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

A Service Transformation Model Collaboration Demand & Capacity Skill layering Leadership

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?

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!

Ready for Change?

Traditional CAMHS… Referral Triage / assessment process – often lengthy Initial ASSESSMENT Standard treatment by SAME clinician Specialist Referral Waiting List = long delay

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 Specific work Demand and Capacity Flow management Segmentation

The 5 Big Ideas p 27-31 These are... 1. Choice 2. Selecting clinician for Partnership 3. Core and Specific work 4. Team Job Planning 5. Peer group discussion

1st Big Idea Choice

Choice p 46-57 Choice philosophy: throughout the whole service – Choice and 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 Assessment and Risk Joint Formulation Goals Alternatives Choice Point Next Steps Engagement in their Choices

None A little Some A fair bit A lot Loads 1 2 3 4 5 6 How 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?

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

The Quantum Super-position of Choice! Collaborative Let them be “them” Letting them know what will happen Connecting as a person Curiosity and Listening Going at their pace Keeping it safe Deciding together Professional Risk Recording Diagnostic screening Safe guarding Agreeing outcomes and goals Formulating Keeping to time etc

Choice Facts Most people or all can do Choice (if have skills) Single clinician Lasts varied time [clinical + admin] Choice + is possible Choice introduction… Choice letter Includes Formulation, goals, homework and action Key worker responsibility clarified Post- Choice discussion weekly

2nd 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 Core Partnership diary

Why? Allows Core Partnership onset with right clinician with the right Core Partnership 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!! Separating the Choice from the Core Partnership work allows Choice activity to be based on referral rate Core 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 Core 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 core skills in Core work Need to have done team job planning to have new Core Partnership appointments to book in to

Patient Experience Have Choice appointment Choose with Choice clinician the Partnership clinician based on Skills Availability Leave the Choice with that appointment [= fully booked]

Team Experience Many staff doing Choice Booking Partnerships in Partnership diary Then each clinician books their follow-up in THEIR diary

3rd Big Idea Core and Specific Work

Clinical skills ABCD’S Skills (Alphabet skills): These are the range of skills that clinicians need: Assessment Behavioural Cognitive Dynamic. Systemic

“Traditional” skills pattern

Extended skills clinician

Single modality Core work

Single modality Core work II

CBT: core vs advanced skills Core CBT: Core/basic work- explain model, structure sessions, using homework, reviewing homework Specific CBT: (using advanced skills) 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 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.

Integrative Core work

Skill summary Advanced Skills are often distinct skills in a single modality trained to a higher level and delivered a higher intensity CORE skills are either to be competent at that modality = single modality Integrative work across modalities at lower fidelity

A Possible Pattern… Effects?

A Possible Pattern… Effects?

A Possible Pattern… Effects?

A possible team pattern Assessment Behavioural Cognitive Dynamic Systemic

Work streams So now we’ve defined the streams by skill / intervention into Core Specific We need to work out how much we can do in THAT stream… This is a PACKING problem.

Splitting the streams The demand and capacity term for identifying different streams is segmentation Dividing a group up into smaller groups with similar characteristics But first lets look at what happens with no segmentation…

No segmentation? One big fruit crate… Hard to know quite how much fruit we can get in.

Segmentation Segment the big crate into 4 smaller crates… Fill 2 of the crates with the SAME sized fruit – apples and oranges… CORE fruit Now we know how much of averaged sized fruit we can pack in…

Specific 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

Another fruit What if we have some bigger fruit? A 4th crate could have pumpkins They are bigger still… So even less can be packed in

Why have separate core and specific work? Segments and so helps flow Segments have different clinical needs and characteristics so that… Many can be helped by core work Extended core skills reduces bottlenecks to specifc work Extended core skills increases clinical flexibility (fewer queues into ‘specific interventions’ streams) Allows us to identify AND PROTECT specific work with advanced skills

4th Big Idea Team Job Planning

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

Recap: 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!

Step 1 What is everyone doing at the moment?

Job planning: Blank Diaries Mon Tue Wed Thu Fri Psychiatrist Am Choice Pm Partnership Team Meeting SW Other Tasks Specific Clinical Admin Psychologist Systemic

Insert Team Meeting… Am TM Choice Pm Partnership Team Meeting Mon Tue Wed Thu Fri Psychiatrist Am TM Choice Pm Partnership Team Meeting SW Other Tasks Specific Clinical Admin Psychologist Systemic

Specific Clinical Can be advanced clinical skill OR core skill deployed in a specific or structured way E.g. groups, parenting

Other Tasks Non clinical tasks such as Management, Professional meetings & management Supervision, supervising Care bundle development Committees Inter agency panels Research & audit CPD

Add Specific Clinical and Other Tasks Mon Tue Wed Thu Fri Psychiatrist Am TM Choice Pm Partnership Team Meeting Social Worker Other Tasks Specific Clinical Admin Psychologist Systemic Therapist

Add Big Admin Am TM Choice Pm Partnership Team Meeting Other Tasks Mon Tue Wed Thu Fri Psychiatrist Am TM Choice Pm Partnership Team Meeting Social Worker Other Tasks Specific Clinical Admin Psychologist Systemic Therapist

Sessions Free for Core Work… Mon Tue Wed Thu Fri Psychiatrist Am Choice Pm Partnership Team Meeting Social Worker TM Other Tasks Specific Clinical Admin Psychologist Systemic Therapist

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

Decide who will do Choice Probably good if most / all of the team 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 And the ability to FORMULATE!

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” Need to time table a “Post-Choice” discussion in team diary In this example 4 referrals accepted and 2 clinicians see 2 each on Monday afternoon (admin may overflow)

Choice added… Am Choice Pm Partnership Team Meeting TM Other Tasks Mon Tue Wed Thu Fri Psychiatrist Am Choice Pm Partnership Team Meeting Social Worker TM Other Tasks Specific Clinical Admin Psychologist Systemic Therapist

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 3? 97-103 Maths… 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

Core and Specific Revisited Reasons Takes 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?

Exploring Job Planning Write down and discuss in small groups the Specific bits of your job plan… Takes longer or shorter than average Allocated to a specific task Uses advanced skills What is it? How much time?

Step 4 Is the team in balance?

Team Core Partnership CAPACITY per 13 week quarter TOTAL TEAM CAPACITY = 36 new Core Partnerships per 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

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

5th Big Idea Peer group discussion

What is it? Meeting weekly in small groups to talk about ongoing work About 1 to 1.5 hours 3 to 5 people Not single discipline Stable or random groups Pro’s and con’s to both Aim for everyone to present each week

Why? This is about letting go Developing a learning culture re core skills Get advice from colleagues Keep a focus on clients goals

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

Why not do CAPA? Can’t think of a reason! Challenges Your IT and processes may need to be adapted Cultural change to transparency, user focus and striving to improve requires excellent leadership and change management skills

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 core 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