using feedback and clinical outcome tools to improve collaborative practice and enhance supervision...

© Duncan Law

Using Feedback and Outcomes Tools to Enhance Collaborative Practice & Improve Supervision!

Duncan Law Clinical Lead

London and South East CYP-IAPT Learning

Collaborative !

Hertfordshire Partnership University NHS Foundation Trust

Leanne Walker Young Sessional Worker

GIFT !

Kate Martin Director/Independent

Consultant Common Room Consulting Ltd

!

© Duncan Law, London & SE CYP-IAPT Collaborative Outreach

Overview!

•  Quick reminder about CYP-IAPT •  Focus on the CYP-IAPT feedback and outcomes

process (ROMS, PROMS. PREMS): •  what is it •  why do it etc….

•  A chance to learn from each other •  Q & A!

2

© Duncan Law

Feelings about routine feedback & outcomes monitoring?

Hate them 0

Love them 10

Mixed feelings 5

CAMHS Challenges

ACCESS: % With anxiety or diagnosable depression not in contact with mental health services

Source: Ford et al. (2005) Child & Adol Ment Health, 10:2-9

Dean et al., (2004) DoH; McCrone et al., (2008) King’s Fund

80%

70%

60%

50%

40%

30%

20%

Adults with depression

5-15 year olds

Percent

unknown

to any

service

35%

76%

Age of onset for life-me mental disorder

Source: Kim-‐Cohen et al, 2003; Kessler et al, 2005; Kessler et al, 2007

Funding

•  Only 6% of Mental Health funding goes to services aimed at children (Kennedy 2010)

•  Spending on child mental health con-nues to be cut – by up to 95% in some local authori-es (YoungMinds 2014)

•  Savings in MH is 1.8% per annum, compared to 1.5% in physical health (DH 2014)

London & South East ��

IAPT Learning Collaborative

Steering Group Meeting Agenda

Date: 30th September 2013 Time: 10am - 2pm Location: Room 9, Hamilton House, Mabledon Place, London, WC1H 9BD Attending: Andy Wiener (Camden), David Pentecost (Islington), Ian Petch (Wandsworth), Sherbanu Sacoor

(Hackney), Jessie Earle (Haringey), Joanne Guerin (Waltham Forest), Emma Morris (Westminster), Janet Grimes (Richmond), Stephen Scott (KCL), Tracey Lewis (Lambeth & Southwark), Lesley French (Greenwich), Peter Fuggle (UCL), Sarah Brennan (Chair), , Stephen Butler (UCL), Sue Goode (Croydon), Karen Stott (Croydon � Off the Record), Bill Williams (Tower Hamlets), Duncan Law (Herts), Rosey Singh (West Sussex), Ayla Humphrey (Cambridge), Alex Goforth (Project Manager), Nikki Bedwin (UCL CYP IAPT Administrator)

Apologies: Derek Bolton (KCL), Julie Proctor (Bromley),

Item Lead Timing Time(mins) Attached papers

Outcome

Part 1: Agenda Items

1. Introductions, Apologies & AOB All 10:00-10:10 10

2. Learning Collaborative Clinical Lead Appointment PF/DL 1010-

10:15 5

3. GIFT update CS 10:15-10:30 15

4. Launch event AG 10:30-10:35 5

5. Secure Video Demo CY 10:35 � 10:45 10

6. Course Review Feedback PF 10:45-10:50 5

7. Planning for Wave 3 Courses PF 10:50-10:55 5

8. Feedback & Outcomes Data Across the Collaborative AG 10:55-

11:10 15

Comfort break (10mins) Part 2: Small Group Discussions 9. Working Groups

1. Evidence-Based Practice 2. Feedback & Outcomes 3. Participation 4. Commissioning

Service development will run through all groups. This might require a few minutes to work out, and then discussion which question to begin with.

All 11:20-12:20 60

10. Feedback � What has been discussed? How should the groups proceed outside of the steering group meeting?

All 12:20-12:40 20

Part 3: Q & A 11. AOB All 12:40-

12:50 10

12:40-2:00pm Lunch (provided) & Networking

CAMHS Opportunity?

Opportuni-es: •  CAMHS Select CommiPee inquiry •  Children's Task Force •  General Elec-on Threats: •  Lack of good Data

(c) Duncan Law & Alex Goforth -‐ London & SE CYP-‐IAPT Learning Collabor-ve








Outcome




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11:10 15




All 11:20-12:20 60


All 12:20-12:40 20

Part 3: Q & A 11. AOB All 12:40-

12:50 10


What is CYP-‐IAPT? (a reminder!)








Outcome




10:15 5

3. GIFT update CS 10:15-10:30 15






11:10 15




All 11:20-12:20 60


All 12:20-12:40 20

Part 3: Q & A 11. AOB All 12:40-

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CYP-‐IAPT is a set of principles for Whole Service ‘TransformaIon’

The CYP-‐IAPT principles: 1.  BePer Evidence Based Prac0ce 2.  BePer Collabora0ve prac0ce -‐ Clinically

Meaningful use of feedback tools 3.   Authen0c par0cipa0on of families and Young

People who use the service 4.  Rigorous outcomes monitoring Leading to effec0ve and efficient use of resources


Feedback & Outcomes Monitoring

Feedback & Outcomes Forms

Why bother using them?

© Duncan Law

Values behind outcomes and feedback

1.  Demonstrate/celebrate/prove: effectiveness of interventions and service

2.  Enhance collaborative practice:

– Better service user voice in therapy (& supervision)

– Facilitates good clinical practice

© Duncan Law

It’s not (just) about measurement, it’s about a culture of collaboration


The evidence base

What’s the evidence?

There is evidence that use of feedback forms/measures can:

•  Improve clinicians ability to detect worsening of symptoms (Lambert, 2010)

•  Provide informa-on that may have otherwise been missed (Worthen & Lambert, 2007)

•  Reduce drop out (e.g. Miller et al. 2006) •  Increase speed to reach good outcomes (Lambert et al. 2005)

•  Improves outcomes (Bickman et al 2011)

Mike Lambert •  Feedback to clinicians on outcomes trajectories •  Reduced drop-‐out •  BePer outcomes •  No advice given to clinicians on how to use the feedback

•  Lambert, M. J. (2007). PRESIDENTIAL ADDRESS: A program of research aimed at improving psychotherapy outcome in rou-ne care: What we have learned from a decade of research. Psychotherapy Research, 17, 1-‐14.

Len Bickman •  Big RCT (28 sites in 10 states) ‘real world CAMHS’ •  Feedback weekly or every three months •  Faster improvement with weekly feedback •  Even bePer if clinicians looked at the feedback! (paraphrased)

•  Bickman, L., Kelley, S., Breda, C., De Andrade, A, & Riemer, M. (2011): Effects of rou-ne feedback to clinicians on youth mental health outcomes: A randomized cluster design, Psychiatric Services, 62(12), p.1423-‐1429

Measurement for a purpose: Guiding treatment to bePer outcomes

Weisz et al. (2012). Tes-ng standard and modular designs for psychotherapy trea-ng depression, anxiety, and conduct problems in youth: a randomized effec-veness trial. Archives of General Psychiatry, 69(3), 274-‐282. With permission from Peter Fonagy

0

0.5

1

1.5

2

2.5

3

Usual Care Standard Condi-on Modular

Number of diagnoses Pre

Number of diagnoses Post

Manualized therapy without Match

Usual care Therapy delivered on basis of Match

15% 33%

TAU EBP EBP+Outcomes Monitoring

Evidence Based TransformaIon

Research evidence YP/Family’s goals preferences, values, and unique context

Clinician exper-se

+ +

Frueh et al (2012) Evidence-‐Based Prac-ce in Adult Mental Health. Handbook of Evidence-‐Based Prac-ce in Clinical Psychology. Published online.

Adapted and used with thanks to Peter Fonagy


Enhancing Collabora-ve Prac-ce

A personal account

Leanne Walker

Young Sessional Worker GIFT

Thought Id try something a liYle different.

But, before I do. I want to share something. I saw the film The Maze Runner the other day and it really made me think. Watching it, I thought to myself, we all have this one life. And, our life, is made up of choices. I thought, we don’t choose to appear here on this Earth but, everything we all do, that is our choice and only us at the end of the day ..who makes that choice. So, our life is made up of a series of decisions. And in the film, the characters are trapped in this square of land and every morning a passage into a maze opens and they can choose to run into it to find an exit, or they can choose to stay, safe. But, if they don’t get back before night fall they get trapped inside the maze. And I thought to myself. Some-mes it takes one decision and one decision to commit and that’s how things can change. So one person deciding to go into that maze and look for an exit. If they ran into that maze half-‐heartedly, they would have got trapped and died. Now things aren’t quite that dras-c here but the point is the same, you have to be commiPed and I thought this applies to a lot of things in life but also applies to outcome measures, you have to want bePer and that’s how you get somewhere. What im trying to say is, if we carry on doing the same thing, like staying in that safe square of land of what we know, we don’t know what we could have. If we stay in the safe square of what we know, nothing changes. Nothing gets worse, but nothing gets bePer either. Some-mes you have to take the fear of change, like outcome measures as a way of prac-se and you have to say, uno what. I want things to change, I want to try different ..I am going to do this.

‘What Outcome Measures Did For Me’

Once upon a -me, around the -me of 9, I had a dream, of all the things I wanted to do, In this World so big, it floated in my mind, All these images of mankind. Unfortunately, I become lost and my dreams became hidden under a permanent layer of frost. It’s hard you see, having the World in your head, Its hard, struggling to go to sleep when your in bed, Its hard when the place you called home, is like a warzone of its own, When you have feelings that you don’t want to feel, When you feel everything is a big cycle and you’re the middle, you’re the spinning wheel. I’m telling you this so you can see, the way in which outcomes measures actually helped me. For I was a girl so lost in the strife, I reached a point where I wanted to take my own life. Its not that I wanted to die, I just couldn’t find a reason why, I should stay. My feelings unbearable, I had lost more than my way,

It was at this point, when I nearly let go of my life, My counsellor introduced me to a therapist, I learnt about IAPT, started Cogni-ve Behavioural Therapy. It was here, I would learn what would help me. Now some people think outcome measures aren’t all that cool, But for me, in therapy, they were a very powerful tool. Together is a key word here, for Outcome measures, Really gave my therapist and me an ear. To listen and to understand each other. We used Goal Based Outcomes and set goals, Enabling us to work at the same end of the poles. Each session we agreed on homework, Which gave me thoughpul contempla-on, And also mo-va-on. For, my therapist and me were a team, and together we worked on chasing my dreams. These goals shaped and changed as we worked together, And together we monitored if I felt bePer. My opinions maPered and my voice could be heard, Using Session-‐Ra-ng-‐Scales, some-mes on paper so I didn’t have to say a word.

This stability, lent me the ability to achieve, Seqng achievable goals gave me hope, to believe. In myself and in my life. And as days turned to night, Outcomes Measures developed my insight, My therapist giving me wings for flight. All the while, making sure I was alright. And the ques-onnaires’, which professionals can learn to hate. Honestly, they are not a source of bait. They were a good thing for a person like me, Because they helped me to see what was bothering me, And in my sessions, they helped me to see areas in my life, That I might like to work on, each day and each night, They helped me to see what was working and what wasn’t quite right. All this gave me steps of brightness, in front of me, guiding my sight, My vison becoming focused, Offering me a different way, to see my difficul-es in life, a new approach to the darkness that is night. My progress on paper clear to see, And this is how a path out of the dark tunnel appeared to me. Each goal achieved made me more aided to believe, increasing the light and each progress tracked showed me I can do it, I can be alright.

Now these tools weren’t just useful in my therapy, But also when I les they were good for me, Reflec-on is powerful, and I was able to look back at all the things id achieved, the goals, I had worked on, The sense of reward, a strong one. And this sense of reward was also shown, in the bond formed, With the people of the service I had known. Everything was clear to see, not just on paper, but the real life change was in me. For Outcome measures used in my therapy, the amazing people and the service that I received, Make this ending a happy one indeed, For now I have the dreams back, alive in my head, These dreams, they don’t burden me but sing to me instead. I have a few things les to say, If I had to make a change along the way, I would have wanted more of an explana-on of the value of these tools, Maybe a source of informa-on, I could go to ..like a pool A place where the informa-on is easy to understand, Together in one place, Accessible by curious hands. Examples of experiences And maybe a few faces making appearances. I think I should also men-on, I have some friends from therapy who feel the same, For Outcome measures really helped them too, to change. We are now able to understand ourselves bePer and one another,

We are like words on a lePer, sat on the same page together. For outcome measures and our therapy, also gave us friendships which I know will forever last, Because we all share this thing, this experience in the past, A friendship so strong, I can feel it, in my heart, these friends, I know, we shall never part. So here is my thank you. Thank you to the service which did so much more than save my life. Thank you for doing so much more than making sure I was alright. My thank you to each one of you as professionals here today, For you have a special gis to change a life, even in small ways. Outcome measures are so much more than people assessors, These tools they are treasures, life long investors in the people of tomorrow, And its you guys who help these people, you help them with their sorrow. So here is my thank you, Because, if it wasn’t for people like you, I would have given up my fight. On the World that I knew. Thank You, for doing what you do.

Leanne Walker

GIFT Young Sessional Worker

Common Room Consul-ng Ltd. is a company registered in England and Wales. Registered No. 8534680. VAT Registra-on No 181 0516 34. Registered Office: 27 Mor-mer Street, London, W1T 3BL

Using measures with young people

Amy Feltham Kate Mar-n


•  Young people osen report feeling excluded from decision-‐making

•  Young people want collabora-ve involvement in their treatment where they can be involved in the analy-cal stages of decision-‐making, including weighing up the benefits and risks of treatment op-ons.

•  This can improve adherence to treatment, and increase their safety, autonomy and empowerment (Simmons, Hetrick and Jorm, 2011)

•  Osen a gap between our beliefs and our ac-ons. What we intend isn’t always what’s received or expected…


How do young people say feedback and outcomes tools can help?


Five steps to shared decision making in CAMHS…

1. Young people and those working with them agree key problems and goals together

2. Those working with young people support them to understand the options available to them

3. Young people and those working with them agree which options they will try

4. Young people and those working with them review progress

5. Young people and those working with them discuss options and make any changes as necessary


•  They can help to close the communica-on gap. –  Have access to the same informa-on.... Balancing –  They can make what we’re doing together explicit. –  ‘I know you've understood me’ –  Gesture of listening

“Some-mes it’s easier to have things on paper or wriPen down. It makes things explicit between you and can be easier than trying to weave something into a conversa-on. If you’re just talking about something, it’s hard to know what you are or aren’t allowed to say or what they’ve understood.”


They can help young people to say or express things •  They can help normalise difficult feelings – ‘not the only one’

•  Helps me understand and make sense of things “The first -me I did a measure on depression… it’s got a ques-on in it like ‘do you cry’. It had answers like 'some-mes, a lot, all the -me, I feel like I want to cry but I can’t'. It made me realise that feeling like I wanted to cry but couldn't was a valid way to feel, that it didn’t mean I wasn’t depressed."


•  I can see what's changed, how far I've come “It’s like losing weight, it can be so gradual, it can feel like nothing is changing. It’s good to have something to help see what’s changed… how far I’ve come.” “I kept all my papers from when I was first in CAMHs. I look back on them when I feel like I haven’t made any progress and I can see that I really have.”


•  Feedback – personalise support. •  It’s the liPle things that make all the difference

“I used to get really upset in CPA mee-ngs. When I got an advocate I started to take fiddle toys with me and make everyone play with them, so everyone was doing something else at the same -me. It made it a much less scary room to walk in to.”


Some ways young people say they can be unhelpful

•  It’s about HOW they’re used… •  They’re just another piece of paper if

–  No clarity about why they are being used or how they can help –  Different expecta-ons about what they are for –  No meaningful conversa-on about them (unless this is pre agreed) –  The tool doesn't feel the right fit for the young person –  There is no choice which ones to use or how to use them

“I find it hard to say how I feel… it takes me a while. I hate the scale 1-‐9 thing. I like the ones with words.” “It’s like -cking boxes rather than, like, help. Like their criteria… numbers… like their number thing, it’s so rigid.”


NEW QUOTES ADDED •  Most of the -me you don’t have a clue about what PROMs are for •  Inpa-ent – I always got given forms but no one talks through what

they mean, what the data says or how it is gonna be used. so I just completely lied

•  When you are at the op-cian you always doubt yourself about which is the brightest light, and I’m always doing it on the proms as well and think I don’t actually know! I always struggle when people give me that sort of thing – no one ever talks them through

•  A lot of my change has come from the fact that I know I don’t have to get to crisis point to get someone to listen to me now, and that actually gets other people to respond bePer. It was having people start asking and start checking in with me prePy much on a weekly basis and saying what can we do? What’s working? What’s not working? So I began to trust that they actually did care. And if I said ‘no this isn’t working’ they’d say ‘ok what can we do?’


Key messages •  It’s the spirit in which they’re used that is most important

•  If it’s for service evalua-on only – that’s ok. Just be honest about it

“This is to help us learn as a service. We won’t look at it together, but it could help the service to learn what we’re good at, what we need to get beEer at.”


“At the moment I’m doing a piece of work with my doctor in CAMHS and it’s learning for both of us…. this is a piece of work that hasn’t been done much before….and she’s only done it once or twice before, and we’re both learning from each other but that’s bePer.”


•  Learn together about what works. It’s ok not to be an expert in all the measures… if you don’t know something just say

“’Do you now what, I need to check this with someone else.’ It’s good… it shows you’re human and that we’re learning together.”

•  We can learn from young people about the measures too…

“eeerrrm… Jennifer, it says 0-‐8 there, so I don’t think it can be 12…”

© Duncan Law


Clinically Meaningful Uses

Assessment/Choice

•  “What’s the problem?” •  “What do you want to change?”

Partnership/on-‐going work

•  “How are we gecng on together?” •  “How are things going?”

Review & Close

•  “Have we done as much as we need to?” •  “How has this been generally?”

6 useful quesIons that forms can help with

Assessment/Choice

• "What’s the problem?” •  (assessment) This is understanding the issue the young person or family have come for help with

• Helpful forms: RCADS, SDQ, ORS

• “What do you want to change?” •  (goals or aims of therapy) – this is understanding the specific goals the young person or family have -‐ the things they want to work on in coming to a service

• Helpful Forms: Goals (GBO)

Hertfordshire Partnership NHS Foundation Trust

© Duncan Law 2012 45

RCADS:

What does it look like?


Goals Based Outcome Tool:

What does it look

like?

NHS ID: Service allocated case ID 1/1— Goal Progress Chart— C h i l d / Y o u n g P e r s o n 23

© Duncan Law, Hertfordshire Partnership NHS

Visual Solution © Slavi Savic, EBPU

You can turn this chart on its side for a quick look at progress over the sessions.

Goal N o

Goal progress chart

Session DateToday I would rate progress to this goal:

(please circle the appropriate number below)

Remember a score of zero means no progress has been made towards a goal, a score of ten means a goal has been reached fully,

and a score of five is exactly half way between the two

1

0 1 2 3 4 5 6 7 8 9 10

2

0 1 2 3 4 5 6 7 8 9 10

3

0 1 2 3 4 5 6 7 8 9 10

4

0 1 2 3 4 5 6 7 8 9 10

5

0 1 2 3 4 5 6 7 8 9 10

6

0 1 2 3 4 5 6 7 8 9 10

7

0 1 2 3 4 5 6 7 8 9 10

8

0 1 2 3 4 5 6 7 8 9 10

9

0 1 2 3 4 5 6 7 8 9 10

10

0 1 2 3 4 5 6 7 8 9 10

11

0 1 2 3 4 5 6 7 8 9 10

12

0 1 2 3 4 5 6 7 8 9 10

GOAL:

Who agreed this goal (tick below):Child/young person

Family membersPractitioner

Other (please specify) :

Partnership/on-‐going work

• "How are we gecng on together?” •  (engagement or alliance) It is important to check that the young person or family feel you are working well together

• Helpful Forms -‐ SRS, CSRS, Session Feedback Ques-onnaire: "How was this Mee-ng?",

• “How are things going?” •  (Symptom/goal tracking) – this is tracking to see if things are progressing during and interven-on

• Helpful Forms: Symptom Trackers: "How are things?" forms, Goals (GBO), ORS/CORS, RMQ


© Duncan Law 2012

An Example of a Symptom

Tracker

Worries (GAD)

h '

Date: / / 20 Time: Please put a circle around the word that shows how often each of these things happen to you.

There are no right or wrong answers.

SUM: NHS ID:

Service allocated case ID

1/1— Anxious Generally (Generalized Anxiety) — C h i l d / Y o u n g P e r s o n 31

Questions © 2003 Bruce F. Chorpita, Ph.DVisual Solution © Slavi Savic, EBPU

How are things?Session No

0 1 2 3

1 I worry about things

Never Sometimes Often Always

2 I worry that something awful will happen to someone in my family


3 I worry that bad things will happen to meNever Sometimes Often Always

4 I worry that something bad will happen to meNever Sometimes Often Always

5 I worry about what is going to happenNever Sometimes Often Always

6 I think about death



Session Rating Scale (SRS)!

49

Review & Close

• "Have we done as much as we can/need to?” •  (decision to close or refer on) -‐ help in making collabora-ve decision

• Helpful Forms: Time2 SDQ, RCADS, GBO, ORS/CORS

• “How has this experience been generally?” •  (experience of service overall) -‐ Help to review the over experince of the service

• Helpful Forms: CHI-‐ESQ

© Duncan Law

Current use of feedback information in supervision

•  What do you already do? •  What more would you like to/plan to do?

© Duncan Law

0

2

4

6

8

10

12

14

16

18

Session 1 Session 2 Session 3 Session 4 Session 5 Session 6

Subs

cale

Sco

re

Session

Symptom tracker

© Duncan Law

What can supervisors do? •  Be Active – spot and discuss potentially

off track cases •  Support – trainees to reflect on cases

using feedback from young people and families

•  Introduce alternatives – esp. where therapy appears not to be progressing


What next? Make a plan….!•  One thing you will do to

implement feedback and outcomes to improve collaborative practice: •  in your own practice •  in your supervision •  In your team?!

57

Resources and Other InformaIon








Outcome




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3. GIFT update CS 10:15-10:30 15






11:10 15




All 11:20-12:20 60


All 12:20-12:40 20

Part 3: Q & A 11. AOB All 12:40-

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© Duncan Law, Stephen Butler, & Alex Goforth

For more information on outcomes and feedback

http://www.corc.uk.net/resources/additional-information-about-the-measures/ !

© Duncan Law

Other Resources •  www.cypiapt.org •  www.corc.uk.net •  www.myapt.org.uk •  www.vimeo.com/tag:cyp+iapt •  www.MindEd.org

Contacts

Duncan Law Clinical Lead

London & South East CYP-‐IAPT Learning Collabora-ve [email protected]








Outcome




10:15 5

3. GIFT update CS 10:15-10:30 15






11:10 15




All 11:20-12:20 60


All 12:20-12:40 20

Part 3: Q & A 11. AOB All 12:40-

12:50 10


(c) Duncan Law -‐ London & SE CYP-‐IAPT Learning Collabora-ve


[email protected] 07739 316211


[email protected]


Common Room Common Room is a consultancy that promotes the views and exper-se of people with lived experience across disability, health and mental health.

We connect the exper-se of people with lived experience with the exper-se of researchers, commissioners, prac--oners and policy makers.

We believe that it's bePer to work together, use our collec-ve exper-se and be partners in change to ensure people •  Are ac-vely involved in decisions about their lives, treatment and support •  Are empowered to manage their health and self-‐direct their support •  Are ac-ve partners in the development and management of services •  Are equal partners in research, quality improvement and policy programmes •  Have a collec-ve voice and about social, policy and prac-ce issues that affect their

lives

© Duncan Law

We hope you found this presentation useful

Feel free to use all are parts of it to help train other staff in your organisation & to

further implement CYP-IAPT

If you do use slides please reference the authors appropriately

These slides must not be used in training for commercial gain

using feedback and clinical outcome tools to improve collaborative practice and enhance supervision...

Healthcare