Transforming Procedural Care Services with AHA Delegation​

Aim

To evaluate the relative effectiveness of the AHA delegation model in reducing child anxiety (primary outcome) and child distress (secondary outcome).

Outcomes

• Journey from Initial session to Feedback session was improved by 74 days.
• Journey from  Initial session to Goal Setting was improved by 70 days.
• Initial session to Outcome improved by 65 days.
• Overall impact on CDS South-wide long waits was reduced by 284, of which Toddler Track accounted for 193 (68%)

Background

The prevalence of neurodevelopmental (ND) disorders among children continues to increase and there is a growing need for early identification and assessment that can best inform intervention and promote future outcomes. Most children require comprehensive multidisciplinary developmental assessments due to the severity, complexity and/or diagnostic  uncertainty (Bentley et al., 2024). More than 85% of children diagnosed with Autism have mention of developmental concerns before 36 months of age when accessing medical supports. Unfortunately, far less than half receive an evaluation by that time. This  contributes to an average age of diagnosis above 4yrs of age (Hine et al., 2020).

Further, children from disadvantaged backgrounds including socioeconomic and diverse ethnicities are disproportionately affected (Hine et al., 2020). There is a significant need  for review of current developmental assessment procedures, along with identification of novel systems in triaging and caring for neurodiverse (ND) children and their families at the right time (Hine et al., 2020). The journey to assessment and diagnosis from  parent perspectives is well understood--parents report it takes an average of 3-5 professionals, with significant time commitments that result in stress and frustration. Families also report barriers to diagnosis such as false reassurance or dismissal from  health care providers, lack of expertise by those they consult with, and their own lack of developmental knowledge and awareness that can also be influenced by cultural differences.

Families spend a lot of time waiting to reach experts, experience misdiagnosis  and need for further assessment resulting in more wait times (Makino et al., 2021). Expensive private assessments were sometimes more favourable as they had shorter wait times but can result in disproportionate access to care. Interestingly, no significant  differences in parental satisfaction, perceptions of family centred care, or shared decision-making were reported between a Paediatrician-led model and an allied health clinician-led model. There were also no significant differences in delivering care via  in-person clinic appointments only versus mixed mode delivery with telehealth supports (Makino et al., 2021). Complex developmental and behavioural concerns must be understood at several diagnostic levels including behavioural, neuropsychological, biological  and environmental and is understandably demanding of clinicians time (O’Keeffe & Macaulay, 2012). This, however, means that health services face challenges in balancing significant demand as well as provision of timely care that meets best practice standards.

Due to the significant demand for developmental assessment, lengthy waitlists are a serious and ongoing battle for healthcare providers. MDT child diagnostic services are the best practice for evaluating children with complex ND disorders however major barriers  exist to accessing publicly funded paediatric developmental clinics in a timely manner. The literature addressing this is limited. Therefore, new and more streamlined approaches that maintain quality and best practice standards are required.

Discussion

Improvement in Journey Time A primary outcome of the study was the reduction in journey times for toddlers accessing developmental services and the reduction in long waits that supported family access and service needs. Such time reductions align with previous research emphasizing the importance of early intervention, which can significantly  improve developmental outcomes for children (Hine et al., 2020; Bentley et al., 2024).

Impact on Service-Wide Waitlists

The pilot also showed a positive impact on service-wide waitlists. This demonstrates that the modified model not only benefited individual  families but also helped reduce the overall strain on the system. Long wait times for developmental assessments remain a persistent issue in healthcare systems globally, and this model offers a potential solution to managing these challenges more efficiently  (Makino et al., 2021).

Strengths of the Model

One of the key strengths of the modified model is its ability to integrate best practice standards while streamlining processes. The model’s use of a multidisciplinary approach—bringing together paediatricians  and allied health professionals through a mixed mode approach that included telehealth services—improved efficiency and reduced the number of appointments required. Families from culturally and linguistically diverse backgrounds were accommodated to ensure  equity. The use of Single Session Thinking also helped focus on achieving clear goals during each appointment, reducing the need for multiple visits.

Limitations

The primary limitation of this project is the lack of formalized parent feedback, which was largely  anecdotal. To gain a more comprehensive understanding of the model's impact, future evaluations should incorporate more structured surveys and feedback mechanisms from families. Another limitation is the logistical challenge of coordinating multidisciplinary  teams. Effective communication and scheduling across different professionals can be complex, and there were instances where delays occurred due to this coordination.

Next Steps and Suggestions for Improvement

Given the positive outcomes, the next steps should  focus on several key areas:

1. Parent Feedback and Satisfaction: More comprehensive feedback from families should be gathered to assess the model's effectiveness in meeting their needs.
2. Expand Data Collection: A broader data set is needed to assess the  model’s effectiveness in different demographics, such as children from diverse socioeconomic backgrounds. This will ensure the model is equitable and applicable to all families in need.
3. Scalability and Sustainability: To evaluate the potential for scaling  the model across other regions in Queensland, further research should investigate whether the improvements in wait times lead to better long-term developmental outcomes for children.
4. Formalizing Multidisciplinary Coordination: Improving the efficiency of  team coordination through digital tools or better scheduling systems could reduce delays and improve the workflow of this model.
5. Incorporating Telehealth: Telehealth options, particularly for initial consultations, should be further evaluated for its effectiveness

References

1. Average wait time for autism assessments in children is over 3 years. (n.d.). The  University of Sydney. Retrieved 12 January 2025, from https://www.sydney.edu.au/brain-mind/news-and-events/news/2023/02/06/average-wait-time-for-autism-assessments-in-children-is-over-3-y.html

2. Bentley, S. E., Garg, P., Gudes, O., Hurwitz, R., Vivekanandarajah,  S., & So, L. Y. L. (2024). Access to child developmental assessment services in culturally and linguistically diverse metropolitan Sydney: A retrospective cohort analysis. BMC Health Services Research, 24(1), 342. https://doi.org/10.1186/s12913-024-10800-y

3. Child Development In Queensland Hospital & Health Services 2 Act Now for kids 2morrow: 2021 to 2030. (2021). Queensland Health.

4. Hine, J. F., Allin, J., Allman, A., Black, M., Browning, B., Ramsey, B., Swanson, A., Warren, Z. E., Zawoyski, A., & Allen,  W. (2020). Increasing Access to Autism Spectrum Disorder Diagnostic Consultation in Rural and Underserved Communities: Streamlined Evaluation Within Primary Care. Journal of Developmental & Behavioral Pediatrics, 41(1), 16–22. https://doi.org/10.1097/DBP.0000000000000727

5. Makino, A., Hartman, L., King, G., Wong, P. Y., & Penner, M. (2021). Parent Experiences of Autism Spectrum Disorder Diagnosis: A Scoping Review. Review Journal of Autism and Developmental Disorders, 8(3), 267–284. https://doi.org/10.1007/s40489-021-00237-y

6. Model for Improvement & PDSA cycles—Clinical Excellence Commission. (n.d.). Retrieved 12 January 2025, from https://www.cec.health.nsw.gov.au/CEC-Academy/quality-improvement-tools/model-for-improvement-and-pdsa-cycles

7. O’Keeffe, M., & Macaulay, C. (2012).  Diagnosis in developmental–behavioural paediatrics: The art of diagnostic formulation. Journal of Paediatrics and Child Health, 48(2). https://doi.org/10.1111/j.1440-1754.2011.02071.x 8. Single Session Thinking. (n.d.). Retrieved 12 January 2025, from https://www.latrobe.edu.au/research/centres/health/bouverie/practitioners/specialist-areas/single-session-thinking