2What is CAPA? …the Choice and Partnership Approach Began with conversations between us many years ago…a clinical system that evolved in Richmond CAMHS from 2000developed and implemented wholesale in East Herts. CAMHS 2005 andnow being used in many CAMH teams across the world
3Values of CAPA Users are at the heart of the process “Led by them and guided by us”Shift in clinician stance toFacilitator with expertise rather than expert with powerEverything we do must add value to the user“Just the right amount”Is this working for this young person?
5What CAPA is… It is about Doing the right things = on the right goals With the right people = with the right skillsAt the right time = with no waits
6CAPA Myths p19 There are lots of myths! The Mental Health Foundation report these…Choice means they can choose anything (p33)Partnership is limited to sessions (p37, 41, 53) or 3 (p 53)Only allowed one Choice appt and for 1 hour (p38)Choice does no assessment (p38)Complex cases don’t fit into CAPA (p 49)Not allowed to do specialist work (p 49)Job plans are inflexible (p 50)No long term work (p54)
7CAPA - lite Many teams struggle to implement all of CAPA… Formal detailsFull booking from Choice to PartnershipTeam Job PlanningValuesWorking in a Choice frameworkAdding value to user vs. organisational targetsChanging languagePractical thingsMonitoring of Partnership ActivityRegular away daysSmall peer group weekly IntraVisionHowever they do manage to call it CAPA!
8CAPA-ccino Has less coffee in it A frothy top that Belies the lack of substance inside!
11What are the 7 HELPFUL Habits? 158 Broad framework that can guide service redesignEvidenced based in terms of theory and clinical experienceMix of Lean Thinking/demand and capacity techniques and quality parametersMeets most standards that we need to applyCan be done in steps or as one
127 HELPFUL Habits There are 36 items 7-HAT self-rating tool Handle Demand (9 items)Extend Capacity (7)Let Go of Families (3)Process Map (4)Flow Management (7)Use Care Bundles (3)Look after staff (4)There are 36 items7-HAT self-rating toolCAPA is a system that integrates these…
14Why do CAPA? p 16 Gains Users: Reduced waits Increased engagement Collaborative & respectfulTeamsLearning cultureTogethernessTransparentIts Fair!ManagersFlexible workforceDefines capacity
15Why does CAPA work?It is our experience that CAPA seems to enable CAMH teams to deal with their current workload in what seems a much more efficient and effective wayTask AllianceFocus on patient goalsFamily ownership of changeTherapeutic allianceTeam organisationCapacity planningCore and Specialist workDemand and CapacityFlow managementSegmentation
16The 4 Big Ideas p 27-31There are 4 ideas that separate CAPA CAMHS from more “traditional” models. These are...ChoiceCore and Specific workSelecting clinician to PartnershipTeam Job Planning
18Choice p 46-57 Choice philosophy: throughout Partnership Choice appointments: first contact with the service
19Aims of Choice Find out what they want Use our knowledge to jointly form an understandingTogether choose what will be helpfulNOT…Assessing a passive young person and familyHanding down a diagnosis and treatment plan
20Interior Decorator Work in PAIRS One choose to be a CLIENT The other an interior decoratorChoose a room to be changedExplore what the client wantsOffer some advice (as an expert)Reach a decision together
21Tasks in the Choice appointment/s CuriosityHonest OpinionJoint FormulationAssessment and RiskAlternativesChoice PointEngagementEngagement in their Choices
22Choice: A Directed Conversation USER: ConversationFollow the families’ process and thinkingNon-hierarchicalEngaging, motivating and respectfulHUMANProcess FocussedPROFESSIONAL: DirectedWe reach an understanding about the issuesThat considers riskAnd any appropriate diagnostic frameworksACTIVEGoal Focused
24Core and Specific work p 58 - 63 Key idea of separating our clinical work into core and specific work streamsCore work is majority of what we can doAll cliniciansExtended threshold clinical skillsAverage duration 7 sessionsManages most familiesSpecific work (3 types)Specialist therapy, assessment or skillAdditional to Core workOften done in a more formal wayA Specific piece of work using threshold skillsCore work with different average durations
25Why have separate core and specific work? Many can be helped by threshold level workExtended threshold skills reduces bottlenecks to specifc workExtended threshold skills increases clinical flexibility (fewer queues into ‘specialised’ streams)Allows us to identify AND PROTECT specific workSegments and so helps flow
26CBT: core threshold vs specialist skills Core CBT:Core/basic work- explain model, structure sessions, using homework, reviewing homeworkSpecialist CBT:All the above PLUSSocratic questioning/guided discoveryAutomatic thoughts/assumptions/beliefsProblem specific competencies eg in ERP for OCDCould 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 Health 2007.
27Key concept: extending clinical skills ABCD’S Skills Clinicians (Alphabet skills)Clinicians who have extended their skills to include the threshold competencies of:AssessmentBehaviouralCognitiveDynamic.Systemic
34What is a typical CAPA clinician? Range of extended threshold clinical skillsAble to work flexibly between these skillsSome Specialist skills that are job plannedReceive internal referrals for…Some Specific pieces of work (reserved or non-average durations)Spend time (job planned) doing both Core and Specific
35Service Skills 1. Must it be Specialist skill? 2. Do we have to Reserve the capacity?3. Is it of Short duration?4. It is average duration with threshold skills?
36Job Plan Exercise FT team Specialist Children in Care Choice Reserved Brief CoreASD screenEMDRSpecialistCBT – depr.PartnershipBrief CoreCBT (OCD)Tier 2 liaisonFamily workSpecialistPartnershipReservedSchool phobiaADHD reviewAnorexiaSpecialistPartnershipSpecialist
37An actual Job Plan… Monday Tuesday Wednesday Thursday Friday FT team SpecialistChilredn in CareChoiceReservedBrief CoreASD screenEMDRSpecialistCBT – depr.PartnershipBrief CoreCBT (OCD)Tier 2 liaisonFamily workSpecialistPartnershipReservedSchool phobiaADHD reviewAnorexiaSpecialistPartnershipSpecialist
39Selecting Partnership Clinician p64-68 This isAt the end of the Choice appointmentWith the young person’s and family’s goals in mindSelecting a clinician in Partnership who has theSkills to work towards those goals andA personality that matches the young person and familyFully booking them in using the Partnership diary
40Why?Allows Partnership onset with right clinician with the right skillsFrees family and clinician to make good use of session as encourages curiosityAllow families and adolescents to feel more open (user feedback)Engagement with their change not with clinician andHelps capacity management!!
41How does it help with Capacity? Separating the Choice from the Partnership work allowsChoice activity to be based on referral ratePartnership activity to be based on reasonable job plansThis means thatStaff 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
42How do you find someone with the right Core Partnership skills? Need to have mapped team skillsNeed to know each otherNeed extended threshold skills in Core workNeed to have done team job planning to have new Core Partnership appointments to book in to
44Team Job Planning in CAPA p 85-89 Each individual has a job plan that describes their work in various waysCombined to form a team job planUseful to managers and clinicians as describes predicted activityCan show effects of lossesContains activity for cliniciansBased on “do-able”numbers
46You need to work outWhat is everyone doing at the moment? ie. current job plansHow many Choice sessions need to be added to those job plans to match referrals?What is the capacity for Core Partnership in the job plans?Managers: is the team in balance?Do job plans need reviewing?
47AssumptionsFamilies and young people who have Core Partnership work need an average of 7.5 appointmentsYou can offer two appointments in a 3.5 hour session / half dayOut of 52 weeks of the year, only 45 are actually workedFor some of the capacity planning / rules of thumb thatOnly 2/3 of those having Choice will continue into Core Partnership work
53Other Commitments Am Choice Pm Partnership Free Tier 2 Specific Admin MonTueWedThuFriPsychiatristAmChoiceFree = 2PmPartnershipFreeSWTier 2Free = 4SpecificAdminPsychologstNon clinicalTeam meetingSystemic
54Free sessions for Core work MonTueWedThuFriPsychiatristAm2PmSW4PsychologistSystemicpmTEAM TOTAL= 14 sessionsPer weekAll Choice and Core Partnership
55Step 2 How many Choice sessions need to be added to the Job Plans?
56How many Choice appointments need to be added to those job plans? You need as many Choice as referrals accepted per weekCan accept about 1 referral per FTETime taken will depend on admin / IT tasks per ChoiceYou canScatter then around the team diary orOrganise together in a “Choice clinic”In this example 4 referrals accepted and 2 clinicians see 2 each on Monday afternoon (admin may overflow)Need to time table a “Post-Choice” in team diary
57Decide who will do Choice Think skills not profession or seniorityGood at engagement- to service and not clinicianFacilitator with expertiseKnows local servicesCan communicate best practiceConfident but not overconfident
58Choice Clinics TOTAL TEAM DEMAND = 4 Choice appointments per week MonTueWedThuFriPsychiatristAmPmSWPsychlgistChSystemicTOTAL TEAM DEMAND= 4 Choice appointments per weekTOTAL TEAM CAPACITY= 4 Choice appointments per week
59Step 3 What is everyone’s capacity for Core Partnership?
60Capacity for Core Partnership? p 88-89 Calculate capacity for each clinicianCount free sessions in job plan for Core Partnership workMultiply by 3 (Partnership Multiplier)This is number of new Core Partnership clients each clinician will take on in a period of 13 weeks
62How many fixed appointments does Andrew offer? ie how much of his diary has he given up?2 Choice appointments a week9 new Core Partnership appointments over 13 weeksHe will have left approximately 60 appointments for follow-up
64Why?Why 3?In 13 weeks each clinician is there for weeks (leave etc)So for each half day in their diary they do half days per quarterIn each half day they can do 2 appointmentsSo over the quarter they can do x 2 = 22.5 appointmentsEach family and young person averages 7.5 appointmentsThis means that the 22.5 appointments divided by 7.5 appointments = 3 children and young people can be seen and treatment completedButIf your session average is more than 7or you can only do 1 appointment in a half day e.g for LDThe multiplier will be less
66Team Core Partnership CAPACITY per 13 week quarter MonTueWedThuFriPsychiatristAm2 x 3 = 6PmSW4 x 3 =12Psychlgist3 x 3 = 9ChSystemicTOTAL TEAM CAPACITY= 36new Core Partnerships per quarter
67Is there enough capacity? ChoicePartnershipTOTAL TEAM CHOICE DEMAND= 4Choice appointments per weekTOTAL TEAM CORE PARTNERSHIPDEMAND= 35 per quarter66% will need Core Partnership2/3 x 4 x 13 wks =35 partnershipsTOTAL TEAM CHOICE CAPACITY= 4 Choice appointments per weekTOTAL TEAM CORE PARTNERSHIPCAPACITY= 36per quarterBALANCED!
68Core service Percentage It is useful to know what % of the service is given to all Choice and Core PartnershipWHY?40% is the realistic ceiling;this is challenging and needs excellent clinical and managerial leadershipWE FIND...40% in Choice and Core Partnership works for most teams:This could be...40% for Choice and Core Partnership work35% Specific work (i.e. 75% of time is in clinical work)25% in supporting work e.g. management, CPD etcTeam example...14 sessions for core out of 40 = 35%
69Reasons for Choice-Partnership Imbalance Too many referralsToo many referrals acceptedTransferring a high % from ChoiceHigh need, Not full choice, “all need help”Choice taking too large a slice of coreLong choice durations than planned forShirkingLack of monitoringVague job planning: low core% of whole serviceVacant postsPressure…Long average core partnership durationsLess than 2 appointments per session
70Flexing your Choice capacity Each week count the number of referrals accepted for Choice(plus…Add the number of accepted referrals from last week who have not yet opted in (they may yet come))Then count the number of vacant Choice in the next 6 weeks.If there aren’t enough find some more…
71How could a rural service deliver CAPA? A rural service example:Single clinicianLong travel timesLots of local relationship workMany settingsShort contact durations (minutes)
72Summary Choice activity based on referrals (remember to flex…) Core Partnership based on job plansThe number is 3Admin time based on core activityJob plans should be reasonable based on what you and the team NEED to doShift to Team Job Planning and activityMay or may not be in balance
75Choice components The first contact with our service Needs… Not assessment and treatmentCriteria, full booking, flexing ChoiceAs described…
76The Choice – Partnership transfer Choosing the right Partnership clinician needs…from Choice…partnership diaryThinking about skills not professionsWhich is the second Language aspect
77Partnership All the interventions of the team both core and specific. This needs…Extending and valuing threshold skillsIncluding Core and Specific time etc
78Letting go of families – throughput p 75-77; 168-170 Keeping a focus and working effectively requires…Reaching a Choice point leading to goalsWeekly, small groups for ongoing work discussion and reviewing the goals
79Team Components And finally to make it all work you absolutely need… a team of management, admin and clinical4 days a year to think and work together…
80The 11 ComponentsFoundationChoiceTransferPartnershipLetting Go