Factors that influence clinical decisions about offering parent coaching for autistic youth served within the Medicaid system

BACKGROUND: Parent coaching is an evidence-based practice for young autistic children, but it is underutilized in lower-resourced community settings like the Medicaid system. Clinicians often struggle to implement parent coaching with low-income and marginalized families, but little is known about which factors influence clinician decision-making processes about providing parent coaching to this population. METHOD: This qualitative analysis used the framework method and thematic analysis. We used the Exploration, Preparation, Implementation, and Sustainment (EPIS) framework to identify factors in the clinical decision-making process that community providers use when offering parent coaching to families of Medicaid-enrolled autistic children. Interviews with 13 providers and a focus group with 13 providers were analyzed. RESULTS: The following themes emerged: (a) Policies drive provider task priorities and affect competing demands; (b) Providers are more likely to use parent coaching when agency leaders monitor parent coaching benchmarks, though this is rarely done; (c) Logistical factors like scheduling and treatment location affect perceived feasibility of using parent coaching; (d) Previous experience or coursework in parent coaching and/or family systems supports the quality of parent coaching implementation; (e) Provider perceptions of “parent readiness” are initially indicated by overt expressions of parent interest. CONCLUSIONS: In the absence of outer-context and inner-context policies, providers have more decision-making power to offer parent coaching based on their own judgments and preferences, which may result in fewer families being offered parent coaching and increased bias related to which families are offered this service. State-, agency-, and clinician-level recommendations are provided for increasing equitable provision of this evidence-based practice for autism. PLAIN LANGUAGE SUMMARY: We explored how providers make clinical decisions when offering parent coaching to Medicaid-enrolled autistic children. The data came from 13 individual interviews and a focus group with 13 providers. We found that there were five main themes that providers discussed: (a) Providers prioritize using their time to follow requirements made by state or agency policies, and are less likely to prioritize other things that are not required by these policies; (b) Providers are more likely to offer and use parent coaching if their agency leaders monitor how often they do parent coaching; (c) Logistical factors like scheduling and treatment location affect how likely the provider is to use parent coaching with a family; (d) Providers with previous experience or classwork about parent coaching and/or working with families feel more comfortable to use parent coaching with families; (e) Providers think parents are more “ready” to do parent coaching sessions if parents show they are interested with specific actions such as directly asking providers for advice about how to work with their child. These results suggest that policies must prioritize this evidence-based practice to ensure that providers are implementing it equitably to all families who are appropriate for parent coaching. We provide recommendations for clinicians and agency leaders/administrators to improve the implementation of parent coaching in lower-resourced settings.