Impact of austerity on re-design

Birmingham CAMHs

Central components of CAMHs re-design

Work to date

• Defining groups / pathways

• Process mapping

• Content analysis

• Defining content

To do

Define organisation and structure

Process Mapping -what we have learnt

• Timeliness

• Inconsistency / variation – procedures, standards

• Specific / specialist – poorly defined and protected

• Choice / Partnership the most planned part of our system

REF

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SPIT

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UN

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•SOCIAL CARE•SCHOOLS•COMMUNITY•GP’S•OUT OF B’HAM & IN BHAM•OTHER HEALTH PROFRESSIONALS•SCAP

PSYCHOLOGYHP REFER TO BCH PSYCHOLOGY

DECISION POINT

EMERGENCYYES

NO

ERA CLINICIANADMIT TO PAEDS BED

ERA LIASES WITH

REFERRER AND

TELEPHONE RISK

ASSESSMENT

ASSESSMENTYES -

•WHO •WHEN•WHERE

NO - EXIT

SCAP/ERA

URGENT PSYCHOLOGYASSESSMENT

PLANNED WITHIN NEXT 24 HOURS

(UNLESS MITIGATING

CIRCUMSTANCES)

PSYCHOLOGYDECISION

REGARDING EMERGENCY

EXIT

PSYCHOLOGY•PSYCHOLOGY OUTPATIENT WAITING LIST•SIGN POST ELSEWHERE

PSYCHOLOGY

•OUTPATIENT WAITING LIST(13 WEEKS)

•LOCALITIES CAMHS & OUT OF B’HAM

PSYCHOLOGYTREATMENT AS

USUAL, 2/3 RESOLVED WITHIN 3 SESSIONS

(ASSESSMENT COMPLETED, CARE PLAN)

ASSMT & RISK MANAGEMENT

(HOSPITAL WARD,

COMMUNITY, SCHOOL, CLINIC)

•COMMUNITY CAMHS 7 DAY FOLLOW-UP

• HANDOVER TO LOCAL CAMHS TEAM, (NON-BHAM)

AWAIT GATEWAY ASSESSMENT (HTT/TIER 4)

GATEWAY ASSESSMENT

DECISION POINT

•REQUEST HTT/TIER 4 ASSMT•STAY IN /COME INTO HOSPITAL FOR FURTHER ASSMT & RISK MANAGEMENT•INVOLVE SOCIAL CARE•DISCHARGE FROM HOSPITAL

PSYCHOLOGY DECISION POINT

•OUTPATIENTS•ON GOING TREATMENT•TREAT AS INPATIENT•LONGER PIECE OF WORK

•JOINT PLAN WITH MH & SS•DISCHARGED TO SOCIAL CARE PROVISION

OOHHANDOVER FROM ERA

TO ON CALL SPR

OOHTELEPHONE

RISK ASSESSMENT •ADVISE OVER THE PHONE•FACE TO FACE

OOH•HTT MAKES ARRANGMENTS•ASHFIELD ADMITTED•EXIT, 7DAY FOLLOW UP DEPENDING ON HANDOVER

EXIT E PATHWAY TO SCAP

YES

SOCIAL CARE INPUT, JOINT ASSMT

ERA/MEDIC REVIEW/ASSESSMENT

DECISION POINT

•HTT INPUT•TIER 4 BED•EXIT PATHWAY

•POLICE•EDT SOCIAL CARE•A & E•RAID•SCAP

OOHSWITCH

BOARD CONTACTS SPR OR HANDOVER FROM

ERA CLINICIAN

OOHSPR OR

REGISTRA ASSESSMENT

OOHMANAGEMENT

•HHT•INPATIENT•ONGOING

•CONTAINMENT•EXIT

PSYCHOLOGYREFERRAL

•PHONE•FORM•VERBAL

PSYCHOLOGYDUTY

PSYCHOLOGIST/SPECIALIST –

REVIEW REFERRALMON-FRI 9-5

URGENT

NON URGENT

OOHRING SPR

OOHON CALL SPR ,

INVOLVE CONSULTANT

KNOWN /EXSISITING

CASES•PHONE CALL•IS SESSION•TURN UP•INCIDENT

LOCALITY TEAM•TELEPHONE REVIEW & MANAGEMENT•FACE TO FACE CONTACT•REFER TO ERA(WHO, WHEN , WHERE)

•ADVISE OR EXIT

•REFER TO A&E

•FACE TO FACE

•SPEAK TO COLLEAGUES

END

ASSESSMENT COMPLETED

LD ALL ABOVE MINUS REFER TO ERA

LAC ALL OF TIER 3 – INTERNAL PROCESS OF USING INTERNAL CLINCIANS (LESS ROBUST)

HTT •COMMUNITY CAMHS•POS•ERA INPATIENT

•TELEPHONE/FAX •TELEPHONE SCREENING ASSESSMENT (WITHIN 4 HOURS)

OOHRING SPR

DECISION POINTASSESS OR REJECT

TRANSFER BACK TO T3

POSPOLICE TO BCH SWITCHBOARD, POS COORDINATOR

POLICE DECISION POINTMEDICALLY FIT

UNFIT ED

136 SUITE ASSESSMENT MHA

IN HOURS - DR / AMP (ERA)OOH – ON CALL SPR DUTY AMP

DECISION POINTDETAINED NOT DETAINED

DECISION POINTMANAGE-MENT PLAN

ADMISSION TO T4

LIASON

REFERRAL FROM GENERAL PAEDS CAMHS AT BCH, ERA

SCREENINGSIGNPOSTING

ASSESSJOINT ASSESSMENT WITH REFERRER

ENDCAMHS LIASON

•ASSESSMENT ON GOING•CRISIS MANAGEMENT•LIASON MANGEMENT

NO

HTT INPUT, ALONGSIDE TIER 3

Key issues regarding pathways

• Importance of – good decision making (evidence driven)

– making it simple and understandable (enhancing patient and clinical experience)

– each component part doing its job well (competent + skilled workforce)

– avoiding unnecessary hand offs, cul de sacs and passing on (enhancing patient experience, responsibility taking)

– clarity regarding what people should do (keeping high standards)

– organisational structure which supports the work people are expected to complete (making it manageable).

Community CAMHS – basic pathway

Clinical pathways

• Each pathway have worked on content

– What should people be providing, in terms of assessment, formulation and treatment

– Expectation that clinical staff will follow structure and content of pathways

– Possible to break the pathway into constituent parts with specific responsibilities to be completed at each stage (to a specific level)

Basic CAMHs process

Mood - assessment, formulation, psycho- education, intervention

Formulation and goal setting (use additional

assessment questions to help formulate as well as

outcome measure questionnaires to identify

depression-specific issues)

Psycho-education about depression (direct to self-help materials as well as discussing depression,

what it is, how common it is and how it affects

you)

Emotion recognition (use rating scales and mood

monitoring forms, bag of feelings, feelings cards)

Activity scheduling (may need to involve parents in making sure activities

are available and realistic)

Problem solving skills training

Mindfulness/relaxation/grounding skills training

(tracks available to download from

Cognitive strategies to address

distortions/deficits (use think good feel good

worksheets or Friends red/green thoughts

worksheets )

Relapse prevention/blueprinting

Stock take• Each of the groups were asked, in preparation for the

awayday to take stock

• Some groups e.g. City wide CAPA, SCAP are in the midst of implementation and have coherent plans. LD probably in same place.

• Neuro-developmental, Emotional / Behavioural are well positioned to look at implementation – fitting in with existing CAPA model. Some issues such as use of groups outstanding

• STEP pathways – most challenging area not just content but also how to incorporate lean organisation – are there more radical patient friendly solutions

• ED pathway – slightly out of kilter with other pathways (set up later) – some clear progress that can be made

Pathways – where to gate keep

Which pathways?

Raising Thresholds

Merged pathway – based on integration of clinical presentations (?interventions)

‘I skate to where the puck is going to be, not where it has been’

Preparing for the future Things that can help us

• Patient experience

• IAPT

• Training

• Trust values

• Valuing basic care (and tasks)