Elopement and Water Safety

The Arc Insurance Advocacy Resource Center (INARC)

Water Safety and Medical Necessity

Can a water safety program be part of a health insurance funded medical intervention program?

It is widely recognized that drowning is a leading cause of injury and death among persons with autism, especially young children. As such, water safety should be considered to be a health concern for persons with autism and should be allowed to be included in medically necessary behavioral therapy. Because drowning often occurs as a result of elopement (running away from care takers), behavioral plans may address both together.

With that said, addressing these health and safety concerns must be done in a way that meets medical necessity criteria, insurer requirements for network providers, and behavioral therapy ethical guidelines for treatment and business practices.

What should be allowable under health insurance:

1) Writing water safety and elopement goals into a behavioral treatment plan

2) Addressing water safety and elopement across settings – home, clinic, community – including but not limited to school, playgrounds, neighborhood, and novel (new) settings.

3) Parent and caregiver training to teach prevention and safety strategies and interventions once interventions have been successful in controlled settings with trained clinical staff.

4) On-going maintenance of the skill or treatment to address regression in safe behaviors or elopement

5) Reimbursement for BCBA, BCaBA, and RBT services to address water safety and elopement as part of a preauthorized behavioral treatment plan, including specific written clinical goals to address water safety (not swimming skills as an end goal)

What would NOT be allowable under health insurance:

1) Pool, gym or activity center memberships

2) Adaptive Swim Lesson fees

3) Recreational therapy to teach swim skills (this may be a service that can be added to an Individual Service Plan under a Waiver, and could also be provided by other waiver staff beyond Recreational Therapists. See Waiver Services for Adaptive Swimming below).

What would a behavioral treatment plan water safety goal look like?

Retention Pond

The following goals are for illustrative purposes only – a qualified behavioral health provider would need to write specific water safety goals for the individual under his/her care, and include such goals in a behavioral treatment plan submitted to insurance for preauthorization.

Goal: Johnny will walk past the neighborhood retention pond while maintaining at least 20 feet distance from the edge of the pond while under the supervision of two staff members who are actively linking elbows with Johnny.

Goal: Johnny will walk past the neighborhood retention pond while maintaining at least 20 feet distance from the edge of the pond while under the supervision of two staff members who are holding Johnny’s hands.

Goal: Johnny will walk past the neighborhood retention pond while maintaining at least 20 feet distance from the edge of the pond while under the supervision of two staff members who are directly next to Johnny.

Goal: Johnny will walk past the neighborhood retention pond while maintaining at least 20 feet distance from the edge of the pond while under the supervision of two staff members who are at arm’s length to Johnny.

Goal: Johnny will walk past the neighborhood retention pond while maintaining at least 20 feet distance from the edge of the pond while under the supervision of one staff member who is linking elbows with Johnny while the second staff is 5 feet behind.

Goal: Johnny will walk past the neighborhood retention pond while maintaining at least 20 feet distance from the edge of the pond while under the supervision of one staff member who is linking elbows with Johnny while the second staff is 10 feet behind.

Goal: Johnny will walk past the neighborhood retention pond while maintaining at least 20 feet distance from the edge of the pond while under

the supervision of one staff member who is linking elbows with Johnny while the second staff is 20 feet behind.

Goal: Johnny will walk past the neighborhood retention pond while maintaining at least 20 feet distance from the edge of the pond while under the supervision of one staff member who is linking elbows with Johnny while the second staff is out of sight but supervising for signs of bolting, and ready to step in for safety.

Additional goals would be added here and mastered according to mastery criteria until Johnny is able to walk past the retention pond in his neighborhood with one staff member who is within an acceptable distance…And so on until this is mastered at a park or other novel pond, and mastered and maintained by the family or caregivers. Depending upon Johnny’s age and skill level, mastery may include walking independently around the pond while maintaining a safe distance.

Swimming Pool Goals

*For illustrative purposes only

Swimming pool goals would focus upon safety, not learning specific swimming skills. For example, “Johnny will learn the freestyle stroke and swim across the short width of the pool” would not be an acceptable clinical water safety goal. This goal would be an appropriate recreational goal for waiver services or a swimming lesson goal.

Examples of water safety pool goals:

1) Johnny will float on his back for 3, 5, 8, 10, 15, 20 seconds, up to x minutes.

2) Johnny will turn from being face down in the water where he can touch to floating on his back with physical prompts, with a touch prompt, with no prompts.

3) Johnny will turn from being face down in the water where he cannot touch to floating on his back with physical prompts, with a touch prompt, with no prompts.

4) Johnny will move hand over hand across the side of the pool to the ladder and hold on – from 1 ft., 3 ft., 5 ft., 7 ft., 9 ft., 12 ft., 15 ft. etc.

5) Johnny will be lowered into the pool, turn to the wall, and move hand over hand until he reaches the ladder and hold on from 1 ft., 3 ft., 5 ft., 7 ft., 9 ft. etc.

As part of a behavioral treatment plan, on-going data must be collected and progress demonstrated on treatment goals.

Adaptive Swimming, Water Safety and the Waiver

Waiver services can also be used to help fund adaptive swimming and water safety classes.

For example:

1) Recreational therapy can provide swim lessons and/or work on water safety goals with a recreational therapist as part of the Individual Service Plan to improve the individual’s functioning and independence. They can organize and direct adapted sports, dramatics, arts and crafts, social activities, and other recreation services designed to restore, remediate, or rehabilitate.

2) PAC services can provide staff to accompany the individual to swim lessons and to work on water safety goals, especially as it relates to the reinforcement of the principles of health and safety. This may not be appropriate for persons who have impulse control issues with water or bolting/elopement issues due to safety concerns.

3) Respite services can provide staff to accompany the individual to swim lessons and to work on water safety goals as a way to improve the individual’s ability to access the community and community activities. This may not be appropriate for persons who have impulse control issues with water or bolting/elopement issues due to safety concerns.

4) Community Habilitation services may be used for staff to accompany the person to swim lessons and to work on water safety goals and to monitor, train, educate, demonstrate, or support to assist with the acquisition and retention of skills in leisure activities, and/or to acquire skills that enable the participant to become more independent, integrated, or productive in the community.

5) Family and Caregiver Training can be used for parents and unpaid caregivers to learn strategies and behavioral interventions related to water safety so parents and unpaid caregivers can provide appropriate and better care related to water safety to their child with a disability.

(Words in bold reflect the allowable activities for a particular service available under the waiver.)

If you have any questions, please contact The Arc of Indiana at 317-977-2375 or at   thearc@arcind.org

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