capa- choice and partnership approach: the 4 big ideas and the 11 key components steve kingsbury and...
TRANSCRIPT
CAPA- Choice and Partnership Approach:
the 4 Big Ideas and the 11 key components
Steve Kingsbury and Ann York
[email protected]@btinternet.com
www.camhsnetwork.co.uk
The Basics
What are they?
What is CAPA?
…the Choice and Partnership Approach
a clinical system that evolved in Richmond CAMHS from 2000
developed and implemented wholesale in East Herts CAMHS 2005 and
now being used in many CAMH teams across the UK, New Zealand and parts of Australia
Ancestors of CAPA
Demand and
CapacityTheory
7 HELPFUL Habits of Effective CAMHS
10 High Impact
changes
User accessible services
Evidence Based
practice
Choice and Partnership Approach
Our Choices inMental Health
New Ways of Working
You’re Welcome Standards
What are the 7 HELPFUL Habits?
Broad framework that can guide service redesign
Evidenced based in terms of theory and clinical experience
Mix of Lean Thinking/demand and capacity techniques and quality parameters
Meets most standards that we need to apply
Can be done in steps or as one
7 HELPFUL Habits
Handle Demand
Extend Capacity
Let Go of Families
Process Map
Flow Management
Use Care Bundles
Look after staff
CAPA is a system that integrates these…
What CAPA is…and isn’t…
It is about Doing the right things With the right people At the right time
By applying the majority of the 7 HELPFUL Habits
Myths CAPA prescribes clinical interventions - NO CAPA is time-limited - NO CAPA is classic Triage - NO It is rigid – NO You have to give up your whole diary – NO Choice appointments have to be done in 45 min – NO No specialist work allowed – NO A plot by the Government - NO
Values of CAPA
Users are at the heart of the process
“Led by them and guided by us”
Shift in clinician stance to Facilitator with expertise rather than
expert with power
The CAPA system…
The 4 Big Ideas
What are they?
The 4 Big Ideas
1. Choice2. Core and Specific work3. Selecting clinician to Partnership4. Team Job Planning
1st Big Idea: Choice
Choice philosophy: throughout Partnership
Choice appointments: first contact with the service
Aims of Choice
Find out what they they want Use our knowledge to jointly form an
understanding Together choose what will be helpful
Interior Decorator
Explore what the client wants
Offer some advice (as an expert)
Reach a decision together
Curiosity Honest Opinion
Joint Formulation
Alternatives Alternatives Alternatives
Choice Point Engagement
Tasks in the Choice appointment/s
Choice: A Directed Conversation
USER: Conversation Follow the families’ process and thinking Non-hierarchical Engaging, motivating and respectful HUMAN Process Focussed
PROFESSIONAL: Directed We reach an understanding about the issues That considers risk And any appropriate diagnostic frameworks ACTIVE Goal Focused
2nd Big Idea: Core and Specific work
Key idea of separating our clinical work into core and specific work streams
Core work is bulk of what we do All clinicians Extended clinical skills Manages most families
Specific work Specific therapy, assessment or skill Additional to Core work Often done in a more formal way
Why have separate core and specific work?
Many can be helped by threshold level work
Extended core skills reduces bottlenecks to specifc work
Extended core skills increases clinical flexibility (fewer queues into ‘specialised’ streams)
Allows us to identify AND PROTECT specific team / individual capacity for specific work
Segments and so helps flow
Key concept: extending clinical skills
ABCD’S Skills Clinicians (Alphabet skills) Clinicians who have extended their skills to include
the core competencies of:
AssessmentBehavioural CognitiveDynamic.Systemic
A B C D S
Threshold
Specialist
Skill level
Specialist skills pattern
A B C D S
Threshold
Specialist
Skill level
Core Extended threshold skills
So what does a typical clinician look like?
Range of extended Core clinical skills Able to work flexibly between these skills
Some Specific skills that are job planned Receive internal referals for…
Spend time (job planned) doing both Core and Specific
Clincian 1 Clincian 2 Clincian 3 Clincian 4 Clincian 5
A B C D S
Specialist
Threshold
Common team pattern
Team skill issues
Question:
How does the distribution of these skills affect the team?
A Possible Pattern… Effects?
0
1
2
3
A B C D E F G H
.
Specialist
Threshold
A Possible Pattern… Effects?
0
1
2
3
A B C D E F G H
.
Specialist
Threshold
A Possible Pattern… Effects?
0
1
2
3
A B C D E F G H
.
Specialist
Threshold
CBT: core threshold vs specialist skills example
Core CBT: Core/basic work- explain model, structure sessions, using
homework, reviewing homework
Specialist CBT:All the above PLUS Socratic questioning/guided discovery Automatic thoughts/assumptions/beliefs Problem specific competencies eg in ERP for OCD
Could you manage a bottleneck to CBT by extending clincal skills to increase capacity at threshold/core level?
Ref: The competencies required to deliver effective cognitive and behavioural therapy for people with depression and with anxiety disorders. Dept of Heatlh 2007.
3rd Big Idea: selecting clinician
This is
At the end of the Choice appointment With the young person’s and family’s goals in
mind Selecting a clinician in Partnership who has the Skills to work towards those goals and A personality that matches the young person
and family Fully booking them in using the Partnership
diary
Why?
Allows Partnership onset with right clinician with the right skills
Frees family and clinician to make good use of session as encourages curiosity
Allow families and adolescents to feel more open (user feedback)
Engagement with their change not with clinician
and
Helps capacity management!!
How does it help with Capacity?
Separating the Choice from the Partnership work allows
Choice activity to be based on referral rate Partnership activity to be based on reasonable job
plans
This means that Staff are happy to flex Choice (as no follow-up
work burden) Low risk of overload as Partnership activity rates
set (and do-able) Can use staff who are leaving by moving their
capacity into Choice
How do you find someone with the right Core Partnership skills?
Need to have mapped team skills
Need to know each other
Need extended skills in Core work
Need to have done team job planning to have new Core Partnership appointments to book in to
4th Big Idea: Team Job Planning
This is Each individual having a job plan that describes their
work: core, specific, choice, admin etc This plan being written with team needs in mind All the individual plans integrated into one team plan
Why?
Plans activity for the whole service Calculates capacity Makes work load manageable Flexibility to move and build resources Transparent monitoring Set standards for activity as well as protects staff
from over activity
Key task
Defining different types of clinical work Choice Core Partnership Specific Partnership
Core vs Specific work in job plan
Core work Tends to be of standard duration- on average 7
sessions Uses threshold level extended skills (ABCDS)
Specific work specialist level skill used to complement the core
work e.g specific assessment or intervention May be shorter (e.g. Specialist assessments) or
longer duration (e.g. high intensity interventions)
Specific work protected in job plan
You decide as a team what you need to protect.
Examples could be...
Shorter duration ASD assessment WISC
Longer duration psychodynamic psychotherapy EMDR Specialist level/’high intensity’ CBT
How do we job plan Core and Specific work?
Need to identify:1. Core work- using extended threshold level skills2. Specific work- using specialist level skills
Using:Competencies ideas Threshold and specialist level Alphabet skills This helps work out what to put in job plans and how
much
And information onFlow rates shorter term vs longer term durations This helps work out new activity rates/capacity
Things to think about...
Can a specialist do Core work?
What about Long term core work?
Anorexia nervosa- is it always specilaist?
Team Job Planning
How to do it...
Team Job Planning in CAPA
Each individual has a job plan that describes their work in various ways
Combined to form a team job plan Useful to managers and clinicians as describes
predicted activity Can show effects of losses Contains activity for clinicians Based on “do-able”numbers
Job plans include…
Supporting work: admin, management, CPD
Other: consultation, YOT, LAC
You need to work out
1. What is everyone doing at the moment? ie. current job plans
2. How many Choice sessions need to be added to those job plans to match referrals?
3. What is the capacity for Core Partnership in the job plans?
4. Managers: is the team in balance?5. Do job plans need reviewing?
Assumptions
1. All referrals that you accept will be guaranteed a Choice appointment within 6 weeks of referral
2. Only 2/3 of those having Choice will continue into Core Partnership work
3. Families and young people who have Core Partnership work need an average of 7.5 appointments
4. You can offer two appointments in a 3.5 hour session / half day
5. Out of 52 weeks of the year, only 45 are actually worked6. You will design job plans according to what is currently
being done
Step 1
What is everyone doing at the moment?
ie. current job plans
Job planning: Blank Diaries
Mon Tue Wed Thu Fri
Psychiatrist Am Choice
Pm Partnership
Free
SW Am Tier 2
Pm Specific
Admin
Psychlgist Am Non clinical
Pm Team meeting
Systemic Am
Pm
Team Meeting
Mon Tue Wed Thu Fri
Psychiatrist Am Choice
Pm Partnership
Free
SW Am Tier 2
Pm Specific
Admin
Psychlgist Am Non clinical
Pm Team meeting
Systemic Am
Pm
Admin Time
Mon Tue Wed Thu Fri
Psychiatrist Am Choice
Pm Partnership
Free
SW Am Tier 2
Pm Specific
Admin
Psychlgist Am Non clinical
Pm Team meeting
Systemic Am
Pm
Specialist and specific time
Mon Tue Wed Thu Fri
Psychiatrist Am Choice
Free = 3 Pm Partnership
Free
SW Am Tier 2
Free = 6 Pm Specific
Admin
Psychlgist Am Non clinical
Free = 4 Pm Team meeting
Systemic Am
Free = 7 Pm
Other Commitments
Mon Tue Wed Thu Fri
Psychiatrist Am Choice
Free = 2 Pm Partnership
Free
SW Am Tier 2
Free = 4 Pm Specific
Admin
Psychlgist Am Non clinical
Free = 4 Pm Team meeting
Systemic Am
Free = 4 Pm
Free sessions for Choice and Core Partnership work
Mon Tue Wed Thu Fri
Psychiatrist Am
2 Pm
SW Am
4 Pm
Psychlgist Am
4 Pm
Systemic Am
4 pm
TEAM TOTAL
= 14 sessions
Per week
Step 2
How many Choice sessions need to be added to those job plans?
Team Job Planning Example
Anywhere CAMHS...
4 full time staff (4 FTE)
4 referrals per week
How many Choice appointments need to be added to those job plans?
All accepted referrals are offered a Choice appointment
Number of referrals per week (that are accepted) = 4 They need 4 Choice appointments.
HOW?
Each staff member can do 2 Choice appointments in one 3.5 hour session / half day
1.30 pm
1.30 pm
3 pm
3 pm
Decide who will do Choice
Think skills not profession or seniority Good at engagement- to service and not clinician Facilitator with expertise Knows local services Can communicate best practice Confident but not overconfident
Choice Clinics
Mon Tue Wed Thu Fri
Psychiatrist Am
Pm
SW Am
Pm
Psychlgist Am
Pm Ch
Systemic Am
Pm Ch
TOTAL TEAM CAPACITY
= 4 Choice appointments per week
TOTAL TEAM DEMAND
= 4 Choice appointments per week
Step 3
What is the capacity for Core Partnership in the job plans?
What is the capacity for Core Partnership in the job plans?
Calculate capacity for each clinician
Count free sessions in job plan for Core Partnership work
Multiply by 3 (Partnership Multiplier) This is number of new Core Partnership clients each
clinician will take on in a period of 13 weeks
Andrew Down, systemic therapist
Total sessions 10Team meeting 1YOT 1Systemic Therapy clinic 1LAC consultation 1Management 1Admin 1Choice 1
Remaining Core sessions 10 – 7 = 3
Core Partnership new clients per quarter 3 x 3 = 9
Mon Tue Wed Thu Fri
Systemic Am
Pm CH
Team Core Partnership CAPACITY per 13 week quarter
Mon Tue Wed Thu Fri
Psychiatrist Am
Free = 2 Pm
SW Am
Free = 4 Pm
Psychlgist Am
Free = 3 Pm Ch
Systemic Am
Free = 3 Pm Ch
Team Core Partnership CAPACITY per 13 week quarter
Mon Tue Wed Thu Fri
Psychiatrist Am
2 x 3 = 6 Pm
SW Am
4 x 3 =12 Pm
Psychlgist Am
3 x 3 = 9 Pm Ch
Systemic Am
3 x 3 = 9 Pm Ch
TOTAL TEAM CAPACITY
= 36
new Core Partnerships per quarter
Why?
Why 3?
In 13 weeks each clinician is there for 11.25 weeks (leave etc) So for each half day in their diary they do 11.25 half days per
quarter In each half day they can do 2 appointments So over the quarter they can do 11.25 x 2 = 22.5 appointments Each family and young person averages 7.5 appointments This means that the 22.5 appointments divided by 7.5
appointments = 3 children and young people
AndWe know this number works for most UK CAMHS teams
ButIf your session average is more than 7 or you can only do 1 appointment in a half day e.g for LDThe multiplier will be less
How many fixed appointments does Andrew offer?
ie how much of his diary has he given up?
2 Choice appointments a week
9 new Core Partnership appointments over 13 weeks
How does he plan his work?
Tue
am
Fri
Summary
Choice activity based on referrals (remember to flex…)
Core Partnership based on job plans The number is 3 Admin time based on core activity Job plans should be reasonable based on what you
and the team NEED to do Shift to Team Job Planning and activity May or may not be in balance
Core service Percentage
It is useful to know what % of the service is given to all Choice and Core Partnership
WHY?
40% is the realistic ceiling; this is challenging and needs excellent clinical and managerial
leadership
WE FIND:
40% in Choice and Core Partnership works for most teams:This could be... 40% for Choice and Core Partnership work 35% Specific work
(i.e. 75% of time is in clinical work) 25% in supporting work e.g. management, CPD etc