2 nd Big Idea Core and Specific Work

1. 2nd Big IdeaCore and Specific Work Ann York and Steve Kingsbury 2010

2. Core and Specific work p 58 - 63 • Key idea of separating our clinical work into core and specific work streams • Core work is bulk of what we do • All clinicians • Extended clinical skills • Manages most families • Specific work • Specific therapy, assessment or skill • Additional to Core work • Often done in a more formal way

3. Why have this distinction? • Effective use of skills - threshold and specialist • Helpful in job planning - segments activities according to duration and skill level of task • Smoothes flow through the system - by balancing demand and capacity • Reduces bottlenecks - by extending skills, reducing demand for and protecting specialist skills

4. Definitions • Core work • Clinicians using a range of extended, threshold skills • Specific work • TYPE 1: Specialist skill • Using a specialist level skill often in specific “pure” ways • For a defined task • Perhaps with a more formal structure • time, place or frequency • E.g WISC, psychotherapy • TYPE 2: Threshold skills • Using extended, threshold skills • For a defined task • e.g parenting group, CLA, Tier 2 etc

5. Why have separate core and specific work? • Many can be helped by threshold level work • Extended core skills reduces bottlenecks to specifc work • Extended core skills increases clinical flexibility (fewer queues into ‘specialised’ streams) • Allows us to identify AND PROTECT specific team / individual capacity for specific work • Segments and so helps flow

6. So what does a typical clinician look like? • Range of extended Core clinical skills • Able to work flexibly between these skills • Some Specific skills that are job planned • Receive internal referrals for… • Spend time (job planned) doing both Core and Specific

7. Links to Real Skills Plus CAMHS www.werrycentre.org.nz/?t=441 • CAMHS competency framework • Implementation to be complete by 2010 • Can be done independently of Workforce Planning and 7HH tools from Werry • Resource guide available • Informed by 7HH/CAPA concepts • Compliments professional competency frameworks • Links to Let’s Get Real for addictions • Practitioner –Core • Practitioner- Specialist

8. How to decide? • Three basic questions • Question 1: Skill • Does this work NEED specialist skills? • Question 2: Capacity • Do we need to reserve some clinical capacity for a particular task? • Question 3: Duration • Is the average duration of this work MUCH shorter or longer than the average

9. Whole Service • Separate service into short, average and long durations

10. Question 1: skills • Does this work specialist skills? E.g. WISC ASD assessment Psychotherapy

11. Threshold skills • The rest of the service is using extended threshold skills.

12. Question 2:reserve capacity? • Do we need to reserve some specific capacity for a particular task or function? E.g Parenting work, CLA consult, Tier 2 functions

13. Long term work? • Perhaps for long term work too? E.g. long-term problems associated with parental mental illness

14. Letting Go! • Some long term durations may not be CAMHS a all • Often social care issues

15. Question 3: Duration • Is the duration of the extended skills work significantly shorter? • E.g. Choice

16. The rest: Core Partnership work • The rest of the work is the bulk of the service – core partnership work using extended threshold skills

17. Core Work • Choice and Core Partnership we describe as Core work

18. Specific Work • The rest of the work we call Specific Work

19. The Whole model… • Must it be Specialist skill? [BLUE block] • Do we have to Reserve the capacity? [PURPLE] • Is it of Short duration? [GREEN] • Is it average duration with threshold skills? [YELLOW]

20. CBT: core threshold vs specialist skills example: England Core CBT: • Core/basic work- explain model, structure sessions, using homework, reviewing homework Specialist CBT: All the above PLUS • Socratic questioning/guided discovery • Automatic thoughts/assumptions/beliefs • Problem specific competencies eg in ERP for OCD Could you manage a bottleneck to CBT by extending clincal skills to increase capacity at threshold/core level? Ref: The competencies required to deliver effective cognitive and behavioural therapy for people with depression and with anxiety disorders. Dept of Health 2007.

21. England Core : Explain model Structure sessions Use homework Review homework Specialist : All the above PLUS Socratic questioning/guided discovery Automatic thoughts/assumptions/beliefs Problem specific competencies eg in ERP for OCD NZ Real Skills Plus CAMHS p30 Core: Challenging thoughts Thought reframing Mood and feelings diary Self monitoring Self soothing techniques Specialist: CBT as described by Beck CBT: core threshold vs specialist skills example:England cf NZ

22. Key concept: extending clinical skills • ABCD’S Skills Clinicians (Alphabet skills) • Clinicians who have extended their skills to include the threshold competencies of: • Assessment • Behavioural • Cognitive • Dynamic. • Systemic

23. Specialist skills pattern

24. Core Extended threshold skills

25. A possible team pattern Behavioural Cognitive Dynamic Assessment Systemic Staff 1 Staff 2 Staff 3 Staff 4 Staff 5

26. A Possible Pattern… Effects?

27. A Possible Pattern… Effects?

28. A Possible Pattern… Effects?

29. Specific work protected in job plan You decide as a team what you need to protect. Examples could be... Shorter duration • ASD assessment • WISC Longer duration • psychodynamic psychotherapy • EMDR • Specialist level/’high intensity’ CBT