How Should Delivered and Recommended ABA Hours Be Compared?

Delivered Versus Recommended ABA Hours

Choose a mature period, then calculate delivered direct hours divided by recommended direct hours for that same window. Report raw hours, cancellations by source, staffing gaps, authorization holds, client choice, health, travel, and setting changes. Keep indirect components in their own comparison.

Match the time period and component

Compare the same dates, service category, and units. Recommended direct service belongs against delivered direct service. Caregiver work, assessment, supervision, and coordination need their own rows. A mixed recommended total divided by direct delivery creates a misleading percentage.

Use a mature period whose visits have had time to occur and whose records are complete. State the start and end dates. A current week should not be compared with a full-month recommendation before the week closes.

Build a simple service funnel

Track recommended, authorized, offered, scheduled, delivered, documented, billed, adjudicated, and paid hours separately. Each transition answers a different question:

• recommended to authorized shows a clinical-payer decision gap
• authorized to offered can reveal capacity or scheduling limits
• offered to scheduled reflects family choice and fit
• scheduled to delivered reflects cancellations, shortening, and attendance
• delivered to paid reflects documentation, claim, coverage, and adjudication processes

Do not treat a later state as proof of every earlier one. Payment does not establish clinical quality, and authorization does not prove delivery.

Use reason codes with accountable ownership

For every missed or shortened interval, record provider absence, client illness, family choice, authorization hold, inaccessible setting, transportation, weather, practice closure, unsafe conditions, or another defined reason. Add an owner and next action when one exists.

Avoid a single “family canceled” bucket that includes client illness, an unusable offered time, or an inaccessible location. The reason should describe the event without assigning blame.

Keep no opportunity separate from zero performance

If a session does not occur, the client had no treatment opportunity in that interval. Do not enter zero skill performance. Preserve cancellation and missing-service data in the access comparison while keeping clinical outcome denominators limited to actual defined opportunities.

This separation prevents service gaps from appearing as clinical regression and prevents clinical percentages from hiding missing access.

Interpret the gap with the client and clinician

A delivery percentage describes implementation or access during the selected window. Whether the recommended schedule remains appropriate requires separate review. Consider the client’s feedback, fatigue, burden, preferences, health, school, other care, meaningful opportunities, and outcomes.

If staffing caused most of the gap, the solution differs from a family-requested reduction. If the client consistently declines a configuration, revisit fit and consent rather than focusing only on makeup time.

Report counts and percentages together

Suppose 40 direct hours are recommended, 36 offered, 34 scheduled, and 29 delivered. Delivered-to-recommended is 29/40, or 72.5%. Offered-to-recommended is 36/40, or 90%. Delivered-to-scheduled is 29/34, or 85.3%.

Each denominator tells a different story. Report all raw hours and do not select the most favorable ratio. Keep provider and family reasons visible and define how partial visits are counted.

Use component-level comparisons

Create separate rows for direct service, caregiver-focused work, assessment, program review, supervision, and coordination. For each, show recommended, authorized, offered, scheduled, delivered, and billed amounts over the same dates. Mark “not applicable” rather than zero when a state does not apply.

A single total can hide that direct care was underdelivered while caregiver work exceeded the plan, or that professional review occurred without family-facing time. Component rows show which decision or capacity needs attention.

Lock the cohort before reporting a rate

If comparing across clients, define whose plans were active for the complete period, which service components are included, and how mid-period starts or changes are treated. Keep new or incomplete records visible rather than excluding them after seeing the result.

For one client, lock the date window and use the recommendation effective during that window. If hours changed midway, split the calculation by period. Summing two different recommendations into one denominator can obscure whether delivery matched either plan.

Connect each gap to a next action

Provider shortages may require recruitment, routing, or a continuity plan. Payer holds require the responsible payer workflow. Repeated family-requested reductions need clinical and feasibility review. Access failures require remediation. Client illness may call for health coordination and schedule flexibility.

Assign the owner and review date instead of treating the percentage as the endpoint. A dashboard that displays 72.5% without the six never-offered hours and their owner is less useful than a short reason table.

Keep quality and outcomes in their own analysis

Service delivery is an important access measure, but more delivered time is not automatically better. Review goals, harms, side effects, client preference, generalization, family burden, and meaningful participation with measures appropriate to those questions.

A low delivery ratio can explain why outcome evidence is difficult to interpret. It cannot prove that more hours would have produced a specific benefit. State that limitation when using the comparison in a plan review.

Keep clinical recommendation individualized

The CASP public summary places assessment, treatment planning, implementation, and evaluation within its autism-treatment scope. The BACB Ethics Code addresses competence, client involvement, consent and assent when applicable, assessment-based intervention, risk, and data-based evaluation for covered behavior analysts.

The CASP early-intensive-ABA paper discusses evidence for a specific young-child comprehensive-treatment population. It is not a universal dose rule. Individual recommendations still require current assessment, fit, risks, preferences, and review.

Keep payer and delivery states separate

HealthCare.gov explains that preauthorization may be required before care and does not promise cost coverage. Clinical recommendation, authorization, scheduled time, delivered time, claim, and payment remain different states.

Protect communication and basic access

The ASHA AAC portal supports continuous AAC access. Communication, mobility, health, bathroom use, rest, and emergency help remain available regardless of scheduled or completed treatment hours.

A practical example

A plan recommends 40 direct hours in four weeks. The practice offers 36, schedules 34, and delivers 29. Of the eleven-hour recommendation gap, six were never offered, two scheduled hours were lost to staff absence, two to client illness, and one to an authorization hold.

The report shows 29/40 delivered-to-recommended, 36/40 offered-to-recommended, and 29/34 delivered-to-scheduled. Illness remains an illness reason rather than family noncompliance, and canceled time remains outside any clinical-performance denominator. The clinician reviews whether the recommendation still fits while operations owns the staffing gap and payer staff own the authorization task.

Questions families can use

Ask whether the period, units, and service components match; what was authorized, offered, scheduled, and delivered; who canceled and why; which holds applied; whether makeup fits the client; what the person reports; how no-opportunity intervals are treated; and how the clinician interprets the gap alongside burden and outcomes.