Context of implementation

The implementation of the integrated care model was conducted according to the detailed plan developed during the preparation phase. The process began with the deployment at a rural location. The site established a dedicated implementation team composed of case managers, healthcare providers, school representatives, and community leaders. Core elements of the solution, including personalized care plans, case management coordination, and digital tracking tools, were rolled out in a phased manner.

Implementation goals

Implementation process goals:

• - Establish care teams and hire ten case managers for three pilot sites.
• - Deliver training sessions on neurodiversity-affirming care, case management protocols, and the use of digital tools.
• - Develop and deploy the digital care coordination platform for tracking goals and progress.
• - Collaborate with schools and healthcare providers to align service protocols and roles.
• - Begin enrolling neurodivergent children and implementing personalized care plans in the urban, suburban, and rural pilot sites.
• - Facilitate weekly care team meetings to evaluate individual cases and improve coordination.
• - Conduct quarterly stakeholder review meetings to discuss progress and address challenges in implementation.

Metrics / indicators used for evaluating the implementation

Metrics:

• - Number of care teams established and case managers hired.
• - Percentage of staff completing training sessions and achieving competency in neurodiversity-affirming care.
• - Functionality and utilization of the digital care coordination platform as measured by system usage logs.
• - Number of partnerships formalized with schools and healthcare providers.
• - Enrollment numbers of neurodivergent children within the first six months.
• - Attendance and productivity of weekly care team meetings (e.g., cases reviewed and actions implemented).
• - Attendance rates and actionable feedback collected during quarterly stakeholder review meetings.

Methods used for evaluating the implementation

The implementation process was monitored and evaluated using a combination of quantitative and qualitative methods aligned with each goal and metric. Data collection and analysis were integrated into the ongoing activities to assess progress and inform adjustments in real time.

• Staff Training Evaluation: Staff participation in training was tracked through attendance logs, while knowledge and competency in neurodiversity-affirming care were evaluated using pre- and post-training assessments. Completion rates and assessment scores provided measurable indicators of training effectiveness.
• Digital Platform Evaluation: The digital care coordination platform’s implementation was evaluated through system usage analytics, including login frequency, time spent on the platform, and completion of care tracking activities. User feedback was collected during care team meetings to assess usability and functionality.
• Care Team Functioning: Weekly care team meetings were evaluated based on attendance records and documentation of case reviews. Meeting minutes and action logs were reviewed to assess the number of cases discussed and the timeliness of follow-up actions.
• Partnerships and Collaboration: Formal agreements and collaborative activities with schools and healthcare providers were tracked through documentation review and coordination logs. Interviews and check-ins with partner representatives assessed alignment of service protocols and role clarity.
• Child Enrollment and Service Delivery: Enrollment progress was tracked quantitatively, and implementation of care plans was monitored through case management records and digital platform entries.
• Stakeholder Engagement: Quarterly stakeholder review meetings incorporated structured surveys and facilitated focus group discussions to gather feedback on the implementation process. Thematic analysis of feedback identified challenges, areas for improvement, and stakeholder satisfaction with coordination efforts.

These evaluation methods ensured continuous monitoring of implementation fidelity, timely identification of challenges, and data-driven improvements throughout the process.

Implementation evaluation results

During the implementation phase, ten care teams were successfully established, and all designated case manager positions were filled across the three pilot sites. Refresher training sessions for staff achieved a 100% completion rate, with post-training assessments confirming that over 90% of participants demonstrated a high competency in neurodiversity-affirming care practices. 

The digital care coordination platform was deployed on schedule, with system usage logs showing that 85% of care team members regularly used the platform to track goals and document progress. Partnerships were formalized with twelve schools and 6 healthcare organizations, ensuring seamless coordination of services. 

Within six months, 60 neurodivergent children were enrolled, surpassing the initial target of 50, and personalized care plans were implemented for all enrollees. Weekly care team meetings maintained consistent attendance, averaging 12 cases reviewed per meeting, and facilitated timely action on identified needs.

Stakeholder review meetings had a 95% attendance rate and collected detailed feedback, leading to process improvements such as streamlined communication between care teams and schools. These results demonstrated strong progress in achieving the implementation goals, while also identifying areas for further refinement to enhance the model’s efficiency and effectiveness.

Outcome goals

Outcome Goals:

• - Increase timely access to diagnostic and intervention services for neurodivergent children by 30% within the first year.
• - Improve therapy adherence rates to 80% among enrolled children by the end of the second year.
• - Enhance school inclusion rates for neurodivergent children by 20% within two years.
• - Achieve a 90% caregiver satisfaction rate with case management services and coordinated care within the first year.

Metrics / indicators used for evaluating the outcomes

Metrics:

• - Timely Access to Services: Measured through tracking the average time from referral to diagnosis and intervention for enrolled children.
• - Therapy Adherence: Monitored through attendance logs for therapy sessions and follow-up reports from healthcare providers.
• - School Inclusion Rates: Evaluated through school attendance records, Individualized Education Plans (IEPs), and feedback from educators.
• - Caregiver Satisfaction: Assessed through structured surveys and focus groups with families, capturing their experiences with the integrated care model.

Methods used for evaluating the outcomes

Evaluating the achievement of outcome goals involved several methods. To measure timely access to diagnostic and intervention services, the average time from referral to diagnosis and intervention for enrolled children was tracked. Therapy adherence rates were monitored through attendance logs for therapy sessions and follow-up reports from healthcare providers. School inclusion rates were evaluated using school attendance records, Individualized Education Plans (IEPs), and feedback from educators. 

Caregiver satisfaction was assessed through structured surveys and focus groups with families, capturing their experiences with the integrated care model. 

Outcome evaluation results

By the end of the first year, there was a 35% improvement in timely access to diagnostic and intervention services, surpassing the initial goal of 30%. This was attributed to the streamlined processes introduced by case managers and better collaboration between healthcare providers and schools. 

Therapy adherence rates reached 78% by the second year, just shy of the target of 80%, but consistent progress was observed as families became more engaged and motivated to attend sessions. 

School inclusion rates for neurodivergent children improved by 22%, exceeding the two-year goal, as schools implemented more inclusive practices and partnered closely with care teams. 

Caregiver satisfaction surveys revealed that 92% of families reported positive experiences with the program, citing the case management framework as a significant factor in reducing stress and improving access to services. These results highlight the program's early successes while providing valuable insights for areas of ongoing enhancement.