Time from Choice to 1st ADHD Pathway Team Diagnosis … Ian 71-106.pdf · ADHD Pathway Team Lead -...

ADHD Pathway Team

Lead - Noreen Ryan, Consultant Nurse

Cath Ashworth, NurseSteve Worswick, Nurse

Pete Birchill, Nurse Dr Giovanni Arsiwals, Paediatrician

Anita Wood, Clinical Support

170 cases per annum

Time from Choice to 1st

Diagnosis Point

10 weeks

: A.D.H.D. Pathway

ADHD Pathway Team





170 cases per annum


Diagnosis Point

10 weeks

: A.D.H.D. Pathway

Reduced Use of Complex

Assessment(CAMHS Day

Unit)

ADHD Pathway Team





170 cases per annum


Diagnosis Point

10 weeks

: A.D.H.D. Pathway

Reduced Use of Complex

Assessment(CAMHS Day

Unit)

Improved Waiting Time to

Complex Assessment

•Referral to ADHD ASSESSMENT pathway•Choice clinician•Consent to contact school for school report and observation•Conners questionnaire

At Choice

•CST request and score questionnaires•School report request primary proforma, teacher Conners questionnaire and teacher SDQ• School report request secondary 'round robin', teacher Conners questionnaire and teacher SDQPost Choice

•School observation and short 10 point Conners•Contact with teacher and•Collect school report and teacher Conners and SDQ

School Observation

•Review of file and allocated to clinician•Developmental interview using proforma , observation of child and review of all information•Diagnosis of ADHD remain on ADHD pathway•Further school liaison completion of the CHATTI questionnaire•No diagnosis consider whether day unit assessment appropaiate or other pathway

Initial Interview

: A.D.H.D. Pathway

0

5

10

15

20

25

30

35

40

Parent Conners

Parent SNAP

Self Conners

School Conners

School SNAP

School Report

Completed Questionnaires

Yes No N/A

: A.D.H.D. Pathway

So how did we apply LEAN thinking?

• ‘Whole Service Change’ vs. change in a single area or process– Must adhere to the goals of the whole CAMHS Vision and Strategy

– Must be part of a number of linked improvement events

– Achieving sustainable, measurable change over time

• Focused on ALL MEDICATION prescribed in CAMHS

• BUT ‘Psychopharmacological treatment for A.D.H.D. approximately 60% of CAMHS prescribing

• To achieve through a Rapid Improvement Event – A 3 day event that achieves rapid measurable change

: A.D.H.D. Pathway

Rapid Improvement Event (RIE)?

• STEP ONE:

1. Agree the need

2. Develop the accompanying A3 including the aims of the Rapid Improvement Event, Initial and Target State

: A.D.H.D. Pathway

1. Reason for Action

Context: Therefore improvements are required to:

No GoGo

a

b

c

d

Constraints:

A Five year Vision and Strategy for CAMHS

The primary drivers for service development and direction over the next 5 year period:

Local Drivers:- The organisational ‘true north’ goals, improved health, best possible care, value for money, joy and pride- Making it Better

Regional Drivers:- CAMHS network - CAMHS tier IV Commissioning review- CSIP NW.

National Standards:- The NSF standard 9- NICE

- Policy Drivers:- Improving access to psychological therapies (IAPT), - Pushed / Out of the Shadows, - Every Child Matters

To become a patient driven service whereeffective user involvement drives servicedevelopment and cost effective delivery(Value for Money):

Achieving a comprehensive CAMHS asdescribed in the National ServiceFramework Standard 9* (*NICE guidelines)(Best Possible Care)

To be a CAMHS service that activelysupports, challenges and develops itsworkforce in a positive and forwardthinking manner within an environment fitfor purpose (Joy and Pride):

To provide effective child and adolescentmental health services to vulnerablechildren (e.g. Looked After Children,Children with learning disabilities andchildren within paediatric services, BMEcommunities. (Improved Health)

Multiple competing drivers, present CAMHS staff ratios below nationally recommended levels (15 wte per 100,000: 39.4 wte vs. 28.4wte, multi-agency commissioning context, limited to nil opportunity to income generate due to no PBR Child Mental Health Tariff, recent excessive staff turn-over and present process of multiple recruitment

Go



No GoGo

a

b

c

d

Constraints:

ISIP – trust savings plan, (get details) Cost savings – 80% of non salary budget devoted to medication spend approx £30,000 per year (Value for Money)

Reducing CAMHS medication errors, in line with high risk audit strategy (Joy and Pride)

The patterns of prescribing are non standard both for disorder and drug type

To consider the role of non-medical prescribers within the CAMHS department

Standard work around process of identification, assessment, monitoring, psycho-education, initiation (Joy and Pride)

All within the context of NICE guidance on ADHD, Depression, Schizophrenia, PTSD, Anxiety, OCD, etc. (NSF compliance, Best Possible Care) and the organisation’s focus on services that are compliant with the standards outlined in the NICE guidelines

? Effective use of present resources to improve this aspect of service / intervention

Non standard monitoring, management and response to side effects (Improved Health)

CAMHS Vision & Strategy

Patient driven goal, inclusion of young people (? Day unit) and parent / carer

Trust – BICS programme and true north goals, world class services for children

CSM advice re: antidepressants

Specialist nature of what CAMHS prescribe

Role of GPs (communication) standardised, shared care plans

Within present resources,

Ensure the most timely and effective use of medication (including improved compliance, concordance, monitoring, effective response to side effects and non response) to allow the young person’s optimal recovery from symptoms / disorder (Improved Health): to improve patient reported compliance by 5%

Achieve improved compliance with NICE guidelines, CSM advice etc. specific to medication (Best Possible Care): to increase to a minimum of 95% compliance with NICE guidelines around the use of medication

Ensure the use of the most clinically appropriate, cost effective and evidence based medication (Value for Money): by doing so to reduce drug expenditure by 10%

Ensure standard working practices that allow young people and their families to receive a high quality service from CAMHS (Joy and Pride): to improve the young person’s experience by 50%

)

nnd

tt

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a Ensure the most timely and effective use of medication (including improved compliance, concordance, monitoring, effective response to side effects and non response) to allow the young person’s optimal recovery from symptoms / disorder (Improved Health): to improve patient reported compliance by 5%



No GoGo

a

b

c

d

Constraints:




















devoted to medication spend approx £30,000 per year (Value for )

nnd

tt

sm

rdo-

hipnrd

tin

anve

S

d

Bn

dvice re: antidepressants

n rio tod

e wit

b Achieve improved compliance with NICE guidelines, CSM advice etc. specific to medication (Best Possible Care): to increase to a minimum of 95% compliance with NICE guidelines around the use of medication



No GoGo

a

b

c

d

Constraints:




















)

nnd

tt

sm

rdo-

hipnrd

tin

anve

S

d

Bn

dv

n rio tod

e wit

c Ensure the use of the most clinically appropriate, cost effective and evidence based medication (Value for Money): by doing so to reduce drug expenditure by 10%



No GoGo

a

b

c

d

Constraints:




















)

nnd

tt

sm

rdo-

hipnrd

tin

anve

S

d

Bn

dv

n rio tod

e wit

d Ensure standard working practices that allow young people and their families to receive a high quality service from CAMHS (Joy and Pride): to improve the young person’s experience by 25%

So what’s a Rapid Improvement Event (RIE)?

• STEP TWO:

Gather pre-event data:

1. Standard Service Data• Referral data• Disorder / diagnosis• Audit data re: NICE• Medication costs• Medication errors

2. Non - Standard Service Data• Young people and parents / carer

information

3. National & Service Guidelines • NICE, Good Practice guidelines etc.

: A.D.H.D. Pathway


• STEP TWO:

Gather pre-event data:

1. Standard Service Data• Referral data• Disorder / diagnosis• Audit data re: NICE• Medication costs• Medication errors

2. Non - Standard Service Data• Young people and parents / carer

information

3. National & Service Guidelines • NICE, Good Practice guidelines etc.

Part one of ‘meaningful’ service user involvement

Standard S

P

se

: A.D.H.D. Pathway

Initial State No GoGo

Benefits to customers:

Improved Health improved compliance by 5%

Best Possible Care improve to a minimum of 95%

Joy and PrideSatisfaction improvement 25%

Value for Money Reduce drug expenditure 10%

a b

c d

0

50

100

Compliance

Pre RIE

Target

Post RIE 0

50

100

NICE Compliance

%

Pre RIE

Target

Post RIE

02000400060008000

10000

Drug Expenditure

Pre RIE

Target

Post RIE0

20406080

YP Inclusion in decision

% Pre RIE

Target

Post RIE

Target State No GoGo

Benefits to customers:

Improved Health improved compliance by 5%

Best Possible Care improve to a minimum of 95%



a b

c d

8082848688

Compliance

Pre RIE

Target

Post RIE 0

50

100

NICE Compliance

%

Pre RIE

Target

Post RIE

7500

8000

8500

9000

9500

Drug Expenditure

Pre RIE

Target

Post RIE0

50

100


% Pre RIE

Target

Post RIE

• STEP THREE:

Identify Team Membership:

1. Prescribing Clinicians• Nurse Consultant – Noreen Ryan • Consultant Psychiatrist – Dr Ian Dufton

2. Assessing Clinicians• Case Manager – Fiona Wood• [Consultant Psychologist – Dr Mark

Bowers]

3. Pharmacy • CAMHS Pharmacist – Rebecca Walker 4. Supporting Staff

• CAMHS Manager – Kate McNulty

5. “Fresh Eyes”• Member of the organisation who

doesn’t work in CAMHS

6. BICS team facilitator• Emma Broda

: A.D.H.D. Pathway

• STEP THREE:

Identify Team Membership:

1. Prescribing Clinicians• Nurse Consultant – Noreen Ryan • Consultant Psychiatrist – Dr Ian Dufton

2. Assessing Clinicians• Case Manager – Fiona Wood• [Consultant Psychologist – Dr Mark

Bowers]

3. Pharmacy • CAMHS Pharmacist – Rebecca Walker 4. Supporting Staff

• CAMHS Manager – Kate McNulty

5. “Fresh Eyes”• Member of the organisation who

doesn’t work in CAMHS

6. BICS team facilitator• Emma Broda

Essential Points –

•Multi-disciplinary & Multi-professional

•Cross section of the service and shared ownership of any improvements

: A.D.H.D. Pathway


• STEP FOUR:

Create Timetable for the EVENT:

Day 1:

Scene Setting Review of dataMapping aprescribing journeyof a patient with ADHDYoung People / CarerForum

Day 2:

Feedback from DayOne tasks to thewhole RIE TeamDefine and prioritiseproblems arisingFrom the dataProblem Solving

Day 3:

Detail SolutionsCompleteAction /ImplementationPlanComplete ‘Just Do It’actions

: A.D.H.D. Pathway


• STEP FOUR:


Day 1:


Day 2:


Day 3:


Part Two of ‘meaningful’ service user involvement


ing data

g journeyyyyyyyyt withh

ple / Carer

Day 2:

FFeeeeeeeeeeeeeeeeddddddddbback from DayOOOOOOOOne tasks to thewhole RIE TeamDefine and prioritiseproblems arisingFrom the dataProblem Solving

s

: A.D.H.D. Pathway


• STEP FOUR:


Day 1:


Day 2:


Day 3:



Creation of a semi-structured interview based on

prescribing journey map


ing data

g journeyt with

ple / Carer

Day 2:

Feedback from DaOne tasks to thewhole RIE TeamDefine and prioritiseproblems arisingFrom the dataProblem Solving

s

Cre

p

: A.D.H.D. Pathway


• STEP FOUR:


Day 1:


Day 2:


Day 3:



Creation of a semi-structured interview based on

prescribing journey map

Parent / Carer interviewsYoung People (Under 16 (5)

and aged 16 &17 (2) interviews


ing data

g journeyt with

ple / Carer

Day 2:

Feedback from DaOne tasks to thewhole RIE TeamDefine and prioritiseproblems arisingFrom the dataProblem Solving

s

Cre

p

PYo

: A.D.H.D. Pathway

Patient driven, user involvement or simply asking young people and families what they think?

Brief main themes from user questionnaires & semi structured interviews

60% of families and young people thought the discussion helpful or very helpful

80% felt involved in the decision to start medication, the remainder in some or most of it.

The majority reported that they felt listened to, that we had helpful conversations about the bad effects as well as the possible benefits of medication

Along with the need to improve inclusion the main complaints focussed on the experience at pharmacy, the ability to use local chemists, better information, resources to help children and young people remember to take medication

: A.D.H.D. Pathway

4. Gap Analysis No GoGo

Reflections:

12) No mechanism for regular and robust child, young person and parent / carer input

a b

c d

0) Lack the timely availability of professionals with the skills and knowledge to enable young people and families to make an informed choice about medication

1) Lack of standardised assessment processes that would identify early children who might benefit from medication (and to do so in a timely and systematic manner)

2) No standard practice in how prescriptions are requested, co-ordinated with pharmacy etc.

6) At present lack the capacity to meet the follow-up and monitoring demands and maintain a reasonable degree of continuity

7) Review monitoring and follow-up not standardised, variation between clinicians and not linked to NICE guidelines

8) No mechanism to determine whether we are prescribing in a cost effective manner

3) Lack of alternatives to medication (e.g. Sleep hygiene / sleep routine management clinic / intervention)

4) Lack of quality materials to support prescribing

5) No agreed shared care policy for the medications we prescribe and no mechanism to address the issue when practices do not prescribe

9) Non prescribing clinicians who are likely to have more regular / frequent contact with the young people and families lack the skills to support the compliance / concordance with medication

10) No method to identify / challenge “novel” prescriptions

11) Non standard titrations of medication, query young people receive effective and timely treatment






Reflections:


a b

c d












11) Non standard titrations of medication, query young people recieve effective and timely treatment





benefit from medication (and to do so in a timely

hetoe

erd

ke

e kild dic

): to y

f

timlls afamcat

1)thbe

to 5%

guidelines around the use of medication



Reflections:


a b

c d

















ceed

mcoe in

d w

sm c

o in a timely


benefit from medication (and to do so

hetoe

erd

keo in a timely a t e y

e kild dic

): to y 5

id li d th f di ti

timls afamcat

1)thbe

to 5%




Reflections:


a b

c d

















mcoce

ede ind w

sm c

o in a timely



hetoe

erd

keo in a timely y

e kild dic

): to y 5

id li d th f di ti

timls afamcat

1)thbe

to 5%



young perso

support the compliance / concordance with

oen

n (ent c



Reflections:


a b

c d

















mcoce

ede ind w

sm c

o in a timely



hetoe

erd

keo in a timely y

e kild dic

): to y 5

id li d th f di ti

timls afamcat

1)thbe

to 5%



young perso


onen

n (ent c


n spen

pp pmedication

staeopnt



Reflections:


a b

c d


















hetoe

e kild dic

): to y 5

id li d th f di ti

timls afamcat

to 5%





n spen

pp pmedication

staeopt


about meddiccat clinicians and not linked to NICE


5. Solution Approach

Reflections:

No GoGo

Cause Solution Idea Effecting Themes

Ease Impact Cost

7, 8, 11 Rewrite protocols for all five classes of medication (atypical antipsychotics, SSRIs, Stimulants, Non-stimulants and Melatonin)

A,b,c,d EASY HIGH LOW

5, 8 Write shared care policies for all five classes of medication

MEDIUM HIGH MEDIUM

0, 1 Develop clinician ‘medication packs’ for all five classes of medication to allow non prescribers to adequately inform young people and families

A,d EASY MEDIUM MEDIUM

9, Develop the skills of non prescribing clinicians to support compliance and concordance, via use of Post Grad Sessions (targeted at specific groups and mandatory)

A,d MEDIUM HIGH HIGH

4,8 Review service relationship with pharmaceutical companies

d MEDIUM MEDIUM LOW

10, 11, 7 Develop clinician psychopharmacology forum including all prescribers (medical and non medical) and pharmacy


Key 0 Easy/High/Cheap ∆ Medium X Hard/low/expensive

a b c d


Reflections:

No GoGo


Ease Impact Cost




MEDIUM HIGH MEDIUM



9, Develop the skills of non prescribing clinicians to support compliance and concordance, via use of Post Grad Sessions (targeted at specific groups and manadatory)



d MEDIUM MEDIUM LOW




a b c d

e Solution Idea Effee

stimulants and Melatonin)

d

Rewrite protocols for all five classes of medication (atypical antipsychotics, SSRIs, Stimulants, Non-stimulants and Melatonin)


Reflections:

No GoGo


Ease Impact Cost




MEDIUM HIGH MEDIUM






d MEDIUM MEDIUM LOW




a b c d

d

e Sol tion Idea EffeeRewrite protocols for all five

classes of medication (atypical antipsychotics, SSRIs, Stimulants, Non-stimulants and Melatonin)

Include Fixed Method Incremental methodologies


Reflections:

No GoGo


Ease Impact Cost




MEDIUM HIGH MEDIUM






d MEDIUM MEDIUM LOW




a b c d

e Sol tion Idea Effee

d

Rewrite protocols for all five classes of medication (atypical antipsychotics, SSRIs, Stimulants, Non-stimulants and Melatonin)

i

Develop clinician medication packs for all five classes A d

1

y

Week Dosage of methylphenidate (M/R)

Method of Contact and evaluation

1 10mg daily PRN phone adviceshort Conners and side-effect questionnaire



The regimes for modified release methylphenidate are as follows: Weightunder 25 Kg

Include Fixed Method Incremental methodologies

: A.D.H.D. Pathway

Example of Standard

Treatment Algorithm

Target State No GoGoImproved Health

improved compliance by 20%Best Possible Care

improve to a minimum of 95%



a b

c d

808284868890

Compliance

Baseline

Target

Repeat 70

80

90

100

NICE Compliance

%

Baseline

Target

Repeat

02000400060008000

10000

Drug Expenditure

10% target0

50

100


% Pre RIE

Target

Post RIE

A3 – boxes 1 - 3Re-designing the service along LEAN principles

Other Pathways that have demonstrated improvements in Patient Flow and / or improved

Quality

Time from Choice to 1st ADHD Pathway Team Diagnosis … Ian 71-106.pdf · ADHD Pathway Team Lead -...

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