1. The Choice and Partnership Approach (CAPA): Improving the Delivery of Mental Health Care
Christine Slepanki & Dr. Gail Beck Royal Ottawa Mental Health Centre
Dave Murphy & Dr. Marjorie Robb
Children’s Hospital of Eastern Ontario (CHEO)
Monica Armstrong
Youth Services Bureau of Ottawa

2. Collaborators

3. Collaborators CHEO Youth Services Bureau of Ottawa Kathleen Pajer
William Gardner
Dave Murphy
Marjorie Robb
Karen Tataryn
Youth Services Bureau of Ottawa
Joanne Lowe
Jane Fjeld
Monica Armstrong
Francine Gravelle
Ted Charette
Centre Psychosocial
Rene Guy Cantin
Guy Bouchard
Crossroads Children’s Centre
Michael Hone
Cherry Murray
The Royal Mental Health Centre
Laura MacLaurin
Christine Slepanki
Gail Beck
Dr. Judy Makinen
Rebekah Ranger

4. Doing the right thing, at the right time, with the right people.

5. Overview
What is CAPA?
How is CAPA different from other service delivery systems?
How does CAPA work?
CAPA in Ottawa
Lessons learned
Questions/Discussion

6. What is CAPA?

7. “You do not have to have a waiting list. It can be eliminated
“You do not have to have a waiting list. It can be eliminated. We need to stop talking about assessment and treatment—things we do to people—and talk instead about partnership and collaboration.” 
Dr. Ann York, Psychiatrist, CAPA Developer

8. CAPA is an innovative method to deliver Child and Youth Mental Health Services.
It improves client flow and quality of care.
Widely used across the UK, New Zealand, Australia.
CAPA makes child and youth mental health services:
user-friendly
client/family focused
accessible
safe
effective

9. CAPA Internationally Ireland UK Belgium Nova Scotia NSW WA Victoria
Ottawa Ontario NZ

10. How is CAPA different from other service delivery systems?

11. Philosophy and mechanics.

12. Fundamental change in philosophy of clinical care
Challenges all assumptions and asks the “system” hard questions:
What is the role of the family in care?
What is the role of the clinician/physician in care?
What is our “core business”?
What is value-added?

13. Values Professional Client Skills Knowledge Skills Knowledge
Experience
Knowledge
Skills
Experience
Knowledge
Slide from capa.co.uk

14. Shared decision making
A consultative process where a clinician and client jointly participate in making a health care decision, after discussing the options and their benefits and risks, and considering the client’s values, preferences and circumstances.
Involves the professional and the service user bringing together their individual sources of expertise

15. Shift in responsibility
The bus ride doesn’t start at MH care facility.
The bus ride destination is not the MH care facility.
So, how do we get on the bus with family?
Family bus ride has already started.

16. Value-added care
Value is anything that improves health, well-being or care experience of client/family.
Value is defined by client or family.
We identify the ‘value stream’ or key set of actions required to deliver value.
The trick is to maximize actions that both add value and eliminate waste.

17. Importance of letting go.
“CAPA is all about empowering people and helping them access their own resources – and those in their communities – to move their lives forward. Part of this is not to assume they need services….” CAPA Manual, 2013, p. 81
“Release people back into the wild”

18. Mechanics: CAPA uses quantitative approach to service delivery.
Demand and Capacity Theory
Lean Principles

19. Demand and capacity Too much capacity or too many resources = idleness
Not enough capacity = waits
Resource manager must trade these off taking into account system objectives and available resources
Should we set capacity equal to demand?
This is called a balanced system
It works perfectly when there is no variation in the system
It works terribly when there is variation! Why?
Once behind, you never can catch up.
Puterman, Martin, 2012, BHAC 510 Coursework

20. In summary lean is… Engage Front Eliminate Non- Continuous Line Staff
Value-Add
Continuous
Improvement
Don’t wait for perfection – it may never show up
Take many small steps.
Try-storm ideas
Gain the benefit of immediate progress
Involve the people who deliver care on a daily basis
Create an environment of empowerment and contribution
Focus on eliminating waste, or Non-Value-Added work in the process
Waste is defined by the Client/Family

21. Push-Pull: the milkman
Push – the milkman delivers every day
The delivery rate come from the milkman
Pull – the family puts out a bottle when they need milk
The rate comes from the family across continuum of care
Slide taken from CAPA.co.uk

22. CAPA: Putting it all together
Demand
Each referral is a request for a clinical service; demand is the number of clinical hours needed
Capacity
Skills bank and resources required to deliver those skills
Skill bank built with targeted recruitment and clinician education
Capacity is not number of clinical staff, but number of clinical hours available to meet demand
Lean principles are used to map out efficient care with least waste.

23. How does CAPA work?

24. 11 Key Components CAPA Key Component Aim Why? 1. Leadership
To drive and sustain
Change management
2. Language
Active, understandable, non judgmental
Engages clients
3. Handle demand
Transparent and agreed
Flow, transitions, joint working
4. Choice framework
Shared decision making
Adds value, reduces waste, reduces drop outs
5. Full booking
Smoothes flow, improves engagement
Client has activities ‘pulled’ towards them as they need
6. Selection by skill
Matching skills to need
Increase effectiveness of help
7. Core and advanced skills
Evidence informed practice
Effectiveness, workforce development
8. Job planning
Defines and deploys capacity
Flow, monitoring, flexing, commissioning
9. Goal setting and outcomes
Regular outcome monitoring
Effectiveness and satisfaction, reduces drop outs and drift
10. Peer group supervision
Learning, governance, reducing variation
Safety, effectiveness, flow
11.Team away days
Team functioning
Effectiveness, satisfaction, reduced sickness, retention

25. 5 BIG ideas. Choice Core and Specific Partnership Work
Selecting Core Partnership clinician
Job Planning
Peer group discussion

26. #1 What is Choice? Choice appointment = first face to face contact
Find out what child, youth and family want
Use clinical knowledge to collaboratively formulate problem
Choice is single session intervention
Clinician and family design plan to help with problem:
Choice is enough and they can exit or
Return to clinic for treatment matching problem or
Refer to another agency or care provider for better match
Slide content taken from CAPA.co.uk

27. Choice: menu of treatments.
Establish treatment goals with clients
Match goals with menu of treatments
Methods: group, 1:1, in-home, family, school
Intensity: outpatient, inpatient, acute care, day treatment, intensive services
Consider client/family’s capacity for change

28. #2 Core and Specific Partnership Work
Slide content from capa.co.uk

29. What is core partnership?
If client/family will stay at clinic after Choice appointment, then go to Core Partnership
treatment matched to Choice-defined problem and goals, i.e., family “pulls” care in
assigned by reviewing who on team has skills best suited
evidence-based treatments effective across wide range of problems, e.g. CBT
Can be individual or group care
CAPA model suggests average of 7.5 sessions

30. Specific Partnership Specific: Specific Partnership examples:
When a particular technique, assessment, or skill is needed for specific symptoms or problems as a complement to Core work
Treatment duration is shorter or longer than Core
Specific Partnership examples:
Diagnostic Assessments
Medication consultation
Cognitive Assessments
Walk in clinic
Home based intensive services
DBT

31. 3. Selecting Clinician for Partnership
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
Booking them in before they leave using the Core Partnership calendar

32. # 4 Job Planning: Pooling Our Time on Teams.

33. Goals to Methods
Better match the treatment options to the goals identified by the client.

34. Specific: Cognitive Ax
# 4 Job planning.
Monday
Tuesday
Wednesday
Thursday
Friday
8:30
9:00
10:00
11:00
12:00
1:00
2:00
3:00
4:00
5:00
6:00
7:00
Discipline Meeting
Group
Big Admin
Choice
Team Meeting
Priority Ax
Carepath
Specific: Cognitive Ax
Partnership
Partnership
Partnership

35. #5: Peer group discussion.

36. Weekly peer group discussion.
Weekly meetings of all clinicians on team:
Discuss Choice appointment outcomes
Distribute workload
Do clinical peer supervision
Purpose
Builds trust within teams
Supports “letting go”
Specifies clear treatment goals and monitoring using outcome measures
Helps develop a learning culture
Reduces variability in responses to client’s needs
Improves safety and risk management

37. CAPA in Ottawa

38. CHEO CHEO Mental Health Program, Outpatient Service:
Psychiatry Dept. (4.8MD, 4.2 psychiatry FTE) provides all psychiatric care includes pediatricians
12.5 total FTE allied health professionals and support staff that is in addition to the MDs
15/16: 1479 referrals to Outpatient; 8715 visits; all off site; Outpatient Eating Disorders is separate
In care partnership with the Youth Program at The Royal Ottawa Hospital: Young Minds Partnership
CHEO launched CAPA February, 2016

39. Progress to date
Pre-CAPA: wait time to first appointment = average 200 days
Current wait time: 4.5 weeks
Current wait time for Partnership (excluding groups) = 8 weeks
Skills and competencies assessment identified following gaps:
Trauma care, brief interventions, some group therapies, family therapy

40. The Royal Ottawa Mental Health Centre
The Royal is a specialized mental health centre to treat people with complex, serious mental illness in Eastern Ontario.
The Youth Program provides intensive, specialized mental health services to year-old youth with early onset major psychiatric disorders or complex psychiatric illnesses resistant to treatment.
Number of clinicians and psychiatrists = 15
Waitlist blitz – early 2015; CAPA March 2016

41. Progress to date Wait times: January 2015 ~ 18 months (blitz)
March 2016 ~ 2 months
Currently ~ 4 weeks

42. Progress to date Parent Choice experience (N = 30/171)
“Overall, the help I had here was good.”
All true 93.3%
Partly true 3.3%
Don’t know 3.3%
“Did you feel that people here listened to your concerns?”
Very much 86.7%
Pretty much 13.3%
“Was today’s session helpful for you?”
Very much 66.7%
Pretty much 20.0%
A little 13.3%

43. Client & Clinician Ratings/Choice (N = 55/184)
Q1 – “How much were they/you curious about their/your view point…?”
RESPONSE
CLIENT
CLINICIAN
None 0%
A little
Some
3.6%
6.3%
A fair bit
10.7%
29.2%
A lot
39.3%
35.4%
Loads
46.4%

44. Client & Clinician Ratings/Choice (N = 56/184)
Q2 – “How much did they/you share their/your thoughts and opinions for you to discuss?”
RESPONSE
CLIENT
CLINICIAN
None 0%
A little
3.6%
Some
19.6%
4.1%
A fair bit
25.0%
24.5%
A lot
30.4%
22.4%
Loads
21.4%
49.0%

45. Client and Clinician Ratings/Choice (N = 56/184)
Q3 – “How much did they/you come to a share view as the nature of their/your problems?”
RESPONSE
CLIENT
CLINICIAN
None 0%
2.0%
A little
5.4%
Some
8.9%
18.4%
A fair bit
30.4%
30.6%
A lot
33.9%
22.4%
Loads
21.4%
24.5%

46. Community Implementation of CAPA
Fits with mandate of lead agency and our community consultations
Three core service providers – Centre Psychosocial, Crossroads, YSB
Training recently completed
Long term vision of system level transformation

47. Lessons learned.

48. Key CAPA elements
Systematic evaluation of progress: use data to inform decision-making.
Fidelity is critical.
Mechanics done without philosophy change is “doing to” our clients, not “engaging with” them.
Need to build continuous skill development:
Choice Clinic = pushing out the private practice model and building trust.
Team Peer Supervision = creating an environment where clinicians can ask for help.
Developing clinical capacity in specific clinics to strengthen core skills.

49. Lessons learned.
Program administration needs to be actively supporting CAPA
Achieving flow of clients means radically new thinking.
Change will come in waves.
People may accept CAPA and then drift back to old ways.
The power of families as collaborators is freeing.
Stick with it.
Share what you’ve learned.
Find mentors and stay in close communication.
Fidelity to model and consistency between agencies are critical.

50. Resources
All the CAPA ideas and concepts presented today were developed by Drs. Steve Kingsbury and Ann York.
Please see the website for more information or refer to their publication:
The Choice and Partnership Approach: A Service Transformation Model (2013)