Autism service providers looking to scale walk the tightrope between ensuring speed, clinical excellence and financial stability.

Scaling necessitates repeated checks, such as verifying that each step on a ladder is securely fastened. But what that ladder really needs under it to help stabilize movement to new heights is a concrete foundation.

“Foundationally, the first thing you want to have in place is a really clear understanding of your mission and your values,” Mike Cairnes, CEO of JoyBridge Kids, said during a panel at BHB’s Autism Investor Summit in April. “Then you’ve got to make sure that you have your key people also in place as part of that infrastructure… Then, brick by brick, start putting in those operational clinical processes and procedures.”

JoyBridge Kids is an applied behavior analysis (ABA), speech and occupational therapy provider headquartered in Brentwood, Tennessee. It also has locations in North Carolina and Georgia.

Even when you’re anticipating rapid growth, taking time to methodically align values, personnel and clinical procedures together one by one will tee up sustainability for your business model, Carines explained. Investing in scalable technology like a strong EMR and scheduling software is also helpful.

“If you really know what you’re trying to accomplish within your clinic and you’re really focused on outcome-based therapy, continue to just dial into that,” Eric Plunkett, co-founder, chief financial officer and owner of Axis Therapy Centers, added. “Slow is smooth, smooth is fast. If you can grow methodically, that methodology will start to expand upon itself.”

Ultimately, he said, it also comes down to revenue cycle management and understanding that “if there is no margin, there is no mission.”

Ankeny, Iowa-based Axis Therapy Centers is a multidisciplinary clinic that provides ABA, speech and occupational therapy to children with autism and other developmental disabilities. The company operates four locations throughout the state.

Busting through bottlenecks

Though the autism services sector is projected to have more workforce stability throughout 2025 than in years prior, staffing challenges like high turnover rates and retention issues are still top concerns.

Operational bottlenecks around the talent pool of Board-Certified Behavior Analysts (BCBAs) and Registered Behavior Technicians (RBTs) are the most common issue in scaling as an autism provider, the panelists agreed.

Typically, this is due to three major things happening at once:

• Pairing up new client learners with RBTs
• Building up caseloads
• Lining up BCBAs to take on the caseload

“All three of these moons have to converge, and you’d like to converge them perfectly, so it’s a timing exercise,” Cairnes said. “So from the time of intake and assessment, when that learner hits day one, you want to make sure you are hiring at the point where you can bring that person to train, certify and have those two marry up, and then build the caseloads. But in the absence of that [timing] that’s where the bottleneck comes in. It’s either delaying a learner, or a delay in hiring RBTs, or you don’t have the BCBAs, and that’s really the whole game.”

The threshold for excessive growth

Matching external market demands regarding compensation and service needs while balancing quality workflows, clinical outcomes and processes is also an art. While there may be an appetite to “run fast” and exceed demands related to expansion, growing too quickly can also be an obstacle.

“I think it ultimately comes down to having that infrastructure in place, the right systems and a foundation that is strong enough to tolerate that level of growth,” Brad Zelinger, founder and CEO of Stride Autism Centers, said. “I don’t think there’s a one-size-fits-all answer.”

Des Moines, Iowa-based Stride Autism Centers specializes in ABA therapy for young children with autism. It has 22 locations across Iowa, Nebraska and South Dakota.

Scaling quickly, he noted, can also lead to better clinical outcomes because of adding additional resources as a result of the growth, but “you can’t take your eye off the ball,” especially related to balancing financial risk.

“I think in addition to having a clear understanding of your unit economics, breakeven analysis and all that is, at least for us, a lot of the time we’re focused on lining everything up as best as we can,” Zelinger said.

This really comes down to knowing when “you’re ready to press play” while monitoring capital for an ongoing construction project; investing in credentialing, contracting, hiring and marketing efforts can help providers ramp up without crashing, he added.

Something that can get lost in times of rapid scaling is also staffing and turnover.

“As long as you can maintain a low turnover rate and you’re operating well, then that becomes your financial model, and that’s what mitigates your risk,” Cairnes said.

Ultimately, accelerating growth without compromising quality or financial sustainability comes down to people.

“On the staffing side, I think it’s balancing a game of speed with quality,” Cairnes explained.

Hiring, recruiting and retaining top talent requires building internal talent pipelines, creating development pathways and being proactive in hiring, credentialing and onboarding new talent. However, attracting talent through culture rather than overly competitive pay is usually a more sustainable strategy.

“We have seen, in more competitive geographies, companies that try to differentiate on the basis of wages and I don’t think that’s a sustainable strategy,” Zelinger said. “It becomes very transactional with your team. That’s just not the nature of the relationship that we want to build… It’s an important factor, yes, not dismissing that, but it’s not where we want to differentiate.”