Autism therapy workforce challenges have shifted from being centered on volume to sustainability, mirroring the industry’s overall direction.
Industry insiders from across autism therapy say that its workforce is “strained,” “misunderstood” and “unprepared” by the organizations that make up the industry, speakers on an Autism Investor Summit West panel said. The autism therapy workforce is under strain because the field has not yet established systems — operations, regulation, scheduling, career design and employer support — that truly sustain its hourly wage, frontline workforce.
“We’ve always seen a workforce shortage. I think now it’s a workforce durability problem,” Tia Glover, regional director for Villanova, Pennsylvania-based Devereux Advanced Behavioral Health, said during a panel. We have more RBTs, we have more BCBAs than we’ve ever had, and the field will continue to grow. … I think organizations now are looking into what [they can] do to retain these staff; instead of looking at volume, they’re looking at sustainability.”
Despite the rise of the autism therapy industry — with more providers in the space than ever — patients in some regions will still face access challenges, illustrated by waitlists. Many providers may have the systemic capacity to grow their patient census but lack the paraprofessional workforce to do so. This, in turn, fundamentally challenges providers’ viability: if they can’t find, hire, and keep staff, they cannot provide the services that generate their revenue.
Technicians often face unenviable working conditions because of the system that provider organizations create in the context of in-network health care. Generally, it’s unpredictable work. Behavior technicians will likely miss pay if a patient doesn’t show up. Their hours often have to reflect typical off-work hours. They also may have limited engagement with a supervising BCBA or other support. This comes on top of the sometimes highly demanding work of engaging with autistic patients. Because of this, the industry faces profound turnover. One report finds that turnover rates range from 77% to 90% for frontline staff, depending on the size of the organization.
RBTs are also systemically limited in their career progression. For the most part, the autism therapy industry looks at the behavior technician workforce as a pipeline for BCBAs.
“One of the problems is we tend to look at RBTs as transitional objects in our field,” Dr. Steven Merahn, enterprise chief medical officer for Perimeter Healthcare, said during the panel. “We get them in, and then we convince them to become BCBAs, so already they’re not attached to their RBT identity.”
Merahn added that this dislocates behavior technicians from the identity of their work and challenges ideas of a long-term future in that role. He said a potential example for solutions could be the direct support professional (DSP) workforce. That group has a strong identity and clear steps for progression within its own services as presented by groups like the National Alliance for Direct Support Professionals (NADSP).
Dr. Saba Torabian, CEO and founder of Cupertino, California-based Intervention Center for Autism Needs (ICAN), said that the industry’s use of hourly workers and therapy generally do not line up with the federal and state regulations that dictate hourly work.
Behavioral Health Business.Intervention Center for Autism Needs CEO Saba Torabian, center, speaking at Autism Investor Summit West.
For example, hourly workers in California are entitled to a 10-minute paid break after the first four hours of work and every few hours thereafter.
“This is not a desk job … What do I do with an autistic kid for 10 minutes?” Torabian said. “Do I leave them unattended? Because a lot of these people are so severely or profoundly impacted, we cannot leave them 10 minutes by themselves or even one minute. So that’s why at my business we have now hired 10-minute breakers that go around the center, and they say it’s your time.”
The industry still sees a lot of care delivered in homes and communities. The addition of travel adds additional operational and compliance challenges as well. If providers do not make the appropriate investments in systems and staff to ensure regulatory compliance, they may face existential legal challenges in the form of class-action lawsuits from former staffers.
“A lot of organizations, if they’re small or medium, they just shut down — they simply close down because of these matters,” Torabian said.
In addition to structural reforms, general strategies to address the workforce can be boosted if they increase the overall attentiveness of the organization and its staff to workforce needs.
Behavioral Health BusinessSteven Merhan, enterprise chief medical officer for Perimeter Healthcare, discusses workforce issues on a panel at the Autism Investor Summit West.
Autism Investor Summit West autism therapy workforce panel focused photo
“There is a retention strategy to being attentive to the problem and trying, even though you may fail,” Merhan said. “If the RBT feels like you did make your best effort to find another slot to swap out with somebody else, knowing somebody else is going on vacation, that’s a retention strategy in and of itself. It’s not just about the money; it’s the idea that [they are] being cared for.”
More structurally, this positioning would lend organizations to having high-touch hiring, screening, training and onboarding processes. Glover said organizations fail when they focus on getting people into roles and not on giving the staffer the feeling that they can succeed.
Yet deeper issues remain. Merhan and Torabian point out that the industry still has to grapple with workforce rules that apply more to the food service, construction or manufacturing industries. Advocacy with lawmakers and regulators is required to address those. In the meantime, organizations must do all they can to ensure some degree of sustainability for frontline staff and themselves going forward.
“I think that we have the compassion and the want to do it,” Glover said. “I just think the need outpaces the infrastructure that we currently have.”