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Global Appraisal of Individual Needs GAIN: How it acts as a key piece of infrastructure for supporti

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Title: Global Appraisal of Individual Needs GAIN: How it acts as a key piece of infrastructure for supporti


1
Global Appraisal of Individual Needs (GAIN) How
it acts as a key piece of infrastructure for
supporting the move towards evidenced based
practice
  • Michael Dennis, Ph.D.
  • Chestnut Health Systems,
  • Normal, IL
  • Presentation at the Adolescent Treatment
    Summit, Saratoga Springs, New York October
    19-20, 2009. The meeting and presentation are
    sponsored by St. Peters Addiction Recovery
    Center (SPARC) and New York State Office of
    Alcoholism and Substance Abuse Services (OASAS).
    This presentation reports on treatment
    research funded by the Center for Substance Abuse
    Treatment (CSAT), Substance Abuse and Mental
    Health Services Administration (SAMHSA) under
    contracts 270-2003-00006 and 270-07-0191, as well
    as several individual CSAT, NIAAA, NIDA and
    private foundation grants. The opinions are those
    of the author and do not reflect official
    positions of the consortium or government.
    Available on line at www.chestnut.org/LI/Posters
    or by contacting Joan Unsicker at 448 Wylie
    Drive, Normal, IL 61761, phone (309) 451-7801,
    Fax (309) 451-7763, e-mail junsicker_at_Chestnut.
    Org

2
Goals of this Presentation are to
  • Provide an overview of the role of the GAIN as a
    piece of infrastructure in support the move
    toward both evidence based practice and practice
    based evidence
  • Describe each of the measures, the reports that
    they use to help the assessment guide clinical
    decision making and illustrate how they provide a
    successively more detailed picture of client
    needs
  • Highlight our current work to using actuarial
    estimates of outcomes to improve placement
    decisions
  • Summarize the status of efforts to make the data
    available for secondary analysis and translate
    the software, measures and reports from English
    into Spanish, French, Portuguese and other
    languages

3
Part 1. Provide an overview of the role of the
GAIN as a piece of infrastructure in support the
move toward both evidence based practice and
practice based evidence
4
The Global Appraisal of Individual Needs (GAIN)
is ..
  • A family of instruments ranging from screening,
    to quick assessment to a full Biopsychosocial and
    monitoring tools
  • Designed to integrate clinical and research
    assessment
  • Designed to support clinical decision making at
    the individual client level
  • Designed to support evaluation and planning at
    program level
  • Designed to support secondary analyses and
    comparisons across individuals and programs

5
As of June 30, 2009, there were 1127
administrative units (agencies, grantees,
counties, states) collaborating to use the GAIN
in the U.S.,
State or County System GAIN-Short
Screener GAIN-Quick GAIN-Full
6
Canada and other countries
State or County System GAIN-Short
Screener GAIN-Quick GAIN-Full
1-10 Sites Other Countries Brazil, China,
Mexico, Japan
7
So what does it mean to move the field towards
Evidence Based Practice (EBP)?
  • Introducing explicit intervention protocols that
    are
  • Targeted at specific problems/subgroups and
    outcomes
  • Having explicit quality assurance procedures to
    cause adherence at the individual level and
    implementation at the program level
  • Introducing reliable and valid assessment that
    can be used
  • At the individual level to immediately guide
    clinical judgments about diagnosis/severity,
    placement, treatment planning, and the response
    to treatment
  • At the program level to drive program evaluation,
    needs assessment, performance monitoring and long
    term program planning
  • Having the ability to evaluate client and program
    outcomes
  • For the same person or program over time,
  • Relative to other people or interventions

8
Key Issues that we try to address with the GAIN
Instruments and Coordinating Center
  • High turnover workforce with variable education
    background related to diagnosis, placement,
    treatment planning and referral to other services
  • Heterogeneous needs and severity characterized by
    multiple problems, chronic relapse, and multiple
    episodes of care over several years
  • Lack of access to or use of data at the program
    level to guide immediate clinical decisions,
    billing and program planning
  • Missing, bad or misrepresented data that needs to
    be minimized and incorporated into
    interpretations
  • Lack of Infrastructure that is needed to support
    implementation and fidelity

9
1. High Turnover Workforce with Variable Education
  • Questions spelled out and simple question format
  • Lay wording mapped onto expert standards for
    given area
  • Built in definitions, transition statements,
    prompts, and checks for inconsistent and missing
    information.
  • Standardized approach to asking questions across
    domains
  • Range checks and skip logic built into electronic
    applications
  • Formal training and certification protocols on
    administration, clinical interpretation, data
    management, coordination, local, regional, and
    national trainers
  • Above focuses on consistency across populations,
    level of care, staff and time
  • On-going quality assurance and data monitoring
    for the reoccurrence or problems at the staff
    (site or item) level
  • Availability of training resources, responses to
    frequently asked questions, and technical
    assistance

Outcome Improved Reliability and Efficiency
10
2. Heterogeneous Needs and Severity
  • Multiple domains
  • Focus on most common problems
  • Participant self description of characteristics,
    problems, needs, personal strengths and resources
  • Behavior problem recency, breadth , and frequency
  • Utilization lifetime, recency and frequency
  • Dimensional measures to measure change with
    interpretative cut points to facilitate decisions
  • Items and cut points mapped onto DSM for
    diagnosis, ASAM for placement, and to multiple
    standards and evidence- based practices for
    treatment planning
  • Computer generated scoring and reports to guide
    decisions
  • Treatment planning recommendations and links to
    evidence-based practice
  • Basic and advanced clinical interpretation
    training and certification

Outcome Comprehensive Assessment
11
3. Lack of Access to or use of Data at the
Program Level
  • Data immediately available to support clinical
    decision making for a case
  • Data can be transferred to other clinical
    information system to support billing, progress
    reports, treatment planning and on-going
    monitoring
  • Data can be exported and cleaned to support
    further analyses
  • Data can be pooled with other sites to facilitate
    comparison and evaluation
  • PC and web based software applications and
    support
  • Formal training and certification on using data
    at the individual level and data management at
    the program level
  • Data routinely pooled to support comparisons
    across programs and secondary analysis
  • Over three dozen scientists already working with
    data to link to evidence-based practice

Outcome Improved Program Planning and Outcomes
12
4. Missing, Bad or Misrepresented Data
  • Assurances, time anchoring, definitions,
    transition, and question order to reduce
    confusion and increase valid responses
  • Cognitive impairment check
  • Validity checks on missing, bad, inconsistency
    and unlikely responses
  • Validity checks for atypical and overly random
    symptom presentations
  • Validity ratings by staff
  • Training on optimizing clinical rapport
  • Training on time anchoring
  • Training answering questions, resolving vague or
    inconsistent responses, following assessment
    protocol and accurate documentation.
  • Utilization and documentation of other sources of
    information
  • Post hoc checks for on-going site, staff or item
    problems

Outcome Improved Validity
13
5. Lack of Infrastructure
  • Development
  • Clinical Product Development
  • Software Development
  • Collaboration with IT vendors (e.g., WITS)
  • Over 36 internal external scientists and
    students
  • Workgroups focused on specific subgroup, problem,
    or treatment approach
  • Labor supply (e.g., consultant pool, college
    courses)
  • Direct Services
  • Training and quality assurance on administration,
    clinical interpretation, data management,
    follow-up and project coordination
  • Data management
  • Evaluation and data available for secondary
    analysis
  • Software support
  • Technical assistance and back up to local
    trainer/expert

Outcome Implementation with Fidelity
14
Across measures, the GAIN has a Common Factor
Structure of Psychopathology
Source Dennis, Chan, and Funk (2006)
CFI.92, RMSEA.06 allowing for age
15
Alcohol and Other Drug Abuse, Dependence and
Problem Use are Age Related
100
90
Percentage
80
70
60
Severity Category
50
Other drug or heavy alcohol use in the past year
40
30
Alcohol or Drug Use (AOD) Abuse or Dependence
in the past year
20
10
0
65
12-13
14-15
16-17
18-20
21-29
30-34
35-49
50-64
Age
Source 2002 NSDUH and Dennis Scott, 2007
16
Co-occurring Mental Health Problems are Common,
but the Type of Problems also Changes with Age
Internalizing Disorders go up with age
Externalizing Disorders go down with age (but do
NOT go away)
Source Chan, YF Dennis, M L. Funk, RR. (2008).
Prevalence and comorbidity of major
internalizing and externalizing problems among
adolescents and adults presenting to substance
abuse treatment. Journal of Substance Abuse
Treatment, 34(1) 14-24 .
17
Progressive Continuum of Measurement (Common
Measures)
  • Screening to Identify Who Needs to be Assessed
    (5-10 min)
  • Focus on brevity, simplicity for administration
    scoring
  • Needs to be adequate for triage and referral
  • GAIN Short Screener for SUD, MH Crime
  • ASSIST, AUDIT, CAGE, CRAFT, DAST, MAST for SUD
  • SCL, HSCL, BSI, CANS for Mental Health
  • LSI, MAYSI, YLS for Crime
  • Quick Assessment for Targeted Referral (20-30
    min)
  • Assessment of who needs a feedback, brief
    intervention or referral for more specialized
    assessment or treatment
  • Needs to be adequate for brief intervention
  • GAIN Quick
  • ADI, ASI, SASSI, T-ASI, MINI
  • Comprehensive Biopsychosocial (1-2 hours)
  • Used to identify common problems and how they are
    interrelated
  • Needs to be adequate for diagnosis, treatment
    planning and placement of common problems
  • GAIN Initial (Clinical Core and Full)
  • CASI, A-CASI, MATE

More Extensive / Longer/ Expensive
Screener Quick
Comprehensive Special
18
Part 2. Describe each of the measures, the
reports that they use to help the assessment
guide clinical decision making and illustrate how
they provide a successively more detailed picture
of client needs
19
Next slides will
  • Describe the difference in the breadth of
    information you get with different levels of
    assessment
  • Summarize validation studies to date
  • Illustrate the difference using data from a
    single sample (Reclaiming futures project)
  • Demonstrate that multi-morbidity is the norm and
    varies by type of client and program

20
GAIN-Short Screener (GSS)
  • Administration Time A 3- to 5-minute screener
  • Purpose Used in general populations to
  • identify or rule-out clients who will be
    identified as having any behavioral health
    disorders on the 60-120 min versions of the GAIN
  • triage area of problem
  • serve as a simple measure of change
  • Easy for administration and interpretation by
    staff with minimal training or direct supervision
  • Mode Designed for self- or staff-administration,
    with paper and pen, computer, or on the web
  • Scales Four screeners for Internalizing
    Disorders, Externalizing Disorders, Substance
    Disorders, Crime/Violence, and a Total

21
GAIN-Short Screener (GSS) (continued)
  • Response Set Recency of 20 problems rated past
    month (3), 2-12 months ago (2), more than a year
    ago (1), never (0)
  • Interpretation Combined by cumulative time
    period as
  • Past month count (3s) to measure of change
  • Past year count (2s or 3s) to predict diagnosis
  • Lifetime count (1s, 2s or 3s) as a measure of
    peak severity
  • Can be classified within time period low (0),
    moderate (1-2) or high (3)
  • Can also be used to classify remission as
  • Early (lifetime but not past month)
  • Sustained (lifetime but not past year)
  • Reports Narrative, tabular, and graphical
    reports built into web based GAIN ABS and/or ASP
    application for local hosting

22
GAIN-Short Screener (GSS)
23
GAIN SS Psychometric Properties
Low Mod. High
100
Prevalence ( 1 disorder)
90
Sensitivity ( w disorder above)
80
Specificity ( w/o disorder below)
70
(n6194 adolescents)
60
Using a higher cut point increases prevalence
and specificity, but decreases sensitivity
50
40
At 3 or more symptoms we get 99 prevalence, 91
sensitivity, 89 specificity
30
20
10
0
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Total Disorder Screener (TDScr)
Total score has alpha of .85 and is correlated
.94 with full GAIN version
Source Dennis et al 2006
24
GSS Performance by Subscale and Disorders

Prevalence

Sensitivity

Specificity

Screener/Disorder


1

3

1

3

1

3

Internal Disorder Screener (0-5)

Any Internal Disorder

81

99

94

55

71

99

Major Depression

56

87

98

72

54

94

Generalized Anxiety

32

56

100

83

44

83

Suicide
Ideation

24

43

100

84

41

79

Mod/High Traumatic Stress

60

82

94

60

55

90


External Disorder Screener (0-5)
Any External Disorder

88

97

98

67

75

96

AD, HD or Both

65

82

99

78

51

85

Conduct Disorder

78

91

98

70

62

90

Substance Use Disorder Screener (0-5)

Any Substance Disorder

96

100

96

68

73

100

Dependence

65

87

100

91

30

82

Abuse

30

13

89

25

14

28

Recommend Triage as 0Not likely 1-2
Possible 3Likely
Crime Violence Screener (0-5)

Any Crime/Violence

88

99

94

49

76

99

High Physical Conflict

31

46

100

70

38

77

Mod/High General Crime

85

100

94

51

71

100

Total Disorder Screener (0-5)
Any Disorder

97

99

99

91

47

89

Any Internal Disorder

58

63

100

98

8

28

Any External Disorder

68

75

100

99

10

37

Any Substance Disorder

89

92

99

92

20

51

Any Crime/Violence
68

73

100

96

10

32












25
GAIN SS Total Score is Correlated With Level Of
Care Placement Adolescents
26
GAIN SS Total Score is Correlated With Level Of
Care Placement Adults
27
GAIN SS Can Also be Used for Monitoring
20
12 Mon.s ago (1s)
2-12 Mon.s ago (2s)
16
Past Month (3s)
Lifetime (1,2,or 3)
11
12
10
10
9
9
8
8
3
4
2
2
0
Intake
3
6
9
12
15
18
21
24
Mon
Mon
Mon
Mon
Mon
Mon
Mon
Mon
Total Disorder Screener (TDScr)
Monitor for Relapse
28
GAIN Short Screener Profile Reclaiming Futures
(Range based on 0/1-2/3 Symptoms)
Source Reclaiming Futures Portland, OR and
Santa Cruz, CA sites (n192)
29
GAIN Short Screener Number of Problems Mod/Hi in
Reclaiming Futures
93 endorsed one or more problems (40 4 or more)
Source Reclaiming Futures Portland, OR and
Santa Cruz, CA sites (n192)
30
Construct Validity of GSS Internalizing Disorder
Screener
Source Education Service District 113 (n979)
and King County (n1002)
31
Construct Validity of GSS Externalizing Disorder
Screener
Source Education Service District 113 (n979)
and King County (n1002)
32
Construct Validity of GSS Substance Disorder
Screener
Source Education Service District 113 (n979)
and King County (n1002)
33
Construct Validity of GSS Crime/Violence
Screener
Source Education Service District 113 (n979)
and King County (n1002)
34
Adolescent Rates of High (2) Scores on Mental
Health (MH) or Substance Abuse (SA) Screener by
Setting in Washington State
Problems could be easily identified
Comorbidity is common
Source Lucenko et al (2009). Report to the
Legislature Co-Occurring Disorders Among DSHS
Clients. Olympia, WA Department of Social and
Health Services. Retrieved from
http//publications.rda.dshs.wa.gov/1392/
35
Adult Rates of High (2) Scores on Mental Health
(MH) or Substance Abuse (SA) Screener by Setting
in Washington State
Lower than expected rates of SA in Mental Health
Childrens Admin
Source Lucenko et al (2009). Report to the
Legislature Co-Occurring Disorders Among DSHS
Clients. Olympia, WA Department of Social and
Health Services. Retrieved from
http//publications.rda.dshs.wa.gov/1392/
36
Adolescent Client Validation of Hi Co-occurring
from GAIN Short Screener vs Clinical Records by
Setting in Washington State
Two page measure closely approximated all found
in the clinical record after the next two years
Source Lucenko et al (2009). Report to the
Legislature Co-Occurring Disorders Among DSHS
Clients. Olympia, WA Department of Social and
Health Services. Retrieved from
http//publications.rda.dshs.wa.gov/1392/
37
Adult Client Validation of Hi Co-occurring from
GAIN Short Screener vs Clinical Records by
Setting in Washington State
Source Lucenko et al (2009). Report to the
Legislature Co-Occurring Disorders Among DSHS
Clients. Olympia, WA Department of Social and
Health Services. Retrieved from
http//publications.rda.dshs.wa.gov/1392/
38
Other Validations
  • Confirmatory Factor Analysis
  • Dennis, Chan Funk (2006) found that the 20 item
    GSS and its four subscales were highly correlated
    (.84 to .94) with the full scale, had 90
    sensitivity and over 90 area under the curve
    relative to the full GAIN Confirmatory factors
    analysis also found it to be consistent with the
    overall model of psychopathology after allowing
    for age (CFI.92 RMSEA.06).
  • Substance Disorders
  • McDonnell and colleagues (2009) found that the
    5-item GAIN SS Substance Disorder Screener had
    92 sensitivity and 85 correct classification
    relative to the Diagnostic Inventory Scale for
    Children (DISC) Predictive Scales (DPS Lucas et
    al 2001) and 88 sensitivity and 88 correct
    classification relative to the CRAFFT (Knight et
    al 2001)
  • Internalizing Disorders
  • McDonnell and colleagues (2009) found that the
    5-item GAIN SS Internalizing Disorder Screener
    had 100 sensitivity and 75 correct
    classification relative to the Youth Self Report
    (YSR Achenbach et al, 2001) and that the 5-item
    GAIN SS Externalizing Disorder Screener had 89
    sensitivity and 65 correct classification to the
    YSR.
  • Riley and colleagues (2009) found that the 5-item
    GAIN SSs Internalizing Disorder Screener had 92
    sensitivity and 80 area under the curve relative
    to the Structured Clinical Interview for DSM
    (SCID) and was more efficient relative to 11 item
    Addiction Severity Index (ASI) psychiatric
    composite score (McLellan et al., 1992), 10 item
    K10 (Kessler et al., 2002) and the 87 item
    Psychiatric Diagnostic Screening Questionnaire
    (PDSQ Zimmerman and Mattia, 2001)

39
GAIN Quick (GQ)
  • Administration Time 20-30 minutes (depending on
    severity and whether reasons for quitting module
    used)
  • Training Requirements 1 day (train the trainer)
    plus certification within 1-2 months
  • Mode Generally Staff Administered on Computer
    (can be done on paper or self administered with
    proctor)
  • Purpose Designed for use in targeted populations
    to support brief intervention or referral for
    further assessment or behavioral intervention.
    Not originally designed for follow-up.
  • Scales The GQ has total scale (99-symptoms) and
    15 subscales (including more detailed versions of
    the GSS scales and subscales plus scales for
    service utilization, sources of psychosocial
    stress, and health problems).

40
GAIN Quick (GQ) (Continued)
  • Response Set Breadth (past year symptom counts
    for behavior and lifetime for utilization) and
    Prevalence (past 90 days)
  • Interpretation
  • Items can be used individually or to create
    specific diagnostic or treatment planning
    statements
  • Items can be summed into scales or indices for
    each behavior problem or and for recent service
    utilization overall
  • All scales, indices and selected individual items
    have interpretative cut-points to facilitate
    clinical interpretation and decision making
  • Some people repeat just days items for follow-up.
  • Reports Narrative, tabular, graphical, validity
    and motivational interviewing reports built
    into web based GAIN ABS Program level reports
    available in SPSS/Excel

41
GAIN Quick Profile of Reclaiming Futures Sites
(Range based on 0-24 / 25-74 / 75-100 of
Symptoms)
More detail within each area
Risk Stress Health
Source Reclaiming Futures Chicago, IL, Dayton,
OH, Portland, OR and Santa Cruz, CA
sites (n475).
Summary Measure
42
GAIN Quick Number of Problems Mod/Hi
97 endorsed one or more problems (69 4 or more
problems)
Source Reclaiming Futures Chicago, IL, Dayton,
OH, Portland, OR and Santa Cruz, CA
sites (n475).

43
Validations
  • Titus and colleagues (2008) found that the
    internal consistency of the full scales ranged
    from .82 to .90 among adults and adolescents with
    alpha above .7 for 7 of 8 subscale scores for
    adults and 7 of 8 subscale scores for the
    adolescents.
  • Titus and colleagues (2008) found that the mental
    health scales from the GAIN quick have good
    internal consistency (.86 to .90), are correlated
    with the full GAIN dimensional measures (.92 to
    .97) and .99 to 100 sensitivity relative to the
    full GAIN.

44
GAIN Quick (GQ) In Transition
  • Strengths Length (20-30min) in desired range,
    range of topics, efficiently categorizes,
    narrative reports to support screening, brief
    intervention, and referral to treatment
  • Problems
  • Lacks scales or recency to support analyses or
    outcomes related to change over time
  • Item response choices do not provide information
    about lifetime problems
  • Current Personal Feedback Report focuses only on
    substance use and does not address the other
    content areas of the GAIN-Q
  • Only about 60 of the items can be directly
    imported into the GAIN-I

45
GAIN Quick (GQ) In Transition
  • Plans for Version 3
  • Keep focus on screening, brief intervention and
    referral to treatment
  • Break out sections for Crime/Violence, HIV risk,
    Work and School problems
  • Subsume GSS and add similar screeners in other
    GAIN Q areas with recency response to address
    change and lifetime issues
  • Change measures for each symptom count and days
    items
  • Create reasons for change items in each area to
    support brief intervention, reducing number of
    items in substance use
  • Make all questions importable into full GAIN
  • Expand narrative report to have more treatment
    planning statements and to allow motivational
    interviewing within each area
  • Plans for Version 4 Add computer adaptive
    testing (CAT) component to get at more detailed
    diagnosis where needed

46
GAIN Initial (GI)
  • Administration Time Core version 60-90 minutes
    Full version 110-140 minutes (depending on
    severity)
  • Training Requirements 3.5 days (train the
    trainer) plus recommend formal certification
    program (administration certification within 3
    months of training local trainer certification
    within 6 months of training) Advanced clinical
    interpretation recommended for clinical
    supervisors and lead clinicians
  • Mode Generally Staff Administered on Computer
    (can be done on paper or self administered with
    proctor)
  • Purpose Designed to provide a standardized
    biopsychosocial for people presenting to a
    substance abuse treatment using DSM-IV for
    diagnosis, ASAM for placement, and needing to
    meet common (CARF, COA, JCAHO, insurance,
    CDS/TEDS, Medicaid, CSAT, NIDA) requirements for
    assessment, diagnosis, placement, treatment
    planning, accreditation, performance/outcome
    monitoring, economic analysis, program planning
    and to support referral/communications with other
    systems

47
GAIN Initial (GI) (continued)
  • Scales The GI has 9 sections (access to care,
    substance use, physical health, risk and
    protective behaviors, mental health, recovery
    environment, legal, vocational, and staff
    ratings) that include 103 long (alpha over .9)
    and short (alpha over .7) scales, summative
    indices, and over 3000 created variables to
    support clinical decision making and evaluation.
    It is also modularized to support customization
  • Response Set Breadth (past year symptom counts
    for behavior and lifetime for utilization),
    Recency (48 hours, 3-7 days, 1-4 weeks, 2-3
    months, 4-12 months, 1 years, never) and
    Prevalence (past 90 days), patient and staff
    ratings
  • Interpretation
  • Items can be used individually or to create
    specific diagnostic or treatment planning
    statements
  • Items can be summed into scales or indices for
    each behavior problem or type of service
    utilization
  • All scales, indices and selected individual items
    have interpretative cut-points to facilitate
    clinical interpretation and decision making

48
GAIN Initial (GI) (continued)
  • Reports
  • Validity Report (VR) identifying missing/bad
    data and potentially problematic areas of
    assessment
  • Individual Clinical Profile (ICP) lab report
    with graphical and tabular summary with links
    back to the items
  • GAIN Recommendation and Referral Summary (GRRS)
    Draft of biopsychosocial narrative for clinician
    to use for initial assessment summary, diagnosis,
    placement and treatment planning
  • Personal Feedback Report (PFR) used to support
    Motivational Interviewing (MI) / Motivational
    Enhancement Therapy (MET)
  • Program Profile program level report that allows
    comparison of client characteristics, services
    received and outcomes between programs, cohorts
    or types of clients.

49
GAIN Initial Profile Substance Problems Past
Year(Range based range of clinical/logical/statis
tical rules)
Source Reclaiming Futures Portland, OR and
Santa Cruz, CA sites (n192)
50
GAIN Initial Profile Substance Problems by
Time(Range based range of clinical/logical/statis
tical rules)
Source Reclaiming Futures Portland, OR and
Santa Cruz, CA sites (n192)
51
GAIN Initial Profile Motivation and
Readiness(Range based range of
clinical/logical/statistical rules)
Source Reclaiming Futures Portland, OR and
Santa Cruz, CA sites (n192)
52
GAIN Initial Profile Crime/Violence(Range based
range of clinical/logical/statistical rules)
Source Reclaiming Futures Portland, OR and
Santa Cruz, CA sites (n192)
53
GAIN Initial Profile Environmental Risk(Range
based range of clinical/logical/statistical
rules)
Source Reclaiming Futures Portland, OR and
Santa Cruz, CA sites (n192)
54
GAIN Initial Profile Internalizing
Disorders(Range based range of
clinical/logical/statistical rules)
Source Reclaiming Futures Portland, OR and
Santa Cruz, CA sites (n192)
55
GAIN Initial Profile Externalizing
Disorders(Range based range of
clinical/logical/statistical rules)
Source Reclaiming Futures Portland, OR and
Santa Cruz, CA sites (n192)
56
GAIN Initial Profile Personality
Disorders(Range based range of
clinical/logical/statistical rules)
Source Reclaiming Futures Portland, OR and
Santa Cruz, CA sites (n192)
57
GAIN Initial Profile General Factors /
Stress(Range based range of clinical/logical/stat
istical rules)
Source Reclaiming Futures Portland, OR and
Santa Cruz, CA sites (n192)
58
GAIN Initial Profile Other Problem Scales(Range
based range of clinical/logical/statistical
rules)
Source Reclaiming Futures Portland, OR and
Santa Cruz, CA sites (n192)
59
GAIN Initial Profile Measures of Behavior Change
(Range based range of clinical/logical/statistica
l rules)
Source Reclaiming Futures Portland, OR and
Santa Cruz, CA sites (n192)
60
GAIN Initial Number of Problems Mod/Hi
99 endorsed one or more problems (98 4 or more)
Source Reclaiming Futures Portland, OR and
Santa Cruz, CA sites (n192)
61
GAIN Treatment Planning/Placement Grid
Current for Intoxication Withdrawal Past 7
days
62
Reclaiming Futures ASAM Placement Cells
Source Reclaiming Futures Portland, OR and
Santa Cruz, CA sites (n192)
63
Other Common Treatment Planning Needs Reclaiming
Futures
Source Reclaiming Futures (n192)
64
Part 3. Highlight our current work to using
actuarial estimates of outcomes to improve
placement decisions
65
CSAT Adolescent Treatment GAIN Data from 203
level of care x site combinations
Source Dennis, Funk Hanes-Stevens, 2008
66
Ratings of Problem Severity (x-axis) by
Treatment Utilization (y-axis) by Population Size
(circle size)
1.00
F. Hi- Hi (CC)
H. Hi-Hi (Intx Sx PH/MH Tx) 12
0.80
12


0.60
G. Hi-Mod (Env Sx/ PH Tx) 9
C
E
Average Current Treatment Utilization
.
Hi- Mod
0.40
Mod-Mod
B
14
14
Low- Mod
0.20
20
A
D
0.00
Low-Low
Hi-Low
8
12
-0.20
-0.20
0.00
0.20
0.40
0.60
0.80
1.00
Average Current Problem Severity
67
Variance Explained in 10 NOMS Outcomes
Percent of Variance Explained
0
5
10
15
20
25
30
35
26
No AOD Use
24
No AOD related Prob.
11
No Health Problems
25
No Mental Health Prob.
15
No Illegal Activity
33
No JJ System Involve.
26
Living in Community
18
No Family Prob.
14
Vocationally Engaged
8
Social Support
24
Count of above
\1 Past month \2 Past 90 days All
statistically Significant
Source CSAT 2007 AT Outcome Data Set (n11,013)
68
Predicted Count of Positive Outcomes by Level of
Care Cluster A Low - Low (n1,025)
69
Best Level of Care Cluster A Low - Low
(n1,025)
Source CSAT 2007 AT Outcome Data Set (n11,013)
70
Best Level of Care Cluster B Low - Mod
(n1,654)
Source CSAT 2007 AT Outcome Data Set (n11,013)
71
Best Level of Care Cluster C Mod-Mod (n1209)
Source CSAT 2007 AT Outcome Data Set (n11,013)
72
Best Level of Care Cluster D Hi-Low (n687)
Source CSAT 2007 AT Outcome Data Set (n11,013)
73
Best Level of Care Cluster F Hi-Hi (CC) (n968)
Source CSAT 2007 AT Outcome Data Set (n11,013)
74
Best Level of Care Cluster Cluster H Hi-Hi
(Intx/PH/MH) (n1,017)
Source CSAT 2007 AT Outcome Data Set (n11,013)
75
Best Level of Care Cluster E Hi-Mod (n1,190)
Source CSAT 2007 AT Outcome Data Set (n11,013)
76
Best Level of Care Cluster G Hi-Mod (Env/PH)
(n749)
Source CSAT 2007 AT Outcome Data Set (n11,013)
77
Best (x) by Actual (y) Level of Care Placement
78
Exploring Need, Unmet Need, Targeting of Mental
Health Services in AAFT
218/22497 to targeted
553/77172 unmet need
771/98279 in need
Size of the Problem
Extent to which services are not reaching those
in most need
Extent to which services are currently being
targeted
79
Mental Health Problem (at intake) vs. Any MH
Treatment by 3 months
3 on ASAM dimension B3 criteria
Source 2008 CSAT AAFT Summary Analytic Dataset
80
Why Do We Care About Unmet Need?
  • If we subset to those in need, getting mental
    health services predicts reduced mental health
    problems
  • Both psychosocial and medication interventions
    are associated with reduced problems
  • If we subset to those NOT in need, getting mental
    health services does NOT predict change in mental
    health problems

Conversely, we also care about services being
poorly targeted to those in need.
81
Residential Treatment need (at intake) vs. 7
Residential days at 3 months
Opportunity to redirect existing funds through
better targeting
Source 2008 CSAT AAFT Summary Analytic Dataset
82
Part 4. Summarize the status of efforts to make
the data available for secondary analysis and
translate the software, measures and reports from
English into Spanish, French, Portuguese and
other languages
83
Secondary Analysis
  • We currently pool data from Center for Substance
    Abuse Treatment (CSAT) grantees annual and make
    it available for secondary analysis
  • Requires abstract length proposal/ feasibility
  • Requires agreement to respect privacy and not
    attempt to re-identify
  • We will get permission from any active grantees
  • No cost to the end user
  • Over 36 scientist and evaluators have already
    accessed the data and about 1-2 more come get
    approval each month
  • We can also negotiate access to additional data
    from individual grantees and/or regional projects

84
Status of Translations
85
Acknowledgments and Contact Information
  • This presentation was supported by analytic runs
    provided by Chestnut Health Systems for the
    Substance Abuse and Mental Health Services
    Administration's (SAMHSA's) Center for Substance
    Abuse Treatment (CSAT) under Contracts
    207-98-7047, 277-00-6500, 270-2003-00006 and
    270-2007-00004C using data provided by the
    following 152 grantees TI11317 TI11321 TI11323
    TI11324 TI11422 TI11423 TI11424 TI11432 TI11433
    TI11871 TI11874 TI11888 TI11892 TI11894
    TI13190TI13305 TI13308 TI13313 TI13322 TI13323
    TI13344 TI13345 TI13354 TI13356 TI13601 TI14090
    TI14188 TI14189 TI14196 TI14252 TI14261 TI14267
    TI14271 TI14272 TI14283 TI14311 TI14315 TI14376
    TI15413 TI15415 TI15421 TI15433 TI15438 TI15446
    TI15447 TI15458 TI15461 TI15466 TI15467 TI15469
    TI15475 TI15478 TI15479 TI15481 TI15483 TI15485
    TI15486 TI15489 TI15511 TI15514 TI15524 TI15524
    TI15527 TI15545 TI15562 TI15577 TI15584 TI15586
    TI15670 TI15671 TI15672 TI15674 TI15677 TI15678
    TI15682 TI15686 TI16386 TI16400 TI16414 TI16904
    TI16928 TI16939 TI16961 TI16984 TI16992 TI17046
    TI17070 TI17071 TI17334 TI17433 TI17434 TI17446
    TI17475 TI17476 TI17484 TI17486 TI17490 TI17517
    TI17523 TI17535 TI17547 TI17589 TI17604 TI17605
    TI17638 TI17646 TI17648 TI17673 TI17702 TI17719
    TI17724 TI17728 TI17742 TI17744 TI17751 TI17755
    TI17761 TI17763 TI17765 TI17769 TI17775 TI17779
    TI17786 TI17788 TI17812 TI17817 TI17825 TI17830
    TI17831 TI17864 TI18406 TI18587 TI18671 TI18723
    TI19313 TI19323 TI655374. Any opinions about
    this data are those of the authors and do not
    reflect official positions of the government or
    individual grantees. It is available at
    www.chestnut.org/li/posters. Comments or
    questions can be addressed to Michael Dennis,
    Chestnut Health Systems, 448 Wylie Drive, Normal,
    IL 61761. Phone 1-309-451-7801 E-mail
    mdennis_at_chestnut.org.
  • More information on the GAIN is available at
    www.chestnut.org/li/gain or by e-mailing
    gaininfo_at_chestnut.org .

85
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