Whanganui DHB: Improving Service Transitions through focusing on CHOICE

Janice Bowers, clinical nurse manager at Whanganui DHB has been leading a project for ICAMHAS (Infant, child and adolescent mental health and addiction services) to improve the way the department manages service transitions.

'As a department, we have committed to implementing the CAPA (Choice and Partnership Approach) model of care, which values young people being at the centre of decision making,' says Janice. 'Yet when we applied this model, we realised our young clients and their families often felt therapy was being ‘done to them’, and that they weren’t actively involved in their own journey to recovery.'

The CAPA model recommends clients set their own goals for recovery at their initial assessment, to help build resilience, improve problem-solving skills and help them feel empowered to work on issues proactively between appointments.

'We realised many of our young clients weren’t actively setting their own goals at this first assessment and often weren’t given clear areas to work on between appointments. Also, they weren’t involved in designing the transition plan that was being developed for them,' says Janice.

The project team, led by Janice, decided to focus first on improving the quality of the initial assessment.

'All clinicians working across our service carry out CHOICE appointments (the first assessment), even though they may not be the clinician who provides the ongoing therapy. By improving the quality of this first appointment we realised we could influence the success of the service transition, as from here people will either be referred onto another service, clinician or transition plan. It’s a really important stage in a client’s recovery journey.'

The team set a target of increasing the number of personalised plans being set at the initial assessment by the young person or their family to 100 percent, and measured the number of letters mailed containing a personalised plan.

The team also identified that ensuring consistent, client-centred communication would support effective transitions; 'by listening to our young clients and their families, we realised they didn’t want to be sent full details of their personal history, they just wanted to know the transition plan and when their next appointment was. Simple as that,' says Janice.

As well as standardising all written communication, the team created a new pamphlet, and multi-disciplinary team document, to support the initial assessment and help clinicians when they saw clients for the first time.

Janice says the steps taken have been successful. 'Since February, 100 percent of our CHOICE appointments have resulted in a personalised plan which has been communicated to our young clients and their families in the new letters. We feel we are starting to get young people and their families taking charge of their own mental health goals, plus it’s much better for the clinicians, as they don’t have to do as much paperwork!'