The Online and Applied System for Intervention Skills (OASIS)—Scaling Up!
University of Kansas Medical Center
Department of Pediatrics
Submitted by Linda S. Heitzman-Powell, PhD; Jay Buzhardt, PhD; and Alice Zhang, PhD
This project utilizes principles of implementation science (ExpandNet & World Health Organization [WHO], 2009; Fixsen et al., 2009) to scale up the Online and Applied System for Intervention Skills (OASIS) from the University of Kansas Medical Center and the Juniper Gardens Children’s Project to the broader community. The OASIS program uses a research-to-practice outreach training model to teach parents of children with autism how to implement empirically based interventions with their children. As part of its knowledge translation (KT) strategy, the project has conducted internal testing to increase the scalability of OASIS, pursued policy change to address environmental barriers that limited the capacity of clinicians to implement OASIS, and designed a train-the-trainer program (whereby OASIS service providers learn how to train others to use the OASIS model) to increase the project’s capacity and sustainability to support parents using the program.
OASIS development began in 2006. The first project, which ran from 2006 to 2009, sought to address challenges faced by geographically remote families in accessing effective intervention services for their young children diagnosed with autism. The team developed a program that used a research-to-practice outreach training model to teach parents how to implement empirically based interventions with their children through online tutorials and coaching sessions. Between 2011 and 2014, the project culturally and linguistically adapted the OASIS Training Program for use with Hispanic/Latinx parents who have a child with autism. A quasi-experimental study found that parents achieved mastery in learning OASIS evidence-based practices, and they were able to implement the practices with their child with high fidelity after training (Heitzman-Powell et al., 2014).
The current project promotes the broader dissemination and adoption of OASIS through an expanded training program and other support for scaling up the intervention. The goal is to expand access to evidence-based practices and intervention services for families of children with autism, especially those families who otherwise have limited access to such services.
This project’s KT approach is drawn from World Health Organization guidelines for scaling up a healthcare innovation (ExpandNet & WHO, 2009), as well as guidelines for scaling up evidence-based practices in education (Fixsen et al., 2009). These guidelines prompted the team to consider scaling up the program in the following stages: (1) ensuring the usability and usefulness of OASIS, (2) increasing the capacity of user organizations (e.g., service providers) to implement OASIS at scale, and (3) increasing their own capacity to train OASIS coaches.
Each stage of developing and scaling up OASIS has involved pursuing a KT strategy suited to a particular stakeholder group. These strategies are summarized in Exhibit 1 and discussed in more detail in the sections that follow.
|Objective||Stakeholder group||KT strategies|
|Ensuring the usability and usefulness of OASIS||Parents of children with autism||Focus groups and usability testing|
|Community stakeholders (e.g., educators and social service providers), including Hispanic/Latinx stakeholders||Participatory action research|
|OASIS coaches||Monthly technical assistance conferences|
|Increasing the capacity of user organizations to implement OASIS by changing insurance codes so OASIS would be eligible for reimbursement under health insurance policies||Clinical service providers||Advocacy (“having a champion”), assisting with treatment authorizations, holding regular trainings to increase availability of OASIS coaches|
|State Medicaid agencies and legislative bodies|
|Health insurance companies|
|Increasing the capacity of the resource team to support scaling up||OASIS coaches||Train-the-trainer|
Involving parents, coaches, and other stakeholders in design and testing
The project team first identified a need for parent training when they encountered parents who were participating in training programs designed for practitioners. While this was due primarily to a lack of programs designed specifically for families, it also was inspired by the lack of service providers in rural areas. As a result, children and families were going without treatment services. Since then, the project has consistently involved its intended users—parents of children with autism—in the development and implementation of OASIS. Parents were recruited to participate in focus groups that informed the program design, and approximately 20 parents were involved in usability testing, in which researchers observed their use of the online system in a one-on-one environment. The goals of this testing were to evaluate differences in intended versus actual use and to collect parents’ qualitative feedback.
In addition, the OASIS team undertook participatory action research to learn how to adapt the program for Hispanic families. As part of this approach, the team conducted a focus group with Hispanic parents and recruited a diverse advisory board of local Hispanic educators and social service providers from a variety of Hispanic cultures (e.g., Mexico, Puerto Rico, Venezuela) to assist with content translation and provide recommendations for cultural adaptations. These KT activities resulted in changes to the content and dissemination of the program for Hispanic families. For example, the team determined that coaches should be bilingual with a Hispanic background and developed coaching strategies for households with multiple children or extended family involved in childcare (Buzhardt et al., 2016).
As OASIS is scaled up, the project team continues to refine the content and design of the program in response to stakeholder feedback and the evolving needs of parents and clinicians. In addition to collecting ongoing feedback from parents, the team conducts monthly technical assistance conferences in which they collect feedback from coaches who work directly with parents.
“Having a champion”: Advocating for policy change to remove barriers to implementation
A key component of the project’s KT strategy involves addressing environmental barriers to transferring and implementing the intervention. In this case, the primary barrier was that the American Medical Association had not established Current Procedural Terminology (CPT®) codes for applied behavior analysis (ABA) when OASIS was developed. Therefore, providers were not able to bill insurance companies for the evidence-based practices that OASIS aims to promote. The OASIS team recognized that if providers are to adopt evidence-based practices, they must be able to generate revenue from these services.
Dr. Linda Heitzman-Powell (one of the project’s two principal investigators) personally advocated for state-level policy change in Kansas by serving on the Kansas Legislative Task Force on Autism, delivering testimony to the state legislature and working with the state Medicaid program to implement codes for ABA. Due to these efforts, Dr. Heitzman-Powell was able to provide input at the initial BCBA® (Board Certified Behavior Analyst®) Practice Parameters Board, a national coalition of professionals, advocates, and clinicians that eventually were successful in advocating for the addition of permanent codes for ABA to the CPT manual. Most recently, Dr. Heitzman-Powell contributed to the Practice Parameters for Telehealth-Implementation of Applied Behavior Analysis (Council of Autism Service Providers, 2021) to provide guidance on, and advocate for, broader access to applied behavior analysis services delivered via telehealth.
Multiple OASIS team members continue to work with state Medicaid systems (particularly in Kansas and Alaska), insurance companies, coalitions of advocates, and other agencies or organizations to support the implementation of the new CPT codes and promote access to services such as parent training. The state of Kansas now mandates that large group health plans cover services for children with autism, including ABA, and the state’s managed care program uses the new CPT codes to reimburse previously uncovered ABA services, one of which specifically refers to parent training. Because of these changes, the OASIS project can now help clinicians properly bill for their services, paving the way for broader adoption of evidence-based practices among providers with an increased ability to reach families in geographically remote and underserved areas.
Train-the-trainer: Expanding organizational capacity
In 2018, the OASIS project had only two coaches who were trained to assist with parents’ use of OASIS with children. To increase the availability of certified OASIS coaches while ensuring program fidelity, the team has implemented a train-the-trainer model.
In this model, certified coach trainers are responsible for training parent coaches, who in turn coach families through the OASIS parent training program. The coach training program involves a combination of online learning, whereby trainees complete all parent training tutorials and take knowledge assessments, and applied practice, in which trainees observe and ultimately lead parent coaching sessions under the tutelage of a certified OASIS coach trainer. As of 2022, there are 73 certified OASIS parent coaches and two certified coach trainers.
The train-the-trainer model is the main focus of the project’s current work with funding from the National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR). The project is working to train additional certified coach trainers to increase capacity to train parent coaches. By increasing the supply of coaches, the project can improve access to evidence-based services for children with autism and their families.
The team attributes the project’s success in large part to the fact that it was designed in response to an authentic, identified need in the field, with ongoing input from families of children with autism. Additionally, the team planned for commercialization early on in order to facilitate the dissemination of OASIS to the broader community. Scaling up OASIS has required the team to ensure that clinicians can generate revenue by billing insurers and to invest in long-term technical support (e.g., maintaining servers and updating the application).
NIDILRR Grant Name: The Online and Applied System for Intervention Skills (OASIS)—Scaling Up!
Organization: University of Kansas Medical Center, Center for Child Health and Development
Mailing Address: 3901 Rainbow Boulevard, MSN 4003, Kansas City, KS 66160-2937
Key Contacts: Linda S. Heitzman-Powell, PhD, LHPowell@ku.edu; Jay Buzhardt, PhD, firstname.lastname@example.org
- Batton, B., Kaplan, R., Ellis, K., Schmidt, C., & Nudelman, E. (2022). Telehealth Training in Principles of Applied Behavior Analysis for Caregivers of Young Children with Autism Spectrum Disorders during the COVID-19 Pandemic. Education and Treatment of Children, 45(3), 299-303. https://doi.org/10.1007%2Fs43494-022-00081-7
- Boydston, P., Redner, R. & Wold, K. Examination of a Telehealth-Based Parent Training Program in Rural or Underserved Areas for Families Impacted by Autism. Behavior Analysis in Practice (2022). https://doi.org/10.1007/s40617-022-00763-z
- Buzhardt, J., Rusinko, L., Heitzman‐Powell, L., Trevino‐Maack, S., & McGrath, A. (2016). Exploratory evaluation and initial adaptation of a parent training program for Hispanic families of children with autism. Family Process, 55(1), 107–122.
- Council of Autism Service Providers. (2021). Practice parameters for telehealth-implementation of applied behavior analysis, second edition. https://casproviders.org/practice-parameters-for-telehealth/
- ExpandNet & World Health Organization. (2009). Worksheets for developing a scaling-up strategy. World Health Organization. https://expandnet.net/PDFs/ExpandNet-WHO%20Nine%20Step%20Worksheets%20with%20cover.pdf
- Fixsen, D., Blase, K., Horner, R., & Sugai, G. (2009). Scaling-up evidence-based practices in education. FPG Child Development Institute, University of North Carolina at Chapel Hill. https://nirn.fpg.unc.edu/resources/scaling-evidence-based-practices-education
- Heitzman-Powell, L., Buzhardt, J., Rusinko, L., Turek, J., & Miller, T. (2014). Formative evaluation of an ABA outreach training program for parents of children with autism in remote areas. Focus on Autism and Other Developmental Disabilities, 29, 1, 23–138.
- Heitzman-Powell, L., Buzhardt, J., Zhang, E., & Barr, J. (2022). Evaluation of the Effects of the Online and Applied System for Intervention Skills (OASIS) With Parents of Children with ASD Using a Randomized Waitlist Control Trial. Behavior Analysis: Research and Practice. Advance online publication. https://doi.org/10.1037/bar0000261
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