Precision, Passion, and a Pint with Dr. Kerri Milyko, BCBA-D (Part II)

ABA pn Tap is proud to present Dr, Kerri Mlyko, BCBA-D (Part 2 of 2):

Pull up a chair and pour yourself a cold one! In this episode of ABA on Tap, hosts Mike Rubio and Dan Lowery sit down with the powerhouse of Precision Teaching herself, Dr. Kerri Milyko, BCBA-D, LBA.

Dr. Milyko isn't just an expert in the field; she’s a pioneer in instructional design and evidence-based curriculum development. Known for her "Capital-P" passion for Precision Teaching, Kerri joins the guys to break down how we can move beyond standard "check-the-box" therapy and start driving real, outcomes-based results for neurodiverse learners.

In this "pour," we dive into:

• The Component-Composite Relationship: Why failing to master foundational "element" skills makes higher-level learning nearly impossible—and how to fix it.
• Precision Teaching 101: How Kerri first "caught the bug" at the University of Florida and how she’s using it today to transform clinical practice.
• Modernizing ABA: A look at her work with CentralReach in creating digital, integrated curricula that actually work in the real world.
• Systems & Leadership: How to balance clinical priorities with effective leadership to improve both staff engagement and client outcomes.
• Backyard Tinkering: We get to know the "human" side of the BCBA-D, from her love of sci-fi novels and true crime to the perfect wine and butter pairing.

Whether you’re a seasoned BCBA or an RBT just starting out, this episode delivers high-level science with the laid-back, "straight talk" vibe you love.

Grab a glass, settle in, and always analyze responsibly.

Transcript

SPEAKER_06 0:01

Welcome to ABA on Tap. A mic review with Dan Lowry. So without further ado, sit back, relax, and always analyze responsibly.

SPEAKER_00 0:32

La la la la la la la. Just warming up for AVA on top. Thank you so much for listening. This is part two of our interview with Dr. Carrie Maliko, and it's gonna be fire.

SPEAKER_03 0:46

That's that's super interesting, which kind of leads you. Covered a lot of ground there. I think a lot of what you're saying comes down to incentives, and I think a lot of incentives, which is kind of why we started our own company, because we were really burnt out with the field and the billable standard and that kind of stuff until we went to CPABA conference and found out there are other people maybe outside of the direct application field that are still doing the good work, and we were like, okay, well, that's that's motivating. I think a lot of the incentives for company is to build more hours, which means we don't really want to be innovative. We want to be efficient with our time. And innovation's actually counterproductive a lot of times to efficiency because then we have to rewrite things. So don't worry about like figuring out how to be more clinically sound, just figure out how you can build more hours, which means the EHR is going to cater to that more. Which kind of led us to something that we ran into, which was one of the themes that I wanted to ask you about. You you talked about it, was like Central Reach was our first kind of big experience in the EHR, and not disparaging at all. They made our life a lot easier. A lot of good stuff there. What I found though was that there's an interesting dichotomy about the how much they allowed us to represent our what we're doing clinically versus how much we then altered what we're doing clinically to fit into their EHR to be more efficient. Yeah. And like I said, the VB map at that time, maybe it still is, we no longer use Central Each at our company. Is it was all based around like the V Map. So if you run the VB map, you can net put everything in, you can get like basically goals printed out for you, and boom, you're you're there ready to work with the child. And we didn't, or the individual, we didn't run the VB map for various different reasons. So we kind of had to go on the back end, and it was just a lot more work, which we were willing to do at the time. We had a capitated contract, which was amazing. But we were kind of like you said, values-based, and we were like, No, even if it takes longer, we want to do it this way because we think it's the individual in the person receiving service's best interest. Yeah, so I guess that's a long way of me saying your thoughts on how it helps, it it certainly makes things more efficient, way easier than paper data on Excel sheets than graphing and stuff like that. Sure. But also, like you're saying, do we run the risk of now catering our sessions around the data which was made to make it easier, if that makes sense?

SPEAKER_01 3:08

Like like I I I really think the moral of the story is it's necessary but not sufficient. And you you said it, it's that people are adjusting care to fit the software. There you go, yeah. But it's a software adjusting care to fit best practices, yeah. And because the care, the the innovation of the the clinical delivery, there's the practice management, which I think across the board has made amazing gains and stuff like that. But the care side of it has been neglected and not followed along the same trajectory. And as such, a lot of people are still stuck with the the the old way or or lack of innovative way of providing care and have not kept up with advances in their field. Or people are like, I've done this thing really sophisticatedly. And but now I I see this insurance world and I know that I have to get on electronic software, but I can't like so now I have to compromise how I provide care because if not, I'm still doing paper data and I'm worried about how I show up in an audit. And then that means that if I don't show up well, then my business will close. And I'm now no longer providing services where that person likely was providing very great quality level of services that was innovative and very personalized. So it's like again, I think that like a lot of the state, and well, so a lot of the roadmaps, you said it too, that were dictated, were dictated by conversations with enterprise level organizations, their CEOs or CFOs or CRO, whatever, right? Some some MBA that wasn't a behavior analyst and said, Hey, we need we need this because we're expanding and we need to like we and and we want their doors to be open. We we need people providing services.

SPEAKER_02 5:05

Yeah.

SPEAKER_01 5:06

Then and but they don't understand the issues around care. And and all and so when this also shows up when you don't have behavior analysts in C lines, when you don't have behavior analysts like C lines of either the tech company or the service provider company. And so when you have two MBAs having these conversations, they're going to make decisions that are around business efficiency that allow business growth and things like that. But now we're in a situation that even like our funders are saying, like, just even the last six months, it's been shocking how the insurance companies are like they they're looking at quality. Yeah, they want, they want the quality. And so when something isn't showing up as quality, they're like, Well, why aren't you, why don't you have it? Why aren't you doing it this way? You know, these are what you guys say are your standards, or or you guys don't even know your standards. And so, as such, we're gonna give you some quality standards because you didn't give any to us, so we're gonna have to pick something. And so, but none of the, but like, and as much as like uh, you know, behavior analysts would feel like they were screaming into the void, uh, operational efficiency was what was chosen. But now we're left in a situation where we can't defend the quality of service, or services have to completely transform in order to get it to that quality level. And with that, you know, given size of organizations and changed management, things like that, it takes some time. And so, you know, I don't want to blame the EMRs, but it but it it didn't help us uh get in the situation that we find ourselves in. It helped us grow and it helped us provide services to more people and it allow us to build more. Yeah.

SPEAKER_03 6:57

But really, when it came to providing the level of care that and the level of analysis really that we need, I feel like they uh in a lot of ways I feel like it actually reduced the analysis that because now since everything's auto-progressed and stuff like that, that it it does everything that the BCBA really would need to do, and it's auto-progress, and who knows if the data was even put in right and if it was actually ready to be progressed or whatever. So, yeah, and I I think a lot of what you're saying actually reems true. I never thought about it, but you know, people are at a bigger at any uh EHR company, they're gonna partner with somebody to to get their uh product off the ground, and that's gonna be higher level discussions, and they're gonna say, you know, what features do you want? And those features are typically not gonna be the ground level BCBA, it's gonna be somebody higher saying, like, hey, can we progress these things or can we pass an audit more? I know a lot that's a lot of the the features that a lot of them are like, you know, we'll get you ready to pass whatever audit or we'll make the clinical notes good for tri care, which is an interesting thing. And and you mentioned the insurance piece too, which is also interesting because I do a lot more of the the back-end stuff. Mike does more of like the direct, still face-to-face with the clients. He has a lot of direct clients. I'm more on the the back end side of things. And I say this now as I'm sure next week I'll be on the phone for three hours going from department to department, trying to figure something out. But in some ways, I do kind of feel for the insurances because I think it the way that it's practiced right now hasn't been the most refined and the easiest way for insurance. It's like just give us 40 hours, and again, we uh maybe do like five or six hours. I'm saying us as a field, not us as a company. We're not asking for 40 hours, but it's like just give us 40 hours. Well, why how do you justify? Uh, just give it give us 40 hours and then in six months we're gonna ask for another 40 hours and another 40 hours. So I in some ways, like you're saying, I do I I don't feel for insurance companies per se, because I don't know what their necessarily and their incentives are, but motivation, yeah. I don't think we've done ourselves much of a favor in that.

SPEAKER_01 9:02

Yeah, I don't know if they're asking like justify these hours because is it clinically or medically necessary? So like now I feel like they're doing it because they need to cut their own bottom lines. Yes. But but but let's you know, for shits and giggles, let's give them grace and say it is clinically motivated, then it is we like we we are in the situation where it's well now we have like a really it's it's a vicious circle because now we have like a really green pop, like a population of behavior analysts who maybe didn't have to like defend this medical necessity or or think about these things in a different way, given how like our experience was and things like that. And so there's a lot of like training that has to be done. Like you you said, like a lot of things are automated so things can happen without them knowing. And it it creates a situation that is hard. But I think a lot of it is because we as an industry have been debating over perfection instead of driving for good when it comes to these standards. So, like I I gave this one keynote that was it, it's the title was like getting dirty with data. And if you don't just put something down on a chart, right? Like some so many people wait for like, I'm gonna have this perfect program, or I'm gonna have all these like the stars are in alignment, and then and then we're gonna execute. And it's like sometimes you just need to drop a dot on a chart and start to evaluate behavior, and then you're like, okay, this I don't want to count it this way, I don't want to measure it this way. Face change line, let me do it this way. Okay, cool. I realized that I didn't have this intervention in place. I obviously need this, okay. Yeah, face change line. And it's only by it like behaving in which we can shape behavior and get to that point of being like, yeah, this is really good. And I think as a field, we're debating over what are outcomes and what are these agreed upon outcomes and things like that. Oh, you can't measure that, that's not saying you can't do this, that, and all these other things. And as such, we're just living in this world of debate as opposed to being like, hey, let's just like, I don't know, let's just let's just claim it, let's just call something, let's look at these things. And if these aren't the right things, at least we'll have data that'll tell us these are not sensitive enough, or these don't measure like our intervention, or like they're not, they're not linked, or this isn't the right tool, or whatever, right? And so that that gets us there. Yeah, and so as such, a lot of these insurance companies, gosh, one that my my CCO, Tim Yeager, talked to literally told him, Hey, we've waited 10 years for you guys to figure this out. You guys haven't. As such, we're gonna set the criteria because because we've been waiting for you to do it and you haven't. We saw this with licensure in Nevada when everyone was more like, you know, him and Han about like, oh, more governor, government oversight, and we don't want to pay $400 a year. Well, guess what? Licensure was coming. And because too many behavior analysts were whining about it, when it came to the establishment of the ABH board, the government just wrote it and it was a shit show. It was a mess. And that's because they were they were trying to create something like I I don't know, maybe it's not the right thing, but it was like, you know, it was like waiting for perfection. But the what's what's this what's the phrase? Is like uh perfection is the enemy of good or some right. And so it's just like you just gotta put something down and then and then we're behavior analysts, right? Our whole thing is shaping. So let's shape up to what is good, make sure that what are to perfection and maybe not actual perfection, but start with with decent enough so that way that's you know not harmful to the business or the client or whatever, right? And and then shape from there and learn and have some insurance partners to help us like guide that way to create that. Because I think that we need to have insurance companies partner with us with that to allow us to be like, yeah, this isn't as sophisticated as some other like behavioral health models or or physical health models, but we're kind of we're kind of like new in our world uh as an industry, and so we want to shape up to that. So I think it's um, I don't know, it's it's hard because you're right. Like I can't really blame them. I don't like them. I'm I'm absolutely angry at them. Yes, I but at the same time, it's like I get it.

SPEAKER_03 13:45

We kind of did it.

SPEAKER_01 13:46

And we haven't we haven't produced.

SPEAKER_03 13:48

It's funny you mentioned the perfection piece because you have a a good saying that you use is that the science has already been proven. Like we don't have to reprove the science with every single client that we work with. Like we don't have to reach that level of in internal validity and that level of proof with like each each individual client that's already been proven. I have a couple more questions, but I'll pass it back to you. Uh wait, hold on.

SPEAKER_01 14:10

Just to your point, like I have two, my I've had kids, my my own children, in like speech or or like therapy. And I always ask their people I was like, the documentation that I've seen and received around that, and I like one was just getting discharged. I was like, Oh, do you have like a discharge report that indicates like why you think that they no longer need therapy or something like, oh yeah, no, we don't we don't do that, we just like write a note for their last day. And I'm like, we have to produce like a 40-page discharge when we do the assessment, indicate like how bit like all these things, and it's it's I also wonder if our adherence to being so databased has created a situation in which we've now the insurance companies are like, well, we can ask them for all of these things. Um, so I don't know.

SPEAKER_05 15:00

Yeah, 100%. Somewhere in the medical model, there's a level of precision that I think you're right. We we have to empathize as much as we don't want to with the insurance companies, it's like, hey man, how long is this gonna take? You know, the idea that you go in for a surgery, well, that's got a nice encapsulated time frame. The idea that you're gonna be in physical therapy after that surgery, now there's a different story there, a different level of measurement quantification, you know, in terms of your agility and the angles of motion and all these things that we would have to do.

SPEAKER_01 15:33

But even the physical therapy, it's like, okay, 12 weeks.

SPEAKER_05 15:35

Right, right. And then so yeah, to your point, is like I I that's I think what we have a hard time with is in saying if we if we tell you it's gonna be two years of this, then you're gonna hold us to that, and we're just not so sure that we're gonna be quite there, given that those eight hours, twelve hours of assessment only give us this initial plan. So the idea that we're coming up with goals that we can guarantee are gonna be achievable in six months. So there's there's like this back and forth that's really interesting. And I I mean there's gotta be models out there that are a little more open-ended, maybe like addiction recovery or I don't know. Because clearly these things do get funded by insurance. Yeah, right?

SPEAKER_01 16:13

But like but I think Well, there you go.

SPEAKER_05 16:15

And even that, I mean, you know that that if anything, it's recidivism, right? Like the one of the things that plagues addiction recovery is relapse. And that's I think that's a lot more. I mean, that's closer to the things that we look at from a developmental perspective, from a family dynamics perspective. There's so many variables that are gonna affect how our data demonstrates some level of mastery.

SPEAKER_01 16:35

So I'm but we're not but we're not trapped, like, yeah. Do we know, like again, like okay, client walks in as an ASD diagnosis of a like level two, they're four years old. They have parents who are divorced. Dad is dad is on it, mom, mom is she spread thin. Um, and so she's maybe not as adherent to protocols in the home. You they also have a additional diagnosis of 80, well, no, no, this is four. So they also have an additional diagnosis of like epilepsy. And you know, and then and then their violence scores show like, right? Like we, I think we sometimes are led more by my clap, my past clinical experience has led me to recommend these many hours, right? And and it's kind of like I don't want to say like it's it's a well-educated gut, right? Like I've I've worked with clients similar, it's in this in your experience as the end, right? It's your experience as the end of this this client profile. 100% and and so we as a field need to get to the point where you know these now, these I think this is where it's like we have to do stuff and then insurance companies have to do stuff. We need to get to the point in where we can say, like, hey, we got some client profiles and we found success in with this course of treatment, like this intensity, these type of like this amount of like programs to these content areas or whatever, this focus, this level of parent engagement. And we've seen this percentage points of increase on the violin in these this many of years. And so the insurance company can start to make predictions, okay, okay, cool, cool, cool, cool. So we can start thinking that we'll titrate ours, you know, after two years of intensive services or something like that, right? But we right now are we're kind of going in there on a small end of your own experiences. And then I can't tell you how many times I've been like, I also have had clients where I've like, cool, I've I've worked with a very similar client, and I I think that they're gonna do this, and they do. And I show a client shows up, same profile, and we'll we'll see, you know, my my understanding of the and show up completely different, and it's twice as long that I need before that they're discharged, right? And so what is the difference there?

SPEAKER_03 19:20

And the temperature of the butter, yep.

SPEAKER_01 19:23

Yes, temperature of the butter, exactly, but and so and so but we but we don't have so this is where I do want to bring AI in because we don't have maybe the sensitivity or like we're not looking at all the variables or we're looking at the big variables, but there's some like minutiae in there, such as temperature of butter that isn't written in the recipe, right? And so I think that as good partners in the medical field, it is on us to to start to think like, how can we how can we start to make some of these predictions? But the insurance company, on the other hand, has to allow flexibility within those predictions, right? Hey, this variable was not accounted for as such, like more time is needed or something like that. It's just like it just everything can't be in the dark. Some things have to be a little bit, you know, clarified, if you will.

SPEAKER_03 20:12

Is it possible that behavioral, like behavior is more variability than the recovery of the human body?

SPEAKER_01 20:19

Yes, absolutely, absolutely. And it's and it's in contact with so much more like contingencies that allow it to be very variable, right? But and so that's why I think we we have to be again finding those partners to allow for that graciousness and and just to start and be like, hey, we're gonna start, we're gonna, we're gonna start with something. We're gonna start saying, like, okay, this, you know, come in with this diagnosis. We're estimate, we're we're predicting a discharge in two years. Let's follow this and see if we're right. If we're not right, let's learn from that. What variable led it? Was it, you know, you know, poor utilization rates, cancellation rates on either the side of the organization or the side of the family? Was it a co-occurring diagnosis that was not discovered until they were eight years old? Like, right? That four-year-old turned out to also have ADHD, wasn't uh diagnosed until they were eight or something. Like there's so many other things. It could be also the level of the technicians working with the client, but that's something that we need to, that's our side of the street that we need to clean up on. But I think all of this though can't happen without some standardization in our curriculum and our instruction. And so, and not standardization in that everyone just uses uses Betty Crocker cake mix, right? But it's that like standardization of saying, like, here's the outcomes we're working towards. Here are the behavioral cusps that help generate these outcomes. Here are the programs underneath those cusps that that lead up to right. All of this is that constellation. And with having standardization, it allows us to say, like, Okay, we know that they received a similar type of intervention. That doesn't mean the instructional arrangement is the same. That doesn't mean it's play-based versus tabletop. Like all that can be variable. But it's like it's it's it's more about like the standards of these skills and ensuring that all of the critical attributes are taught, as well as we're sophisticatedly piecing together the variable attributes to personalize it for the client. And when we have the critical attributes in place with personalized variable attributes, then we kind of we have a skeleton, right? Like we all have kind of like the same bones in our bodies, right? Ish, and then but we all look different, right? So we can still personalize everything, but we need to have some sort of like framework to work from that is standardized.

SPEAKER_03 22:51

Is that what so in the beginning you mentioned that individualization sometimes or over-individualization may have been a disservice to our field in general? Is that kind of what you're talking about right there? What you just said?

SPEAKER_01 23:02

Like if everything is totally different, then it's really hard for us to say, like, to make claims. So, like the Tri-Care report that was released five years ago or whatever, that talked about how ABA didn't make adequate gains in in the time in which they had. It we can't necessarily say that. We can't group data together and say, like, oh, look at all these learners who didn't make it. All of their programming could have absolutely been so wildly different that it we cannot we can't make any assumptions about gains or not. It has to be only single subject, right? Like this one learner who whose programming looks like this. So if we have some sort of it's like it's like driving the car without any roads, right? Like I want to go wherever I want to go and I'm not, I don't care, like before roads were created, right?

SPEAKER_02 24:05

Yep.

SPEAKER_01 24:05

The roads create a sort of framework that allows us to say, it'll take you approximately this time to drive from Reno to San Diego, right? But if we're off-roading and we're going over this mountain, we're, you know, there's different paths that you can take that are easier than others, and some are harder or whatever, like this. Now you can drive differently on the road. You can use different cars, you can churn, you can go faster, you can go slower, you can change lanes, you can pass people up, you can get in a car accident if you want, right? But but there's still so there's individualization within the road, but the road itself provides some structure to give us some guidance because we are in a in the medical field that requires a level of reporting and a level of accountability that when everything is personalized, it's really hard for people to be held accountable because they're like, well, this is just how I do it. And it's well, oftentimes it's personalization just based on the experience of the clinician and not necessarily the needs of the client.

SPEAKER_03 25:12

That is that is really enlightening. Because I when you initially said that, like before we even got on the podcast, I was like, individualization, like actually disservicing ABA. I I was thinking it was going to be so different. And now that you've explained it, yeah, I think that's so so valid. Who who would fund that? So let's say we're working with an individual that maybe isn't making progress for whatever the multitude of reasons might be, or they're done, they're discharged, and we're trying to figure out why it took them four years instead of two years. Yeah. The individual companies probably aren't going to want to do that because that's going to be time that they have to spend. And who's going to comp is the insurance company going to compensate them on the back end to go look at all the confounding variables that might have been there? Are the insurance companies going to have somebody on their end to take a look at all of the reports and try to through the figuring it out through the reports? That seems like a great idea and certainly should be done. I'm just wondering how that would be fun to do.

SPEAKER_01 26:08

Who owns it? Yeah. Who does that? Who's going to have that? Yeah, that's a good question. You know, it's something that we at Centria want to do within our own framework, but also we have the capability to do that because you know, we're an enterprise level organization. We own our own EMR, we develop our own software, we can customize it to these things. But that, so that's, I think, a bit of a luxury. I think it I think it's a partnership with agencies that maybe like an aggregation of like some that are doing really high quality work and some that have deep pockets, and some that have both, right? And so it's and like a like a consortium, if you will. And so where where their C-line are like, hey, if we can answer some of these things for insurance companies, it'll put us in a more like unrocky scenario, right? We're we're now having to have all these conversations about justifying our rates and preventing rate slashes and nitpicking documentation and things like that. And so if we have if we have this stuff figured out, I think we will be able to breathe a little bit easier. And so if we have C line who who acknowledge that and come together and work together and not see each other as competitors, but as partners and answering an industry-wide question that is for me seems excess existential. Like absolutely right, and and it can it can really make or break our field today. Like I've I see behavior analysts who are working for insurance companies that I feel like sold their soul because they're asking some questions. And I'm like, how like do you not know that like no, we can't we can't guarantee this level of supervision per week because the client can get sick, and you know, like so we that's why we look at it per month or something, you know, like whatever it is. Like we have to have also partners and then it in the insurance field that allows that we are at least on track to finding answers to this solution, we're making the right steps with the best intentions. But yeah, you're right. Like it, like it we this long insurance company is saying, like, hey, we'll be flexible. If you said it was going to be two and it turns out to be four years, right? Sure, sure. Be flexible because we know you're doing putting forth all of this work over here. And then with us, you know, I think it's different agencies coming together and partnering.

SPEAKER_03 28:46

So I think something that's a little interesting with that, I don't want to seem like I'm glass half half empty with this, is that I think that puts a lot of the responsibility on the the mom and pop shops, the ones that really care, the the ones like us that are really kind of caring. And from my understanding and and research, there's a lot of you know private equity getting involved in ABA, and they're the big companies, the ones that actually have the big say, and the ones that have the lobbyists and the things like that. And yeah, for like the stuff you've been talking about, I'm thinking in my head, like, oh, it'd be cool for us to go back and look at our clients and figure out maybe an estimated trajectory, why they either exceeded it or didn't meet that trajectory. That'd be awesome, and I'm sure that's something that we'll look into. On the the private equity side of things, it's I I think, and you said I think it's an existential crisis, and I I I agree on multiple fronts, ABA is getting hit, and that's why we started the podcast on the clinical side too. There's countless you we post stuff on whatever, and then we get comments, you know, ABA is abuse and things like that. You know, you get a lot of that side of things. So I bring this up because I agree that it's existential. I wonder if the private equity that has the ability to make the change really cares because they're in it so short term, they're out within five years as long as they're good. They don't care what six years or seven years is gonna be. So it's kind of putting it on the mom and pop shops that I don't know how much leverage we have to be able to prove to the insurance companies that it should be done a certain way. That made sense in my head. Did that make sense to you?

SPEAKER_01 30:15

No, it does. So, you know, as you know, I so I straddled both worlds. Okay. I am still a silent partner in our very mom and pop shop here in Reno, and I am a VP at one of our, you know, largest ABA organizations. I and so I I see all the goodness that both areas are doing. I think some are able to respond to change faster than others. Um, and and with that, like, yes, you know, I see like, you know, like Areno companies, they they track, they report on decisions made in every supervision session, the type of decision made. They talk about how many goals per day, and not goals like like assessment goal, like our treatment goals, but how many like every client has a daily goal per program and how many goals are met per program per day for a client. We know what percentage we want to have. We want our clients to earn 75% of those goals obtained per session. If it's too high, if it's over 75%, then the level of intervention is too easy. If it's under 75%, then it might be a little bit too hard. And we look at it at a monthly rate, you know, because like each each you know, day and week can fluctuate depending on different circumstances, things like that. These are things that I think a lot of enterprise organizations, you know, aren't looking at and are trying to, you know, because they're spending their focus are on more other necessary, but again, not not fully sufficient things. When it comes to intention and things like that, the the the you know, Daddy Warbucks, who is the PE firm in the back, yeah, they I mean, they wanted to see a return on their investment in five years. Absolutely. What we're seeing though now in conversations is that the the conversation isn't around necessarily build hours, it is around quality care, which was a pivot than what it was before. So that is that is good, but also they still want to see a return on their investment. But they know that now they won't get a return on their investment unless services are meeting a particular level of quality. And that if they go to sell the organization and it has a reputation of high quality, they're actually gonna get a it's they're gonna get a bigger payback payout.

SPEAKER_02 32:37

Okay.

SPEAKER_01 32:39

So but to your point though, I think that that's why we need people who have experience in mom and pop shops to help guide like that. That's how I view my role.

SPEAKER_02 32:50

Yeah.

SPEAKER_01 32:50

Is that like I, you know, I've had a lot of people, when I when people learn that I joined Centria, you know, oh, you sold your soul, or uh course, same thing I'm saying to these BCBAs who work for insurance companies. But it's but it's like but here's the thing. You're on the right side still, though. I worked for I chose Centria because of uh to be absolutely frank, uh uh Timmy Yeager, Timothy Yeager, is because he is someone who is making the right steps. Not every step is perfect, and not, you know, some steps have to be compromised, but we have a mission and it's bringing this level of quality up that I I like I can subscribe to that mission. And it's his trust in me and listening and other VPs in my level of of guiding that mission, and it's not on him and it's not just dictated by the CEO, right? It's like, do we have someone in leadership who has that same level of expectation? He's he's a student of Doug Greer, right? And so he's done all of this stuff as well, and so we know where we want to get, and it's and granted, these steps to get there are smaller because of the change management that you have at enterprise organizations, as it was in you know, organization that has, you know, 50 uh staff with 50 or even you know 50 BCBAs, right? Like that looks different than when you have 500 BCBAs. And so, so making the incremental change. And so it's like as long as I know that we are making the right steps there, because here's the Mac the fact of the matter is that we need uh everyone, we need the small businesses because I think that that that there's so much richness and value. And I think that you guys can be innovative and and really start to be like, hey, like we've we've put in this place, and and you're so like your organizations can be so responsive to these shifts and to how the field is is shifting with respect to care or even like organizational work. And then, but also there is, you know, if we're just mom and pop shops, we can't service the industry at large and these and these PE firms are going to be there. And so my thing is like if it's gonna be there, right? If it's gonna exist, I'd rather them exist with us trying to shepherd it into towards quality, as opposed to just allowing them to, you know, like be run without quality in mind. Um and so, and so finding like-minded people with that. So I so I think it's I I I hope that it's not the onus is just on, you know, like small um mom and pop businesses. But that's why I think I think like a consortium of learning and growing and saying, like, okay, you you did that, but can we do that at scale, right? Is it sustainable at scale? And how do we bring this about? So it is a partnership between, you know, these two that sometimes seem to be at polar ends of the spectrum, and there's a lot of like, you know, back and forth. But it's like, how can we show up in in partnership? Because like for me, I think like we all need to we need to be all in and fight this fight instead of like, you know, debating what they used to say was like, I don't know, some argument about angels yelling at the tip of a pin. I don't know, I don't know. This is an old saying that you kind of just say now is like, I don't know what that means. But you know, like like just complaining over things that I think are are ignoring the grander issue, right? Let's not complain about Trump's like reorganization of like the the White House. Let's talk about some other things that are absolutely more critical. Like let's not get distracted, right? Yeah, and so we see that in ABA. Let's not get distracted over the things in which that are really showing up for us. And I think with that, we need that we need a partner across some lines here.

SPEAKER_03 36:48

That makes sense. One more question, but let me pass it to you, Mike. Well, I've got a big one though.

SPEAKER_05 36:53

So I'm not in the shift gears too. So if you if you're on the same thread, let's keep going.

SPEAKER_03 36:57

You sure?

SPEAKER_05 36:58

Yeah, I'm positive.

SPEAKER_03 36:59

So we kind of going back to the original thing that we talked. Thank thank you for sharing that. That is really enlightening to know that again, I uh P kind of gets a negative rep, and there's good and bad, just like there's good and bad mom and pop shops. So it's good to know, you know, it's good to thank you for that perspective more from kind of the inside as well. It's sure it's good to hear that. So we've talked about goals and and goal banks and things like that, and a lot of your careers in curriculum development. One thing that at least recently we've been exploring the idea is the difference between goals and procedures. And I feel like historically, ABA, at least again, I'm just speaking from my anecdotal experience, and even I guess how it's reported, because it's reported through progress reports with just goals. There's not really procedures written in the reports. It was like here's your goal sheet. You've got, you know, five wordmans and name and personal information and stuff. Here's your goal sheet, run these goals, and you kind of figure out how to run those goals. Which led to a lot of decontextualization and made more sense maybe when it was more DTT oriented, and we're gonna sit down, and doesn't matter what goal we're working on, we're gonna sit at the table in the chair, and I got my reinforcers, and I'm gonna ask you, and it's all very regimented and standardized. Versus now, especially more naturalistic. It seems like procedures might be more important than the goal of like how what are we how are we actually engaging on this person with this person? Is what we're doing functional? Am I asking you like to touch your nose while you're rolling a car? Like, is that even relevant? So, thoughts on kind of the differentiation between procedures and goals, how procedures fit into a curriculum and how they can be reported about in a way that can be then implemented into the session?

SPEAKER_01 38:40

Sure. Yeah, really good question. And I think that again, the newness of our field, some procedures are maybe necessary, but I I think you need both. I even if you're play based, I still there's so many people. So, like I I was trained in tabletop activities, and so when NAT was showing up and I was trying to do that stuff, it was harder.

SPEAKER_03 39:12

Same.

SPEAKER_01 39:13

Like I had I could bust out a session, like no one's table, right?

SPEAKER_02 39:18

Yep.

SPEAKER_01 39:19

And I had to be really creative about like, okay, I really want I need to work on prepositions, I need to work on and like different learning channels, and I need to work on like some imitation, like whatever, right? And so, like, how can I craft all this while we're playing with the dollhouse, right? And so I would I would do this, and it took a lot of a lot of time to be like, what fun activity can I create in order for us to work on like to have practice opportunities around these things? Because well, you can't acquire a skill without practice opportunities, right?

SPEAKER_02 39:53

For sure.

SPEAKER_01 39:54

And so I think that's like I think procedures are necessary to begin with, and especially when we have again such a new field and we're looking for like fidelity. Sometimes there is very much a way that you have to work with a learner and you're like, don't deviate from we're not ready yet to deviate, right? Deviation will come, but we may need to start this way, or you start with a whole bunch of things, but there's this one thing that they keep on tripping up on. And we as like we as human behaviors or behaviors, we do a lot of things the same way and we don't shape, we don't show up variable. And so your procedures sometimes have to guide you to be variable, to be creative and things like that. But I think that this really and and I hope that this gets to your answer, but the way that I see this is not so much it's it's at a micro data and messo-level data lens. So you have micro data are the data that you collect on targets, you know, it's direct, discrete, right? We macro data are your assessment data that are, you know, infrequent, but you're looking at kind of developmental levels, right? These come from like vineland. Uh, your criterion reference assessments, they're more like a macro level, but they're like more proximal, closer because a lot of the things that you're looking at are what you're collecting data on at the micro level, but it's actually the score is showing up at a as a macro level data, right? And not necessarily the align item. What connects the two is messodata. Mesodata is looking at the combination of micro data that is a linking to macro data. I actually have Kristen Smith and I are submitting a we're like on Monday submitting this paper for publication.

SPEAKER_03 41:42

Oh, congrats.

SPEAKER_01 41:43

Yeah, thanks. I mean, well, is that published for submitting it?

SPEAKER_03 41:47

Congrats on the bunch of work that's in front of you.

SPEAKER_01 41:49

It's something that I've been like talking about for like the last 10 years, but it's and then they do this in precision teaching as well, just again, not at scale in the big ABA organizations. But so I see the messodata as more of tracking intermittent goals. And so your micro data is like your intervention. And so your procedures and things like that. Now, what you want to happen, and it would really be terrible behavior analysts if it if this didn't happen, is that like we see increasing trends or or skills acquired at the micro level. You teach it, you have reinforcement, skills acquired that rinse, we can rinse and repeat that every day, right? But the question is, is the gaining of skills at that level actually making an impact at the macro level? And the way that we assess that instead of just waiting for six months and hoping that it does, is that we have those messo-level checks. So it's like ongoing assessment throughout your time. And so what I want to do is see if I get emergence on these messo-level skills for free as a function of my intervention. So the thing that I'm really interested in is looking at the data here and not so much here. I actually could probably ignore that. It makes me scared to say that, but I could maybe ignore that data if all of these things are improving because that lets me know my intervention is working.

SPEAKER_02 43:24

Yeah.

SPEAKER_01 43:25

And it's only that I have to get into the wheeze of your procedure is if I don't see immersion at the messo level, right? It's like Gilbert talks about this with respect to like process and outcomes. Do I need to focus on your process if like if I if if if you're actually producing the outcome, the output, right? So and then that's kind of how I show up as like a manager, anyways. It's like I don't want to micromanage you be like, well, did you, you know, use Asana or did you do this? And did you? But if if you're actually producing, cool. I don't have to go into the weeds with you. If you're not producing, well, then we have to go into the weeds. We'll have to figure that out. So we think about it at a learner's aspect is that like I think that we can get to a point where we can free up the procedures if we have if we are looking at messo-level data and ensuring that progress is being made. But what makes me nervous is that no one's really doing that. Like across the board, I say messo data, and then and it's and it's not it's not common. And a lot of like our EMRs aren't set up this way for progress monitoring and things like that. And so, as such, like the only messo-level data, and it's not messo, it's metadata, is that they're talking about long-term goals. And these are more about like, you know, it's the roll-up of of whatever targets are completed and things like that, right? And so it's it's not a roll-up, it's a combination of skills that shows up, right? So if you are doing single word manned or single single mans on, let's say, preferred objects, and that's what your intervention is, then a more proximal man, mesa-level chat could be, you know, maning with two words, or it could be you could be looking at tacks, whereas how the man transforms into a tact, right? And so is it that like, yes, I want them to be able to man for granola bar if granola is their favorite thing in the world, or I want them to man for Mickey Mouse, absolutely, because those are the preferred things, but it's really about teaching this repertoire, right? And it's and how can this repertoire of asking for your wants and needs translate to other skills that allows you to interact with your world, which would be tax, right? And so if our focus is on the Mesa-level data, which could be those goals, depending on how you slice it, then the procedures are micro data, we don't have to be so tightly wound to them that it can show up. So that's why saying, like, you want to do DTT, you want to do NET, you wanna, you wanna be completely, you want to do everything while kids on a skateboard, you wanna, you know, like however it shows up, cool, cool, cool. How is it, how are you tracking it at the metal level data to ensure that we're seeing progress? So again, that's that that's that standardized skeleton that I think that we need that we don't have. And so what we're doing is we have so much variability at the micro level, and we have measures that are not really created for how we're showing up in the medical model of care. And so when everything is showing up so different here, and you don't have some sort of system and tracking your in measuring performance, then you just can't you you sometimes it's just a wait and see. And we know that just like the generalization strategy of like, oh let's just train and hope isn't the best model.

SPEAKER_03 47:21

Yep. Yeah. I love that term mesodata, and that's something that we've prescribed for a while. In fact, uh, when I joked about nobody knows more than a newbie C BA, one of them a while ago reported us to the board, which completely got vindicated immediately. But when we were talking about, hey, imagine you don't have to run 10 trials for you don't have to have 10 data. Your child won't spontaneously combust. Like it's okay. How many times do we have to poke this you know turkey breast in the oven to realize that it's not cooked yet? Like you don't have to do it every two seconds. Like you can chill on the data a little bit and teach, right? Because that's how education works, right? It's teach, teach, teach, then test, not teach, test, teach, test, teach, test, teach, test. You don't have to constantly come up with they can't do it, they still can't do it, they still can't do it, they still can't do it.

SPEAKER_05 48:03

Like, I use the other analogy of the planting the seed, and then there's no seedling yet, but we keep measuring. Oh, no seedling yet, no seedling yet, no ceiling. It's like, why don't you just keep watering and providing the sunlight, and then you're gonna see that seedling, and then boom, jump in with your data, buddy.

SPEAKER_01 48:20

But but we also need, but because we've had, we know carrot seeds will sprout up in two weeks, and corn seeds require a right, so we need some sort of standardization to to get to that point where we're like, listen, you do this, you know, like you you got I love this metaphor now. Thank you for this, but you have like zones of area of growth, these seeds will not grow if you're in this temperature or climate. Like you know, oranges are supposed to grow in Nevada, right? You have and you have different germination rates of different seeds and and different times of year in which different seeds need to be planted. And so I think to get to knowing that, you kind of be like, okay, I'm monitoring, I'm monitoring. Okay, now now we've collected all of these data across different states and different zone temperatures with different seasons and different types of seeds. We now have a system in which we understand these things. And as such, with this system, we're able to free up some of the scrutiny because we have somewhat of a predictive model. Now, granted, it's not going to be 100%, right? There's been times in which, you know, something doesn't grow and you need this, you need more water because it was a really dry year, things like that, right? And that that's where the personalization comes in. Yeah. But and and where you have to be like, oh, let me let me dig in and see what what happened. And that's where you need to go into the microdata. But I do, I envision a world in which because we've created some sort of standardized process. And again, this doesn't have to be like completely everyone's using the same curriculum, everyone's teaching the same way. That's not what I'm saying. I'm seeing it, I'm saying like we have we have we have roads, right? We just need some roads. And if everyone can agree to these roads, then it allows us to start collecting data to create a generally predictive model that is 80% of the time reliable. And maybe it shows up at the first time, 60%, and we gotta tweak it some or whatever, right? Yep. And then we have to be like, okay, now what's the temperature of our butter? Or now did I, you know, did I plant a week too early for my seeds, or did I buy a just was my packet, you know, not whatever.

SPEAKER_05 50:43

Sure. But when you say seasons, I'm going crazy with this metaphor. Well, when you say seasons, it makes me uh hearken back to the idea of strengths under certain domains, developmental domains. Like this kid is gonna be more prepared to grow these seeds, given uh you know the idea that they love to skateboard. So the notion that we're gonna have them sit at a table, unlikely. But if we can do all this stuff while they're skateboarding, awesome. And then now the behavior's available, and we can worry about whether or not it's gonna show up at the table at some future, right? But at least we know it's available where it wasn't before, or we didn't think it was available. It wasn't measurable yet. I love that. I love that.

SPEAKER_03 51:19

Pass it to your question, brother. We might be we might be at the end of our time here.

SPEAKER_05 51:25

No, I'm just saying, no, not at all. Um, we could talk to Dr. Carey for another four hours or have her back on for sure. We're gonna have to have you back.

SPEAKER_03 51:31

We haven't even got into what is precision teaching to the people that don't even know what that is.

SPEAKER_05 51:36

So I I do have one I think one thing that we can end on. Great uh because you alluded to it at the beginning, but sort of the future of our field. I can say something like there's a lot of very harsh, very unfounded, and at the same time very valid criticism about ABA intervention practice from say the neurodivergent community based on everything you talked about in terms of standardization. As far as I know, our medical utility is still for one diagnostic code and one only in terms of medical reimbursement. What let me just throw those two major things out there and let you run with it for a little while.

SPEAKER_01 52:12

Yeah, no, I I think the criticisms criticisms of our field are valid and we should listen to them and learn from it and grow. I a metaphor that I would always link it to is that something showed up similarly with maternal healthcare on how women were given birth and you know, like physicians did what they want because it was in the best interest of the mother, but it wasn't a good experience for the mother, right? And so there's a lot of like there's you know, if if uh the people that we serve are saying that they want to look different and show up different, and they say, well, yeah, like still help us out, like there's some things that we need help with, but also not this way, yeah, um, then yeah, let's listen to that. But I see as the future of our field, you know, what I would love to get to, and I I talk about this with some colleagues, we call it like the centers of the future. And Dan, to your point about technology, it's not about more billable hours. Although, you know, it would be great, like if we it's it's about getting clinicians out of their laptop, right? I wanted to see how I love that about right. If we can if we can have if we can have technology collect the micro data through AI, I love it, right? And and it's a center of the future. Gosh, that client is going to be so engaged with you. Like, I I see the people that you guys have on your podcast and know what you guys talk about, right? Like, this is a value of ours in the field, is is creating more connection with our clients, and not just for the sake of like this is an enjoyable moment for you, but also this enjoyable moment is going to produce better outcomes, yeah, right. And so, and so those like this is the best of both worlds. And so, if we can create a scenario where the technology is collecting all that microdata, the the behavior analyst is evaluating the messo data, right? And then they can they can go in and tweak the intervention elsewhere, something like that. The behavior analyst, like there's you know, we have some like structured reports that funders agree upon that are collecting and they personalize it and and and innovate, but you have you run an assessment and it creates, you know, a proposed plan because again, we have we know these constellations of skills, and based on these holes, it's saying, like, we recommend these goals, and here's a whole bunch of programs that map to that. What what what should we change about this? What do you edit, accept, delete, retweak, prioritize, right? But it like a learner's profile is usually always Swiss cheese, and there's holes and gaps, and it's never completely linear. And so even you have the skill up here, you could have this glaring deficit down here that we need to go back and fix, right? So being able to like have lever like using technology to leverage you to be more connected and more like in tune with the nuances so that you have capacity to identify that the butter temperature is is different, right? I think right now there's so much of like, well, I gotta do it in this amount of time and I gotta make sure that I do medical necessity, did I justify this enough? Right, like all of the paperwork added and stuff, that is too many tabs are open mentally. And as such, we don't have capacity to dive into the rich and nuanced, like of being a sophisticated behavior analyst or even a sophisticated RBT. And so if we can free us up from that, and I think that for us to justify ABA with other diagnoses, although we are seeing in some states, like here in Nevada, it's opened it up to a few different diagnoses. But I think that we need to get our shit together. We need to be able to create a defensible model of care, and we need to have outcomes that we can we can reliably produce on some sort of predictive schedule-ish. Like this is all like with with buffers, right? That then we can start to say, like, hey guys, this thing really works. How about we try it across these diagnoses? Because again, like it is about behavior and not diagnoses, but it's really hard for us to have this argument and fight when we can't defend it with the one diagnosis that it's like already working with, right? And so, so I think that we need to be able to have a defensible care model that is, and when I say defensible, like don't don't people come at me. I think people are gonna come at me. I I've I've let all my guardrails off, but like I know, but like it's it's not about yes, when you I every behavior analyst I know working with that one client and you're changing their life, and it's amazing. When I talk about defensibility, I'm talking about at scale, at an aggregate, right? Yeah, and right now we don't have a way in which we have found how we can do that.

SPEAKER_02 57:20

Yep.

SPEAKER_01 57:21

And so, and so when we are able, and it's not, and it's not the science, it's the it's the is the industry, it's the practice of the science in this very specific manner under these regulations and restrictions that really limit some of the things that you can do that we've already talked about. So it's like, so how can we use technology to free up that restrictions to get us more like back to our roots of being like free to connect and and not live in the red tape because the red tape is take is being taken care of for you on the back end. And so you need to obviously validate and and ensure that that stuff is happening and and have IOA and all that good stuff, right? And make sure it's ethical. And but at the same time, like I really envision a future where we kind of get back to our roots of of that connectiveness with the people that we serve and the people that we supervise.

SPEAKER_05 58:21

Yeah. So well, if we had known any better, we would have scheduled Dr. Carey's second today and just continue this conversation for four hours. Many hours, yes. I have so many more things I want to ask you. I and I know you'd be able to answer them beautifully, but we will no.

SPEAKER_01 58:41

I appreciate your all's time. Thank you so much.

SPEAKER_05 58:44

We appreciate your time so much. A couple of things. Where do you want people to find you if you want them to find you? And then secondly, if ever you if if ever you need, if you ever you think our platform can help you disseminate and pour in information, just reach out. You know where to find us. So awesome. Yeah, it's been a pleasure to have you. But where I mean, if you want to plug anything here as we wrap up or you know, go for it.

SPEAKER_01 59:08

Yeah, I I mean, I'm on LinkedIn, I'm not on Facebook, that place got two.

SPEAKER_02 59:13

Ugh.

SPEAKER_01 59:15

I mean, I can't fight all the battles, you know. So I had to free myself, but I'm on LinkedIn. I'm I'm you know, it's terrible, but I'm on there. And so if people want to reach out to me there, I also am at, you know, most of the major conference conferences. My they want to just email me, Carrie.milico at Centria Healthcare.com. You can always reach me there. But yeah, and like always ready for round two.

SPEAKER_05 59:43

Y'all just uh you're part of a short list of people that have said, hey, I thought we were gonna drink beer that we'll have to kick off our uh we'll have to kick off our uh our new plan with. So I I like to to close up with a few wrap-up points. And I had written this one early on, and then you guys used it several more times. You know which one it is. I love it. I I always talk about cooking and baking analogy, and then now you've just expanded that, so thank you. So what I've got here is let the service drive the technology, not the tech drive the service. Watch the temperature of your butter and always analyze responsibly. Cheers. Thank you so much, Dr. Carrie. Thank you so much. Thank you so much.

SPEAKER_02 1:00:22

Thank you, y'all. Always analyze responsibly.

SPEAKER_04 1:00:26

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.