Choice detail and administration
Choice appointments are the first contact the family have with the service. This section explains how to set them up and how they work in practice.
Referrals
Ideally, referrals should be attended to daily, using clear eligibility and threshold criteria (see the 7 HELPFUL Habits later in this book). This can be done by one clinician, a rota, or by a pair. You decide. Then the family are contacted and invited to book an appointment. You could contact the family by letter or phone - in both our services we use a letter. Choice appointments are therefore ‘fully booked’ in this system, meaning that the young person and family are offered a choice of at least 2 appointments. We aim for this Choice appointment to be available within 6 weeks of referral, according to user preference. We chose 6 weeks as user feedback (Richmond) showed this to be suitable and sooner is hard for many families to organise. In practice this means that, at the point a family phones to book, an appointment is often available within the next 2 weeks or so. Of course, you can set the time scale to be whatever suits you locally.
In both East Herts and Richmond the letter invites them to phone in and book a Choice appointment. Along with the letter they we enclose a leaflet that explains CAPA and the purpose, and duration, of the Choice appointment. It emphasises that the clinician they see may not be the one they see if they decide to return. The opportunity to explore what they need and find out about the service is highlighted. When they ring they are offered all the free appointments in the Choice diary (see Implementation for creating one of these) and then sent a confirming letter with the date and time for the appointment they have chosen. Young people and families can choose which clinician they want to see if they have come before and want to specifically see – or avoid – that person. This may mean a longer wait but this is their choice.
Vulnerable families
Many families are able to use such a booking system. However, some could be disadvantaged as they may find it hard to get organised to phone in or are unable to read. Some may have found it hard to engage previously, or are vulnerable teenagers such as those Looked After. You need a system for them. We allow them the same opportunity to book in, but if they don’t we ensure we take steps to phone them or ask the referrer to help them book in (and maybe come with them). We may offer a wider range of venues to be seen in, including home visits.
Emergencies
In both our teams, emergencies and overdose/hospital self harm referrals are not handled using this full booking system but are attended to using a next-up system (see next page). Emergency appointments are available the same day to within 48 hours according to need. However, the key principles of choice are retained as the philosophy in emergency appointments. The same paperwork is used.
Emergency appointments can be handled in different ways. Most services using CAPA find that they have far fewer emergencies, as waiting times are short. In our teams we just slot the appointment into our diary. This may mean rebooking a routine appointment or using time allocated for admin or a meeting, taking this time back at a later date. If you have regular and predictable heavy demand for, say, hospital self harm assessments you may find it works best to have protected time in job plans.
Next up system: This is a rota that has clinicians' names in order. The person at the top of the rota is the next to take the case. So for self-harm both Richmond and East Herts have a next up rota. The top clinician, who is at work, is responsible for the first overdose that comes in. If two in the same day then the first and second person etc. We find that on really busy days another member of the team who has a cancellation is often happy to swap as they get to come off the rota by working when they are less busy. However at worst it might mean cancelling and rebooking more routine clinical work.
The Choice appointment itself
Choice appointments usually last around an hour. In practice they tend to last anything from 45 minutes (usually these are with families who are well known and have clear goals) to 90 minutes. A number of clinicians can work together for all or part of a half-day session (a Choice clinic), meeting at the end to discuss the cases and complete rating scales etc. This team discussion is not to decide what to do, as this has already happened with the family, but is useful for learning, to share ideas about resources that can then be sent to the family if needed. It also reduces variation in practice. For example in East Herts the Choice clinic on a Monday afternoon has two slots – 1.30 and 3.00. Some staff do both, others only one and then they all meet for a 4.00 discussion slot. There is a rough half-hour gap between the two slots for admin but some admin from the second slot carries over to ‘Big’ admin time. There are more details in Implementation section. If you offer Choice appointments on different days and sites then the team discussion needs to happen at another time in the week, say linked to the weekly team meeting (the system used in Richmond).
It isn’t always possible to reach a Choice Point in one Choice appointment (for us, maybe 10% of the time). If so, then you just arrange one or more further Choice appointments (Choice Plus) in your own or the Choice diary until you do. It’s the initial Choice clinician’s responsibility to continue until a Choice point is reached.
Rating scales: Richmond uses HoNOSCA, CGAS, Strengths and Difficulties Questionnaire (SDQ), and Mood and Feelings Questionnaire (MFQ) at Choice (families do MFQ and SDQ beforehand, to inform the Choice conversation) and East Herts uses the CAMHS Outcome Research Consortium measures: CHI Experience of Service Questionnaire, CGAS, and SDQ (www.corc.net.uk). You choose what you would find useful.
Correspondence
At the end of each appointment a written communication is sent to the family, referrer and agreed network summarising the nature of the issues, choices discussed and chosen and actions. This includes what the family will do to help themselves, goals and what services are needed. If they have chosen to return to CAMHS then details of the key worker, Partnership appointment and Partnership clinician/s are given. This can be done in a letter (as in East Herts) or as a structured form (as in Richmond).
The clinical notes should contain any other information that would be helpful to the clinician at Partnership, that isn’t in the letter. Bear in mind ‘if I were to take on this family at Partnership would the letter and notes tell me all I need to work effectively?’. Remember, as is true for all records, these can be made available to the family if they want.
Full booking to Partnership
If the family choose to return to CAMHS then a Partnership appointment is booked at the end of the Choice appointment i.e. fully booked. This will be with a clinician/s with the best skills to help and will aim to offer a choice of appointment times (and venues if possible) using the Partnership diary (see Implementation).