Title: Global Appraisal of Individual Needs GAIN: How it acts as a key piece of infrastructure for supporti
1Global 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
2Goals 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
3Part 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
4The 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
5As 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
6Canada and other countries
State or County System GAIN-Short
Screener GAIN-Quick GAIN-Full
1-10 Sites Other Countries Brazil, China,
Mexico, Japan
7So 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
8Key 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
91. 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
102. 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
113. 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
124. 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
135. 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
14Across measures, the GAIN has a Common Factor
Structure of Psychopathology
Source Dennis, Chan, and Funk (2006)
CFI.92, RMSEA.06 allowing for age
15Alcohol 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
16Co-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 .
17Progressive 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
18Part 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
19Next 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
20GAIN-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
21GAIN-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
22GAIN-Short Screener (GSS)
23GAIN 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
24GSS 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
25GAIN SS Total Score is Correlated With Level Of
Care Placement Adolescents
26GAIN SS Total Score is Correlated With Level Of
Care Placement Adults
27GAIN 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
28GAIN Short Screener Profile Reclaiming Futures
(Range based on 0/1-2/3 Symptoms)
Source Reclaiming Futures Portland, OR and
Santa Cruz, CA sites (n192)
29GAIN 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)
30Construct Validity of GSS Internalizing Disorder
Screener
Source Education Service District 113 (n979)
and King County (n1002)
31Construct Validity of GSS Externalizing Disorder
Screener
Source Education Service District 113 (n979)
and King County (n1002)
32Construct Validity of GSS Substance Disorder
Screener
Source Education Service District 113 (n979)
and King County (n1002)
33Construct Validity of GSS Crime/Violence
Screener
Source Education Service District 113 (n979)
and King County (n1002)
34Adolescent 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/
35Adult 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/
36Adolescent 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/
37Adult 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/
38Other 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)
39GAIN 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).
40GAIN 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
41GAIN 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
42GAIN 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).
43Validations
- 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.
44GAIN 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
45GAIN 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
46GAIN 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
47GAIN 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
48GAIN 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.
49GAIN 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)
50GAIN 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)
51GAIN Initial Profile Motivation and
Readiness(Range based range of
clinical/logical/statistical rules)
Source Reclaiming Futures Portland, OR and
Santa Cruz, CA sites (n192)
52GAIN Initial Profile Crime/Violence(Range based
range of clinical/logical/statistical rules)
Source Reclaiming Futures Portland, OR and
Santa Cruz, CA sites (n192)
53GAIN Initial Profile Environmental Risk(Range
based range of clinical/logical/statistical
rules)
Source Reclaiming Futures Portland, OR and
Santa Cruz, CA sites (n192)
54GAIN Initial Profile Internalizing
Disorders(Range based range of
clinical/logical/statistical rules)
Source Reclaiming Futures Portland, OR and
Santa Cruz, CA sites (n192)
55GAIN Initial Profile Externalizing
Disorders(Range based range of
clinical/logical/statistical rules)
Source Reclaiming Futures Portland, OR and
Santa Cruz, CA sites (n192)
56GAIN Initial Profile Personality
Disorders(Range based range of
clinical/logical/statistical rules)
Source Reclaiming Futures Portland, OR and
Santa Cruz, CA sites (n192)
57GAIN 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)
58GAIN Initial Profile Other Problem Scales(Range
based range of clinical/logical/statistical
rules)
Source Reclaiming Futures Portland, OR and
Santa Cruz, CA sites (n192)
59GAIN 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)
60GAIN 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)
61GAIN Treatment Planning/Placement Grid
Current for Intoxication Withdrawal Past 7
days
62Reclaiming Futures ASAM Placement Cells
Source Reclaiming Futures Portland, OR and
Santa Cruz, CA sites (n192)
63Other Common Treatment Planning Needs Reclaiming
Futures
Source Reclaiming Futures (n192)
64Part 3. Highlight our current work to using
actuarial estimates of outcomes to improve
placement decisions
65CSAT Adolescent Treatment GAIN Data from 203
level of care x site combinations
Source Dennis, Funk Hanes-Stevens, 2008
66Ratings 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
67Variance 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)
68Predicted Count of Positive Outcomes by Level of
Care Cluster A Low - Low (n1,025)
69Best Level of Care Cluster A Low - Low
(n1,025)
Source CSAT 2007 AT Outcome Data Set (n11,013)
70Best Level of Care Cluster B Low - Mod
(n1,654)
Source CSAT 2007 AT Outcome Data Set (n11,013)
71Best Level of Care Cluster C Mod-Mod (n1209)
Source CSAT 2007 AT Outcome Data Set (n11,013)
72Best Level of Care Cluster D Hi-Low (n687)
Source CSAT 2007 AT Outcome Data Set (n11,013)
73Best Level of Care Cluster F Hi-Hi (CC) (n968)
Source CSAT 2007 AT Outcome Data Set (n11,013)
74Best Level of Care Cluster Cluster H Hi-Hi
(Intx/PH/MH) (n1,017)
Source CSAT 2007 AT Outcome Data Set (n11,013)
75Best Level of Care Cluster E Hi-Mod (n1,190)
Source CSAT 2007 AT Outcome Data Set (n11,013)
76Best Level of Care Cluster G Hi-Mod (Env/PH)
(n749)
Source CSAT 2007 AT Outcome Data Set (n11,013)
77Best (x) by Actual (y) Level of Care Placement
78Exploring 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
79Mental Health Problem (at intake) vs. Any MH
Treatment by 3 months
3 on ASAM dimension B3 criteria
Source 2008 CSAT AAFT Summary Analytic Dataset
80Why 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.
81Residential 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
82Part 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
83Secondary 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
84Status of Translations
85Acknowledgments 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