Towards Co-Design in Delivering Assistive Technology Interventions: Reconsidering Roles for Consumers, Allied Health Practitioners, and the Support Workforce

A complexity of factors, from health and technology innovations to policy redesign to achieve consumer-directed care, are impacting traditional roles for Australian allied health practitioners (AHPs). This pilot study considers roles for AHPs in relation to assistive technology (AT) interventions. Articulating ‘who does what’ may serve a number of purposes including de-professionalization of the discourse; better utilization of support networks and workforces; and alignment with contemporary policy. Yet, a suitable framework to assist with collaborative AT implementation between relevant stakeholders was not identified within the existing literature. This research aimed to develop and pilot an AT collaboration tool which enables AHPs, consumers, their support networks and the support workforce, to navigate policy redesign toward ethical consumer-directed implementation of AT interventions. An AT collaboration tool was developed based upon practice-based knowledge, relevant regulatory and practice evidence and identifies relevant stakeholders, AT service steps and roles, and quality indicators to support competent practice. The tool was piloted in four separate and diverse practice analyses of AT interventions (custom prosthetics, home enteral nutrition, communication devices, and vehicle modifications) considering four allied health professions (prosthetics and orthotics, dietetics, speech pathology, occupational therapy). Pilot testing of the tool supports the feasibility of re-framing AT provision using competency-based and risk-informed approaches and enabling more inclusive roles for consumers and the support workforce. Further testing of the tool is indicated, followed by strategic actions for uptake by individuals, professions and policymakers. The AT collaboration tool has potential to enable AHPs to fulfil ethical obligations for consumer-centered practice, and to facilitate consumer choice, both in Australia and internationally.


Supercomplex Environments and Allied Health Professions
Allied health practitioners (AHP) operate within 'supercomplex' health and social care systems [1,2]. Some of the overarching factors at play include the paradigm shifts from deficit-based models to a bio-psycho-social approach [3,4]; developments in rehabilitation to focus on functioning, participation and enablement [5,6]; and the development of personalized or 'n of 1' medicine [7]. The evidence base of allied health professions is also dynamic and the evolution of individual professions over time can be seen in profession-specific journals and through the competency standards of various professional associations. Allied health practice has long adhered to evidence-based practice principles [8] and is also shaped Int. J. Environ. Res. Public Health 2022, 19, 14408 2 of 18 by imperatives to work with service users [9] and to integrate experience-based co-design into services [10,11].
Policy redesign towards consumer-directed care and individualized funding also impact allied health practice. Many countries are reconstructing disability and aged care policy to person-centered care, which places consumers and their individual goals in the center of service systems [12], including Australia [13,14]. This represents a substantial change to the previous service contexts in which AHPs worked. Person-centered care is consistent with integrated care principles [15] and promises to strengthen the consumer voice during health interventions [16,17]. An absence of choice and control for consumers and their families under the previous systems is acknowledged [18] and a realignment of 'power' is occurring in the form of individualized plans and budgets alongside consumer discretion over the services and therapies (including AT) upon which these budgets can be spent [19]. In essence, consumers must select their own allied health practitioner and nominate their therapy of choice within some broad commitments to evidence-based approaches [20].

Assistive Technology-A Key Intervention for Many Allied Health Professions
AT is an umbrella term for assistive products and related services. Assistive products refer to specifically made or mainstream devices or software which can maintain or improve people's ability to function and live independently.
Allied health professions in Australia includes multiple professions. AT is an intervention used by a subset of professions including occupational therapy, speech and language pathology, podiatry, dietetics, physiotherapy and prosthetics and orthotics. Professions outside allied health, such as nursing and rehabilitation engineers, may also have some aspects of AT within their scope of practice.
Australian and international standards classify over 650 types of assistive product categories with many thousands of individual products. There are twelve broad classes of assistive products related to AHPs for whom they are within scope. These can be seen in Appendix A [21]. There are one or more AHP roles listed for each product class. Roles were matched based upon prescribing conventions in Australia, that is, the AHPs nominated as prescribers in equipment funding schemes as well as the authors' experiences.
Assistive products are only effective if they are tailored to the user, user goals, and the environments of use. Forty years of AT research demonstrates this tailoring requires AT services or 'wraparound services' including screening and assessment, product selection, product fitting and adjustment, user training, and follow up for review and maintenance and are summarized in the World Health Organization Position Paper on AT provision [22]. These elements have often been provided by AHPs, as described in Appendix A, or through the skilling of alternative workforces such as community-based rehabilitation workers in low-and middle-income countries [23][24][25].

The Australian Context
Over the last decade, Australian national disability and aged care acts and policies have been rewritten to reflect the philosophies of consumer directed care alongside market economics: referred to hereafter as the National Disability Insurance Scheme (NDIS) and My Aged Care (MAC) [26,27]. The repositioning of the service recipient as a consumer of services has many consequences. This repositioning may place significant demands upon consumers to manage this marketized approach to purchasing the services necessary for AT interventions [28]. Consumers are expected to have clear ideas of their goals and understanding of how and what AT may contribute to achieving them; to make choices about which practitioner they wish to assist them in provision of AT; and whether they require a practitioner at all to mediate their AT choices [29,30]. Much AT provision, previously managed by an AHP, can now be initiated by consumers themselves, with minimal sign off from funder delegates such as package brokers (My Aged Care) or planning or local area co-ordination staff (NDIS).
If consumers are to be afforded the opportunity for self-directed care whilst continuing to access the wraparound services required for successful AT implementation, all stakeholders need to understand who is performing which tasks ('who does what'). Guidance tools would need to align with contemporary policy and practitioner and ethical obligations, and to be inclusive of consumers, their support networks, alternative workforces and AHPs. Such guidance or frameworks were not identified within the existing peer reviewed or practice support (grey) literature.
This research aimed to develop and pilot an AT collaboration tool which enables AHPs, consumers, their support networks and alternative workforces, to navigate policy redesign toward ethical consumer-directed implementation of AT interventions.

Method
An iterative development and case study test, review and revise approach was used to (a) develop and (b) pilot an AT collaboration tool. Figure 1 lists these steps which are described below.
choices about which practitioner they wish to assist them in provision of AT; and whether they require a practitioner at all to mediate their AT choices [29,30]. Much AT provision, previously managed by an AHP, can now be initiated by consumers themselves, with minimal sign off from funder delegates such as package brokers (My Aged Care) or planning or local area co-ordination staff (NDIS).
If consumers are to be afforded the opportunity for self-directed care whilst continuing to access the wraparound services required for successful AT implementation, all stakeholders need to understand who is performing which tasks ('who does what'). Guidance tools would need to align with contemporary policy and practitioner and ethical obligations, and to be inclusive of consumers, their support networks, alternative workforces and AHPs. Such guidance or frameworks were not identified within the existing peer reviewed or practice support (grey) literature.
This research aimed to develop and pilot an AT collaboration tool which enables AHPs, consumers, their support networks and alternative workforces, to navigate policy redesign toward ethical consumer-directed implementation of AT interventions.

Method
An iterative development and case study test, review and revise approach was used to (a) develop and (b) pilot an AT collaboration tool. Figure 1 lists these steps which are described below.

Step 1: Recruit Expert Panel
An intersectional lens was used to identify practitioner participants for the development and piloting of the AT collaboration tool. Involvement was sought across the key professions listed in Appendix A. Key characteristics to consider capability included: substantive practice knowledge; experience in at least one of policy design and implementation; and/or use of AT as a consumer. A minimum of four disciplines were to be represented.
Participants were invited to join the panel to develop and pilot the tool through dialogue with allied health practitioner associations and communities of practice such as ARATA (Available online: www.arata.org.au (accessed on 1 March 2021)). Due to the exploratory and iterative nature of the study, only one expert from each discipline was recruited.

Step 1: Recruit Expert Panel
An intersectional lens was used to identify practitioner participants for the development and piloting of the AT collaboration tool. Involvement was sought across the key professions listed in Appendix A. Key characteristics to consider capability included: substantive practice knowledge; experience in at least one of policy design and implementation; and/or use of AT as a consumer. A minimum of four disciplines were to be represented.
Participants were invited to join the panel to develop and pilot the tool through dialogue with allied health practitioner associations and communities of practice such as ARATA (Available online: www.arata.org.au (accessed on 1 March 2021)). Due to the exploratory and iterative nature of the study, only one expert from each discipline was recruited.

Step 2: Identify Key Constructs
Existing Frameworks Relevant to Co-Design of AT Interventions The literature was identified based on the collective expertise and knowledge of the field of our team members, and through literature search using Google Scholar to locate current applicable black and grey sources, prioritizing reviews and authoritative guidelines where this level of evidence was available. Three key constructs were identified from the data sources as vital to the AT collaboration tool: AT stakeholder roles, AT service delivery steps and competence.
A consensus on constructs to be included within the AT collaboration tool was determined based on (i) each health practitioners understanding of best practice principles in person-focused AT service delivery [22], (ii) utilization of relevant existing tools and data sources identified during the literature review and (iii) participants expertise and lived experience knowledge.

Step 3: Develop AT Collaboration Tool
Data fields were then populated within key constructs using the seven AT service delivery steps (Initiate, Evaluate, Trial, Select, Procure, Implement, Review) based on each participants years of experience working in their field of work. These key constructs were discussed amongst participants to ensure consensus.

Step 4: Pilot AT Collaboration Tool
Each AHP was asked to independently test the AT collaboration tool developed to a common practice scenario within their discipline.

Step 5: Review and Revise AT Collaboration Tool
Once populated, each panel participant was to review all of the developed examples independently, then review and revise the tool collaboratively. Review and revision of the AT collaboration tool to be repeated until consensus of key constructs and data fields achieved.

Results
Four AHP participants volunteered to be involved in the tool development, piloting and subsequently authorship of this paper. Table 1 demonstrates the array of multidisciplinary perspectives across job roles, clinical streams and practice settings as well as experience as AT service users (consumers). Participants gained this experience across Australian states and territories and international workplaces and collaborations. The panel conducted 6 months of regular virtual meetings across 3 states (VIC, SA, NSW) between September 2021-March 2022 for the final iteration.

Data Sources
A collaborative approach between members of the research team sought the literature upon a range of conceptual and international frameworks to inform the co-design of AT interventions. These included (i) competency standards for AHP, (ii) AT service delivery standards, and (iii) relevant Australian regulations and literature pertaining to risk management, AT education/training, and quality measures relevant to disability, aged care and AT [31,32].

AT Stakeholders
An ecosystem of factors influences the effectiveness of AT, including AT personnel (a term which encompasses AHPs) [33]. Work is underway globally to further understand the AT ecosystem including a World Health Organization supported position paper on AT provision [22]; position paper on the roles of AT users and families [34]; and a position paper on skilled personnel [35].
In Australia, collaboration across professions already addresses complex problems in remote and rural settings [36], and primary health [37] with innovations such as transdisciplinary teams. Such initiatives represent models to safely and effectively share expertise, demonstrate a focus on shared competence and ensure practitioner governance. Collaborating with users of AHP services was less common. The literature suggests that AT stakeholders in Australia may include the AT user or consumer, their family member or circle of support; a range of AHPs and allied health assistants; and ancillary or support workforces including support workers/aged care workers, indigenous and/or disability liaison officers.
Key construct 1 for the AT collaboration tool was therefore determined to be a base set of AT stakeholder roles. The data fields within this construct were identified as: • AT user and support network; • disability support worker/peer supporter; • allied health practitioner; • team (multidisciplinary or interdisciplinary).

AT Service Delivery Steps
AT service provision steps were identified from the literature [22,24,33]. We additionally sought a consumer-empowerment approach that would foreground the desires and rights of consumers regarding their AT. Little is published by AT users themselves, hence we selected work undertaken by de Jonge et al. [38][39][40] involving consensus statements from Australian AT users regarding what they wanted from AT service delivery ( Figure 2). This series of service delivery steps was utilized within the AT collaboration tool as construct 2: AT service delivery steps. The related questions are used as a verbatim guide in the 'consumer' column, and as a guide within other stakeholder columns to deliver on this set of consumer priorities.

Competence
Finding ways to role-share and collaboratively achieve outcomes clearly resonates with the ethical imperative of AHPs to empower service users: but how to do it? Competence refers to the ability to successfully perform a task, usually requiring a set of relevant knowledge and skills. A person's capability to conduct a task in a competent way is incremental: AHPs learn these skills in tertiary training and through practitioner practice. A range of alternative workers may also take on 'AT personnel' roles within and beyond AHPs, for example allied health assistants [41]. International contexts present very different pictures depending upon the availability of skilled personnel, for example use of community-based rehabilitation workers in low-and middle-income countries [42]. In some jurisdictions, agreed delegations of authority combined with favorable regulatory settings have supported devolution of non-complex AT tasks. Examples of these, including evidence of their successful implementation with low cost, low risk AT include the UK Trusted Assessor Framework supported by the UK Colleges of Occupational Therapy and Physiotherapy along with several Disabled Persons Organisations [43], and Ireland's AT Passport [44]. Did I feel empowered to initiate re-entry into the service delivery process? Could I give feedback to my AHP? Given the substantial resetting of 'prescribing' requirements in disability (NDIS) and ageing policy (MAC) in Australia, the evidence base supporting changed policies is surprisingly scant. Some recent initiatives were identified which enable AT prescribing roles 'beyond' AHPs to include AT suppliers, and AT consumers as peers and mentors (ATPM).
Government funded initiatives include the 2013 NDIS funded options paper which explored national credentialing and accreditation for AT practitioners and suppliers [45]; however, its recommendations were not implemented. Additionally, in 2014, the National Disability Insurance Agency developed but did not trial an AT capability framework which scaffolds the capability of AT users according to health literacy, AT experience, length of lived experience, and the risks, complexity, and novelty of the AT in use [46,47]. Related initiatives in aged care policy include the Department of Health's report on roles for the aged care assessment workforce in relation to AHPs [48] and funding guidelines for AT users, families and home care workers delineating AT into low risk; under advice; or prescribed, with the latter categories subject to AHP input [49].
There are currently few recognized training opportunities for an AT-focused workforce (including roles for peer mentors with lived experience), and role demarcation and relationship between such a workforce and AHP is not yet explicit.
Another model of AT peer mentorship is explicitly founded on principles of shared competence and capability between AT users and AHPs, envisioning AT users as potential AT peer mentors able to contribute to AT service delivery [50]. The AT Chat approach comprises a co-designed framework, associated training package and community of practice inclusive of AT users and AHPs. Grounded in an evidence review, the project has documented a risk-informed, competency-based and capability-enabled approach to sharing AT knowledge and roles. Features include the translation of what AT users saw as professionalized language of the AT service delivery steps into plain or 'fit for purpose' language, and the building of a hierarchy of AT risk levels and AT roles (See Figure 3-reproduced with permission from page 6).
Related initiatives in aged care policy include the Department of Health's report on roles for the aged care assessment workforce in relation to AHPs [48] and funding guidelines for AT users, families and home care workers delineating AT into low risk; under advice; or prescribed, with the latter categories subject to AHP input [49].
There are currently few recognized training opportunities for an AT-focused workforce (including roles for peer mentors with lived experience), and role demarcation and relationship between such a workforce and AHP is not yet explicit.
Another model of AT peer mentorship is explicitly founded on principles of shared competence and capability between AT users and AHPs, envisioning AT users as potential AT peer mentors able to contribute to AT service delivery [50]. The AT Chat approach comprises a co-designed framework, associated training package and community of practice inclusive of AT users and AHPs. Grounded in an evidence review, the project has documented a risk-informed, competency-based and capability-enabled approach to sharing AT knowledge and roles. Features include the translation of what AT users saw as professionalized language of the AT service delivery steps into plain or 'fit for purpose' language, and the building of a hierarchy of AT risk levels and AT roles (See Figure 3reproduced with permission from page 6).  Evaluation of the AT Chat pilot training and model has demonstrated that consumer's individual capabilities can be built over time and in different ways, within relevant riskinformed quality safeguards. However different consumers want different levels of support and electing to 'take on' aspects of competence is in itself a choice. Such frameworks enable consumers and others who have not historically been formal actors within AT interventions, to develop capability and competency if they so choose [12].
This evidence provides a foundation for the assumption within the tool for co-design of AT interventions, that consumers may value enhanced roles, that capability will change over time and that a risk-informed, quality managed 'sharing' of competence is a sound strategy. For the AT collaboration tool, this work also leads us to propose a set of 'quality indicators', noting broad credentialing frameworks do not yet exist in Australia [45]. Key construct 3 was therefore determined to be competence in the AT intervention with data fields being any relevant quality measures which may support competence for each stakeholder, where these exist.
Based upon the above data sources, the AT collaboration tool was developed and presented in Table 2. Key construct 1: AT stakeholder roles and the data fields are listed across Row 1. These may differ depending on the AT intervention but at a minimum include the AT user, their support network and an AHP. Key construct 2: AT service delivery steps are within Column 1 with the question-based prompting data fields for this construct populated within each column under the relevant AT stakeholder roles. Key construct 3: competence in the AT intervention, and any relevant quality measures which may support competence for each stakeholder, where these exist (data fields) are populated across the bottom row again as relevant to the stakeholder role. The tool provides a way to consider the intersections between the AT service steps, stakeholder roles, and individual competence. Questions in the tool data fields act as prompts for each stakeholder to ask about their 'inclusion practices', that is, have they asked others for input, and have they provided input.
To use the AT collaboration tool, AHPs and the stakeholders with whom they are working in various circumstances populate the table.
The next step entailed piloting the AT collaboration tool. Each AHP selected an exemplar scenario related to their practitioner practice to test the tool: dietetics and home enteral nutrition; prosthetics and custom prostheses; occupational therapy and vehicle modifications, and speech pathology and communication device use. Authors independently tested the AT collaboration tool by applying it to the practice scenarios, taking approximately 20 min on average (see Appendices B-E).
Participants then shared their pilot results with the broader group. Each participant reviewed all 4 pilot results independently. Inconsistencies were identified in the way the tool was interpreted and utilized across the multiple professions represented.
A final step was review and revision of the AT Collaboration tool. Group discussion of the initial results demonstrated the constructs were broadly applicable for all four professions. The tool and its constructs and data fields were revised based on discussion and feedback to address limitations and inconsistencies and to ensure applicability across allied health professions and alternative workforces. It was noted that different interventions required different AT stakeholder role data fields, and the decision was made to enable the framework content to be adapted to be fit for purpose for specific interventions, for example, defining 'vehicle modification agents' (Appendix E) where 3 stakeholder roles are identified, or 'prosthetic technicians' (Appendix D) where 5 stakeholder roles are identified. These changes reflect the varying alternative workforces available for different AT types. This flexibility rendered the framework more specifically relevant to the breadth of scenarios AT consumers and AHPs encounter, while maintaining fidelity to the key construct of AT stakeholder roles. There were no disagreements with regards to roles and scope in reviewing each-others results.
It became apparent through this process that quality measures were both critical, and largely absent, for consumers and the support workforce, and arguably patchy for AHPs. In the absence of micro-credentials, a range of opportunities to build competence were included, and their inclusion is targeted at reminding users of the importance of assuring quality and competence as well as possibility within these constraints.
The authors as a group discussed the language and phrasing of the framework and arrived at consensus on phrasing of data items.
Participants then revised their examples independently to reflect the revised tool. This process was repeated until consensus regarding the tool constructs and data fields was achieved. Two cycles of tool iteration to arrive at a consensus regarding the key constructs and data fields for the tool which produced consistent results was required.

Discussion
To work and flourish in super-complex environments [1], AHPs must possess qualities such as, agility, recognition of personal and practitioner limitations, the ability to reflect, work collaboratively and commit to life-long learning [51]. An ethical foundation of collective allied health professions is that of consumer-centered practice [15]. Responding to the shifting policy and practice landscape led us to critically reflect on how existing systems may have supported practitioner centric models. Health and technology innovations and the rollout of consumer-directed care gives allied heath an opportunity to revisit the locus of the consumer as the center of our work. In responding to this challenge, we suggest AHPs prioritize our roles in empowering and informing other stakeholders to become competent in elements of practice. The AT collaboration tool reconceptualizes previously accepted practices from a delegation of authority approach. Initial testing of this framework suggests it may enable AHPs, and other stakeholders, to acknowledge their personal scope; may acknowledge roles for interdisciplinary teams; and articulate competency-based inputs from a range of stakeholders. It is likely when used with different AHPs that additional or alternate stakeholder categories may need to be utilized. Future testing should be focused on applicability across the remaining allied health professions for which AT tailoring is within scope.
Enacting the implementation of the tool systemically would require actions by individuals, practitioner bodies, and policymakers. Individual AHPs may take the opportunity to revisit their practices and embed roles for relevant stakeholders who would welcome enhanced engagement and capacity building, adjusting over time as individual competence levels grow and alternative workforces develop. Allied health professions, individually or collectively, may utilize models such as this to operationalize a person-centered, capacitybuilding approach to interventions such as AT. For systematic uptake, related aspects would need attention, such as AHP training, articulating stakeholder capacity building in competency standards, and outreach to the cohorts of AHP working in Australia. There are consequences of such a framework for policymakers and AT funders. Collaboration would be needed to discuss and embed the recognition of diverse stakeholder roles into program guidelines, risk and quality frameworks, and also to further establish quality indicators and training options. Finally, we suggest careful monitoring of outcomes to ensure safety and quality of services. Given the identified lack of structured methods for determining task competence prior to assigning roles to various stakeholders, the ever-changing competence of stakeholders and the rapid rate of new AT availability, all stakeholders will need to utilize valid and reliable population appropriate outcome measures to evaluate the suitability of outcomes. As this process is in its infancy, ongoing collaborative efforts from all parties is required to ensure consumer needs are met, and frameworks are consolidated.

Limitations and Future Research
The perspectives of four AHPs are necessarily limited, and the framework presented above, while grounded in the literature and practice knowledge, has only been piloted by the authors. In addition, these four AHPs do not comprise all allied health professions working with AT nor indeed have representation as support networks, alternative workforce or AT consumers other than some intersectional capabilities from within our group. This paper is a starting point for future research and discussion, including the intersect of responsibility with practitioner indemnity, and further exploration of the sliding scale of competence. We also note that methods to assure quality, including credentialing remain key questions to be further explored.
At this time the AT collaboration tool is presented to facilitate further practical application by AHPs, policymakers and consumers. Given the broad nature in which competence has needed to be addressed at this time, it is considered this limitation will need to be addressed as relevant quality measures are confirmed and required by policy makers. Consistent patterns of successful and unsuccessful outcomes resulting from the use of specific quality measures included by users of the tool would assist with providing specific data fields to the competence key construct and would be welcomed. At this time, the identification of such measures are beyond the scope of the paper and the tool, however, the tool is designed in such a way that these can easily be included as it is applied to various types of AT and practice settings.

Conclusions
This paper represents a novel approach from four AHPs to apply innovative systems thinking and a consumer empowerment lens to our practice in relation to AT. Our method entailed an iterative process of critical reflections, review and revision of an AT collaboration by a panel of expert practitioner researchers. We sought a strategy to decouple the narrative of practitioner 'territorialism' and dominance, whilst still recognizing practitioner expertise, within the re-imagined AT policies of NDIS and My Aged Care. The AT collaboration tool is offered in recognition of the pressing need for practice and policy alignment in Australia. We suggest consumer directed care, as it is conceptualized today, requires the reconfiguring of practitioner boundaries in the interests of improved outcomes and authentic co-design with consumers as the experts of their own experiences and needs. Rethinking current practice, as typified by the AT collaboration tool, will enable AHPs to utilize their skillsets in ways that are person-focused, that utilize and support relevant networks of stakeholders, and that allow for both capability building and risk management as workforce dynamics continue to evolve. Institutional Review Board Statement: Ethical review was not applicable as this study did not involve humans or animals and was conceptual in nature.

Informed Consent Statement: Not applicable.
Acknowledgments: We acknowledge the communities of practice for allied health in Australia, including Allied Health Professionals Australia for its leadership and collegiality. We thank the AT users with whom we work for encouraging us to put our endeavors into the public domain through this publication.

Conflicts of Interest:
The authors declare no conflict of interest.