CAPHC Concurrent Symposium Demolishing Silos and Lowering Barriers: New Models of Mental Health Services for Children and Youth

1. The Choice and Partnership
Approach (CAPA):
Improving the Delivery of Mental
Health Care
Sharon Clark, Ph.D.
Registered Psychologist
Advanced Practice Leader:
CAPA
Kathleen Pajer, M.D., M.P.H.
Chief of Psychiatry,
Children’s Hospital of Eastern
Ontario (CHEO)
Professor of Psychiatry
University of Ottawa FOM

2. Collaborators
• Debbie Emberly, Ph.D., IWK
• Susan McWilliam, Ph.D.,
IWK
• Emily DeLong, B.S., IWK
• Alexa Bagnell, M.D.,
F.R.C.P.C.
• Barb Casey, M.B.A., IWK
• William Gardner, Ph.D.,
CHEO RI
• Dave Murphy, CHEO
• Marjorie Robb, M.D., CHEO
• Karen Tataryn, M.S.W.,
CHEO
• Laura MacLaurin, M.S.W. ,
The Royal
• Christine Slepanki,
M.B.A.,The Royal
• Gail Beck, M.D., The Royal
• Dr. Judy Makinen, Ph.D., C.
Psych, The Royal
• Rebekah Ranger, BSoc.Sc., BA,
The Royal

3. Doing the right thing, at the
right time, with the right
people.

4. Overview
• What is CAPA?
• How is CAPA different from other service
delivery systems?
• How does CAPA work?
• CAPA at three Canadian sites.
• Lessons learned.
• Questions/Discussion.

5. What is CAPA?

6. • “You do not have to have a waiting list.
It can be eliminated. We need to stop
talking about assessment and
treatment—things we do to people—
and talk instead about partnership and
collaboration.”
Dr. Ann York, Psychiatrist, CAPA Developer

7. • CAPA is innovative method to deliver Child and
Adolescent Mental Health Services.
• It improves patient flow and quality of care.
• Widely used across the UK, New Zealand,
Australia.
• CAPA makes child and adolescent mental health
services:
– user-friendly
– client/family focused
– accessible
– safe
– effective.

8. CAPA Internationally
NSW
WA
Victoria
NZ
Nova
Scotia
Belgium
UKIreland
Ottawa
Ontario

9. How is CAPA different from other
service delivery systems?

10. Philosophy and mechanics.

11. Fundamental change in philosophy of
clinical care.
Challenges all assumptions and asks the
“system” hard questions:
• What is the role of the family in care?
• What is the role of the clinician/physician in
care?
• What is our “core business”?
• What is value-added?

12. Knowledge
Experience
Skills
Professional
Client
Knowledge
Experience
Skills
Values
Slide from capa.co.uk

13. Shared decision making.
A consultative process where a clinician and client
jointly participate in making a health decision, having
discussed the options and their benefits and harms, and
having considered the patient’s values, preferences and
circumstances.
Involves the professional and the service user bringing
together their individual sources of expertise

14. Shift in responsibility.
Family bus ride has already
started. • The bus ride doesn’t start
start at MH care facility.
• The bus ride destination
is not the MH care facility.
• So, how do we get on the
bus with family?

15. Value-added care.
• Value is anything that improves
health, well-being or care
experience of patient/family.
• Value is defined by patient or
family.
• We identify the ‘value stream’ or
key set of actions required to
deliver value.
• The trick is to maximize actions
that add value and eliminate
waste.

16. Importance of letting go.
“CAPA is all about empowering people and
helping them access their own resources –
and those in their communities – to move
their lives forward. Part of this is not to
assume they need services….” CAPA Manual, 2013, p.
81
“Release people back into the wild”

17. Mechanics: CAPA uses quantitative
approach to service delivery.
• Demand and Capacity Theory
• Queue Theory
• Lean Principles

18. Capacity and resources.
• A key lever for improving patient flow.
• How do we measure capacity?
– What is the capacity of a 20 seat restaurant?
– A 16 bed ward?
• Capacity is a RATE
– Customers/hour
– Patients/day
• We can view a 16 bed ward as a queuing system with 16
servers
– What is the capacity of a bed?
• A delivery system comprises resources with capacities.
– Resources and capacity are not interchangeable; one is a
function of the other
– Capacity may fluctuate
Puterman, Martin, 2012, BHAC 510 Coursework

19. Demand and capacity.
• Too much capacity or too many resources =
idleness
• Not enough capacity = waits
• Resource manager must trade these off taking into
account system objectives and available resources
• Should we set capacity equal to demand?
– This is called a balanced system
– It works perfectly when there is no variation in the
system
– It works terribly when there is variation! Why?
• Once behind, you never can catch up.
– Queuing theory quantifies these tradeoffs in terms of
performance measures.
Puterman, Martin, 2012, BHAC 510 Coursework

20. Queuing models.
• (Mathematical) queuing models help set
capacity (or determine the number of
resources needed) to meet:
– Service level targets
– Average wait time targets
– Average queue length targets
• Queuing models provide more precise
alternative to simulation
• They provide insights into how to plan,
operate and manage a system
Puterman, Martin, 2012, BHAC 510 Coursework

21. Push-Pull: the milkman.
• Push – the milkman delivers every day
• The delivery rate come from the milkman
• Pull – the family puts out a bottle when they need
milk
• The rate comes from the family across continuum ofSlide taken from

22. CAPA: Putting it all together.
• Demand
– Each referral is a request for a clinical service;
demand is the number of clinical hours needed
• Capacity
– Skills bank and resources required to deliver those
skills
– Skill bank built with targeted recruitment and clinician
education
– Capacity is not number of clinical staff, but number of
clinical hours available to meet demand
• Queue estimates used to create job planning.
• Lean principles to map out efficient care with
least waste.

23. How does CAPA work?

24. Slide taken from CAPA.uk.co
11 Key Components
CAPA Key Component Aim Why?
1. Leadership To drive and sustain Change management
2. Language
Active, understandable, non
judgmental
Engages clients
3. Handle demand Transparent and agreed Flow, transitions, joint working
4. Choice framework Shared decision making
Adds value, reduces waste, reduces
drop outs
5. Full booking
Smoothes flow, improves
engagement
Client has activities ‘pulled’ towards
them as they need
6. Selection by skill
Matching skills to need
Increase effectiveness of help
7. Core and advanced skills Evidence informed practice Effectiveness, workforce development
8. Job planning Defines and deploys capacity
Flow, monitoring, flexing,
commissioning
9. Goal setting and outcomes Regular outcome monitoring
Effectiveness and satisfaction, reduces
drop outs and drift
10. Peer group supervision
Learning, governance, reducing
variation
Safety, effectiveness, flow
11.Team away days Team functioning
Effectiveness, satisfaction, reduced
sickness, retention

25. 5 BIG ideas.
1. Choice
2. Core and Specific Partnership Work
3. Selecting Core Partnership clinician
4. Job Planning
5. Peer group discussion

26. #1 What is Choice?
• Choice appointment = first face to face contact
• Find out what child, youth and family wants
• Use clinical knowledge to collaboratively
formulate problem
• Choice is single session intervention
• Clinician and family design plan to help with
problem:
– Choice is enough and they can exit or
– Return to clinic for treatment matching problem or
– Refer to another agency or care provider for better
match
Slide content taken from CAPA.co.uk

27. Choice: menu of treatments.
• Establish treatment goals with clients
• Match goals with menu of treatments
– Methods: group, 1:1, in-home, family, school
– Intensity: outpatient, inpatient, acute care, day
treatment Intensive services
• Consider patient/family’s capacity for change

28. #2 Core and Specific
Partnership Work
Slide content from capa.co.uk

29. What is core partnership?
• If patient/family will stay at clinic after
Choice appointment, then go to Core
Partnership
– treatment matched to Choice-defined problem
and goals, i.e., family “pulls” care in
– assigned by reviewing who on team has skills
best suited
– evidence-based treatments effective across
wide range of problems, e.g. CBT
– Can be individual or group care
– CAPA model suggests average of 7.5
sessions

30. Specific Partnership
Specific:
• When a particular
technique,
assessment, or skills
is needed for specific
symptoms or
problems as a
complement to Core
work
• Treatment duration is
shorter or longer
Specific Time examples:
– Diagnostic
Assessments
– Cognitive
Assessments
Specific Clinics:
- OCD
- Eating Disorders
- Psychosis
- PDD

31. # 4 Job Planning:
Pooling Our Time on Teams.

32. Goals to Methods
• Better match the treatment options to the
goals identified by the client.

33. Monday Tuesday Wednesday Thursday Friday
8:30
9:00
10:00
11:00
12:00
1:00
2:00
3:00
4:00
5:00
6:00
7:00
Team
Meetin
g
Discipline
Meeting
Specific:
Cognitive
Ax
Choic
e
Partner
ship
Partner
ship
Partner
ship
Priority Ax
Group
Big
Admin
Carepat
h
# 4 Job planning.

34. #5: Peer group discussion.

35. Weekly peer group discussion.
• Weekly meetings of all
clinicians on team:
– Discuss Choice
appointment outcomes
– Distribute workload
– Do clinical peer
supervision
• Purpose
– Builds trust within teams
– Supports “letting go”
– Specifies clear treatment
goals and monitoring
using outcome
measures
– Helps develop a learning
culture
– Reduces variability in
responses to client’s
needs
– Increases safety and risk
management

36. CAPA at three Canadian Sites.

37. IWK Health Centre
• IWK Mental Health Program
- Mandate for service delivery across continuum
of care
- total of 400 allied professionals and support
staff providing care across multiple service
areas and 17 psychiatrists
- CAPA started April 2012 in outpatient teams
2015/16 Data:

38. 0
50
100
150
200
250
300
350
400
450
500
Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1
2011-2012 2012-2013 2013-2014 2014-2015 2015-2016 2016-
2017
Referral to Choice: Regular
Overall CMHA
# of New Patients Average wait
Source: IWK Community Wide
Scheduling

39. Source: IWK Community Wide
Scheduling
0
10
20
30
40
50
60
70
80
Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1
2011-2012 2012-2013 2013-2014 2014-2015 2015-2016 2016-
2017
Referral to Choice: Priority
Overall CMHA
# of New Patients Average wait

40. Effect of CAPA: Days from
Referral to First and Second
Visits
TIME
2011 (Pre-CAPA) 2013 (Post-CAPA)
0
100
200
Referralto2ndVisit(Days)

41. IWK client feedback.

42. CHEO
• CHEO Mental Health Program, Outpatient
Service:
– Psychiatry Dept. (3.4 FTE) provides all
psychiatric care
– 12.5 total FTE allied health professionals and
support staff
– 15/16: 1479 referrals to Outpatient; 8715
visits; all off site; Outpatient Eating Disorders
is separate
– In care partnership with the Youth Program at
The Royal Ottawa Hospital: Young Minds
Partnership

43. Progress to date
• Pre-CAPA: wait time to first appointment =
average 200 days
• Current wait time: 4.5 weeks
• Current wait time for Partnership
(excluding groups) = 8 weeks
• Skills and competencies assessment
identified following gaps:
– Trauma care, brief interventions, some group
therapies, family therapy

44. The Royal Ottawa Hospital
• The Royal is specialized mental health centre to
treat people with complex, serious mental illness
in Eastern Ontario.
• The Youth Program provides intensive,
specialized mental health services to 16-18
year-old youth with early onset major psychiatric
disorders or complex psychiatric illnesses
resistant to treatment.
• Number of clinicians and psychiatrists = 15
• Waitlist blitz – early 2015; CAPA March 2016

45. Progress to date
• Wait times:
– January 2015 ~ 18 months (blitz)
– March 2016 ~ 2 months
– Currently ~ 4 weeks

46. Progress to date
• Parent Choice experience (N = 16)
“Overall, the help I had here was good.”
All true 84.6%
Partly true 7.7%
Don’t know 7.7%
“Did you feel that people here listened to your concerns?”
Very much 92.3%
Pretty much 7.7%
“Was today’s session helpful for you?”
Very much 69.2%
Pretty much 15.4%
A little 15.4%

47. Client & Clinician Ratings/Choice
(N = 23)
Q1 – “How much were they/you curious about their/your
view point…?”
RESPONSE CLIENT CLINICIAN
None 0% 0%
A little 0% 0%
Some 8.7% 0%
A fair bit 8.7% 9.5%
A lot 39.1% 47.6%
Loads 43.5% 42.9%

48. Client & Clinician Ratings/Choice
(N = 23)
Q2 – “How much did they/you share their/your thoughts
and opinions for you to discuss?”
RESPONSE CLIENT CLINICIAN
None 0% 4.8%
A little 0% 0%
Some 13.0% 19.0%
A fair bit 21.7% 42.9%
A lot 52.2% 19.0%
Loads 13.0% 14.3%

49. Client and Clinician
Ratings/Choice (N = 23)
Q3 – “How much did they/you come to a share view as the
nature of their/your problems?”
RESPONSE CLIENT CLINICIAN
None 0% 0%
A little 0% 0%
Some 8.7% 0%
A fair bit 8.7% 9.5%
A lot 39.1% 47.6%
Loads 43.5% 42.9%

50. Lessons learned.

51. Key CAPA elements
• Systematic evaluation of progress: use data to inform
decision-making.
• Fidelity is critical.
• Mechanics done without philosophy change is “doing
to” our clients, not “engaging with” them.
• Need to build continuous skill development:
– Choice Clinic = pushing out the private practice model and
building trust.
– Team Peer Supervision = creating an environment where
clinicians can ask for help.
– Developing clinical capacity in specific clinics to strengthen
core skills.

52. Rethink engagement.

53. Lessons learned.
• Program administration needs
to be actively supporting
CAPA
• Achieving flow of patients
means radically new thinking.
• Change will come in waves.
• People may accept CAPA and
then drift back to old ways.
• The power of families as
collaborators is freeing.
• Stick with it.
• Share what you’ve learned.
• Find mentors and stay in
close communication.
• Fidelity to model is critical.

54. Resources
• All the CAPA ideas and concepts presented
today were developed by Drs. Steve Kingsbury
and Ann York.
• Please see the http://www.capa.co.uk/ website
for more information or refer to their publication:
The Choice and Partnership Approach: A
Service Transformation Model (2013)