Moving Into An AMBIT Based Future With “Wheel” Changes

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Initiative Type
Research
Status
Deliver
Added
06 August 2021
Last updated
16 August 2021

Summary

During the pandemic the statewide Assertive Mobile Youth Outreach Service (AMYOS) program utilised a framework that is based in neuroscience and psychology, and a systems-based approach, to manage youth who were isolated and high risk while being able to remain connected to a wheel of people who continued to learn and adapt. The AMBIT framework is not specific to youth psychiatry and can be used in any service within a hospital with great impact.

Key dates
Apr 2020
Implementation sites
Childrens Health Queenslandx2,Metro South and North, Wide Bayx2, Cairns, Gold Coast, West Moreton, Mackay, Sunshine Coast, Central Queensland, Toowoomba, Townsville

Aim

To demonstrate that wherever you are in Queensland, and whatever service you are from, if you have a framework that improves every aspect of service delivery (including maintaining connections between young people, families, networks and team members and being able to apply and adapt continued learnings in “real time") you can adapt to changing clinical practice parameters that occurred during the COVID-19 global pandemic.  
 

Benefits

The AMBIT framework has resulted in a quick and effective change and importantly with no clinical disruption to an integrated technology-based service.  
Results suggest: 

  • continued fidelity of AMBIT framework with telehealth and mobile technology 
  • improved relationships between young persons and stakeholders from real-time feedback 
  • improvement of staff attitudes and satisfaction through a supportive and structured model for working with complex young people, despite the changes with the COVID-19 global pandemic  
  • offers a manual and evidence-based framework to support practice 
  • offers a structured framework which supports local services to marry elements of externally-validated evidence-based practice with their own locally-derived “practice based evidence"
  • further opportunities for collaboration and communication between other health teams. 

 

Background

The statewide Assertive Mobile Youth Outreach Service (AMYOS) had to adopt various technology strategies to ensure continuity of 14 teams across 12 Queensland Hospital and Health Services (HHSs) during the pandemic. The challenge of managing the wellbeing of adolescents and families with complex mental health problems including social, emotional and intergenerational complexity was immense during the pandemic. However, the implementation of the Adaptive Mentalisation Based Integrative treatment (AMBIT) framework resulted in a smooth transition to different ways of working and successful service delivery.  
Not only did service continue - it was enhanced through greater adaption and utility of technology to support direct feedback from young people, real time data and dashboards for service evaluation and research projects and improved connectivity with clinicians across Queensland working in the AMYOS program.

Solutions Implemented

The AMBIT wheel: A new kind of ‘rocket science’.

Rocket science has become the yardstick for describing mind-blowingly complicated, risky, clever, creative and daring work. But rocket scientists have it quite easy. They do not work in circumstances in which frontline mental health workers have to - and more so with the challenges a pandemic throw at you. Personal Protective Equipment (PPE) is pretty weird for a young person when you visit them at home and all their neighbours see you! The AMBIT framework focuses on flexibility and maintaining connection of clinical staff to the client (young person) their team, networks and adapting and learning.

So, Why AMBIT? The AMBIT Wheel is primarily designed for the benefit of workers - helping them to map or mark and balance the range and scope of their work tasks. It emphasises the need to strengthen integration in the complex networks that tend to gather around complex young people - minimising the likelihood of an experience of care that is aversive. The COVID-19 global pandemic involved huge disruptions to networks, systems and processes that tend to support complex mental health youth. During the pandemic we adapted and thrived with our work utilising the four quadrants in the AMBIT wheel which has a specific focus on the team (AMYOS), the client (young people and their family). 

  1. Our team: Enhanced connection and support for the 14 teams across the state occurred through immediate adaptation of mobile technologies for AMYOS teams. State meetings were held as communication and check-ins, breakout sessions and targeted site meetings were used to support specific HHS challenges, along with a supervision system for telehealth. To maintain staff morale with less frequent face to face, statewide 'fierce competitions' were held, including a 60 second video diary of the day in the life of an AMYOS worker. This offered humour and connection during the challenging periods. Quarterly dashboards were implemented and utilised during the pandemic to provide transparency about the AMYOS program - who we see, what we are doing, tracking emerging challenges and changes in clinical complexity of cases across the state and within their local HHS services.   
  2. Our clients: Maintaining the challenges of wearing PPE and safety with outreach work was important. Humour, support and being able to get reflections and responses from the young people was important. We developed an online mobile data collection platform to hear directly from the young people in real time. This online recovery tool collects feedback directly from the young person about their perception of their functioning, sense of engagement with the service, the focus of treatment and their goals.  An engaging video explaining consent to the online data processes was developed.
  3. Our networks (stakeholders): During the COVID-19 pandemic, network relationships with Department of Education, non-government organisations (NGOs) and families went online with regular group meeting to continue connection. Our parent program shifted online with no impact to clinical outcomes.   Furthermore, Queensland AMYOS is part of an international research group that is collecting, reporting and evaluating data related to the implementation of AMBIT. Our results showed at baseline, AMYOS data is matching other countries, but excelling in cohesiveness and connection via technology and working successfully with such a large number of remote teams.   
  4. Learning at work: Statewide supervision, staff training, and shared complex cases all occurred during the pandemic. The AMBIT framework directly facilitates this within the AMYOS program. Catching up for statewide supervision, investment in staff training and supervision, and having several research projects occurring. Baseline data using an implementation science framework indicated that AMYOS staff strongly believe that the strategies AMYOS uses has high acceptability (92%), feasibility (82%), intention to act or adoption of changes (72%), high knowledge transfer and knowledge utilisation (100%).

Evaluation and Results

To measure the effectiveness of AMBIT on teams, young people and their families (client), networks and our ability to learn an evaluation plan was developed. 
At baseline we have feedback from AMYOS teams of AMBIT implementation and utility as being highly effective in managing complex work with clients, teams and networks and highly suitable to a transition to technology-focused modalities for all four aspects of the AMBIT wheel. 
This is the proof that our framework helped us maintain connection despite working with complex and high risk and hard to reach youth often already managing in isolation, with ever changing rules and parameters during the pandemic and the changing lockdown stages and rules across different areas in Queensland. In fact, we adopted technology at super-speed to not only maintain but expand our clinical service to capture direct feedback from our youth. 

Some of the feedback (real names have been changed to protect identity and all are recorded on our compliments and complaints register):
•    18-year-old female Alison "I can honestly tell you that I would not be alive if it hadn't been for the support from AMYOS, I truly don't think I would have been." 
•    “AYMOS worker has been fantastic supporting the Greenslopes Residential team and I'd like for this to be formally recognised. Without her input we would not have been able to manage such a distraught and complex young lady.” 
•    “They (AMYOS workers) understand the systems but sit a little outside it and can hold the different perspectives and how it's possible to work together to find a way forward.” 
•    Mother: “Justin has gone out with his friends to the city today. Has worked hard this weekend on his shifts at the cafe. His self-esteem is rocketing."  
•    “Thank you so much for all you and the team have done to help get Bess on the right path and back to her happy old self, as a mum I am so grateful and words can’t describe how lucky I am she had found such a wonderful caring team. Thank you from the bottom of my heart.”

Robust data collection and analysis by AMYOS teams across the state show that comparison of pre and post treatment outcomes indicated statistically and clinically significant improvements in mental health problems, perceived suicide risk and conduct problems.
In addition, reductions were seen in both the mean monthly admissions and total days spent in hospital for mental health problems following involvement with AMYOS compared to the previous 12 months. However, contrary to hypotheses there was an increase in the mean monthly visits to Emergency Departments (EDs) after involvement with the program.
There were improvements for adolescents over most measures of general functioning and mental health. Almost all clinician-rated measures showed significant improvements in scale scores consistent with large to very large effect sizes. There were reductions in reports of overall mental health problems, hostility, perceived suicide risk and engagement in risky behaviour. 
Improvement was seen in the engagement of families in therapy over time and in adolescent engagement with a General Practitioner (GP).
Overall, parents reported greater improvements than adolescents. For instance, the reduction in emotional problems over time was statistically significant for parents, but not adolescents.
 

Lessons Learnt

Transparent data, open communications and an equal investment in teams, young people and their families, networks and ongoing learnings allowed the AMYOS program to manage the complexity of the pandemic and innovate new ways of working. Embedding evaluation and data collection into practice allows an opportunity for staff and young people to engage in and reflect on the delivery of care.
 

References

Innovations in Practice: Adolescent Mentalization-Based Integrative Therapy (AMBIT) - a new integrated approach to working with the most hard to reach adolescents with severe complex mental health needs. Child and Adolescent Mental Health , 18 (1) 46 - 51. Bevington, D; Fuggle, P; Fonagy, P; Target, M; Asen, E; (2013) 
Applying attachment theory to effective practice with hard-to-reach youth: the AMBIT approach. Dickon Bevington*, Peter Fuggle and Peter Fonagy Anna Freud Centre, London, UK (Received 30 July 2012; accepted 27 September 2014)
A Mentalization-Based Treatment Approach to Caring for Youth in Foster Care Maja Nørgård Jacobsen M.Sc., Carolyn Ha M.A. & Carla Sharp Ph.D. Journal of Infant, Child, and Adolescent Psychotherapy.
Innovations in Practice: evaluating clinical outcome and service utilization in an AMBIT-trained Tier 4 child and adolescent mental health service Helen Griffiths1,2, Abbi Noble1, Fiona Duffy1,2 & Matthias Schwannauer1,2.
The Adolescent Mentalization-based Integrative Treatment (AMBIT) approach to outcome evaluation and manualization: adopting a learning organization approach. Peter Fuggle, Dickon Bevington, Liz Cracknell, James Hanley, Suzanne Hare, John Lincoln, Garry Richardson, Nina Stevens, Heather Tovey and Sally Zlotowitz.
 

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Key contact

Dr Carina Capra
Program Coordinator of Statewide Community AET Service
Children's Health Hospital and Health Service
07 308 42100
carina.capra@health.qld.gov.au

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