CAPA- Choice and Partnership Approach: the 4 Big Ideas and the 11 key components

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CAPA- Choice and Partnership Approachthe 4 Big
Ideas and the 11 key components

• Steve Kingsbury and Ann York
• Steve.Kingsbury_at_hertspartsft.nhs.uk
• Rowe.york_at_btinternet.com
• www.camhsnetwork.co.uk

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The Basics What are they?
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What is CAPA?

• the Choice and Partnership Approach
• 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 UK,
  New Zealand and parts of Australia

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Ancestors of CAPA
Demand and Capacity Theory
10 High Impact changes
User accessible services
Evidence Based practice
7 HELPFUL Habits of Effective CAMHS
Our Choices in Mental Health
Youre Welcome Standards
New Ways of Working
Choice and Partnership Approach
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What are the 7 HELPFUL Habits?

• 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

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7 HELPFUL Habits

• Handle Demand
• Extend Capacity
• Let Go of Families
• Process Map
• Flow Management
• Use Care Bundles
• Look after staff
• CAPA is a system that integrates these

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What CAPA isand isnt

• It is about
• Doing the right things
• With the right people
• At the right time
• By applying the majority of the 7 HELPFUL Habits
• Myths
• CAPA prescribes clinical interventions - NO
• CAPA is time-limited - NO
• CAPA is classic Triage - NO
• It is rigid NO
• You have to give up your whole diary NO
• Choice appointments have to be done in 45 min
  NO
• No specialist work allowed NO
• A plot by the Government - NO

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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

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The CAPA system
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The 4 Big Ideas What are they?
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The 4 Big Ideas

1. Choice
2. Core and Specific work
3. Selecting clinician to Partnership
4. Team Job Planning

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1st Big Idea Choice

• Choice philosophy throughout Partnership
• Choice appointments first contact with the
  service

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Aims of Choice

• Find out what they they want
• Use our knowledge to jointly form an
  understanding
• Together choose what will be helpful

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Interior Decorator

• Explore what the client wants
• Offer some advice (as an expert)
• Reach a decision together

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Tasks in the Choice appointment/s
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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

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2nd Big Idea Core and Specific work

• Key idea of separating our clinical work into
  core and specific work streams
• Core work is bulk of what we do
• All clinicians
• Extended clinical skills
• Manages most families
• Specific work
• Specific therapy, assessment or skill
• Additional to Core work
• Often done in a more formal way

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Why have separate core and specific work?

• Many can be helped by threshold level work
• Extended core skills reduces bottlenecks to
  specifc work
• Extended core skills increases clinical
  flexibility (fewer queues into specialised
  streams)
• Allows us to identify AND PROTECT specific team
  / individual capacity for specific work
• Segments and so helps flow

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Key concept extending clinical skills

• ABCDS Skills Clinicians (Alphabet skills)
• Clinicians who have extended their skills to
  include the core competencies of
• Assessment
• Behavioural
• Cognitive
• Dynamic.
• Systemic

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Specialist skills pattern
Skill level
Specialist
Threshold
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Core Extended threshold skills
Skill level
Specialist
Threshold
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So what does a typical clinician look like?

• Range of extended Core clinical skills
• Able to work flexibly between these skills
• Some Specific skills that are job planned
• Receive internal referals for
• Spend time (job planned) doing both Core and
  Specific

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Common team pattern
Specialist
Threshold
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Team skill issues

• Question
• How does the distribution of these skills affect
  the team?

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A Possible Pattern Effects?
Specialist
Threshold
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A Possible Pattern Effects?
Specialist
Threshold
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A Possible Pattern Effects?
Specialist
Threshold
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CBT core threshold vs specialist skills example

• 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 Heatlh 2007.

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3rd Big Idea selecting clinician

• This is
• At the end of the Choice appointment
• With the young persons and familys 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

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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
  clinicianand
• Helps capacity management!!

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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

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How do you find someone with the right Core
Partnership skills?

• Need to have mapped team skills
• Need to know each other
• Need extended skills in Core work
• Need to have done team job planning to have new
  Core Partnership appointments to book in to

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4th Big Idea Team Job Planning

• This is
• Each individual having a job plan that describes
  their work core, specific, choice, admin etc
• This plan being written with team needs in mind
• All the individual plans integrated into one team
  plan

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Why?

• Plans activity for the whole service
• Calculates capacity
• Makes work load manageable
• Flexibility to move and build resources
• Transparent monitoring
• Set standards for activity as well as protects
  staff from over activity

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Key task

• Defining different types of clinical work
• Choice
• Core Partnership
• Specific Partnership

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Core vs Specific work in job plan

• Core work
• Tends to be of standard duration- on average 7
  sessions
• Uses threshold level extended skills (ABCDS)
• Specific work
• specialist level skill used to complement the
  core work e.g specific assessment or intervention
• May be shorter (e.g. Specialist assessments) or
  longer duration (e.g. high intensity
  interventions)

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Specific work protected in job plan

• You decide as a team what you need to protect.
• Examples could be...
• Shorter duration
• ASD assessment
• WISC
• Longer duration
• psychodynamic psychotherapy
• EMDR
• Specialist level/high intensity CBT

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How do we job plan Core and Specific work?

• Need to identify
• Core work- using extended threshold level skills
• Specific work- using specialist level skills
• Using
• Competencies ideas
• Threshold and specialist level Alphabet skills
• This helps work out what to put in job plans and
  how much
• And information on
• Flow rates
• shorter term vs longer term durations
• This helps work out new activity rates/capacity

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Things to think about...

• Can a specialist do Core work?
• What about Long term core work?
• Anorexia nervosa- is it always specilaist?

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Team Job Planning How to do it...
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Team Job Planning in CAPA

• 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-ablenumbers

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Job plans include
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You need to work out

1. What is everyone doing at the moment? ie.
   current job plans
2. How many Choice sessions need to be added to
   those job plans to match referrals?
3. What is the capacity for Core Partnership in the
   job plans?
4. Managers is the team in balance?
5. Do job plans need reviewing?

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Assumptions

• All referrals that you accept will be guaranteed
  a Choice appointment within 6 weeks of referral
• Only 2/3 of those having Choice will continue
  into Core Partnership work
• 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
• You will design job plans according to what is
  currently being done

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Step 1 What is everyone doing at the moment?
ie. current job plans
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Job planning Blank Diaries
Mon Tue Wed Thu Fri
Psychiatrist Am Choice
Pm Partnership
Free
SW Am Tier 2
Pm Specific
Admin
Psychlgist Am Non clinical
Pm Team meeting

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

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

Systemic Am
Pm
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Specialist and specific time
Mon Tue Wed Thu Fri
Psychiatrist Am Choice
Free 3 Pm Partnership
Free
SW Am Tier 2
Free 6 Pm Specific
Admin
Psychlgist Am Non clinical
Free 4 Pm Team meeting

Systemic Am
Free 7 Pm
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Other Commitments
Mon Tue Wed Thu Fri
Psychiatrist Am Choice
Free 2 Pm Partnership
Free
SW Am Tier 2
Free 4 Pm Specific
Admin
Psychlgist Am Non clinical
Free 4 Pm Team meeting

Systemic Am
Free 4 Pm
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Free sessions for Choice and Core Partnership work
Mon Tue Wed Thu Fri
Psychiatrist Am
2 Pm

SW Am
4 Pm

Psychlgist Am
4 Pm

Systemic Am
4 pm
TEAM TOTAL 14 sessions Per week
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Step 2 How many Choice sessions need to be
added to those job plans?
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Team Job Planning Example

• Anywhere CAMHS...
• 4 full time staff (4 FTE)
• 4 referrals per week

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How many Choice appointments need to be added to
those job plans?

• All accepted referrals are offered a Choice
  appointment
• Number of referrals per week (that are accepted)
  4
• They need 4 Choice appointments.
• HOW?
• Each staff member can do 2 Choice appointments in
  one 3.5 hour session / half day

1.30 pm
1.30 pm
3 pm
3 pm
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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

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Choice Clinics
Mon Tue Wed Thu Fri
Psychiatrist Am
Pm

SW Am
Pm

Psychlgist Am
Pm Ch

Systemic Am
Pm Ch
TOTAL TEAM DEMAND 4 Choice appointments per week
TOTAL TEAM CAPACITY 4 Choice appointments per
week
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• Step 3
• What is the capacity for Core Partnership in the
  job plans?

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What is the capacity for Core Partnership in the
job plans?

• 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

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Andrew Down, systemic therapist
Mon Tue Wed Thu Fri
Systemic Am
Pm CH

• Total sessions 10
• Team meeting 1
• YOT 1
• Systemic Therapy clinic 1
• LAC consultation 1
• Management 1
• Admin 1
• Choice 1
• Remaining Core sessions 10 7 3
• Core Partnership new clients per quarter 3 x 3 9

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Team Core Partnership CAPACITY per 13 week quarter
Mon Tue Wed Thu Fri
Psychiatrist Am
Free 2 Pm

SW Am
Free 4 Pm

Psychlgist Am
Free 3 Pm Ch

Systemic Am
Free 3 Pm Ch
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Team Core Partnership CAPACITY per 13 week quarter
Mon Tue Wed Thu Fri
Psychiatrist Am
2 x 3 6 Pm

SW Am
4 x 3 12 Pm

Psychlgist Am
3 x 3 9 Pm Ch

Systemic Am
3 x 3 9 Pm Ch
TOTAL TEAM CAPACITY 36 new Core Partnerships
per quarter
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Why?

• 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
• And
• We know this number works for most UK CAMHS teams
• 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

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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

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How does he plan his work?
Tue am
Fri
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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

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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