The CAPA Basics

What is CAPA? …the Choice and Partnership Approach Began with conversations between us many years ago… 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 world

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 Everything we do must add value to the user “Just the right amount” Is this working for this young person?

CAPA workshops

What CAPA is… It is about Doing the right things = on the right goals With the right people = with the right skills At the right time = with no waits

CAPA Myths p19 There are lots of myths! The Mental Health Foundation report these… Choice means they can choose anything (p33) Partnership is limited to 6 - 7 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)

CAPA - lite Many teams struggle to implement all of CAPA… Formal details Full booking from Choice to Partnership Team Job Planning Values Working in a Choice framework Adding value to user vs. organisational targets Changing language Practical things Monitoring of Partnership Activity Regular away days Small peer group weekly IntraVision However they do manage to call it CAPA!

CAPA-ccino Has less coffee in it A frothy top that Belies the lack of substance inside!

CAPA Links

Ready for Change?

What are the 7 HELPFUL Habits? 158 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 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 items 7-HAT self-rating tool CAPA is a system that integrates these…

The CAPA system…

Why do CAPA? p 16 Gains Users: Reduced waits Increased engagement Collaborative & respectful Teams Learning culture Togetherness Transparent Its Fair! Managers Flexible workforce Defines capacity

Why 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 way Task Alliance Focus on patient goals Family ownership of change Therapeutic alliance Team organisation Capacity planning Core and Specialist work Demand and Capacity Flow management Segmentation

The 4 Big Ideas p 27-31 There are 4 ideas that separate CAPA CAMHS from more “traditional” models. These are... Choice Core and Specific work Selecting clinician to Partnership Team Job Planning

1st Big Idea Choice

Choice p 46-57 Choice philosophy: throughout Partnership Choice appointments: first contact with the service

Aims of Choice Find out what they want Use our knowledge to jointly form an understanding Together choose what will be helpful NOT… Assessing a passive young person and family Handing down a diagnosis and treatment plan

Interior Decorator Work in PAIRS One choose to be a CLIENT The other an interior decorator Choose a room to be changed Explore what the client wants Offer some advice (as an expert) Reach a decision together

Tasks in the Choice appointment/s Curiosity Honest Opinion Joint Formulation Assessment and Risk Alternatives Choice Point Engagement Engagement in their Choices

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

Core and Specific work p 58 - 63 Key idea of separating our clinical work into core and specific work streams Core work is majority of what we can do All clinicians Extended threshold clinical skills Average duration 7 sessions Manages most families Specific work (3 types) Specialist therapy, assessment or skill Additional to Core work Often done in a more formal way A Specific piece of work using threshold skills Core work with different average durations

Why have separate core and specific work? Many can be helped by threshold level work Extended threshold skills reduces bottlenecks to specifc work Extended threshold skills increases clinical flexibility (fewer queues into ‘specialised’ streams) Allows us to identify AND PROTECT specific work Segments and so helps flow

CBT: core threshold vs specialist skills 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 Health 2007.

Key concept: extending clinical skills ABCD’S Skills Clinicians (Alphabet skills) Clinicians who have extended their skills to include the threshold competencies of: Assessment Behavioural Cognitive Dynamic. Systemic

Specialist skills pattern

Core Extended threshold skills

A possible team pattern Assessment Behavioural Cognitive Dynamic Systemic

A Possible Pattern… Effects?

A Possible Pattern… Effects?

A Possible Pattern… Effects?

What is a typical CAPA clinician? Range of extended threshold clinical skills Able to work flexibly between these skills Some Specialist skills that are job planned Receive internal referrals for… Some Specific pieces of work (reserved or non-average durations) Spend time (job planned) doing both Core and Specific

Service 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?

Job Plan Exercise FT team Specialist Children in Care Choice Reserved Brief Core ASD screen EMDR Specialist CBT – depr. Partnership Brief Core CBT (OCD) Tier 2 liaison Family work Specialist Partnership Reserved School phobia ADHD review Anorexia Specialist Partnership Specialist

An actual Job Plan… Monday Tuesday Wednesday Thursday Friday FT team Specialist Chilredn in Care Choice Reserved Brief Core ASD screen EMDR Specialist CBT – depr. Partnership Brief Core CBT (OCD) Tier 2 liaison Family work Specialist Partnership Reserved School phobia ADHD review Anorexia Specialist Partnership Specialist

3rd Big Idea Selecting Partnership clinician

Selecting Partnership Clinician p64-68 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 threshold 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: How to do it…

Team Job Planning in CAPA p 85-89 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

You need to work out What is everyone doing at the moment? ie. current job plans How 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?

Assumptions Families and young people who have Core Partnership work need an average of 7.5 appointments You can offer two appointments in a 3.5 hour session / half day Out of 52 weeks of the year, only 45 are actually worked For some of the capacity planning / rules of thumb that Only 2/3 of those having Choice will continue into Core Partnership work

Step 1 What is everyone doing at the moment?

Job planning: Blank Diaries Mon Tue Wed Thu Fri Psychiatrist Am Choice Pm Partnership Free SW Tier 2 Specific Admin Psychologist Non clinical Team meeting Systemic

Team Meeting Am Choice Pm Partnership Free Tier 2 Specific Admin Mon Tue Wed Thu Fri Psychiatrist Am Choice Pm Partnership Free SW Tier 2 Specific Admin Psychologist Non clinical Team meeting Systemic

Admin Time Am Choice Pm Partnership Free Tier 2 Specific Admin Mon Tue Wed Thu Fri Psychiatrist Am Choice Pm Partnership Free SW Tier 2 Specific Admin Psychologst Non clinical Team meeting Systemic

Specific clinical / task time Mon Tue Wed Thu Fri Psychiatrist Am Choice Free = 3 Pm Partnership Free SW Tier 2 Free = 6 Specific Admin Psychologst Non clinical Free = 4 Team meeting Systemic Free = 7

Other Commitments Am Choice Pm Partnership Free Tier 2 Specific Admin Mon Tue Wed Thu Fri Psychiatrist Am Choice Free = 2 Pm Partnership Free SW Tier 2 Free = 4 Specific Admin Psychologst Non clinical Team meeting Systemic

Free sessions for Core work Mon Tue Wed Thu Fri Psychiatrist Am 2 Pm SW 4 Psychologist Systemic pm TEAM TOTAL = 14 sessions Per week All Choice and Core Partnership

Step 2 How many Choice sessions need to be added to the Job Plans?

How many Choice appointments need to be added to those job plans? You need as many Choice as referrals accepted per week Can accept about 1 referral per FTE Time taken will depend on admin / IT tasks per Choice You can Scatter then around the team diary or Organise 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

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 TOTAL TEAM DEMAND = 4 Choice appointments per week Mon Tue Wed Thu Fri Psychiatrist Am Pm SW Psychlgist Ch Systemic TOTAL TEAM DEMAND = 4 Choice appointments per week TOTAL TEAM CAPACITY = 4 Choice appointments per week

Step 3 What is everyone’s capacity for Core Partnership?

Capacity for Core Partnership? p 88-89 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 Mon Tue Wed Thu Fri Systemic Am Pm CH Total sessions 10 Team meeting, YOT, Systemic Therapy clinic, LAC consultation, Management, Admin, = 6 Choice = 1 Remaining Core sessions 10 – 7 = 3 Core Partnership new clients per quarter 3 x 3 = 9

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 He will have left approximately 60 appointments for follow-up

How does he plan his work? Tue am Fri

Why? 97-103 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 can be seen and treatment completed But If your session average is more than 7 or you can only do 1 appointment in a half day e.g for LD The multiplier will be less

Step 4 Is the team in balance?

Team Core Partnership CAPACITY per 13 week quarter Mon Tue Wed Thu Fri Psychiatrist Am 2 x 3 = 6 Pm SW 4 x 3 =12 Psychlgist 3 x 3 = 9 Ch Systemic TOTAL TEAM CAPACITY = 36 new Core Partnerships per quarter

Is there enough capacity? Choice Partnership TOTAL TEAM CHOICE DEMAND = 4 Choice appointments per week TOTAL TEAM CORE PARTNERSHIP DEMAND = 35 per quarter 66% will need Core Partnership 2/3 x 4 x 13 wks =35 partnerships TOTAL TEAM CHOICE CAPACITY = 4 Choice appointments per week TOTAL TEAM CORE PARTNERSHIP CAPACITY = 36 per quarter BALANCED!

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 Team example... 14 sessions for core out of 40 = 35%

Reasons for Choice-Partnership Imbalance Too many referrals Too many referrals accepted Transferring a high % from Choice High need, Not full choice, “all need help” Choice taking too large a slice of core Long choice durations than planned for Shirking Lack of monitoring Vague job planning: low core% of whole service Vacant posts Pressure… Long average core partnership durations Less than 2 appointments per session

Flexing 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…

How could a rural service deliver CAPA? A rural service example: Single clinician Long travel times Lots of local relationship work Many settings Short contact durations (minutes)

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

The 11 Key Components of CAPA

11 Components of CAPA p 32-42

Choice components The first contact with our service Needs… Not assessment and treatment Criteria, full booking, flexing Choice As described…

The Choice – Partnership transfer Choosing the right Partnership clinician needs… from Choice…partnership diary Thinking about skills not professions Which is the second Language aspect

Partnership All the interventions of the team both core and specific. This needs… Extending and valuing threshold skills Including Core and Specific time etc

Letting go of families – throughput p 75-77; 168-170 Keeping a focus and working effectively requires… Reaching a Choice point leading to goals Weekly, small groups for ongoing work discussion and reviewing the goals

Team Components And finally to make it all work you absolutely need… a team of management, admin and clinical 4 days a year to think and work together…

The 11 Components Foundation Choice Transfer Partnership Letting Go