Integrated Care Model with Case Management for Neurodivergent Children

Purpose of the solution

The purpose of the solution is to provide an interconnected support system for neurodivergent children by integrating educational, healthcare, and social services. This integration prevents care fragmentation, promotes smooth transitions across life stages, and empowers families with streamlined access to services through case management. The model emphasizes collaboration among stakeholders to ensure sustainability and inclusive practices. 

Solution as a practice

The implementation of the Integrated Care Model with Case Management for Neurodivergent Children is grounded in a systemic approach that views success as emerging from the coordinated interaction between all actors—both human and non-human—involved in the care ecosystem. The underlying theory of change assumes that meaningful, sustainable improvement occurs when these actors align around shared objectives, practices, and tools.

The process begins with a comprehensive needs assessment, where neurodivergent children, their families, educators, healthcare providers, and social workers collaboratively identify goals rooted in the lived experiences of the children themselves. Standardized diagnostic tools, communication platforms, and assessment protocols are used to support this process, enabling consistent identification of needs and progress tracking. This phase fosters mutual understanding and aligns participants toward reducing care fragmentation and delivering inclusive, equitable support.

Following this, case management becomes the linchpin of the model. Case managers serve as the primary coordinators, connecting families with relevant services across educational, healthcare, and social domains. Their efforts are supported by interoperable digital platforms that enable real-time data sharing and communication between sectors. These technologies not only streamline service delivery but also help avoid duplication and gaps in care. The case manager thus functions as a critical connector within the network, guiding families through complex systems with clarity and consistency.

The capacity-building phase focuses on equipping professionals—educators, healthcare providers, and social workers—with the knowledge and tools needed to adopt neurodiversity-informed practices. This includes training on inclusive pedagogy, the use of assistive technologies, and the creation of sensory-friendly environments. These learning opportunities are designed to strengthen human-to-human connections across sectors while embedding systemic support for neurodiversity into daily practices. Success in this phase depends on the meaningful integration of new knowledge and tools into institutional routines.

Cross-sector collaboration is further enabled by shared digital infrastructure and clearly defined protocols, which bring coherence, accountability, and transparency to interdisciplinary work. These systems support information flow and informed decision-making, allowing professionals to respond swiftly and effectively 

to evolving needs.

Integral to the model is a robust feedback loop that supports continuous learning and adaptation. Families and professionals contribute qualitative insights through regular reviews and engagement forums, while data dashboards and performance reports provide quantitative feedback. Together, these mechanisms enable the network to adjust in real time, reinforcing its responsiveness and effectiveness.

This approach to practice is built on the belief that sustainable change results from a resilient, well-aligned network of actors. When professionals, families, and digital tools operate in harmony, the system not only meets immediate needs—such as developing individualized support plans and reducing fragmentation—but also builds toward long-term transformation. The ultimate goal is the creation of lifelong, seamless support pathways that adapt to each child’s changing circumstances.

Success, therefore, depends not only on the efforts of individual people but also on the strength of their relationships, the consistency of their practices, and the interoperability of their tools. The integrated care model thrives when this ecosystem is continuously reinforced and adapted, allowing it to respond to diverse settings and evolving challenges with flexibility and inclusivity.

Organisational requirements of the solution

Effective implementation depends on strong organizational support, including funding to establish case manager roles and technical infrastructure for shared digital platforms. Additionally, inter-organizational collaboration protocols need to be clearly defined to facilitate integrated workflows. Investing in professional development and partnerships between schools and healthcare providers further supports system-wide efficacy. 

Requirements for the broader context of the solution

Broader societal support is essential for the success of this model. Advocacy and public awareness campaigns are required to build acceptance for neurodiversity and foster community buy-in. Policymakers need to enforce regulations for data-sharing and integrated care while providing financial backing for sustainable implementation. Cultural, social, and linguistic considerations must also be addressed to ensure inclusivity across diverse demographics and regions. 

This comprehensive framework lays the foundation for building a supportive, inclusive ecosystem that adapts to the unique needs of neurodivergent individuals, empowering them and their families while fostering systemic reform.