The CAPA Experience The Choice and Partnership Approach as experienced by the Green Team at Child & Family Specialty Service, Whakatata House. Kia ora koutou, welcome to our talk on the CAPA. I am Arya Black a social worker and I am Yvonne Barton Child Psychiatrist

What we are going to talk about….. An Introduction to our service What is CAPA Piloting CAPA –The team’s journey The Family’s Journey CAPA outcomes (Dec 07- April 08) Arya outline schedule.. Firstly, you may think that there is little difference between what we are doing and what you are doing, and there probably isn't. CAPA is more about a mind shift and a way of working. We still do a lot of things the way we always have, we are not here to promote CAPA, just to talk about our experience.

Our Service ARYA TALK…….. Our service is located in Christchurch city and services the Canterbury region for children up to 13 Year 8 We provide outpatient specialist mental health assessment and treatment. Children generally present with known or suspected moderate to severe emotional, behavioural or psychiatric difficulties

The GREEN Team ARYA TALK…….. We have 3 specialist treatment teams, black, yellow, and green which includes a Child & Adolescent Psychiatrist, Clinical Psychologists, social workers, Child Psychotherapist. Each team meets weekly to discuss intake, assessments and treatments options for individual clients and their families. And the Blue team which composes of our Clinical manager, Pukenga Atawhai (Maori Health Worker), typists, SLT and OT. The green team as we are piloting CAPA also has an administrator allocated who attends our weekly meetings

CAPA - Choice and Partnership Approach CORE & SPECIALIST WORK YVONNE TALK……… CHOICE Family is continuously given choice as a partner rather than been assessed and told what to do. (i.e., choice to be engaged, choice as in booking preferences for times, choice of goals, informed choice of therapy, etc) PARTNERSHIP From choice appointment, partnership is arranged with the clinician that is most appropriate. Model recommends partnership clinician to be different from initial choice clinician (make sure we are clear on why) CORE & SPECIALIST WORK CORE (Bread and butter) : Assessment and treatment (Behavioural, cognitive, dynamic, systemic) SPECIALIST: Specialist skill (e.g., Katrina for anxiety management and Heather for child psychotherapy or parent-child Dyadic work) Clinical work in specific time and place (e.g., groups)

The 7 Helpful Habits Handle demand Extend Capacity Let go of families Process Map and redesign Flow management Use of Care Bundles Look after staff ARYA CONTINUE……………… show the workbook

Piloting CAPA, Team Process 2-day CAPA workshop in March 2007, Allocated time at weekly MDT mtg ‘Team away days’ for CAPA development Choice appointment times and partnership slots 2 psychiatrists down-to-earth, CAPA provides guidelines which you can mould to suit your own service Green team made decision to trial CAPA “HEAD SHIFT” All team members read the CAPA workbook Each staff member allocated tasks (e.g, consult with consumer reps, SLT, OT, updated community agency info) Each team member worked out their weekly work plan – their availability for choice & partnership appointments, admin time We decided to focus on “Letting go of Families” and “Looking After Staff”. So we made a concerted effort to discharge families (e.g., We printed out our case lists and discussed how to ‘let go’ or discharge)

Piloting continued… Plan appropriate paper work Updated list of community support services Pukenga Atawhai asked how to ensure service is accessible to Maori Team discussed vulnerable families as a special group Care bundles to be thought about and decided upon for common diagnosis (still working on it) Individual staff encouraged to start thinking about individual training goals and upskilling

Prior to the Choice Apt Referral Letter of invitation (10 days) Choice of time offered for appointment 2nd letter – confirmation of appointment Forms returned Pre- Choice prep Not ‘Rocket Science” and not hugely different from previous administration 1. ! EMPHASISE WHAT IS DIFFERENT ! Val receives files with referral from team co-ordinator weekly 2. We send families a letter inviting them to phone us to make an appointment 3. IF No call for 2 weeks = Val ‘chases up’, gauges motivation and gives available times if still required. If not wanting appointment, letters sent to referrer and family confirming that they do not require an appointment. If Yes, family do call Val back = Family is given a choice about a time to come that suits them, Further conversation that Val may have with family……….. Val asks family asked how many adults (i.e., 1 or 2 CBCLs)-TRF to give to school-Map, Privacy Act, family info sheet Answer any other questions they may have re their choice appointment. 4. 2nd letter sent out to family & referrer confirming appointment time and clinicians, CBCL/TRF included. 5.  TRFs & CBCLs returned to Val, scored then attached to file or put in primary clinician’s cubby If referral suggests OT or SLT difficulties we seek out and consult with OT and SLT as to whether they should and could attend Choice Apt 6. Clinician’s meet in interview room 10 minutes or so before the family are due to read and discuss the        referral and family details in preparation    Val role at the MDT. Checks with Clinician availability for the next month Gives team members appointments that she has booked in. Give feedback about contact with families

The Choice Appointment Purpose and Focus Main Features Casual inquiry, how we do it Paper work Goal sheet Treatment Plan signed Evaluation Form Primary Purpose is to To engage family (give an example here?) To facilitate Informed choice/responsibility (i.e., evidence based treatment) Focus On what the family wants What family are prepared and able to do at this point in time Main Features Hear concerns Identify 1-3 goals of how the family wants things to be SMART Identify strengths Identify what they can do to help themselves giving them some tools to walk away with from the outset Duration 45 minutes-1.5 hours (flexible) Number of clinicians 2 or more (i.e., Pukenga, OT, SLT) Session Layout What are we likely to say to families in a Choice Appointment More casual, inquisitive rather than previous formal rigid structure Start with usual (1) INTRODUCTIONS, explain PURPOSE OF SERVICE, the session and paperwork, confidentiality etc, then…. We want to focus on what brings you here today (your concerns), what help you would like and what you would like to achieve (how you want things to be for your family). Together we can identify some specific goals about how you want things to be or how things could be better. It may be that another service in the community or that another clinician in this building is more suited at helping you achieve your goals.  Ask what have the family have tried and how do they current manage ….. What works well (3) We aim to always cover IN EVERYDAY LANGUAGE Family information Main concerns Func Inq Risk or the absence thereof Brief Dev Hx Goals (Above and more can be covered in “Choice + 1 other appointment” if not appropriate in 1st session) (4) ~ . ~ . ~ . ~ . ~ . ~ . ~ . ~ . ~ TAKE A BREAK ~ . ~ . ~ . ~ . ~ . ~ . ~ . ~ ~ . ~ . This is where Clinicians may “ put their heads together” and where family have private time to fill out goal sheet (5) Re unite. Thank family for coming and sharing Read their goals Share our understanding of whats happening (mini formulation), e.g., “It seems that ……” PAPER WORK Do Goals & Plan together with family, both sign, photocopy given to family so they take the plan with them from the outset, consent forms signed Families complete evaluation form if appropriate and put in box at reception (SHOW THESE) Clinician gives Val signed goals and treatment plan which she enters into SAP

Goal setting 1 2 3 4 5 6 7 Goals (ie how you would like things to be). Date: Goals (ie how you would like things to be). GOAL ONE: How close do you feel you are to meeting this goal at the moment (please rate): 1 2 3 4 5 6 7 As far from I have this goal as I completely can imagine achieved this goal

Treatment Plan Treatment plan (ie What is to happen): Date Aims/goals What will be done Who by/ when Evaluation (How did it go)? Signed: _____staff__________ _____ (Name) (Date) _____parent/s_______ _____ Requirement easily met.

After Choice Appointment Paper work Choice Appointment Summary HONOSCA Psychiatric Assessment Summary if required Partnership work Letter: Opening: Addressed to family (have examples handy) Understanding of main concerns...(have an example) Daily Functioning Risk MSE Brief formulation and diagnosis if relevant Goals Plan OPTIONAL: Dev Hx and Diagnosis What about a psychiatric assessment summary: If required complete in-depth FAMILY ARE SENT EXTRA COPIES

Dear Bruce and Sarah, CC: Dr A Matthews Thank you for bringing Johnny into Whakatata House on the 9th of April 2008. On this day you met with Katrina Falconer (senior clin. psychologist), Erin Bradley (student social worker) and myself. You described your main concerns which included Johnny's hitting behaviour and queried whether he has ADHD. You explained that his behaviour has been an issue since starting school and that hitting tends to occur on a daily basis. You explained that it was not so much the frequency but rather the severity of the hitting that concerned you, such as the incident resulting in his sisters nose bleeding. This has been handled by telling Johnny off and reminding him to keep his hands to himself. You have also used time out, and you say this works. You have noticed that Johnny is irritable and more likely to hit out when he is tired. You mentioned that he is similar to his two older siblings who have ADHD in that he is very active, needs little sleep and can't sit still. Main Purpose is for the family. In the form of a letter written to the family personally in a strength-based way in normal ‘every day’ language (e.g., we tend not to use technical words like “Affect”, “Euthymic” or “Thought form/ content”) More narrative and less report-like i.e., family friendly

Outcomes Feedback from Choice Apts Time referral - choice appointment Presenting problems Team experiences

COMMENTS OF CHOICE APPOINTMENT FEEDBACK FORMS Excellent, thank you You put me at ease and the children also, as they did their own thing quietly. Very relaxed atmosphere, Staff great with children, especially in the way they talked to J. I felt very comfortable and welcome. It was great to get things off my chest and the staff were wonderful. We weren’t made to feel bad about the way we react and we were given some good ideas about how to deal with some issues. Clearly dealing with staff who are emphatic to children. Meeting was useful and positive. Very helpful and staff are approachable. Very helpful and positive. FEEDBACK OF FAMILIES FROM CHOICE APPOINTMENTS IS DISPLAYED IN THIS GRAPH HOW HELPFUL? 5.7 FELT LISTENED TO? 6.2 GIVEN IDEAS TO HELP? 4.6 FELT THAT THEY UNDERSTOOD THE SERVICE? 5.8 SATISFIED ABOUT WAIT? 6.3 CLEAR ABOUT WHAT TO DO? 6

These change in figures are due to single point of entry introduced last year DEC '06 169 DEC '07 65 JAN '07 226 JAN '08 86 FEB '07 184 FEB '08 67 MAR '07 178 MAR '08 37 APR '07 157 APR '08 38

Total CAPA families: 52 children 33 boys, 19 girls, 8 Maori, 1 Asian, 1 Egyptian, 42 European IMPORTANT OUTCOME: 10 families had been before, 8 families where a parent had an un/diagnosed mental health disorder. Thinking about a specialist-treatment group designed for these parents Catchment period for last year’s referrals (6 months) had 195 withdrawal for the whole service and this catchment period was 74 withdrawals (a lot of unnecessary waste in making up files etc) Eventually we hope to have pre and post CBCLs on all cases and goal progress after every set of partnership appointments (eg, after MCB, after stint of psychotherapy, 3-session anxiety stuff etc)

Weaknesses For children who need advocacy Lack of training in psychiatric assessment Compliance with mental health standards

Team experience Feel like a burden has lifted –no longer feel responsible for families not engaging, no longer feel like we are carrying families More “walking the walk” in terms of strength-based practice (focus on how things are working and what is going well rather than focusing on illness and pathologising the problem) More solution-focused and in-line with recovery model (say how) More empowering for families (say how) Efficient use of family’s and clinicians time, Purposeful easy-to-comply paper work requirements

If you have any further questions or comments you can email: THANK YOU If you have any further questions or comments you can email: THANK YOU Katrina.Falconer@cdhb.govt.nz Arya.black@cdhb.govt.nz