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Getting Better Data - Greenwich CAMHS, Greenwich CYP IAPT Partnership

This article describes four areas of success improving data quality; why and how.  It goes on to outline continuing challenges.

1.

The first area of success has been collecting measures at assessments (probably ~85% for the year 2014-2015).  I think some of the reasons for this are:

There is now clear guidance from Team Manager’s that it's EXPECTED (not "suggested" or "encouraged") that the measures are done at all first assessments unless there are extenuating circumstances.  Increasingly the culture is that is a mandatory requirement. The idea of mandatory requirements has been consolidated through CQUIN’s on goal based measures which highlight the importance of using measures in CAMHS standard clinical practice. We have seen a progression in incorporating measures into case discussion.

In some teams sending the measures out to families in advance of their appointments seems to work very well, as they often come with them completed. Some clinician’s have found it clinical meaningful to score up the RCADS and SDQ at the start of the initial assessment to help determine the clinical level of difficulties.

The measures fit well as part of the “Choice” appointment within the CAPA model, which is used in the generic team which sees the most cases

The Assistants have had to be robust about chasing clinicians to do missing time one measures particularly given recent high staff turnover and high caseloads. We have found that this is important at the beginning to support clinicians learning and remembering to do measures but, this can only stand as a short term solution and then a longer term protocol instituted.

Training at all levels of the organisation and within all teams has been important in establishing the culture of using measures. Additionally the role of supervisor in facilitating the use of measures has been essential and UPromise training for lead supervisors has helped to support this.

2.

The second area of success has been in collecting review/discharge measures (increased from a minimal amount to ~50% of cases seen in 2014-2015).

Again, support and guidance from Team Managers that this is expected of all clinicians, and forms a part of the clinical work and is not just a “tick-box” exercise

The Assistants developing a system to remind clinicians when it’s been approx. six months since Initial Assessment or last full review – the reminders are then sent via the Team Managers giving them more “weight”. Clinicians report that this is helpful – however, it’s quite an imprecise method and requires a lot of input to maintain (keeping a local “tracking spreadsheet”) so could definitely be improved

Use of measures as part of referrals within teams to other disciplines and between teams

3.

A third area of success has been an increase in use of session by session measures – What has worked is:

Clinicians who have been on the CYP-IAPT training make up a disproportionately large proportion of the good and meaningful use of session-by-session measures . The training clearly greatly develops their understanding and use of

Ongoing training/guidance through meeting with Assistants and team training slots have helped.

In the absence of an IT system which can easily storage and allow clinicians access to session measures we continue to work on systems around to facilitate clinicians use of them in their therapeutic practice while and at the same time allowing assistant psychologists easy access for data entry.

4.

A fourth area of success is that we now understand more clearly what kind of outcomes the CYP-IAPT quarterly reports are looking for (e.g. making sure that cases are closed; which measures can be “paired”; what “counts” and “doesn’t count” in the different tables).  Some of the guidance for this has come from Central IAPT, but a lot has come about through (painful at times!) trial and error.  In relation to specific variables that Greenwich CAMHS has improved their data return e.g. type of clinician (i.e. CYP IAPT trained, or not), referral source, completion of current view,  the key has been paying attention to exactly what's in the quarterly reports and making sure that data is going on CODE.  Some of this data is cross matched with RIO by assistant psychologist’s and they also have a printed list of what profession all the clinicians are and whether they're IAPT trained.

Briefly, what’s still not working is:

Having to maintain one IT system for clinical records and one for routine outcome measures means there is constantly a “split” between clinical and “data” uses of the measures, which is hindering them being fully integrated into normal practice

This also means that the whole system is reliant on Assistant Psychologists to maintain the “data side of things”, but this is getting increasingly unsustainable as the quantity of measures being used increases

Likewise, the administration side of keeping up with photocopying measures, storing completed measures etc. is also becoming increasingly unsustainable on a limited amount of Assistant Psychologist time

Very unclear still how applicable the measures are for specialist CAMHS teams, though increasingly clear that some are definitely NOT suitable (e.g. measures for LD team)

Ongoing challenge of bringing more established clinicians used to working in the “old ways” on board – much more difficult than with newer or more recently qualified clinicians!

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Self Referral - The Brandon Centre, Camden CYP IAPT Partnership

Context:

The Brandon Centre Psychotherapy Service provides psychological therapies to young people aged 12 to 24 years. It was founded over 40 years ago in the context of a contraceptive and sexual health service addressing the needs of young people. The service was set up to be easily accessible for young people, and confidentiality has always been paramount.

Currently 54% of all referrals to the Brandon Centre Psychotherapy Service are self-referrals (includes referrals by young people or family members). Other referrals come from GPs, Child and Adult Mental Health Services, Social Care, Schools/colleges, universities, drug services, etc.

Self-Referral Process:

Young people or parents/carers can phone, email or drop in to the centre to refer themselves (or their child).  Emails are usually followed up with a phone conversation to gather more information.

The referrals coordinator speaks to the young person/parent and initially gathers some basic information (age, address, GP) to check that they are within our age range and area, then goes through a referral form with the young person/parent, asking sensitively about why they are requesting therapy. They ask about involvement of other services, who recommended the centre, and if they are under 18, whether anyone knows about the referral. If the young person is presenting with risk issues (e.g. suicidal thoughts/behaviours, self-harm, or other ways of putting themselves or others at risk) then advice around safety may be given over the phone, and it is made clear that we do not provide an emergency service. They are asked about their availability times to attend, and informed of the length of time that they are likely to be waiting for their first appointment.

All referrals are discussed with the Lead Clinician or Director, and if appropriate the clinician contacts the young person or parent to gather more information, and with consent, may involve appropriate services to manage risk or direct them to other services (if we are not the appropriate service, or while they are waiting to be seen).

Some of the Pros of self-referral:

The service has validity for young people. They recommend their peers, and even bring in friends if they are concerned about them.

Young people are able to access the service, particularly those who may not be involved in other services and are unlikely to go via their GP.

Young people who self-refer are usually motivated to access help for themselves and are more likely to engage in the service.

Some young people who were referred as young teenagers return to the service when they are a bit older when they feel ready to address some of their difficulties. At this point they may not have been referred by a professional to other services (CAMHS or AMH services), but are now ready to make use of help. The self-referral process allows young people to develop a more proactive relationship to helping services.

Some difficult issues to consider about self-referral:

With the very nature of self-referral, you don’t have much information prior to seeing the young person. Staff need to be open to hearing what the young person is bringing and always consider issues of risk on a case by case basis.

Issues around risk may need to be managed differently because of how confidentiality is interpreted. The therapists are supported to be working with high levels of risk and addressing this using the strength of the relationship with the young person as a way of keeping the young person safe until they can bring in other support around them.

When young people self-refer it can be harder to put in place appropriate support around them.

Referrers often ask a young person to refer themselves when their work is coming to an end. Although this can show motivation in the young person, sometimes they are referred to several other services as well, with poor communication across the services, which can be unhelpful and confusing for young people and staff.

What we have found helpful:

Having excellent administrative staff – who are able to listen to and talk to young people and parents with respect and concern when they are making their first contact. Administrative staff are supported in developing their skills and in knowing their limitations. i.e. when to pass the call over to a clinician or ensure that a clinician follows it up.

Ongoing weekly supervision for admin/referrals staff by the lead clinician

All new assessments are discussed in the weekly team meeting soon after they have been seen.

Monitoring of the waiting list: we contact young people who are waiting to be seen for the first time and if there are concerns we will check in with some young people/parents while they are waiting, and if appropriate signposted to services (e.g. housing, drug services, employment services, crisis team, etc) while they are on the waiting list.

Working closely with other services – GPs, CAMHS and AMH teams, Social Care, schools/colleges, etc.

Reviewing the system as things change in the wider context.