 programs and they've got their stimuli, which are going to be interchangeable between all of their 83-year-old clients that they bring and they sit down and they go to work on these things. Then it's a service and the person is kind of a little bit more interchangeable. Now, if it's more naturalistic learning, then... It's a little bit harder to separate because the linguistic mapping and stuff like that. Hopefully, you've trained the person. You've trained all of your staff to understand what linguistic mapping is. And then it is kind of interchangeable because it's just like, hey, talk about the environment. That's kind of interchangeable. But the more naturalistic it becomes, the more the service becomes the person, and they are a little bit harder to separate because that person does know more of the nuances and can deliver the service more efficiently and effectively together. because they're not as easily separable.

SPEAKER_03: 54:31

It goes back to our parenting styles discussion, right? So the more authoritarian or adult-directed your service is, then the more you're leaning on the service. The more authoritative or child or client-directed your service is, now the idea of rapport, now the idea of a familiar person becomes very important. And the same thing happens, say, when you have a case... We have two or three different therapists or RBTs, right? Parents will start making those comparisons. And, you know, my child, they don't seem as engaged with this person over that person. Okay, we want the child to be engaged. What's going on? My child's crying with this person versus that person. I'd be inclined to be less worried about that in the terms of, well, why are they protesting and how do we resolve that? Because there's value in that. Yes, we don't want the child crying. But in resolving that distress... there's a great deal of value.

SPEAKER_00: 55:23

We also don't want to teach the child that any time they cry in the presence of somebody who might be being reasonable, we're just going to remove that person. We want to work through it on everyone's behalf.

SPEAKER_03: 55:33

Exactly, exactly. So as you can see, we've opened up a can of worms here toward sort of a three, four, maybe five-part series because these are the things that this might be the leading variable that affects fiscal health. So the idea that your RBT's continuity... As to how it affects their pay, meaning that if you don't work for an outfit like ours that does guaranteed hours, the more you miss, if you get sick, now you don't have pay, right?

SPEAKER_00: 56:01

Go ahead. And additionally, like, so either the company takes it or then you can put it back on the clients, right? Then it's, well, let's have late fees or stuff to cover that. But then nobody's happy when the client's now being fiscally impacted as well.

SPEAKER_03: 56:13

Yeah. And then again, so the idea of continuity. So if you have an RBT that has this exact recipe they need to follow, and maybe they're trying to be a little bit more dynamic, so they're getting harshly criticized as to their performance because they're not following the cookie cutter approach, you're kind of killing the dynamism on the other end. But you're making it easier for somebody to come in and do the exact same thing robotically, right? while then affecting the generality of your service as we know traditionally, knowing that something more client or child directed and dynamic from person to person is going to be better. But then at that point, we're not just offering a service, we're offering the skill level, the experience, the training of a particular person as well. And we expect that to be different from person to person. We know that, again, going back to the example of clients that have two, three different staff members, there's gonna be a difference. There's going to be a difference in the way the child performs with each one of those people. And one session looking better than the other isn't necessarily a reason to then say let's change that staff member as much as to train them up or see where you can build engagement for that person. The idea that now the more people that child is accustomed to within reason, the better the generality, the greater the socialization, knowing that we're not in any way making a case for high turnover rates because consistency and concept continuity play an important role too. So there's a lot to consider here. Again, to your point, we're not criticizing anybody, but there's so much to consider. that I know that we're falling short a great deal of the time.

SPEAKER_00: 57:50

And a lot of it is going to come down to rates, which we're going to talk a lot about in the upcoming weeks. But I can even reflect back when I was going through my OT. I had an OT through a different outfit previously, which was more of a corporate outfit. And the way that would work is I would see them from my wrist rehab for an hour. And either the first or second half hour would be done by the OT. And the other half hour would be done by the tech. And I would just always kind of look at that like, huh. But from what I understand, the way that reimbursement rates work is there's different reimbursement rates for OTs versus the techs and things like that. So a lot of it comes down to that as well. Additionally, some of the larger corporate outfits will try to look at ways of figuring out ways of maximally, not fraudulently, but maximally Finding the ways to have the OTs be as many places as they possibly can, presumably within the realms of the... legal ramifications or the reimbursement agreements. But I just bring that up because I would kind of look at that or when I would go on the occasional day and then I would get there and they're like, oh, your usual OT isn't here, but this OT is great and has been debriefed. You know, I would tolerate it, but I wouldn't be super happy about it. And I'd be like, oh, my copayment and all of this is going to... So I can understand what that would be. And the last relevant thing that I'd like to touch base on is that we spend a lot of time talking about the detractors of ABA. And one of the... counter arguments to ABA or one of the oppositions to ABA is that it can be kind of cold. And it's just random people coming, barking orders at the client to do things and expecting the client to do exactly what's, like you said, authoritarian, exactly what's demanded of them. And if that's not performed exactly to the criterion of the person demanding it, then they're not given a reinforcer, they're ignored, and it becomes this very transactional relationship. And looking at RBTs purely as a service, Again, whether that's the chicken or the egg, we'll talk about that in subsequent weeks. I do think lends credence or credibility to that stance of there isn't a relationship developed and expecting a child to just come like we've talked about and follow some stranger's instruction, that is unethical or borderline not humane. And the ABA does have some culpability in that. Again, we'll talk about why, but I do want to acknowledge that. So that's taking the person away from the service. So We have to collaborate both of them in. As the field, it's probably a little bit too service and not enough person. For us specifically, it's too person and not enough service. Let's find a balance there. But hopefully throughout this last hour, we've gone through both sides. Is it a person? Is it a service? Also looked into a little bit of the financial side to come to a happy medium so that you all can take the information that we've provided and formulate your own opinion.

SPEAKER_03: 1:00:52

We've covered a lot of ground here. Thank you to our listeners. Thanks, Dan, for bearing with me today. I had to span two roles today, and it looks like we made it. I did have to employ the wonders of the TV as the child care provider just for a few minutes here, and

SPEAKER_00: 1:01:10

it's working. When you need a sub, just give your kid TV instead,

SPEAKER_03: 1:01:13

apparently. So she doesn't have her mother. She has me, and now she's got TV. Anyway, that doesn't sound great, the optics or the auditory Do what we say, not

SPEAKER_00: 1:01:23

what we do.

SPEAKER_03: 1:01:26

This is a very, very limited circumstance here. I don't always do this. I can assure people that. So the answer we've come up with is RBT is both a service and a person. If we've trained them adequately, if we've informed them adequately, so we've made them comfortable in both open-ended ways. more client-directed approaches, as well as verse them on the specific adult-directed approaches, the more scripted or firm pieces of the programming we're lending, the more you've got both sides of it, the better equipped you're going to be to step into a situation where you're unfamiliar with So you can't expect the rapport to be built. You can't expect a little bit of rejection from the child, which is actually a good thing, despite our motive there to provide some continuous service. And all that being said, it would behoove us to convince, to advise, to inform the parents ahead of time about the possibility of a substitute in service, about the possibility of this coming up when their child's built a good rapport, when they've built a good rapport with that person. And the idea now is toward... the notion of generality and increased socialization, please do consider a substitute knowing that as your case manager, I'm going to make sure and talk to that RBT before they get to your house. As the other RBT is already prepared, something like a subsheet to familiarize that person. And then at the end of the day, let's lower our expectations. The continuity is going to be available. But we don't want the session to be cookie cutter or just merely replicated. However, we want your child's engagement to somehow hit a comfortable mark such that in the future, when the sub-opportunity comes up again, you can err on the side of continuity, knowing that the session might look a little rough, but that there's value in resolving that roughness, if you will, or that change in circumstance toward continuity. greater socialization, and increased generality.

SPEAKER_00: 1:03:24

And hopefully your RBT is taking vacations. Hopefully. Yeah, exactly. So hopefully you're not taking two, three weeks off of services while your RBT is on vacation so we can find a happy medium there.

SPEAKER_03: 1:03:36

So I think we're probably going to end up revisiting a lot of these topics as we talk about fiscal health and ABA and crisis, which may or may not be what we title that series. But we're talking about detractors and also things like equity firms and what they're doing. to the ethics of practice, to the continuity of practice, to the fiscal health of practice, knowing that some big names in the industry have fallen victim. We covered a lot of ground today. It was a little bit disjointed based on my personal circumstance here, so we appreciate everybody's patience and listening to this, but again, we will be revisiting a lot of these topics again in the coming weeks. Mr. Dan, any closing thoughts?

SPEAKER_00: 1:04:18

Yeah, just went down the wormhole the other night and found out three of the major players here in San Diego have gone out or shuttered their operations in various different areas. So yeah, I really look forward to the upcoming weeks because a lot of times we talk about ABA detractors from the outside. Now we might even take a little internal look and figure out how internally things are going.

SPEAKER_03: 1:04:43

So I hate to be facetious here to end, but I will be. So in terms of those... in particular large agencies, the RBT is no longer a service or a person, unfortunately. So he's a warning there to not focus too much or solely on your fiscal health. You've got to keep your clinical integrity. Well, and that's our cue. We went a little long. So that was actually our closing music. This has been a little bit of a circus today. Again, thank you, everybody, for sticking with us. We hope you've gleaned some good points and good discussion on this. And always

SPEAKER_00: 1:05:20

analyze responsibly. Cheers.

SPEAKER_03: 1:05:23

ABA on Tap is recorded live and unfiltered. We're done for today. You don't have to go home, but you can't stay here. See you next time.