What might help reduce waiting times in CAMHS? waiting... · What might help reduce waiting times in CAMHS? Bill Williams, General Manager and IAPT Project Lead, Tower Hamlets CAMHS

What might help reduce waiting times in CAMHS?

Bill Williams, General Manager and IAPT Project Lead, Tower Hamlets CAMHSDr Rebecca Adams, Consultant Child and Adolescent Psychiatrist, Tower Hamlets CAMHSDr Freya Gill, Clinical Psychologist, Newham CAMHS

The Need for Change• High referral numbers

• Long referrals meeting• Poor quality referral information

• Lack of systematic liaison with referrers/ families

• Delays in decision making • Insufficient information about alternative

services or self help

UCL

LCL

60

70

80

90

100

110

120

130

140

150

160

1/1/

13

2/1/

13

3/1/

13

4/1/

13

5/1/

13

6/1/

13

7/1/

13

8/1/

13

9/1/

13

10/1

/13

11/1

/13

12/1

/13

1/1/

14

2/1/

14

3/1/

14

4/1/

14

5/1/

14

6/1/

14

7/1/

14

8/1/

14

9/1/

14

10/1

/14

11/1

/14

12/1

/14

1/1/

15

2/1/

15

3/1/

15

4/1/

15

5/1/

15

6/1/

15

7/1/

15

No. of referrals received by Newham CAMHS per monthCount

Increase in referrals Vs reduction in resource

Key Aims of Front Door Team

• Improve decisions: Do referred children require input from CAMHS? Can they be signposted to alternative services?

• Reduce waiting times for first appointment.

• Improve patient experience of referral process by offering a more responsive service.

A New Referral Process

Referral received

Referral meeting

(FD clinician and Senior)

Allocate (Routine)

Allocate (Urgent)

Redirect/Close

Feedback meeting

(FD clinician and Senior)

Triage

Group Exercise You are part of the CAMHS Front Door Team and as a group you are required to make decisions about incoming referrals.

Stage 1. Identify what should happen with each new referral:• Allocate (Urgent) • Allocate (Routine)• Triage• Redirect/Close

Stage 2. Identify what should happen with the triaged referrals: • Allocate (Urgent)• Allocate (Routine)• Redirect/Close

Newham CAMHS Front Door TeamDr Priti Patel, Consultant Psychiatrist, Project Sponsor

Dr Freya Gill, Clinical PsychologistSari Ross, Clinical Nurse Specialist

Dr Carly Huck, Clinical Psychologist Dr Brigitte Wilkinson, Consultant Clinical Psychologist, Lead Clinician

Frances St John, Family TherapistNazneen Ramsahye, Lead AdministratorAnnabelle Perdido, Team Administrator

Meredith Mora, QI Clinical Fellow

Key Aims of Front Door Team

• Improve decisions: Do referred children require input from CFCS? Can they be signposted to alternative services?

• Reduce waiting times for first appointment at CFCS from 11 weeks to 9 weeks by April 2015.

• Improve patient experience of referral process by offering a more responsive service.

Cycle 1: Develop a standardize triage assessment script

Cycle 3: Pilot the ‘Front door’ (triage) service

Cycle 2: Develop a self-help and local service database

Quality Improvement (QI) Programme

Cycle 4: Use interpreters in triage assessments

Cycle 6: Offer face-to-face ‘drop-in’ appointments

Cycle 7: Pilot combined DLC & ‘front door’ role

Cycle 9: Implement the ‘front door’ service

Cycle 8: Align referral admin with ‘front door’ service

PDSA cyclesPlan, Do, Study, Act

Driver Diagram

To reduce waiting times for CFCS from 11weeks to 9 weeks

by April 2015 and improve the patient

experience of referral to CFCS as demonstrated by

increased attendance at first

appointment

Referral Processes

Define Admin process for handling referrals

Define standards from CAMHS clinicians in liaison

activity with referrers

Streamlining referral processes

Identify and use onward pathways for cases diverted

from CFCS

Demand Management

Information provided to referrers about CFCS

Checklists/ Screening tools for referrers

Awareness events

Signposting to alternative services

Limited Capacity

Increase proportion of telephone consultation time

Workload balancing

Broaden interventions Develop self help materials

Standardise liaison activity with referrers

Develop telephone screening protocol for families

Develop welcome call to families accepted to CAMHS

prior to appt

Develop library of easily accessible self-help materials

Screening checklists for GPs/referrers

Review and rationalise info sent to families

Develop knowledge about alternative services in

community / ‘secret shopper’ users.

Review and develop administrative systems for referrals

AIM PRIMARY DRIVERS SECONDARY DRIVERS CHANGE IDEAS

Outcomes

Waiting Time Data• Average wait for first appointment has dropped from an average of 69 to

54 days for the whole clinic.

UCL

LCL

30

40

50

60

70

80

90

100

1/1/

13

2/1/

13

3/1/

13

4/1/

13

5/1/

13

6/1/

13

7/1/

13

8/1/

13

9/1/

13

10/1

/13

11/1

/13

12/1

/13

1/1/

14

2/1/

14

3/1/

14

4/1/

14

5/1/

14

6/1/

14

7/1/

14

8/1/

14

9/1/

14

10/1

/14

11/1

/14

12/1

/14

1/1/

15

2/1/

15

3/1/

15

4/1/

15

5/1/

15

6/1/

15

7/1/

15

CFCS waiting time (days) referral to first appointment

Front Door Pilot

Warning: Data issues

Waiting Time Data

UCL

LCL

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Jan-

13Fe

b-13

Mar

-13

Apr

-13

May

-13

Jun-

13Ju

l-13

Aug

-13

Sep

-13

Oct

-13

Nov

-13

Dec

-13

Jan-

14Fe

b-14

Mar

-14

Apr

-14

May

-14

Jun-

14Ju

l-14

Aug

-14

Sep

-14

Oct

-14

Nov

-14

Dec

-14

Jan-

15Fe

b-15

Mar

-15

Apr

-15

May

-15

Jun-

15Ju

l-15

% of families seen within 9 weeks

• % of families seen within 9 weeks has increased from an average of 47%to 66% for the whole clinic.

Front Door Pilot

Warning: Data issues

Triage Wait Times• The current average waiting time for a triage assessment is under 2 weeks.

UCL

LCL

0

5

10

15

20

25

30

35

40

45

50

10/6

/14

10/1

3/14

10/2

0/14

10/2

7/14

11/3

/14

11/1

0/14

11/1

7/14

11/2

4/14

12/1

/14

12/8

/14

12/1

5/14

12/2

2/14

12/2

9/14

1/5/

151/

12/1

51/

19/1

51/

26/1

52/

2/15

2/9/

152/

16/1

52/

23/1

53/

2/15

3/9/

153/

16/1

53/

23/1

53/

30/1

54/

6/15

4/13

/15

4/20

/15

4/27

/15

5/4/

155/

11/1

55/

18/1

55/

25/1

56/

1/15

6/8/

156/

15/1

56/

22/1

56/

29/1

5

Average wait (days) from referral received to triage assessmentMeasure

Attendance Rates of First Face-To-Face Appointment

Data snap-shot: All referrals received in February 2015 (N= 60)

0%10%20%30%40%50%60%70%80%90%

100%

Attended DNA'd Declined

ExisitingProcess:

Triage:

Routine

Outcome after Triage Assessment

45%

22%

24%

4% 5%Allocate within CFCS

Close (no support needed/no contact made)

Re-direct to more appropriate service

Provide Self-help only

Re-direct to appropriate service and provideself-help

Service User Feedback

Limitations Advantages

Language barriers Familiar surroundings helps talk

Unexpected call Benefits of unknown voice

Challenges of unknown voice

Less exposing & more focused

‘[The triage call] was a lotmore better than going totalk to someone in person,because when you talk tosomeone in person it’s harderand especially if you’re in adifferent environment aswell… but when you’re athome & more relaxed... I justfind it easier..’

‘I just felt where I’vehad that womantalk to me in such anice way, I thoughtmaybe I’m going tohave that here [atCAMHs] as well…’

Being put at ease• Confidentiality• Expectations• Control• Clinician’s persona

Sense of relief and hope for help • Relief of beginning to talk with the hope of help• Off my chest• New conversations• Positive changes having talked

The experience of the telephone call

A Good Process• Call Length• Questions asked and use of measures• Better than a letter

Possible Areas for Consideration• Text notification of the call

• Clinician measures as conversational tools

From Triage to Assessment• Retelling the Story• Use of triage call in initial assessment

‘Maybe a text an hour before asking whether it’d O.K to call in an hour’.

‘When I’d already come out about the whole situation I thought oh I have to explain the whole situation again.. but I know I have to do it because it is going to help me.. So although it might be annoying saying the same thing over and over again… I found it fine’.

Feedback and ideas for improvementService User Feedback

What next?• Further evaluation - Service user feedback from families of

their experience• Service user participation – Ask young people to rate the self-

help materials we have sent and discuss how they would prefer to access it. Visit other local services to gather information about accessibility, projects etc.

• Eliminate weekly referral meeting – Front Door Team will enable service to respond to risky cases more effectively and for allocations to be made on a daily basis.

• Link up with related pilots within the service (e.g. primary care and schools link)

• Full Implementation – To provide Front Door Team to all referrals on a daily basis. Caution! Resource implications

Discussion and Reflections

Contact details

• Bill Williams: [email protected] 7426 2375/2400

• Dr Freya Gill: [email protected] 7055 8400

• Dr Rebecca Adams:[email protected] 7426 2375/2400