Think back on the last five to ten clients you discharged. For each one, ask yourself:
Was this a planned transition into an environment they were ready for?
Or did the insurance run out, the out-of-pocket cost get too high, the family decide to try school, or the hours become too heavy to keep up?
Based on eight and a half years as a BCBA, my own observation, which isn't research, is that fewer than one in four discharges are actually planned transitions. If your number is much higher and you have a firm process, please contact me. I want to learn from you.
Why so few discharges are planned
There's rarely a single cause. Some of it is how we're paid and how our organizations are built. Some of it is how information moves between people.
Shared urgency gets lost in handoffs. When I do an initial assessment, my brain is focused on what the client can do now and where I want them to go. Much of the answer goes into anecdotal notes and a sequence of skills I keep beside me, because there's no good place for it on insurance paperwork. When a case moves to another clinician, they have to redo that thinking, and the urgency to move the client from point A to point B often doesn't carry over. It's worse when one BCBA does the assessment and another runs the case.
Turnover. Demand for BCBAs has grown every year, and in surveys I've seen, most BCBAs report having left at least one position, with burnout the leading reason. When a case changes hands, a new BCBA often wants to start over, and the question of what was the plan to get this client out gets lost.
Plans written and then not followed. I've gone to a reauthorization and found I had no data on two goals because I never opened targets for them. I took ownership of that, and I decided to do better. Whatever the cause, whether it's a caseload that's too big, a busy season, or a system that doesn't support it, our clients deserve better.
What a planned discharge starts with
Practice guidelines say discharge and transition criteria should be established when services start. That can feel absurd when you have six to eight hours to assess a child you met last week. But it's still your obligation to the client, to payers, and to the field.
The plan can be general at first. What it shouldn't be is general forever. Your behavior intervention plan is a little broader at the initial authorization and much more fine-tuned at six months. Your transition plan should work the same way.
By six months, especially for clients receiving 30 or 40 hours a week, you should have a well-prepared behavior plan and a firm transition plan.
Measure what they can do when we're not there
We measure success by what clients can do when we are present, because that's when we can take data. But the point is what they can do when we aren't. That is harder to observe and measure, and it changes what we target, what we measure, when we know we're done, and what we call a successful discharge.
Practical ways to get at it:
Probe skills in settings that resemble the next environment, such as a community group, with you backing off and stepping in.
Ask which skills have already generalized beyond one-to-one.
Monitor across environments and people from the beginning, not just at the point of transition.
Know where each client is on a defined stage track, and review the step-down and fading rate across your caseload.
When the family asks for less than you recommend
Suppose you recommend 30 hours and the family says they can do three. That's a clinical decision, not just a scheduling one. Something isn't always better than nothing.
If you can't provide the frequency and intensity needed for a client to make progress, even on a smaller set of goals, it may be more ethical to refer to a service built for fewer hours, or to offer a different model, such as parent-training-supported services, than to deliver a diluted version of intensive ABA.
I recommend a clinical minimum that is individualized by client, but I'm flexible within reason. If the gap is too large, I say I'm concerned and we talk about whether we're on the right track.
Talking with funders
We've all had the call where a client with five or seven years of services and very high needs is told the funder is reducing hours because they've been in ABA too long. You can argue the needs are real, but only if your data shows what you want to be true. If the documentation doesn't show progress, a funder won't see it either.
The opposite call happens too: they're making so much progress that it doesn't seem like they need this intensity anymore. That's when it helps to be realistic and clear. A client may be making real progress and still be well behind where their age says they should be.
Some of what funders do is a response to bad actors in the field, and good clinics often end up living with the consequences. You can't control that. You can control your own practice and your shared urgency to build an environment where clients become more independent, more dignified, and safer in the places they actually live.
Before your next reauthorization
Is the destination written down in specific terms for this client, not generic payer language?
Can you name the stage this client is in and what it takes to move to the next one?
Is every goal being worked on, with data, or are some quietly on hold?
Do you know which reductions in hours were based on data and which were driven by funding or family circumstances?
If you left tomorrow, could someone else pick this up with the urgency intact?
Is there a named contact and a plan for after discharge?
If you remember one thing: write the discharge picture down early, and check it at every reauthorization.
Two free tools can help: the Reverse Exit Planning worksheet for individual clients and ANCHOR for your organization. Both are on our Clinical Tools page, and neither saves any data.
If you want help building discharge-focused planning into your clinic's systems, learn about Clinical and Agency Consulting. I offer a free 15-minute consultation if you want to talk it through.
Casey Gressmen, MBA, MEd, BCBA, LBA, is a licensed special education teacher and board certified behavior analyst and the founder of Phoenix Rising Behavior and Academic Consulting.
