Thank you to Diana Deniel-Dawson, Interim Lead at Having Child and Adolescent Mental Health Services (CAMHS), North East London NHS Foundation Trust.
What was the original problem you were trying to solve?
We noticed that there was an increasing demand for CAMHS. The number of referrals that we received was increasing year on year, yet the size of the team was not growing proportionately. We also found that not all of the children and young people who were referred into CAMHS were appropriate for tier 2 or tier 3 services.
What did you do?
We identified that the most effective way to address increasing demand and need would be to look at the ‘Front Door’ of the service which is our Triage process. In 2014 we introduced a Triage model with the aim of ensuring that we were accepting only children and young people for whom a specialist service was appropriate whilst also providing high quality advice and signposting, self-management support and psychoeducation for all those whose needs could be met in this way.
How did you go about introducing the Triage model?
The introduction of the Triage model was the result of a quality improvement (QI) project. Using QI methodology and Plan-Do-Study-Act (PDSA) cycles, we introduced one small change to the service at a time, measuring its impact as we went along.
For the first PDSA cycle we assigned two CAMHS staff to dedicate four days a month each to Triage. Prior to this there was a duty desk which clinicians took turns to be responsible for. We found that this was not effective and there was a lack of continuity and responsibility because there could be a different team member in Triage each day of the week. At the time, it could take the service over a month to make contact with the family, or key professionals.
The first change that we implemented as a result of this was the introduction of a “two week contact letter”. This letter was sent to parents and carers if we had not been able to make contact after a set period of time. The family was informed that the service had been trying to make contact, and they were asked to make contact with the service instead.
The second PDSA cycle led us to assign one dedicated person to Triage on a full-time basis. However, we found there was still a build-up and backlog of referrals as ‘Getting Advice and Signposting’ remained the responsibility of the sole member of staff in triage, rather than being part of a broader team effort.
The third PDSA cycle led us to introduce another full-time member of staff to the triage team. This gave the team more capacity to undertake comprehensive telephone assessments for all referrals and assess which pathways were the most appropriate to meet the needs of the young person.
The Triage service now
The service is now called ‘Triage and Brief Intervention’. Its staff conducts comprehensive telephone assessments and signpost children and young people to the services and resources that will best meet their needs. The Triage team also hold a small case load of clients who would typically sit within the ‘Getting Help’ needs-based grouping of the THRIVE framework (Wolpert et al., 2016) which is outcome-driven.
For every referral that is received into Havering CAMHS, the Triage team will contact the referrer, the parent and other professionals involved with the child within three days of receipt. We are able to provide advice and self-management strategies to the young people and families who have been referred to specialist CAMHS but are have needs more aligned to ‘Getting Advice’ than ‘Getting Help’ or ‘Getting More meaning, the client and families still receive a comprehensive service.
What helped you to do this?
Drawing on my own personal background and experiences working in adult intake services helped me to innovate to find solutions to the demand problem we were facing in CAMHS.
Staffing triage with three highly experienced band 7 nurses has also been extremely helpful. The skill mix of these nurses has enabled them to have a multi-faceted role in Triage; assessing referrals, exploring and assessing risk, offering appropriate psycho-education and signposting families and professionals.
What were some of the challenges?
There were some initial operational challenges, for example, capacity for staff to triage alongside their day-to-day tasks. However, this was resolved when we recruited full-time staff to work in the triage team.
What has been the impact of the Triage service?
Since the Triage model was introduced in 2014 we have experienced a 35% reduction in the number of referrals seen within specialist CAMHS In spite of this, the number of referrals overall has increased year on year so the wider team work load has remained at a similar level.
As a service we have also been able to more effectively support young people who have been referred but have needs that are best met by a non-CAMHS service. With effective signposting and psychoeducation delivered by the experienced clinical nurse specialists, the young person is able to manage their emotional concerns.
Finally, relationships with schools have improved dramatically since 2014 through the service developing close working relationships with Special Educational Needs Co-ordinators (SENCOs) across the borough. There has also been a decrease in referrals from the schools which have strongest relationship with the Triage service. This has also led to opportunities to go out and do lots of preventative and promotional work in schools, colleges and children’s centres, and this has led on to a new schools-link role being developed to develop capacity and competency in the education workforce.
Have there been unintended consequences?
The Triage model has led some clinicians in the service to consider reducing their initial assessments from 1.5 to 1 hour, due to the comprehensive work done by the triage team that is documented on the electronic system.
The library of services that we signpost families to has grown. The result of this is that the broader CAMHS team is now more confident in discharging from CAMHS.
What is your learning for others?
This Triage model has demonstrated good outcomes for our referral flow and the use of resources, however it was challenging to implement, supported through a clear QI process. The key is staffing Triage with experienced practitioners who can explore and assess risk, offer high-quality advice and psychoeducation to families and referrers, and cope with a demanding workload.
How does this relate to THRIVE?
The Triage model at Havering CAMHS provides a service for the ‘Getting Advice and Signposting’ needs-based grouping of the THRIVE framework. Every young person referred will get a phone call from an experienced clinician. The Triage clinicians have a strong understanding of the comprehensive network of community providers, and therefore are able to signpost clinicians, referrers and children, young people and their families where appropriate, whilst also offering advice on self-management to ensure children and young people are linked in with the right service or access appropriate information and self-help resources.
If you would like further information on this Triage model please contact Diana Daniel-Dawson at Diana.Daniel-Dawson@nelft.nhs.uk
Written August 2017.