GAIN SCORING AND CLINICAL INTERPRETATION: Using the GAIN for Diagnosis, Level of Care Placement and

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GAIN SCORING AND CLINICAL INTERPRETATION
Using the GAIN for Diagnosis, Level of Care
Placement and Treatment Planning
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Objectives

• At the conclusion of this session, participants
  will be able to utilize the GAIN tools for the
  purpose of
• Forming diagnostic impressions based on DSM-IV-TR
  (APA, 2000) criteria
• Making and supporting placement decisions based
  on ASAM Patient Placement Criteria
• Prioritizing general areas for treatment planning
  
• Utilizing the information to facilitate effective
  communication with specialists, (e.g. medical or
  psychiatric referrals) who we work with, but
  outside of the immediate treatment system, by
  using the standards and language of their
  professions.

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Organization of This Presentation

• Information is presented in a series of 3 waves
• Each wave further clarifies and gives more
  in-depth information than the previous wave.

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Chapter 5 Diagnosis

• 5.1 Diagnosis of Substance Related Disorders
• Includes information on terminology and its
  relationship to the GAIN, detailed diagnoses,
  withdrawal, and substance induced-disorders
• Cross walk between GAIN items and DSM/ICD
  substances, diagnostic criteria/codes, withdrawal
  patterns, and substance induced health and
  psychological disorders
• 5.2 Supporting Non-Substance Axis 1 Disorders
• Includes information on other mood disorders,
  anxiety disorders, disorders usually first
  diagnosed in infancy, childhood or adolescence,
  and other Axis 1 disorders
• All statements evaluated in the GRRS/ICP are
  printed with formula
• 5.3 Other Axis 2, 3, 4 and 5 Diagnoses
• Including information on personality disorders by
  cluster, biomedical conditions that might
  complicate treatment by ICD-9, severity of
  victimization and other psycho-social stressors,
  and clinical ratings (GAF, SOFAS, GARF see
  p5-17, Exhibits 5-4 to 5-6)
• 5.4 Using the GRRS and ICP to Support Diagnoses

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Chapter 6. Level of Care Placement

• 6.1 Continuum of Care
• Ideally there is a full ASAM continuum of care
• However, there are often local limits on what is
  available
• 6.2 Using the GAIN to Address ASAM Patient
  Placement Criteria
• Crosswalk to ASAM Criterion A (Diagnosis) and
  dimensional criteria (B1. Intoxication and
  Withdrawal Potential B2. Biomedical Conditions
  and Complications B3. Emotional/Behavioral
  Conditions and Complications B4. Readiness for
  Change B5. Relapse Potential and Recovery
  Environment)
• All statements evaluated in the GRRS/ICP are
  printed with formula
• 6.3 Using the GAIN Referral and Recommendation
  Summary (GRRS) and Individual Clinical Profile
  (ICP) to Support Placement Decisions
• Including general conceptualization of placement
  needs organization and use of the GRRS
  organization and use of the ICP

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Chapter 7. Individualized Treatment Planning

• Relationship Between Assessment and Treatment
  Planning
• Rating for service need in each ASAM area
• Treatment recommendations in each ASAM area
  (including monitoring and none)
• Transitioning From Assessment to Planning
• Need to interpret and feedback
• Conceptualization of Core Problems
• Recency, breadth and prevalence
• History of and response to prior interventions
• Feedback and Targeting of Problems
• What they want vs. what you think or policy
  dictates
• Problem solving, simple, small relevant steps
• MET personal feedback report (PFR)
• Prioritizing General Areas for Treatment Planning
• Using the GRRS and ICP

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After all of that work.
This is the part I always hate
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General Issues in Clinical Interpretation
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General Issues in GAIN Interpretation

• The GAIN is just a self report, you should always
  consider other information.
• About 3 of the clients will have severe enough
  cognitive problems to limit its usefulness.
• An overlapping 5 will give answers that the
  assessor does not believe (either due to
  cognitive limits or lying)
• Many clients (particularly adolescents and young
  adults) will have inconsistencies because of
  difficulties with abstract concepts and paying
  attention.
• Interpretation requires learning how to
  synthesize the information.

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Important Checks When Relying on Self Report

• Over reporting
• Exaggeration to achieve an outcome (e.g.,
  diversion from jail)
• Storytelling that is unlikely (e.g., claiming to
  have downed a fifth of vodka by yourself)
• Endorsing everything but then appearing/claiming
  to be fully functional
• Suppression
• Symptoms may be low if currently receiving
  medication, treatment, or in a controlled
  environment (e.g., taking SRI for depression and
  not reporting enough symptoms to meet criteria
  reporting no use because they are in
  detention/jail)
• If condition is in remission or absent for the
  past 1 years.
• Under reporting
• Watch for inconsistencies between a history of
  intervention with no history of problems (e.g., 3
  DUIs, but claiming to have never driven drunk)
• Contexts where there may be substantial penalties
  for acknowledging problems (e.g., a work,
  criminal or juvenile justice setting an
  interview where privacy could not be
  established).

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Clinical Planning Using the GAIN A three-legged
stool
B. GAIN Reports After you conduct the GAIN
interview, the GAIN software can produce reports
(based on ICD-9 and DSM-IV) that you can use for
supporting substance diagnoses on Axis One and
other diagnoses on all five DSM axes.
A. Clinical Judgment Expected Pathology
Patterns Clinical interpretation can be based
on severity scales, which double-check reported
symptoms against the persons life problems,
levels of functioning and treatment history.
C. Additional Diagnostic Information
Information from collaterals, prior treatment,
psychiatrists, and other health professionals is
collected on page 99 for your consideration.
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A. Clinical Judgment
B. GAIN Reports After you conduct the GAIN
interview, the GAIN software can produce reports
(based on ICD-9 and DSM-IV) that you can use for
supporting substance diagnoses on Axis One and
other diagnoses on all five DSM axes.
A. Clinical Judgment -Expected Pathology
Patterns Clinical interpretation can be based
on severity scales, which double-check
client-reported symptoms against the clients
life problems, levels of functioning, and
treatment history.
C. Additional Diagnostic Information
Information from collaterals, prior treatment,
psychiatrists, and other health professionals is
collected on page 99 for your consideration.
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Expected Patterns of Psychopathology
Higher scores associated with the prescription of
alcohol and drug abuse medication (methadone,
naltrexone, antabuse, buprenorphine) and/or
substance induced legal, mental health, physical
health, and withdrawal problems
Higher scores associated with mental health
treatment (e.g., anti-depressants, selective
serotonin reuptake inhibitors (SSRI), monoamine
oxidase inhibitors (MAOI) sedatives) and/or a
history of traumatic victimization, and/or high
levels of stress
Higher scores associated with greater overall
dysfunction (e.g., dropping out of school,
unemployment, financial problems, homelessness)
Higher scores associated with psychopharmacologica
l behavioral health treatment (e.g., Ritalin,
Adderall, lithium), special/alternative
education, school or work problems, gambling and
other evidence of impulse control problems,
and/or anti-social/borderline personality
disorders
Higher scores associated with arrests,
detention/jail time, probation, parole, size of
drug habit
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Supplemental Diagnosis Worksheet (GAIN I page 99)
Add additional diagnosis by number, name or both
so they print out in the GRRS
Can also add course specifiers
Can check any of the Axis 4 psycho-social
stressors
Can make past-year and past 90-day Axis V ratings
Can document any additional sources of
information considered (e.g., records, collateral
report, diagnosis by a prior doctor)
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Interpreting Problem Factors

• Requires a consideration of 3 factors
• Recency
• Breadth
• Current Prevalence
• Lets look more closely at each of these.

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Interpreting Problem Factors (cont)

• Factor 1
• Recency
• Has this problem ever occurred and, if so, when
  did it last occur?
• Things that happened in the past week or 90 days
  will typically play a greater role in current
  treatment than those that happened 4-12 months or
  1 years ago.

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Interpreting Problem Factors (cont)

• Factor 2
• Breadth
• How widespread/diverse is the presentation of
  clinical symptoms or pattern of service
  utilization?
• Typically more diverse presentations are
  associated with higher severity.
• For clinical problems, the focus is on the past
  year (or since the last interview in follow-up
  assessments).
• For services, the focus is on the lifetime
  pattern of service utilization.

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Interpreting Problem Factors (cont)

• Factor 3
• Current Prevalence
• How often has this happened in the past 90 days?
  
• Typically things that happen more frequently
  (particularly if they interfere with
  responsibilities at home, work/school or
  socially) are going to be more important than
  those that happened only once or twice.

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GAIN Approach to ASAM Level of Care Placement

• Rate the Problem Recency and Treatment
  History
• Three time perspectives None, past or current
• Determine treatment planning and service needs
  based on the above rating
• Identify the level of care and/or local program
  that best matches the cluster of service needs
  that are identified
• Use information from average performance of
  different levels of care with similar populations
  to make choices where there is more than one
  possibility or trade-off

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Conceptualization of Treatment Need and Placement
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Conceptualization of Treatment Need and Placement
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Conceptualization of Treatment Need and Placement
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Conceptualization of Treatment Need and Placement
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Conceptualization of Treatment Need and Placement
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Conceptualization of Treatment Need and Placement
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Conceptualization of Treatment Need and Placement
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Supplemental ASAMWorksheet (GAIN I page 100)
Can document impression here so it prints out in
GRRS
SA treatment used for A, B4, B5, and (if
IOP/residential) B6
Can record problem recency by treatment history
rating
Can record comment to help with treatment planning
Record preliminary placement recommendations and
any comments about placement to include at the
end of the GRRS
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Treatment Options Built into the GAIN
Recommendation Referral Summary

• B1 Intoxication/Withdrawal Need for Detox
  Services
• Monitoring for change in intoxication or
  withdrawal symptoms
• Ambulatory detoxification services related to
  withdrawal
• Inpatient detoxification services related to
  current intoxication and withdrawal
• B2 Biomedical Need for Medical Services
• Monitoring for change in physical health (and
  medication compliance)
• The following specific accommodations for medical
  conditions required to participate in treatment
  List out
• A more detailed medical assessment (including
  nutritional guidance)
• Referral for the following specific medical
  services List out
• B3 Emotional/Behavioral Need for
  Psychological Services
• Monitoring for change in mental health (and
  medication compliance)
• The following specific accommodations for
  psychological conditions required to participate
  in treatment List out
• A more detailed psychological assessment
• Referral for the following specific psychological
  services List out

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Treatment Options (Continued)

• B4 Readiness to Change Need for Motivational
  Services,
• Coordination of Pressure and/or
  Access/Resistance Issues
• Monitoring for change in readiness for change
• The following assistance to help address
  treatment resistance list out
• Individual motivational enhancement sessions
• The following specific services to help maintain
  motivation to stay in recovery list out
• B5 Relapse/Continued Use Potential Need for
  Risk Management
• Monitoring for change in relapse potential
• Relapse prevention skills groups
• Increased structure to reduce environmental risks
  of relapse
• The following specific steps to reduce continued
  use/relapse potential list out
• B6 Recovery Environment Need for
  Environmental Interventions and
• Risk management
• Monitoring for change in recovery environment
• A residential or more structured treatment
  setting to temporarily control environmental
  risks
• the following specific steps to reduce recovery
  environment risks list out
• The following specific steps to take further
  advantages of sources of support/personal
  strengths list out

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B. GAIN Reports
B. GAIN Reports After you conduct the GAIN
interview, the GAIN software can produce reports
(based on ICD-9 and DSM-IV) that you can use for
supporting substance diagnoses on Axis One and
other diagnoses on all five DSM axes.
A. Clinical Judgment -Expected Pathology
Patterns Clinical interpretation can be based
on severity scales, which double-check reported
symptoms against the persons life problems,
levels of functioning and treatment history.
C. Additional Diagnostic Information
Information from collaterals, prior treatment,
psychiatrists, and other health professionals is
collected on page 99 for your consideration.
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The GRRS and ICP

• GAIN Referral and Recommendation Summary (GRRS)
  A text-based narrative in MS Word designed to be
  edited and shared with specialists, clinical
  staff from other agencies, insurers and lay
  people.
• Individual Clinical Profile (ICP) A more
  detailed report in MS Access designed to help
  triage problems and help the clinician go back to
  the GAIN for more details if necessary (generally
  not edited or shared).

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GAIN Recommendation and Referral Summary (GRRS)

• When starting a report, you can use the client
  name, initials or another term supplied by the
  person running the report
• Can use the sites organizational name or another
  term supplied by the person running the report
• The GRRS comes out in a MS Word Document file
  (.rtf) that can be read, edited and saved by
  most word processing programs.
• The report includes three types of prompts
  identifying areas where counselors
• Often add additional information or comments from
  other sources of information (e.g. psychiatrist
  or collateral input).
• Must reconcile and finalize potentially
  conflicting diagnoses
• Must make preliminary treatment planning
  recommendations
• The ICP report parallels the GRRS, but provides
  more detailed information to supplement it and/or
  to cross reference back to the GAIN for more
  information.

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GRRS - Continued

• The GRRS summarizes data collected and follows
  existing rules it is a tool to feed into and
  support clinical judgment not to replace it.
• The GRRS can only generate reports using the data
  collected.
• Therefore, a GRRS based on the full (90-120
  minute) version of the GAIN contains more details
  (e.g., name of school, employer, probation
  officer) than a GRRS based on the core (60-90
  minute) version of the GAIN.
• Sites can add in questions that are not in their
  core version, but that they want to have for the
  GRRS.
• Sites can also remove sections of the report they
  do not want and/or modify some of the labels
  (e.g., signature lines).

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G-RRS Organization Content(See Appendix F)

• Presenting Concerns and Identifying Information
• DSM-IV/ICD-9 Diagnoses 
• Evaluation Procedure
• Substance Use Diagnoses and Treatment History
  (ASAM criteria A)
• Level of Care and Service Needs (ASAM Six
  Dimensional Criteria B)
• Summary Recommendation
• Staff Notes from Assessment (should be used and
  removed during editing)

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1. Presenting Concerns and Identifying
Information

• Basic demographics (age, race, gender, marital
  status, children), appearance/disabilities,
  source and reason for referral, current living
  and vocational status
• Provides fixed coded responses plus the clients
  verbatim words (IN CAPS).
• Prompts to add any additional information related
  to
• reason for referral,
• custody arrangements,
• living situation,
• current address,
• parents' marital status,
• addresses of relevant parents/guardians
• When editing Review staff notes to add any
  additional details and finalize text

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2. DSM-IV/ICD-9 Diagnoses 

• Self-Report Based Measures and Codes for 5 axes
  of DSM
• (Summary of current treatment, medication,
  allergies and other sources of information to aid
  interpretation)
• Axis 1. Substance use disorders, major
  depression, generalized anxiety, ADHD, CD, and
  pathological gambling screening for mood/anxiety
  disorders, suicide risk, traumatic distress
• Axis 2. Screening for personality disorders by
  cluster
• Axis 3. Lifetime history by ICD-9 area and check
  for common drug-health interactions
• Axis 4. Traumatic victimization, check for major
  Axis IV bio-psycho-social stressors, and checks
  for other high-stress events
• Axis 5. Staff ratings of psychiatric,
  social/occupational, and relational functioning

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Diagnosis Continued

• Other
• Also reports the additional staff diagnoses
  reported on GAIN Diagnosis page at the end of the
  GAIN
• Ability to document Axis 5 GAF, SOFAS, GARF staff
  ratings for the past year and the past 90 days
• Ability to acknowledge other sources of
  information
• Can collapse, modify or delete diagnoses
• Prompt to reconcile and confirm diagnoses
• ICP prints out the rules/reasons why each
  diagnosis, specifier and rule out was given
• The manual lists all diagnoses, specifiers and
  rule outs that were checked, including the rules
  for when they are to be printed
• When editing Reconcile any differences,
  eliminate duplicates, decide whether to keep,
  change or delete course specifiers, identify
  anywhere you need further information to confirm
  or rule out.

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3. Evaluation Procedure

• Describes the type of administration (e.g. oral
  admin by staff), environmental context, ratings
  of the clients behaviors during the meeting,
  validity concerns and any additional source of
  information reported on the GAINs diagnosis page
  
• Includes a prompt to enter any other sources of
  information consulted as part of evaluation (e.g.
  urine test results, records, referral letters,
  family assessments, probation reports)
• When editing Identify where information comes
  from, add any comments and finalize paragraph.

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4. Substance Use and Treatment History(ASAM
PPC-2R Criteria A)

• Detailed text narrative age of first use,
  preferred substance, and substances for which the
  client perceives a need for treatment.
• For each DSM-IV substance use disorder diagnosis
  (in order of clinical severity from the S9 grid),
  the report will tell
• Diagnosis and specific symptoms reported in the
  past month, year and lifetime
• Recency, frequency and peak amount of use
• (If collected) the date and amount of last use
  (required for some insurance)
• Where a class of drugs (e.g., amphetamines), the
  specific drugs reported
• A list of other substances used (but for which
  diagnostic criteria are not met) a prompt will be
  given to add substances identified through
  biometric (e.g., urine, saliva, hair) testing or
  collateral reports.
• History of substance abuse treatment, including
  (if collected) a detailed treatment history
  (program, level of care, intake and discharge
  date).
• When editing Review and finalize SA Tx history
  paragraphs.

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5. Placement (ASAM PPC-2R Criteria B)

• Arranged by six dimensions of ASAM Criteria B
• Acute Alcohol/Drug Intoxication and Withdrawal
  Potential
• Biomedical Conditions and Complications
• Emotional, Behavioral, or Cognitive Conditions
  and Complications
• Readiness to Change
• Relapse, Continued Use, or Continued Problem
  Potential
• Recovery Environment
• When editing Review and finalize each
  subsection, including the initial treatment
  planning recommendations. Review list of
  treatment planning recommendation at the end of
  ICP, decide whether to use them, and where they
  should go.

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6. Summary Recommendation

• Summary of current systems client is involved in
  and with which treatment needs to be coordinated
• Any level of care recommendation from GAIN
  placement worksheet
• Prompt to
• enter level of care recommendation
• comment on any special barriers to placement and
  what might be done about them
• comment on need to coordinate care with other
  treatment or agencies
• Signatures
• Staff notes from assessment
• When editing Given the client history and
  current service needs, make a placement
  recommendation assuming all levels of care
  available. Repeat this step considering only
  what is available in your community. Add
  comments on any waiting list or other placement
  issues and finalize the recommendation.

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How the ICP Helps with the GRRS

• Identifies the criteria on which the diagnosis or
  statement is made
• Examines scale scores in a given area to better
  understand the severity of what is going on
• Gives complete breakout of demographics,
  behaviors, service utilization
• Provides more detailed information for treatment
  planning

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Individual Clinical Profile (ICP) Organization
Content

• Identifiers
• DSM-IV/ICD-9 Diagnoses 
• Demographics (including appearance, housing
  situation, prior treatment, involvement in other
  systems, potential validity concerns, staff
  notes)
• ASAM placement flags
• ASAM placement profile worksheet
• Behaviors and Service Utilization
• Treatment Planning Worksheet (including client
  and staff rating or urgency, what the client has
  asked for help with, and things that most
  agencies/accrediting agencies would expect to be
  in the treatment plans)
• Note this is a MS Access report, not intended
  for general distribution and only reports on data
  that was collected

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Notes on why the statements were printed

• Notice the addition of the conditions why
  statement was printed.
• Key
• Tx-treatment
• Sx-symptom
• 3 3 or more
• - greater
• than
• CAPS quote
• from staff
• or client

From Phillip ICP page 1
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ICP Demographics sectionlists out code and all
values
Example of Code-Response label
Gives status even if none or negative
Cannot give page numbers as it varies by version
but can jump directly there in ABS with
variable name
From Phillip ICP page 3
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ICP ASAM Flags bulleted out
Minimal Criteria for placement in a level of care
and the basis for printing the statement
Red flags indicating the need for more services
in the area or a higher level of care and the
basis for printing the statement
Manual has a list of all statements evaluated
From Phillip ICP page 5
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ICP ASAM Profile
ASAM Criteria Scale Name basis

• Score or
• Skipped
• Bad Data

Scale triaged into Low, Medium, or High Severity
Scales file has More information on purpose,
interpretation, source, and psychometrics
From Phillip ICP page 6
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Example of Hand Scoring Dependence Scales
Most scorings are counts of yes answers or sums
of answers
From Phillip ICP page 6
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Simple Behavior/Service Utilization Measures
Left side gives behaviors in the past 90 days
Right side gives utilization in the past 90 days
Organized by Section of the GAIN Gives item
number -- skipped, RF refused DK dont know
From Phillip ICP page 9
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Help with Treatment Planning
Compares Client and Staff Urgency Ratings from
the end of each section
Specific things the client has asked for
Other Actions or Things Typically Expected by
Agencies or Accrediting Agencies
From Phillip ICP page 10
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C. Other Sources of Information and Tools
B. GAIN Reports After you conduct the GAIN
interview, the GAIN software can produce reports
(based on ICD-9 and DSM-IV) that you can use for
supporting substance diagnoses on Axis One and
other diagnoses on all five DSM axes.
A. Clinical Judgment -Expected Pathology
Patterns Clinical interpretation can be based
on severity scales, which double-check reported
symptoms against the persons life problems,
levels of functioning and treatment history.
C. Additional Diagnostic Information
Information from collaterals, prior treatment,
psychiatrists, and other health professionals is
collected on page 99 for your consideration.
52
Additional Information

• GAIN-I and collateral questionnaires
• Information, treatment summaries and discharge
  reports from other providers
• Validity Report identifying missing/refused
  items, time, inconsistencies
• GAIN Scales file 1000 page electronic
  encyclopedia in MS Excel with documentation for
  each GAIN scale, subscale, index, created
  variable/text statements used in the GRRS, ICP
  and our research to date

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Ok, but how do you do it in practice?
I think you should be more explicit here in
step two
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Reprise of GRRS Exercise

• Section 1. Review staff notes to add any
  additional details and finalize
  text.
• Section 2.  Reconcile any differences, eliminate
  duplicates, identify any - where you need
  further information to confirm or rule out.
• Section 3.  Identify where information comes
  from, add any comments and finalize
  paragraph.
• Section 4. Review and finalize SA/Tx history
  paragraphs.
• Section 5. Review and finalize each subsection,
  including the initial treatment planning
  recommendations.
• Section 6. Given the client history and current
  service needs, make a placement
  recommendation assuming all levels of care
  available. Repeat this step considering only
  what is available in your community. Add
  comments on any waiting list or other
  placement issues and finalize the recommendation.

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Exercise with Phillip

• Gather the following materials
• Phillip case (GRRS, ICP, validity report, GAIN)
• Pull out last sheet of GRRS (staff notes), and
  last sheet of ICP (treatment planning worksheet)
• GAIN manual and/or CD if you have them
• Identify small group leaders and membership
• Choose a note taker who will edit the GRRS
• Pick someone to report out
• Do exercise try to move through it quickly,
  focusing on getting the GRRS edited with the
  materials readily available and making notes to
  rule out or get other information where there are
  concerns.
• When we come back together, we will..
• Ask each group to talk about a given section, ask
  if other have different or other suggestions
• Next group does next section, and so forth
• Discuss local issues related to service system
  and other paperwork