This is an exclusive BHB+ article
Turnover is a top concern for operators in the autism services industry. While the demand remains high, recruiting and retaining talent is hard–especially when it comes to registered behavioral health technicians (RBTs).
The job of an RBT is challenging, and wages are often comparable to those in retail positions. However, operators have found success with retaining RBTs by creating a supportive work environment and offering career enhancement programs.
In this BHB+ TALKS conversation, Senior Editor Laura Lovett sits down with JoyBridge Kids CEO Michael Cairnes to discuss the latest techniques his organization has used for keeping good staff.
Cairnes explores how to bridge the gap between business and clinical teams, emphasizing the importance of gathering clinician feedback and explaining why ownership structure may not directly determine workforce culture.
Laura Lovett: Hello and welcome, everyone, to BHB Plus Talks. We are so lucky to have with us Michael Cairnes, who is the CEO of JoyBridge Kids. I’m Laura Lovett. I’m the Senior Editor over at Behavioral Health Business, and today we’re going to be talking all about workforce challenges, so please ask your questions as we go, and we will try to answer them as they come in. First, I wanted to kick it off with Michael. Could you tell me a little bit more about JoyBridge Kids?
Michael Cairnes: Good morning. Sure, I’m happy to. A quick backstory on JoyBridge Kids. It was founded by a marvelous man, his name is Rogers Clayton. He started it from the ground up, which is hard to do. I was fortunate enough to meet him in 2021 and tour the very first clinic, and it was just starting up at that point, and I love the DNA of what he was creating with JoyBridge Kids.
As good fortune would have it, in April 2022, he partnered with a group called Frontline Healthcare Partners. They asked me to come on board as the CEO to help finish building out the model and to help scale the business. For me, this was personal because I have a son with autism. The deal we made was, if we’re going to do this, we have to do it right, and we have to do it with the highest level of clinical quality.
Now, fast forward three years later, we’re now 14 clinics in three states at this point, and we’re able to serve hundreds of children and massively change people’s lives. That’s what this is all about for us.
Lovett: I love how so many people in this industry have that personal connection to the space, too. It’s really interesting and really meaningful to hear about. Let’s jump into some of these questions about the workforce. To kick it off, what are some of the main challenges with the workforce in ABA, and how do you think about combating those challenges?
Cairnes: In terms of challenges, there are a lot. First of all, you have this inherent complexity of this one-to-one ratio of one RBT to one learner or child, which puts a lot of pressure on the model from the outset, because on any given day, you have call-outs with kids that are sick, or you have call-outs from the staff. Every day, it’s a chessboard to try to make that relationship work.
It’s a hard job. A lot of behavioral technicians are getting hit, bit, scratched, and it’s not just the physical aspect of where they’re on their feet, but it’s also emotionally taxing. You have a generational workforce that tends to communicate their emotions, their cynicism via chat among themselves, creating a group acceptance. It’s easy to obsess on things that can simply just be born out of misunderstanding or miscommunication.
For many, this is their first real job because it’s a young workforce, or they’ve worked in another ABA company, and they don’t have a professional or pragmatic model to lean on. They just have, therefore, unrealistic and lofty ideals and expectations. Generation Z, which is non-conforming to previous generations, and in some ways, it’s really cool, but this is a generation that will easily quit. Things get really hard, or they don’t feel things are right, they’ll leave, and the average turnover data in the industry supports that.
The latest data I saw says that the average turnover for an ABA company on an annual basis is somewhere between 79% and 99%. What do you do about that? How do you combat those challenges? You do everything in your power to start building trust. It starts with establishing what your mission and your values are.
For us, it’s about the kids. You have to overcommunicate on every single thing that you’re doing, every new initiative, every change in process, and we go out of our way to explain why we’re doing the things that we’re doing. If someone doesn’t necessarily buy into what you’re doing, at least they will at least understand why we’re doing it and they can accept it. The big thing for us, and I need to perhaps provide a little context, we’re not perfect. We don’t have it all figured out. We struggle like everybody else, but we try our best. The one big thing is to head off any issues.
How do you do that? We have several ways we attempt to do that. The first way, it will sound really corny, we call them joy check-ins. This is where the clinical director meets with every single individual in that clinic every single month. It’s 15 minutes, and sometimes it takes longer, and checks in. They’ll just ask very simple questions. How are you doing? How can we help you? Is there anything going on that we can help you with? Do you have any suggestions? What that does is it flushes out any issues before they become bigger issues within the clinic. Then we can act on it.
We also do quarterly engagement surveys or customer satisfaction surveys. It’s eight simple questions. They can also put their commentary in and it gives us the heartbeat of the clinic. We scale it from one to five, and that way, we can score where everyone is at emotionally. If we see scores under four, then we know something’s going on with the clinic. Then we’re able to come in and be available and try to solve that problem. As I said, we’re not perfect. We’re working through all this. We’re still problem-solving. Our turnover last month was 3.02%. We feel like we’re on to something in terms of combating some of those challenges.
Lovett: Great. We have quite a few questions already. One of them is asking about the data of the turnover data and where it comes from. Are there any measurable benchmarks to demonstrate how a practice can perform in this regard?
Cairnes: In terms of the data, we collect the data through– You can collect it through the payroll system. We also use a system called ‘ABA Schedules.’ It basically counts the number of people that leave the company versus the total number of people that you have in the company. We also break it down. We look at the turnover that is less than 90 days and turnover that is greater than 90 days. We just think that’s very relevant, because if it’s less than 90 days, it speaks to either how we’re hiring people or the training aspect of it.
We also, for every single person that leaves, we do an exit interview. We try to understand with every single individual why that person is leaving. We collect that data as well and marry it with the quantitative data with that. That’s the measurement part of it. Then, after that, it’s what you do with the data, which is important.
Lovett: Now, I wanted to talk a little bit about leadership as well. Because the field is so new, many BCBAs have less experience in the field. The bulk have less than 10 years for sure, but I think actually it might even be less than 5 years. How do you think about training younger clinicians, newer clinicians, into leadership positions?
Cairnes: Laura, it’s a really great question, because I think it’s really important as we think about the future of ABA. I’m going to break it down into two parts. We have a group of clinicians who are studying for their masters to become BCBAs. We call it our Joyful Grad Program. These are students enrolled in their master’s ABA coursework. We provide mentorship, curriculum, hands-on experience, and we give them the hours needed, the 2,000 hours that they need, and even tuition assistance. We currently have 42 joyful grads, and then everyone has a specific BCBA mentor that they work with, and we assign them. Everyone follows the same architecture and the same curriculum.
I think the key in this one is giving them hands-on experience. You can get the academic experience through school, but it’s the hands-on experience where I think the learning really kicks in. Also, not just the clinical experience, but the leadership experience in terms of, we coach them in terms of how do you give feedback to our BTs, and practice that, and talk about that. That’s another huge aspect of all this.
Now, the second level, for the way we are structurally set up, the people that run or oversee and lead the clinics are our clinical directors. Our clinical directors are BCBAs. We provide really in-depth training for these clinical directors. Everything from how to read a P&L to how to have difficult conversations. I remember the first training we did, and we just got going, and then the first hand went up, and the first question, which was a great question, is what’s a P&L?
I’ve said this to our clinical directors, none of them are really ready for the role, because this is a really hard leadership role. We have these BCBAs who have spent thousands of hours of training on behavioral analysis, and they’re really smart, and this is where they put their energy. They have not taken business classes, they’ve not read leadership books, because this was not on their radar screen. We feel it’s really important to invest in them in doing this.
Then, as they get into the role, then from there, it’s really important that we stay close to them, we put our arm around them, and as they’re dealing with situations, they know that they have great support in working through anything that comes their way. The people that we look for in clinical directors, and I think it may be a little bit different than how some ABA companies think about it, some ABA companies take their most experienced BCBAs, or in some companies, they put business administrators in these roles.
We look for people who have the greatest leadership acumen, the people who we know can grow into the role and have the attributes to do that role really well. Then, from there, we can train the rest. That’s how we approach that.
Lovett: We have a follow-up question from the audience. The question is: the check-ins and surveys sound great. BCBA mentoring, and specifically BCBA’s mentoring of new RBTs, also seems like such an important aspect of onboarding and retention. Have you implemented a process or system that is monitoring mentoring to ensure it’s happening in a meaningful way?
Cairnes: We have an RBT training program. For many of the people we hire, they start off as BTs. They’re not necessarily experienced RBTs. What we have done is we have crafted our training program such that BT or RBT starts in the home clinic, day one. In fact, I meet with every single person personally and give them a little history of JoyBridge Kids, our values, our mission, et cetera. They go through all the HR onboarding, and then they go to their clinic where they’re going to be working. The way I would describe it briefly is we have them do their modules in the morning. All of this is choreographed, whereby we have RBT trainers in the clinic.
We have trained trainers, RBT trainers within the clinic, which gives the RBTs another step up, by the way. We have RBT trainers who will then work with that BT alongside with the children, but they are reinforcing the material and the principles they learned that morning. Because otherwise, if they just sit there, sit down and do 40 hours of modules, they’re going to forget the first 30 hours of modules. We walk them all through that. Then we take them through competency, and then they are assigned to their respective pod, which is where now the BCBA takes over.
There’s still overlap with the RBT trainers, and then the BCBA then picks it up from there to continue that training, because training doesn’t stop after they get their certification and continues to work with them. We handhold them all the way through. Then it’s important to note that training continues on after they become a certified RBT. I’ve had RBTs tell me that they’re not even comfortable in the role until six months or a year after they’re in the role. We need to recognize that for our RBTs. I think it’s also important to think about the children that you assign to the new RBTs as well, along with getting the right fit with the BCBA. All these things come into play.
Lovett: That’s really interesting. Also, to follow up on that, I noticed you mentioned career progression for RBTs. Could you talk to me a little bit about that? I know sometimes there’s a big question there, like where do RBTs go from that position?
Cairnes: We have several places our RBTs can go. I just talked about the RBT trainer role. If you’re interested in helping other RBTs grow within the role, and that is a perfect place for RBT trainers. We pay them a little bit more for that role as well. Within our clinics, we also have another position called lead RBTs. The lead RBTs, many of them are graduates, the joyful grads, but some are not. The lead RBTs are typically providing direct supervision for about 50% of their time.
The other 50%, they are helping out. They’re the first person to jump in if they’re dealing with a difficult situation with a child, or they also support our BCBAs to provide material for them. It gives relief to the BCBAs. They’re there for lunch coverage. If we’re short-staffed that day, they can then fill in those gaps. Back to that one-on-one relationship. You have an RBT trainer, you have lead RBTs.
Then, just to finish up the architecture of our clinic, we have a clinical director. We have a clinic manager. The clinic manager does the scheduling and all the administrative functions. Does the ordering and make sure that they execute the organization and the cleaning of the clinics, which we call scrubby buddies, and everything that needs to be done within the clinic that takes all that off of the clinicians. We have RBTs, if they are strong organizationally or administratively, they can also progress into the CM role.
That’s another good place. We’ve got really, really terrific clinic managers. It took us a while to figure this out, but we were just putting really great RBTs in that role. What we learned was that we needed to be putting RBTs in that role that had a bent for administrative work, organization, and that detail orientation.
Then, the last place that RBTs can go, we have what we call our clinic support, and that supports all the clinics. We have some of those folks who were RBTs as well. There are multiple places that an RBT can grow, to grow in their career. We’re very fortunate in our world where, as you’re growing clinics, you’re effectively growing more opportunities for people to grow. We’ve got RBTs who are in roles that were even beyond their aspirations, and loving life. I love that. That’s just a part of what I love and what I get to do.
Lovett: That’s really interesting. It seems like there are so many opportunities based on skill set and ability. Really interesting. How do you strategically look at building culture in a workplace? What are some of the actions that you’ve taken?
Cairnes: Oh, wow. Another great question, Laura. There are several principles we try to employ in building game-changing culture. I believe it starts with creating a cohesive senior leadership team. This is a leadership team. We’re not a big senior leadership team. There are effectively four of us. We are tied together emotionally and intellectually. Whether we want to believe it or not, we live in a fishbowl. People can see if there is that cohesiveness.
I think it’s fairly rare that you actually get that. We’re very fortunate that we have a team that really enjoys working together, has each other’s back, and we have that bond. I think also, as I mentioned earlier, you have to articulate a genuine mission that resonates. It’s about the kids. Otherwise, the assumption to the folks on the floor is that it’s about making money. It’s about greed. Therefore, they don’t really trust that you have their best interests at heart.
The other strategic principle we have is that we always try to create absolute clarity in direction in our operations disciplines. You have to have an operating model that works really, really well. Because when it’s messy, when things aren’t working right, that puts a lot of stress on the clinicians. They feel disheveled. That’s actually the type of thing that can create burnout.
We talk about massively overcommunicating. It sounds simple, but it’s a hard principle for people to gather until they’re there. It means repeating the same thing over and over again. I remember when we started talking about this, and they’ll say, “Mike, I communicated this. It’s in our handbook, page three, paragraph four, and it’s there.” You need to pick it up, and you need to communicate that in different ways over and over again. That’s hard in our world, but you have to find ways to do that. As I mentioned before, you seek proactive feedback, which we talked about, and how we do that. Really critical, because otherwise things can just get away from you.
Then we talked about this last principle, which is you’ve got to develop your leaders like crazy. It’s not just as they come into the role, but it’s constant. It’s a constant development. The smaller you are, the harder that is, but you’ve got to find room to make that happen.
Lovett: Something I think about in terms of the whole culture is sometimes the clinical teams are speaking one language, administrators are speaking another language. What do you think about bridging that gap so that everyone’s on the same page?
Cairnes: I get this question a lot. For us, we’ve been able to address it through, mainly through our structure, and I’ll explain. Our clinical directors, as I mentioned, are BCBAs. The reason we have our clinical directors as BCBAs is because I think they’re going to have more credibility with the clinicians on the floor. Many of the questions they’re going to get anyway are clinical-level questions. Then we have to train them up operationally. All the decisions that they’re making, all the operations decisions that they’re making, have clinical quality in mind, or inherently, because there’s a divergence of the two. That’s why it creates this us-versus-them culture sometimes.
The clinical directors report to a VP, their operations leader is a BCBA. She just happens to be a great operations leader in a BCBA body. We don’t have two different silos of operations or business administration and clinical, because in doing that, you are going to have a divergence of objectives, and people are going to question each other’s motives in doing that. That’s how we eliminate the us-versus-them, and that has worked really well for us. It just means we have to work harder to train the clinical directors accordingly, is what we have to do.
I get it. I’ve talked to other ABA companies, and they have their business folks or administrators running the clinics. You’ve got to do everything you can to bridge, make sure that everything that they do is in the best interest of the clinicians.
Lovett: How do you think about bridging those two worlds as a culture, too, so that they’re working cohesively together and there isn’t a tension there? It sounds like a lot of the leadership has experience in the field. How does that play into working on that culture, too?
Cairnes: I think if you do have a structure where you have business administration in the clinics or oversight of the clinics, I think it’s important that those folks have to be in the clinic and they have to listen to the clinicians. If it were me, every decision I’d make, I would ensure that I bring the clinicians into my decision-making process and bring them with me to help communicate all those decisions.
Lovett: I would actually love to dive into that. What do you think about bringing clinicians into the fold? What conversations are they a part of? What level? Which clinicians? What does that look like?
Cairnes: With us, literally 100% of all of our decisions that impact the clinic, new initiatives, process improvements, new ideas, all of them go through the clinics. When we were beginning, when we were just starting and we were opening our second and then our third location, we had to start building our clinic support team, and we can talk about corporate and clinic support. When we were starting that, I made sure that we planted ourselves right alongside the clinics. We made sure that every single decision we made, we would collaborate with the clinicians. The deal I made with them was, don’t let us make stupid decisions. They would, of course, give it to us straight.
Now that we’re 14 clinics, now that you understand that we have the clinical directors who oversee those clinics, we have a monthly call with those clinical directors. We have a monthly call. In that monthly call, any new idea, any decision, new initiative, whatever it is, it goes in front of the clinical directors first. It comes to them in the form of a draft. We say, “This is what we are intending to do,” or “This is what we think we want to do.” We would then love your feedback, which we get a lot of. We’ll get a lot of feedback from the clinical directors right on the spot.
It could be a question. It could be, “I’m going to get these questions from the RBTs. How do I respond? Have you thought about this?” We get all of that. Then we go back and recraft whatever that is until we have it all settled in. Therefore, the clinical directors don’t feel like there’s an us versus them, or there’s a company making decisions that they have to marshal through. It’s their company. It literally is their company. It took a minute to get this process down because good operators, they want to move fast. They want to go.
This slows things down. In doing so, it makes sure that we make really good decisions. It makes sure everything is thoughtful, makes sure we have everything thought through. That’s now how we roll. That’s how we bring our clinicians into the decision-making. We don’t bat 1,000 in every decision. Sometimes when we do get it right and if we do get it wrong, we’re very quick to roll it back and fix it and move forward,
Lovett: It makes a lot of sense. One of the things I know we’ve talked about before is this whole idea of ownership structure, and does that impact the workforce? Does that impact culture? There’s a lot of private equity owned, ABA organizations, also a lot of clinician owned. Does this impact the workforce? Does it have to impact the workforce? How do you think about that?
Cairnes: I did a talk, I said, “Private equity has nothing to do with bad culture” and got all kinds of messages. I really think culture is really going to be impacted by leadership. It’s really important, and I’m very blessed, and I may be unique, but I’m very blessed. I’ve got a great board of directors and a private equity company behind me. First and foremost, we really get aligned on everything. We get really aligned on what we’re trying to achieve, what’s our mission. We have said, day one, what I stated was that our, and this was our very first strategy, was that we would offer the highest quality care first and foremost to the clinicians. That’s the prism in how we think. Our mission is the kids.
The decision-making comes down to what’s in the best interest of the clinicians, what’s in the best interest of the kids. Of course, we have to have an efficient operating model and one that financially works. If we do it right, our philosophy is all the other goodness is going to come out. I talk about this with our team, that yes, we do want to make a profit. We talk about this with the team, that we do want to make a profit. You want us to make a profit so that we can pay your paycheck, and we can continue to grow and help more kids.
That’s why we need to do it, but that’s not our mission. Our mission is the kids. I liken it to oxygen is to a human being, that we need oxygen to live, but that’s not the reason why we live. We got great alignment with the private equity team in what we’re doing and how we lead the team. In addition to that, in some of the boards, in our board meetings, I always start off our board meeting with, I call it a mission moment. By the way, with our private equity group, they have a BCBA on the board too, by the way, which is really cool. She’s terrific. She’s been there and done that.
We start with a mission moment, and many times I’ll invite some of our clinicians from the clinics to come in and speak, or clinical directors, or clinic support folks. I think it helps bridge what we’re trying to do. Then they buy in. I always rotate the board meetings. The mistake that can happen with folks in my spot is, they have these board meetings and they’re going to a conference room and they’re talking about goals and objectives and numbers.
We do our board meetings in the clinics. They can see the clinics. They can see hands-on the impact that they’re having. I have them talk to parents and BCBAs, and clinical directors, and now they’re connected to what we’re trying to do as well. Part of the value for our private equity firm is what we’re doing for these kids as well as trying to drive value in the company as well.
Lovett: That’s really interesting and great perspectives. I think a lot of folks on here probably do have private equity backers. Some are obviously clinician-owned, too. Great perspective to hear. One thing I did want to go back to is, obviously, you do these check-ins, and what happens if the check-in there are some red flags, maybe this person is really burnt out. How do you remedy that? How do you think about that?
Cairnes: It’s a great question. It depends on what it is. Our clinical directors are really good. If it’s something that they can address, within their clinic or within their sphere, they will definitely do that. If it’s a bigger issue, we really encourage them to just talk to our HR person, who they have great trust in, which is great, and brainstorm and talk about it. Because it could be an individual issue that something’s happening with them personally, which may be a reason why they’re off, or it could be a reason why they’re late. At least if we know what’s going on with them, then we can help solve, work with them on their specific issue.
If it’s a broader issue about how people feel or miscommunication or something that’s going on in the clinic, then generally they’ll brainstorm with our HR folks and say, “This is going on, what do you think?” Sometimes it requires us coming back in there and interviewing more people and getting more information, and then we’ll almost always come up with a plan, something. My feeling is, whatever that thing is, some of it may be perceived, some of it may be real, we act on it quickly, like really quickly, because that’s key. Otherwise, this thing can balloon out.
Sometimes the issue is with the clinical director herself. It could be things that she has said or perceptions that they have drawn, or they just don’t feel like she has– She’s got a really tough and busy job, and they just don’t feel like they’ve had enough of her attention or whatever that may be. Then, let’s talk about how we rearrange your priorities to make sure that they’re feeling you.
Lovett: That makes a lot of sense. As we’re coming to the end of the session, one question I wanted to ask you is, if you were a new CEO coming into an ABA organization, what is one piece of advice that you would give on workforce and culture?
Cairnes: We absolutely refuse to use the vernacular, corporate. We’re not corporate. We’re clinic support and we hire people who have a passion to support the clinics. Making sure that the team around you is highly focused on the clinics. Even our financial person really has a great relationship with all the clinics and gets into clinics. Therefore, so does his team.
I think that’s number one. I think just make sure that you take care of the clinicians first. It sounds simple, but if you architect everything around what is important to them, including work-life balance, if you can architect all of the requirements and processes around that, I think we have the best chance of success for these kids. That’s what I would say.
Lovett: Great advice. Thank you so much for coming on, and thank you to all of our members for coming on and asking such great questions. The recording will be circulated to our members, and we also have a transcript for folks who prefer to read the transcript. Thank you so much. This was wonderful. I feel like I learned a lot today.
Cairnes: Thank You.
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