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
3A Service Transformation Model CollaborationDemand &CapacitySkill layeringLeadership
4Values 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!
12Why do CAPA? p 16 Gains Users: Reduced waits Increased engagement Collaborative & respectfulTeamsLearning cultureTogethernessTransparentIts Fair!ManagersFlexible workforceDefines capacity
13Why 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 Specific workDemand and CapacityFlow managementSegmentation
14The 5 Big Ideas p 27-31 These are... 1. Choice2. Selecting clinician for Partnership3. Core and Specific work4. Team Job Planning5. Peer group discussion
16Choice p 46-57Choice philosophy: throughout the whole service – Choice and PartnershipChoice appointments: first contact with the service
17Aims 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
18Interior 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
19Tasks in the Choice appointment/s CuriosityHonest OpinionAssessment and RiskJoint FormulationGoalsAlternativesChoice PointNext StepsEngagement in their Choices
20None A little Some A fair bit A lot Loads 123456How much were they curious about your point of view / what you were worried about / understanding of the problem?How much did they discuss with you risk and any possible diagnoses?How much did they share their thoughts and opinions for you to discuss?How much did they help you come to a view together as to the nature of your problems?How much did they discuss different things that may help (from CAMHS and other places, including the research available for these options and what it means)?How much did you agree together your goals?With these goals in mind, how much did you together agree the things that might help?How much did they talk with you things you could do yourself?
21Choice: 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
22The Quantum Super-position of Choice! CollaborativeLet them be “them”Letting them know what will happenConnecting as a personCuriosity and ListeningGoing at their paceKeeping it safeDeciding togetherProfessionalRiskRecordingDiagnostic screeningSafe guardingAgreeing outcomes and goalsFormulatingKeeping to time etc
23Choice Facts Most people or all can do Choice (if have skills) Single clinicianLasts varied time [clinical + admin]Choice + is possibleChoice introduction…Choice letterIncludes Formulation, goals, homework and actionKey worker responsibility clarifiedPost- Choice discussion weekly
25Selecting 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 Core Partnership diary
26Why?Allows Core Partnership onset with right clinician with the right Core Partnership 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 and…
27Helps capacity management!! Separating the Choice from the Core Partnership work allowsChoice activity to be based on referral rateCore Partnership 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 Core Partnership activity rates set (and do-able)Can use staff who are leaving by moving their capacity into Choice
28How do you find someone with the right Core Partnership skills? Need to have mapped team skillsNeed to know each otherNeed extended core skills in Core workNeed to have done team job planning to have new Core Partnership appointments to book in to
29Patient Experience Have Choice appointment Choose with Choice clinician the Partnership clinician based onSkillsAvailabilityLeave the Choice with that appointment[= fully booked]
30Team Experience Many staff doing Choice Booking Partnerships in Partnership diaryThen each clinician books their follow-up in THEIR diary
37CBT: core vs advanced skills Core CBT:Core/basic work- explain model, structure sessions, using homework, reviewing homeworkSpecific CBT: (using advanced skills)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 core/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.
39Skill summaryAdvanced Skills are often distinct skills in a single modality trained to a higher level and delivered a higher intensityCORE skills are eitherto be competent at that modality = single modalityIntegrative work across modalities at lower fidelity
43A possible team pattern AssessmentBehaviouralCognitiveDynamicSystemic
44Work streamsSo now we’ve defined the streams by skill / intervention intoCoreSpecificWe need to work out how much we can do in THAT stream…This is a PACKING problem.
45Splitting the streamsThe demand and capacity term for identifying different streams is segmentationDividing a group up into smaller groups with similar characteristicsBut first lets look at what happens with no segmentation…
46No segmentation? One big fruit crate… Hard to know quite how much fruit we can get in.
47Segmentation Segment the big crate into 4 smaller crates… Fill 2 of the crates with the SAME sized fruit – apples and oranges… CORE fruitNow we know how much of averaged sized fruit we can pack in…
48Specific Fruit What if we have bigger fruit like melons Can put them in another crate…Again we can calculate how many melons we can fit in
49Another fruit What if we have some bigger fruit? A 4th crate could have pumpkinsThey are bigger still…So even less can be packed in
50Why have separate core and specific work? Segments and so helps flowSegments have different clinical needs and characteristics so that…Many can be helped by core workExtended core skills reduces bottlenecks to specifc workExtended core skills increases clinical flexibility (fewer queues into ‘specific interventions’ streams)Allows us to identify AND PROTECT specific work with advanced skills
52Team 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
54You 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?
55AssumptionsFamilies 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
56Recap: packing and segmentation If we know how big the fruit is…And how much space we have in the crates…We can work out how many fruit we can get in!
59Insert Team Meeting… Am TM Choice Pm Partnership Team Meeting MonTueWedThuFriPsychiatristAmTMChoicePmPartnershipTeam MeetingSWOther TasksSpecific ClinicalAdminPsychologistSystemic
60Specific Clinical Can be advanced clinical skill OR core skill deployed in a specific or structured wayE.g. groups, parenting
61Other Tasks Non clinical tasks such as Management, Professional meetings & managementSupervision, supervisingCare bundle developmentCommitteesInter agency panelsResearch & auditCPD
62Add Specific Clinical and Other Tasks MonTueWedThuFriPsychiatristAmTMChoicePmPartnershipTeam MeetingSocial WorkerOther TasksSpecific ClinicalAdminPsychologistSystemic Therapist
63Add Big Admin Am TM Choice Pm Partnership Team Meeting Other Tasks MonTueWedThuFriPsychiatristAmTMChoicePmPartnershipTeam MeetingSocial WorkerOther TasksSpecific ClinicalAdminPsychologistSystemic Therapist
65Step 2 How many Choice sessions need to be added to the Job Plans?
66Decide who will do Choice Probably good if most / all of the team do ChoiceThink skills not profession or seniorityGood at engagement- to service and not clinicianFacilitator with expertiseKnows local servicesCan communicate best practiceConfident but not overconfidentAnd the ability to FORMULATE!
67How 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”Need to time table a “Post-Choice” discussion in team diaryIn this example 4 referrals accepted and 2 clinicians see 2 each on Monday afternoon (admin may overflow)
68Choice added… Am Choice Pm Partnership Team Meeting TM Other Tasks MonTueWedThuFriPsychiatristAmChoicePmPartnershipTeam MeetingSocial WorkerTMOther TasksSpecific ClinicalAdminPsychologistSystemic Therapist
69Step 3 What is everyone’s capacity for Core Partnership?
70Capacity 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
72How 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
74Why 3?Maths…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
75Core and Specific Revisited ReasonsTakes longer or shorter than average [D]Allocated to a specific task [T]Uses advanced skills [S]Can be multiple reasons…CBT clinic for OCD?Running a DBT group?Incredible years parenting?Medication review?Family Therapy team?
76Exploring Job Planning Write down and discuss in small groups the Specific bits of your job plan…Takes longer or shorter than averageAllocated to a specific taskUses advanced skillsWhat is it?How much time?
78Team Core Partnership CAPACITY per 13 week quarter TOTAL TEAM CAPACITY= 36new Core Partnerships per quarterMonTueWedThuFriPsychiatristAm2 x 3 = 6PmSW4 x 3 =12Psychlgist3 x 3 = 9ChSystemic
79Core 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%
80Reasons 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
82What is it? Meeting weekly in small groups to talk about ongoing work About 1 to 1.5 hours3 to 5 peopleNot single disciplineStable or random groupsPro’s and con’s to bothAim for everyone to present each week
83Why? This is about letting go Developing a learning culture re core skillsGet advice from colleaguesKeep a focus on clients goals
84Flexing 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…
85How could a rural service deliver CAPA? A rural service example:Single clinicianLong travel timesLots of local relationship workMany settingsShort contact durations (minutes)
86Summary 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
87Why not do CAPA? Can’t think of a reason! Challenges Your IT and processes may need to be adaptedCultural change to transparency, user focus and striving to improve requires excellent leadership and change management skills
90Choice components The first contact with our service Needs… Not assessment and treatmentCriteria, full booking, flexing ChoiceAs described…
91The Choice – Partnership transfer Choosing the right Partnership clinician needs…from Choice…partnership diaryThinking about skills not professionsWhich is the second Language aspect
92Partnership All the interventions of the team both core and specific. This needs…Extending and valuing core skillsIncluding Core and Specific time etc
93Letting 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
94Team 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…
95The 11 ComponentsFoundationChoiceTransferPartnershipLetting Go