Ken Huey 0:00

Welcome to the voice of hope, where bold leaders and healers share how they're building hope, not just talking about it. I'm Dr. Ken Huey. Let's meet the changemakers transforming lives from the therapy room to the boardroom. Hello and welcome. Today's guest is Amanda Ralston. She goes by Mandy, CEO of Mirabelle Care and founder of Non-Binary Solutions, a behavioral health leader and autism advocate with over 25 years of experience building innovative, neurodiversity-affirming care models and technology-driven clinical solutions. Mandy, thanks very much for being with us.

Amanda Ralston 0:36

Thanks for having me, Ken. It's nice to be here.

Ken Huey 0:39

Yeah. I'm always interested in understanding what inspires people to join the field in the way that they have. What brought you to applied behavior analysis and autism services?

Amanda Ralston 0:51

So I was a psychology undergrad in the late 90s, before the turn of the century. And my textbook told me that it was one in every 10,000 individuals were diagnosed with something called autism. And so I decided to write a research paper about it because the textbook only had two paragraphs. And so I met seven different families in Lexington, Kentucky that were flying a consultant out from California once a quarter, sharing the cost out of pocket because there was no insurance coverage, et cetera, and cobbling together what was deemed at that point as the quote unquote gold standard treatment for individuals with autism, which was applied behavior analysis. So I wrote the paper, and after I graduated that spring, I ended up working with those seven families as what is now termed a technician. So I got to learn the same way that all the entry-level employees now learn at this point. And I really just got hooked. I always liked kids. I was good working with kids, and then to be helpful in a way that allows them to learn how to communicate and play and be more social, that was all very reinforcing for me.

Ken Huey 1:54

Yeah. All right. You've built and scaled multiple organizations. You know, kind of a serial entrepreneur you describe yourself as. Could you tell us more about that?

Amanda Ralston 2:04

Yeah, I think I'm a glutton for punishment. So, you know, what came out of those first seven families was an understanding of the level of demand and need for these families to find services. And again, in the late 90s, early 2000s, the only people that really afford this therapy were people that could pay out of pocket. And so with three other founders put together the first organization that I ended up being CEO of by the time I was 25. And we grew that very quickly because there was so much demand, but it was not a well-paying rate that we were working under at that point. We weren't very diversified. And so we ended up wrapping up shop with that one in 2003, I think. And the demand continued, right? Again, people were still calling me, emailing me all the time. We need services. Could you help us? Can you help us? Can you help us? And so I ended up driving anywhere between 35 and 40,000 miles per year for the next three years, going between Indiana, Ohio, and Kentucky for anybody that could pay out of my out of pocket for my services as a consultant. And so I got tired of doing that after a while and realized that I couldn't control for quality because these were all independent contractors and they were all over the place in terms of skills and understanding. So I decided to build another clinic in 2007 and did that much more slowly than the first one. And so when we finally got insurance coverage in 2014 in Kentucky, it took a few years for the payers to catch up with their systems. But we really started growing quickly at that point again. And I was lucky enough to get to an exit in May of 2019, six months before I had to make payroll in a pandemic. So yeah, after I did that, again, I spent about three years inside that larger organization, which is where I saw this new problem, which is that I can get a hundred of these behavioral providers in a room together and put one kid in front of them and say, how are you going to approach treatment for that kid? And they will all have completely different approaches. And most of the reason they do it that way is because that's how they've always done it. It's not necessarily based on data or best practices or literature, it's what they learned and how they sort of rinse and repeat. So the technology company, Non-binary Solutions, I made a clinical decision support system to help guide people through treatment decisions. You know, much the same way you go into a doctor's office and they sit down and they say, So what brings you in today? And they start typing into the computer. Well, I built that based off of my 20 years of practitioner experience. So I've made a clinical decision support system with non-binary solutions, which is basically building out digital bumper rails for other practitioner users to help them understand how somebody with 20 years of experience thinks about building out treatment pathways for kids. So it's an algorithmic-based decision tree. You don't see the tree behind it, but it's prompting you different questions based on how you are answering, based on your clinical interview with the patients and the patients' families. And so, yeah, that's something that I spent from 2022 to January this past year doing when I was presented with the opportunity to come to Mirabelle Care and lead up their department as CEO.

Ken Huey 5:02

Very nice. So talk to me a little bit about neurodiversity affirming care. Two things. What are we really saying with that? That will be helpful, I think, to many in our audience. And what does it look like with families and clinicians?

Amanda Ralston 5:16

Yeah, so neurodiversity is generally the assertion, the assumption that there are natural variants in our neurological makeup with our brains, right? And so rather than having a medicalized model of the neurodivergent conditions, which include autism, ADHD, OCD, Tourette's, dyslexia, dyspraxia, dysphasia, like there's several of them, right? So rather than having this medicalized version of those conditions and those people need something fixed, quote unquote, neurodiversity affirming care believes that this is one part of your intersectional being, and that your neurological differences are a natural variation. And only to the degree which you want to change something about your clinical state would we go about making a treatment plan for that. Like I'm not trying to not make you not have autism. I am trying to listen to you what you would want to improve in your quality of life, and does that relate to your autism? And if so, what medically necessary supports can we put in place to help you improve your quality of life? But that's again, that's all coming from the patient side. It's not like I'm coming in and saying, hi, I'm Andy. Looks like you have autism, let me fix you, right? Which is not what actually was happening in the first place, but there's an attitude of a residue that was something that was happening in the past. And I think it's, you know, variations on a theme. I think we always can do better as a field and how we approach these things, but it's like psychology, psychiatry, and medical practice altogether, you know, all of those things, all of those industries had problematic practices in the past, and based on new data and new learnings and new information, they changed. You know, nobody's out here using leeches still, but that was a thing. So that that's where we are.

Ken Huey 7:02

All right. You often talk about moving beyond binary thinking. How does that apply in behavioral?

Amanda Ralston 7:08

Well, binary thinking, first of all, uh, is sort of the notion that there are only two sides to some issue and you have to choose one, right? So it's a false dichotomy. It's seeing everything in black and white, right? And so for autism, I always like to say autism is not a monolith. Telling me somebody has autism tells me about as much about them as if you said Mandy's wearing a black shirt today, right? Like it's just one label and characteristic about me as a person, right? And so to really support individuals, you have to see their full amplitude of their humanity. They are not just their diagnosis, they are also their family, their culture, their geographic domain, you know, their entire learning history. And so you really, in order to treat somebody with autism or with ADHD or whatever the it is, you also have to understand their educational background and their medical health and all of those things, so that it's not just I'm just treating autism. That is never the case. Autism is such a heterogeneous diagnosis. The saying goes, if you met one person with autism, you met one person with autism, and it is absolutely true. And they're a very, very different group of people. And so in order to treat them or support them effectively, you have to understand them as a person.

Ken Huey 8:22

All right. So let's talk a little bit, if we could, pivot to technology. What role does technology play or should it play in improving clinical outcomes?

Amanda Ralston 8:32

Yeah, again, we've had a 500% increase in providers in the last 10 years within behavior analysis. And now over half the field has less than three years of experience, right? So there's not enough old folks like me to be around to mentor these individuals and what best practices and how to make these clinical decisions goes. And that's why I built that clinical decision support system so that there was some kind of digital bumper rails, quote unquote, to help guide them through how to make those decisions. And I mean, most of my expertise has come out of making mistakes and learning, right? And so I can shortcut that process by giving them the rubric of how I think about these things. I've got one platform, obviously, there's lots of other platforms that are coming up and into the industry, but in general, it's about putting systems in place because if you don't have the system guardrails, again, you could have that problem with I got a hundred behavior analysts and one kid, and they all approach treatment differently. And that's not necessarily a good thing.

Ken Huey 9:31

Talk to me about leadership, if you would. How do leaders balance rapid growth and maintaining ethical and high quality care?

Amanda Ralston 9:41

Yeah, systems, system, systems, right? You gotta have the right people in the right chairs and you gotta have the right systems built around those people. So it's a combination of architecture and critical thinking, and you have to know what good looks like. So being able to put systems in place to get to the outcomes that you want and knowing what is in fact ethical and appropriate and state of the art, those are all things that take people experts.

Ken Huey 10:06

How about some of the biggest challenges families face when navigating services today for especially the populations you work with?

Amanda Ralston 10:13

Yeah, it's so striking to me that you know I'm 26 years into my career and the same problems that I had at 21 that their families are having when I was 21 are the problems that they're having now, right? They still have long waiting lists to get a diagnosis. They have providers in some cases that are not willing to give a diagnosis early because there's just a nascent leftover sort of bias, if you will, about giving an autism diagnosis early in some areas. In other areas, we've moved far past that, and we understand that early intervention is critical to outcomes. But yes, they have waiting lists to get the diagnosis in the first place, and then even after they get the diagnosis, they've got waiting lists everywhere to get services. And then they have to advocate for their child all the time, right? They have to be able to educate their cultures and their communities about what their child needs. So yeah, it's a lot of the same, unfortunately, still. The good news is we have insurance coverage in all 50 states and Medicaid as well. But we're going to have to make sure that as this continues to scale, we're putting the right guardrails in place so that we can maintain quality.

Ken Huey 11:18

Where are we missing it relative to ABA and autism-specific care? What are we not addressing as a not organization, but as a community?

Amanda Ralston 11:28

Yeah, I think the industry needs to do a better job of collaborative care, and that's something that we're leaning into at Mirabelle. So Mirabelle's differentiator is the fact that we have both OT, speech, and ABA services all on the same roof. And so families are remove the burden from having to travel from one office to another to get those services, right? We need to do a better job of collaborating with the medical professionals that are also treating that child, right? So again, we really shouldn't be viewing ourselves as the all-in-one service, as ABA alone, that we really need to understand that there's a handoff between those other related services. And I think we've got an opportunity, especially with Mirabelle, that there are a great number of kids that would benefit from speech therapy and occupational therapy, but they may have behavioral impairments or skills deficits that are not allowing them to benefit from that care at this time. So we've got a natural handoff between the ABA department and then being able to say, okay, given this treatment plan, and if we can reach these goals, then this patient will be able to access some additional related services.

Ken Huey 12:33

How can innovation and technology help kind of close the gap with needs for services?

Amanda Ralston 12:39

Yeah, I mean, it's one of the things, again, I was trying to solve for, still am trying to solve for with Noetic and non-binary solutions and the clinical decision support system we built. Part of what the intention of the care navigation technology, which is a robust interview process that builds a patient profile in the background or writes a report. And this is what you told me about this person, and based off of the algorithm, these are some recommendations that we have for you, either referrals or additional services, or here's some goals, and here's what we think about intensity. But on top of that, because you're building, you're bringing all of those patients into a data set in the same structured manner, that allows you a structured data set with labels. So if you have a big enough data set and you have all this information, not just the diagnosis, but all that background information, all the additional diagnoses on top of it, with machine learning and supervised machine learning with the human in the loop, you can start to create behavioral phenotypes. So who are these very, very different people with autism? So you've got very profound autism on one end of the quote unquote spectrum, and you've got very less profound affected individuals on the other end of the spectrum who might have in previous decades been labeled as Asperger syndrome or something like that. So if you have those types of behavioral phenotypes, then you would be able to reasonably say these are the types of outcomes that we expect to see with this phenotype under this type of care for this amount of services. I met a founder in New York that was able to create an algorithm that was able to predict individuals that would be diagnosed with Parkinson's disorder six years ahead of time based on claims data alone. That's the power of big data, but you've got to have structured data and you've got to have humans in the loop who determine is this a meaningful correlation in the first place or not. And I I think that's where we can go with autism services is really understanding the various levels of care that those different phenotypes need so that we don't see situations where everybody gets 30 hours, right? Or everybody only gets this amount of hours. Like it's really gotta be delineated based on their phenotype.

Ken Huey 14:40

I think we live in a time that's got pretty solid pessimism. But I'm interested to have you tell me, Mandy, what gives you hope in behavioral health care and autism services?

Amanda Ralston 14:50

I think the attention that we're getting as a field right now, based on some of the scrutiny that we're under, is ultimately a good thing because nobody's coming to save us. We're gonna have to save ourselves. Like we really are going to have to band together and decide what good outcomes look like and how we're going to get there. What is best practice? Who should be allowed in those practices, and really start to have a relationship with our payers that we could possibly get to a value-based reimbursement model where it's not just fee for service, which is part of the problem and how some of these organizations are run.

Ken Huey 15:26

What is one thing they could do to get started?

Amanda Ralston 15:30

It depends on if you want to be hands-on or what else you want to do. I mean, I think every state and large area, metro area, will definitely have an autism support group of some sort, usually made up of parents and other people. You can learn about becoming a registered behavior technician through the behavior analyst certification board, which is the BACB.com. You could take a look at some advocacy groups in your area. There's always an autism walk, generally speaking, in each of these families. So there's lots of different ways you could have an impact.

Ken Huey 16:02

All right, very nice. So, Mandy, people are listening and they want to know more about what you're doing or your organization. Where would you send them?

Amanda Ralston 16:09

Sure. I'm fairly easy to find on the internet. You can go to AmandaRalston.com. That's my personal website. I always like to say you can follow me on social media. I am vaguely professional on LinkedIn. I'm mostly authentic on Instagram and I'm completely inappropriate on Facebook. But also please go to Mirabelle Care if you're looking for services. Tell us where you are, what you're looking for, interact with us that way. We've got our own social media page. We've got a nice following on Facebook for Mirabelle Care. So look us up.

Ken Huey 16:40

Fantastic. Mandy, seriously, I want to say thank you. I always love talking to folks that are passionate about and making a difference in our field. So thank you for spending time with us.

Amanda Ralston 16:49

Thank you, Ken. I really appreciate your time.

Ken Huey 16:52

Thanks for joining us on The Voice of Hope. If you were inspired, share the light. And remember, hope's not just a feeling, it's a force. We'll see you next time.