Talking about Choice

Was doing some supervision today and talking about a case of a very anxious mum who seemed over involved with a dependent and anxious child with a diagnosis of Aspergers.  What she wanted – for any “help” – didn’t seem to match well our understanding that her relationship with the child was a part of the issues that we’d like to think about.

This raised a challenge of how do you get to a Choice point if your mutual understandings are miles apart. The clinician I was talking to had actually booked the family into a partnership as they “clearly needed help” (i agree) but not with any mutually agreed goal.

I think the “honest opinion” step of Choice maybe should have been used a bit more. Comments on how close they seemed. What did she think of that? Asking whether mum thought how she felt affected how the child felt or maybe what was her view of successful development or separation. Do you have any thoughts? I think this is trying to get at mums formulation of the situation rather that her experience of the situation…

Just goes to show that although CAPA definitely helps (we think) it doesn’t always make every situation easy!

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Choice and Assessment

At a recent consultants meeting in Hertfordshire we spent some time thinking about Choice appointments and, as i discovered, some continuing myths about the role of assessment. First off let me state the myth: that Choice appointments do not contain any assessment – it is just offering a range of Choices. I can see where this myth comes from as Ann and i talk a lot about Choice and the need to work with the users wishes, hopes and wants. As well as our recommendation that we stop calling the initial contact “Assessment” (as we think this word is not collaborative) and to call it something else, maybe “Choice”.

BUT we also say that our job is to “facilitate their choices using our expertise”. In other words we have to do think about both assessment and risk to be able to have conversations with the young person in a collaborative and informed manner. The trick is to move away from an expert assessment that makes the young person and family feel passive to being able to do our assessment and risk thinking in a conversational manner that both gives us the information we need and keeps the young person and family active and engaged.

In fact it is this open and honest conversation with the young person and their family using my ideas as well as their hopes and wishes that I find so rewarding in a CAPA service!

FAQ: how long does it take to do a Choice appointment?

Q: Hi- I am wondering how long it takes to do a Choice appointment?  I have heard that sometimes it takes 20 minutes and sometimes several hours! Which is right? I am worried someone will tell me I have to do them in 20 mins.

A:

Both! The aim of the Choice appointment is to reach a Choice Point ie to have a joint understanding with the family/service user about what is going on, what goals and outcomes are being sought and how these can best be met.

If the family is well known to CAMHS e.g have been before and lots is known AND the goals are clear, then it may take only 20 minutes to work out what is needed together. E.g. a family who move back into the area bring their child who has previously been on medication for ADHD. They want to restart. All the assessment and background is known from before so what is needed is an update- what is going on now? What do they need help with and how can this be done? Any risks?  The intervention in Partnership may then be rapidly agreed.

Similarly, someone coming back with another bout of OCD- the focus may be on what are the symptoms now and how can they restart all the things they learned previously plus an update about circumstances, including any risks.

For brand new service users, the conversation will take longer- getting to know them, what they want, how they see things. If someone key in their system is not at the Choice appointment (e.g. the adolescent did not come, only parents, or dad needs to be included, or the social worker) then a Choice Plus appointment needs to happen to reach the Choice Point.

Timetabling in CAPA generally allows of 2 appointments in a clinical half day so you can spend 90 minutes if needed.

Of course, how many Choice appointments you can do in a half day depends on your admin system. If quick and easy it may only take 30 mins. Since moving to an Electronic Care Record the team I am in need 2 hours to complete the admin in addition to the 1 hour admin staff need.

Ann

 

FAQ: Do Choice numbers factor in leave?

Question: Hi! I wonder if you would kindly answer a question about the CAPA model that is causing some confusion here. The confusion surrounds a practitioner’s choice and partnership in the quarter when they are on holiday.

 Q: If a practitioner has 15 choices to undertake in a quarter and they go on holiday, do they still have to do all 15 choices in that quarter? If they still have to do all 15 Choices, should they be made up in that quarter or the next?

 Hope this makes sense!

 Answer: Hi! OK first to answer a question you didn’t ask (!). The partnership numbers are based on job plan and the multiplier of 3 already accounts for holidays so whatever their number is, that is what clinicians need to do.

 However this isn’t the case for choice. Choice can be organised however suits the team and is reasonable and doable.

 The top rule is that total number of choice offered must equal what is required for the whole team. This total number can be divided up amongst the team in a number of ways:

  •  A quota per person – either prorata, based on FTE, or same number each (or another way!). E.g. a team needs 100 Choice and has 10 FTE. This equals 10 per FTE per quarter. So a 0.5 FTE would need to offer 5 in the quarter (next 3 months).
    The number that this produces then is job planned. E.g. if 10 per Q and each choice takes say 2 hrs including admin then 10 x 2 = 20 hours / 13 weeks = about 1.5 hours per week in job plan.
  • A fixed weekly rota e.g. 1 every week there (= 11.5 per Q – accounting for leave). This does factor in leave as there would not be an expectation to do choice when on leave or to make up when back.

It’s whatever suits the team and delivers the right number so leave doesn’t come into it directly.

 Cheers

 Steve