Wikis, Ways of working, What works, Where, And with whom? Dr Dickon Bevington CLAHRC.

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Wikis, Ways of working, What works, Where, And with whom? Dr Dickon Bevington CLAHRC Slide 2 Mission Creep Survey staff training, attitudes, latent beliefs relationship of these to Adoption and implementation fidelity for AMBIT Outcomes Evaluation of one AMBIT service - CASUS Social Workers Working for Families (SWWFF) Multiple Models, Multiple levels evaluation of service reorganisation (service users, workers, and quantitative outcomes), including partially randomised trial of AMBIT in a Social Care setting. Slide 3 AMBIT a community of practice (Wenger and Lave) supported by innovative wiki manuals Slide 4 Guardian/Virgin Business Media Innovation Nation award for Collaboration www.tiddlymanuals.com Slide 5 Keyworker responsible for integration Intervening in multiple domains Mentalizing Active Planning Wiki Manualization Supervisory structures Addressing network dis-integration Scaffolding existing relationships Clinical governance Respect for evidence Respect for local practice and expertise Individual keyworker relationship Keyworker well- Connected to the team Bevington and Fuggle AMBIT STANCE & BASIC PRACTICE Find AMBIT at: www.tiddlymanuals.com Slide 6 Part 1 Learning about workers and ways of working Developed Questionnaire: the PREACHY (Practice, Relationships, Education, Attitudes and Coherence in Helping Youth) Adapted questions from a validated instrument (Scottish Effective Interventions Unit) for workers in field of dual diagnosis. (Watson, Shaw and Fraser, 2003, Scottish Effective Interventions Unit - http://www.scotland.gov.uk/Resource/Doc/47133/0013810.pdf) http://www.scotland.gov.uk/Resource/Doc/47133/0013810.pdf Added questions. Demographics and levels of training/experience. Experience of Working. Coherence/integration or dis-integration of care. Attitudes towards: Peer and supervisory support Use of treatment manuals and manualized interventions Development and use of evidence. Completed by 70 trainees prior to AMBIT trainings in 2011/12 Slide 7 Education/Training and working experience No. of staff (Total n = 70) Slide 8 At times I feel anxious working with complex hard to reach youth. Strongly Agree Strongly Disagree Slide 9 At times I feel anxious working with complex hard to reach youth. ( n = 67) Strongly Disagree Strongly Agree Slide 10 AMBIT: ORGANISATIONAL A shift of emphasis Family therapist CBT Therapist CPN YOT Worker Social Worker Doctor Young Person and Family Co- workers CBT Young Person and Family worker Social Work/CP Doctor Multi -modal worker Mentalization as the integrative therapeutic stance, AND a shared responsibility sustaining each others Mentalizing Team around the childTeam around the worker Slide 11 "In a team doing this work, it is more important to have people who can offer a range of very different models of understanding and working, than it is to have a shared model." "Strongly AGREE" Strongly Disagree Slide 12 "In a team doing this work, it is more important to have people who can offer a range of very different models of understanding and working, than it is to have a shared model." Slide 13 Mentalizing as an Integrative framework CBT: The value of understanding the relationship between my thoughts and feelings and my behaviour. SYSTEMIC: The value of understanding the relationship between the thoughts and feelings of family members and their behaviours, and the impact of these on each other. PSYCHODYNAMIC: The value of Understanding the nature of resistance to therapy, and the dynamics of here-and-now in the therapeutic relationship. BIOLOGICAL, SOCIAL and ECOLOGICAL: The value of understanding the impact of context upon mental states; development, deprivation, hunger, fear... COMMONLANGUAGE Slide 14 Part 1. Next steps Further stats analysis of existing (70 x 70) dataset, incl regressions. Post-training questionnaires (shorter!) Qualitative interviews of staff in AMBIT trained teams. Develop a regular Training Goals Outcomes Measure Slide 15 CASUS A service for young people with substance use problems Early outcomes evaluation: Analysis of data from a sequential series of 44 clients Part 2. Early Outcomes Slide 16 Inclusion criteria Young people are referred to CASUS by multiple agencies, or self-refer. Every young person seen for initial assessment (commonly via outreach at home, school, or a mutually agreed safe location) is discussed in clinical meeting, where shared decisions are made about formulation, and inclusion/exclusion from routine outcomes measures. By default, all clients accepted for treatment by the team have outcomes measures at treatment start and treatment end, unless the intervention planned is foreseen as very brief (e.g. psychoeducation or preventative work requiring maximum 1 - 2 meetings.) Brief work that translates into longer term work triggers entry into outcomes evaluation as soon as this is decided. Slide 17 Sample First 44 young people (sequential) with pre- and post-treatment measures completed. CASUS clients are all under 18 at referral, and resident in the county of Cambridgeshire (excluding Peterborough). Slide 18 Missing data Where data for a specific analysis was missing meant that the individual was excluded from that specific analysis (numbers in separate analyses are given) The exception was in the analysis of comorbidities; here, unanswered AIM items (usually due to young people declining to complete the interview) were counted as scoring 0 (= no problem) so a likely underestimation of difficulties. Slide 19 Outcomes Measures used AIM 40 items, covering broad range of functional domains (family, relationships, offending, socio-economic, mental health and complexity). Each item is Clinician-rated (0-4 scale of severity with anchored descriptions). CGAS 0-100 Clinician-rated TOP (Treatment Outcomes Profile) Detailed substance use self-report (not analysed here) and three Self-rated items on wellbeing (scored 0-20, Psychological, Physical and Overall) Clinical Global Impression (Severity) Clinician-rated, 7 point scale 1 = normal 7 = Very Severe. Slide 20 AIM severity scale 0 = No problem 1 = Mild problem 2 = Moderately severe problem 3 = Severe problem 4 = Very Severe problem Each item has ratings anchored with example descriptions Slide 21 Slide 22 AIM items: Percentages of 44 CASUS clients scoring 2 or greater on each item. Slide 23 AIM items: Percentages of 44 CASUS clients scoring 2 or greater on each item. Slide 24 DF = 58 P < 0.000 Slide 25 Clinical Global Assessment Scale (CGAS) 100 - 91 Superior functioning in all areas (at home, at school, and with peers); involved in a wide range of activities and has many interests (e.g., hobbies or participates in extra-curricular activities or belongs to an organised group, such as scouts, etc.); likeable, confident; "everyday" worries never get out of hand; doing well in school; no symptoms. 90 - 81 Good functioning in all areas, secure in family, school and with peers; there may be transient difficulties and everyday worries that occasionally get out of hand (e.g. mild anxiety associated with an important exam, occasional "blow-ups" with siblings, parents or peers). 80 - 71 No more than slight impairment in functioning at home, at school, or with peers; some disturbance of behaviour or emotional distress may be present in response to life stresses (e.g. parental separations, deaths, birth of a sibling) but these are brief and interference with functioning is transient; such children are only minimally disturbing to others and are not considered deviant by those who know them. 70 - 61 Some difficulty in single area but generally functioning pretty well (e.g. sporadic or isolated antisocial acts, such as occasionally playing hooky or petty theft: consistent minor difficulties with school work; mood changes of brief duration; fears and anxieties which do not lead to gross avoidance behaviour, self- doubts); has some meaningful interpersonal relationships; most people who do not know the child well would not consider him/her deviant but those who do not him/her well might express concern. 60 - 51 Variable functioning with sporadic difficulties or symptoms in several but not all social areas; disturbance would be apparent to those who encounter the child in a dysfunctional setting or time but not to those who see the child in other settings. 50 - 41 Moderate degree of interference in functioning in most social areas or severe impairment or functioning in one area, such as might result from, for example, suicidal preoccupations and ruminations, school refusal and other forms of anxiety, obsessive rituals, major conversion symptoms, frequent anxiety attacks, poor or inappropriate social skills, frequent episodes of aggressive or other anti-social behaviour with some preservation of meaningful social relations. 40 - 31 Major impairment in functioning in several areas and unable to function in one of these areas, is, disturbed at home, at school, with peers, or in society at large, e.g. persistent aggression without clear instigation; markedly withdrawn and isolated behaviour due to either mood or thought disturbance, suicidal attempts with clear lethal intent; such children are likely to require special schooling and/or hospitalisation or withdrawal from school (but this is not a sufficient criterion for inclusion in this category). 30 - 21 Unable to function in almost all areas e.g. stays at home, in ward, or in bed all day without taking part in social activities or severe impairment in reality testing or serious impairment in communication (e.g. sometimes incoherent or inappropriate). 20 - 11 Needs considerable supervision to prevent hurting others and self (e.g. frequently violent, repeated suicide attempts) or to maintain personal hygiene or gross impairment in all forms of communication, e.g. severe abnormalities in verbal and gestural communication, marked social aloofness, stupor, etc. 10 - 1 Needs constant supervision (24 hour care) due to severely aggressive or self-destructive behaviour or gross impairment in reality testing, communication, cognition, affect or personal hygiene. Slide 26 Slide 27 CGAS score Slide 28 Clinical Global Impression (severity) 1=Normal 2=Close to normal 3=Mild 4=Moderate 5=Quite severe 6=Severe 7=Very severe Slide 29 Slide 30 AIM - Substance Use (item no. 28) 0 = No problem. No use of alcohol or drugs, or only occasional (e.g. once a month) social use of alcohol. 1 = Mild. Occasional use of alcohol or drugs, but with no adverse consequences or regular intoxication; while hospitalised or restricted, denies any problem with substance abuse and intends to continue social use. 2 = Moderate. Use of alcohol or drugs to the point of intoxication at least once a week; while hospitalised or restricted, struggles with cravings, mixed motivation to abstain. 3 = Severe. Frequent (more than twice a week) intoxication; substance use affects relationships, school, and/or work functioning; if hospitalised or restricted, craves substances, talks or thinks repeatedly about use, no plan to abstain. 4 = Very severe. Substance use daily, in spite of adverse effects; while hospitalised or restricted, persistent cravings and attempts to obtain substances. Slide 31 Slide 32 Part 3. SWWWFF Social Workers Working for Families Slide 33 3 years prospective evaluation of a major re- organisation/re-training of Cambridgeshire Childrens Social Services. Budget 350K Multiple methods (Quantitative and Qualitative) and multiple levels (Clients, Staff and Economic cost-benefit analysis.) Including comparison of non-AMBIT trained Units and 6 (randomly selected) AMBIT- trained SWWFF Slide 34 Baseline survey of staff attitudes and experiences (shortened and adapted version of PREACHY) circulated. Ethics approval submitted. Post-Doctoral Research Associate interviewed and appointed. Research Assistant currently being recruited. Outcome measures agreed. Training for SW units in Systemic practice is occurring, augmented training in AMBIT due late 2013 SWWFF