Using the GAIN Recommendation and Referral Summary GRRS to Support Clinical Decisionmaking - PowerPoint PPT Presentation

1 / 49
About This Presentation
Title:

Using the GAIN Recommendation and Referral Summary GRRS to Support Clinical Decisionmaking

Description:

Biomedical Conditions and ... Emotional Conditions (internal mental distress scale score, ... Cognitive Conditions (including Cognitive Impairment Score at ... – PowerPoint PPT presentation

Number of Views:96
Avg rating:3.0/5.0
Slides: 50
Provided by: michael356
Category:

less

Transcript and Presenter's Notes

Title: Using the GAIN Recommendation and Referral Summary GRRS to Support Clinical Decisionmaking


1
Using the GAIN Recommendation andReferral
Summary (GRRS) to SupportClinical Decision-making
  • Michael L. Dennis, Ph.D.
  • Dionna Christian
  • GAIN Coordinating Center (GCC)
  • Chestnut Health Systems, Bloomington, IL
  • Presentation for SAMHSAs
  • Center for Substance Abuse Treatment (CSAT)
  • Adolescent Treatment Grantee meeting,
  • Baltimore, MD, February 23-25, 2004.

2
  • ACKNOWLEDGEMENT
  • The development of the GAIN Recommendation and
    Referral Summary was supported with funds from
    the Center for Substance Abuse Treatment
    (Contract no. 270-2003-00006), Robert Wood
    Johnson Foundation (Grant no. 47266), and the
    National Institute on Alcohol Abuse and
    Alcoholism (Grant no. R01 AA10368). It would not
    have happened without the input from dozens of
    grantees (particularly Susan Godley and the staff
    of Chestnut Health Systems Bloomington, IL
    adolescent treatment unit) and additional hard
    work of several individual beta testers (who
    proofread over two dozen G-RRS against original
    interviews and made many invaluable suggestions
    for improving it) and the grants that sponsored
    their work, this includes Lora Passetti, Matt
    Orndorff, Jenny Hammond and Bobbie Jo Allen from
    Chestnut Health Systems (CSAT grant no TI14456),
    Doug Smith from University of Iowa (CSAT grant no
    TI13354), Alex Kuprion from Seven Counties (CSAT
    grant no TI13345), Benjamin Chambers and Wayne
    Scott from Multnomah County (RWJF grant no
    45054), and Robert Ketterlinus from Philadelphia
    Health Management Corporation (CSAT grant no
    TI14376). The information and the opinions
    expressed herein are solely those of the authors
    and do not represent official positions of the
    government, RWJF, or any other organization.
    The opinions are those of the author do not
    reflect official positions of the government .
    Available on-line at www.chestnut.org/li/apss

3
The Progression of Substance Use Problems
  • Multiple Problem Clients
  • Clinical Disorder
  • Problem Use
  • Frequent Use
  • Bingeing
  • Opportunistic Use
  • Experimentation
  • No Use

Severity
4
Multiple Co-occurring Problems Are the Norm and
Increase with Level of Care
Source CSATs Cannabis Youth Treatment (CYT),
Adolescent Treatment Model (ATM), and Persistent
Effects of Treatment Study of Adolescents
(PETS-A) studies
5
Severity is Related to Other Problems
100
80
60
37
40
22
22
13
20
5
0
Health Problem
Acute Mental
Acute
Attention
Conduct
Distress
Distress
Traumatic
Deficit
Disorder
Distress
Hyperactivity
Disorder
Abuse/Partial Remission (n322)
Past Year Dependence (n278)
plt.05
Source Tims et al 2002
6
Objectives
  • Provide an overview of how to use the GAIN
    Recommendation and Referral Summary (G-RRS) to
    support clinical decision-making.
  • Review procedures of downloading, installing and
    customizing the G-RRS
  • Discuss issues in implementing the G-RRS

7
Part I Overview of how to use the GAIN
Recommendation and Referral Summary (G-RRS) to
support clinical decision-making
8
  • GAIN
  • The Global Appraisal of Individual Needs or
    GAIN
  • is actually a series of standardized instruments
    designed to integrate the assessment for both
    clinical (e.g., diagnosis, bio-psycho-social
    assessment, placement, and treatment planning)
    and program evaluation (needs assessment,
    clustering, fidelity, outcomes, and benefit cost)
    purposes.

9
CSATs Adolescent Treatment Program Grantees
and Collaborators
CSAT
Other Collaborators
Cannabis Youth Treatment (CYT)
RWJF Reclaiming Futures Program
Adolescent Treatment Model (ATM)
RWJF Other RWJF Grantees
Strengthening Communities for Youth (SCY)
Adolescent Residential Treatment (ART)
NIAAA/NIDA Other Grantees
Effective Adolescent Treatment (EAT)
Other CSAT Grantees
10
Main Interpretative Reports to Support
Diagnosis, Placement, and Treatment Planning
  • GAIN Referral and Recommendation Summary (G-RRS)
    - Text based narrative in MS Word designed to be
    edited and shared with specialist, clinical staff
    from other agencies, insurers and lay people.
  • Individual Clinical Profile (ICP) 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)

11
G-RRS Organization
  • 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

12
General
  • 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 G-RRS comes out in a MS Word Document file
    (.doc) that can be read, edited and saved by
    most word processing programs.
  • The report include three types of prompts
    identifying areas where counselors
  • Often add additional information or comments from
    other sources of information
  • Have to reconcile and finalize potentially
    conflicting diagnoses
  • Have to make preliminary treatment planning
    recommendations
  • The ICP report parallels the G-RRS and provides
    more detailed information to supplement it and/or
    to cross reference back to the GAIN for more
    information.

13
General - Continued
  • The G-RRS summarizes data collected and follows
    existing rules it is a tool to feed into and
    support clinical judgment not to replace it.
  • The G-RRS can only generate reports using the
    data collected.
  • A G-RRS based on the full (90-120 minute) version
    of the GAIN contains more details (e.g., name of
    school, employer, probation officer) than a G-RRS
    based on the core (60-90 minute) version of the
    GAIN.
  • Sites can add in questions that are not in their
    core but that they want to have for the G-RRS.
  • Sites can also remove sections of the report that
    they do not want and/or modify some of the labels
    (e.g., signature lines)

14
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
  • Full version includes

15
2. DSM-IV/ICD-9 Diagnoses 
  • Self Reports Based Measures and Codes for
  • Summary of current treatment, medication and
    allergies to aid interpretation
  • Axis 1. Substance use disorders, major
    depression, generalized anxiety, ADHD, CD, and
    pathological gambling to criteria, 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

16
Diagnosis Continued
  • Other
  • Also reports the additional staff diagnoses
    reported on GAIN Diagnosis page
  • Ability to document Axis 5 Past year and Past 90
    day staff ratings for GAF, SOFAS, GARF
  • Ability to acknowledge other sources of
    information
  • Can collapse, modify or delete diagnoses
  • Prompt to reconcile and confirm diagnoses
  • ICP the rules why each diagnosis, specifier and
    rule out was printed
  • The manual lists all diagnoses, specifiers and
    rule outs that were checked, including the rules
    for when they are to be printed

17
3. Evaluation Procedure
  • Reviews type of administration, environmental
    context, ratings of the clients behaviors during
    the meeting, validity concerns and any addition
    source of information reported on the GAINs
    diagnosis page.
  • 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, etc)

18
4. Substance Use and Treatment History(ASAM
PPC-2R Criteria A)
  • Detailed text narrative age of first use,
    preferred substance, 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)
  • 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 substance used (but for which
    diagnosistic criteria are not met) and prompt to
    add more 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)

19
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
  • General
  • ICP gives code for why each text statements
    suggesting the need for a higher level of care
    was printed
  • ICP gives scale scores with triaged ranges (low,
    moderate, high score) by areas of ASAM
  • ICP gives days of behavior and service
    utilization reported in each section of the GAIN
  • GAIN manual lists all statements evaluated
  • Treatment planning embedded by section

20
Conceptualization of Treatment Planning Need for
Each ASAM area
21
B1. Acute Alcohol/Drug Intoxication and
Withdrawal Potential
  • Lifetime history of withdrawal and seizures
  • Current (past week) withdrawal scale score and
    symptoms endorsed
  • Recency of use, with flags on use in the past 48
    hours
  • Frequency of use, with flags on any daily use
    (45/90 days) and weekly use of opioids (13/90
    days)
  • Lifetime history of detoxification and days of
    detoxification in the past 90 days.
  • Prompt to recommend one of the following
  • Monitor for change in intoxication or withdrawal
    symptoms,
  • Ambulatory detoxification services related to
    withdrawal,
  • Inpatient detoxification services related to
    current intoxication and withdrawal.

22
B2. Biomedical Conditions and Complications
  • Overall Health and Pain Assessment (includes
    allergies)
  • Nutrition and Exercise (includes body mass index
    and eating disorder behaviors)
  • Sexual Activity and Orientation (includes
    preferences, activity, and contraceptive use)
  • Treatment History for Health Problems (lifetime
    and past 90 day use of hospitals, emergency
    rooms, outpatient surgery, outpatient treatment,
    and medication in full, current treatment
    duration and provider)
  • Prompt to recommend one of the following
  • Monitoring for change 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.

23
B3. Emotional, Behavioral, or Cognitive
Conditions and Complications
  • Emotional Conditions (internal mental distress
    scale score, past 12 month symptoms related to
    somatic, depression, suicide, anxiety, or trauma
    disorders recency and prevalence of problems,
    suicide risk).
  • Behavioral Conditions (behavior complexity scale
    score, past 12 month symptoms related to
    inattention, hyperactivity, and conduct
    disorders recency and prevalence of problems).
  • Arguing and Aggression (past 12 month symptoms of
    oral and physical violence recency and
    prevalence of problems)
  • Illegal Activity and Juvenile Justice Systems
    Involvement (lifetime and past 90 day number and
    type of arrests recency and prevalence of being
    on/in probation, parole, detention, jail, house
    arrest, electronic monitoring current status
    prompt to enter next court date or other
    important legal system date receny and type of
    illegal activity engaged in during the past year,
    prevalence of illegal activity and relationship
    to substance use).

24
B3. Continued
  • Cognitive Conditions (including Cognitive
    Impairment Score at the time of the evaluation,
    involvement in special education, and any other
    observed indications of cognitive impairment or
    developmental disabilities)
  • Treatment History for Emotional, Behavioral, or
    Cognitive Problems (prior diagnoses lifetime and
    past 90 day use of mental hospitals, emergency
    rooms, outpatient treatment, and medication in
    full, current treatment duration and provider)
  • Prompt to recommend one of the following
  • 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

25
B4. Readiness to Change
  • Perceived pressure to be in treatment and source
    of pressure
  • Treatment Motivation scale score
  • Treatment Resistance scale score
  • (if collected) Reasons for Quitting (RFQ) given,
    perceived ability to stop (or stay abstinent).
  • Note RFQ typically only used the Personal
    Feedback Report is also being used in MET/CBT or
    other MI
  • Prompt to recommend one of the following
  • 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

26
B5. Relapse, Continued Use, or Continued Problem
Potential
  • List of individual risk factors that predict
    continued use/problems or relapse, including
  • Low self-efficacy to resist
  • Low problem orientation (i.e., helplessness)
  • Daily use of anything or weekly use of opioids
  • Using substances to forget about traumatic
    memories
  • First used substances or got drunk under the age
    of 15
  • Reporting 3 or more symptoms of dependence/abuse
    in the past month
  • Continued substance use despite prior treatment
  • Prompt to recommend one of the following
  • 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

27
B6. Recovery Environment
  • Family/Home Environment (including who they live
    with, level of clients involvement with parents
    and own children, use in the home and time in a
    controlled environment)
  • School and Work Environment (including recency
    and prevalence of school and work, problems there
    in the past 12 months, pattern of grades, income
    spend on alcohol/drugs and if collected, the name
    of school/employer and type of job
  • Social Network Environment (For each of above and
    peers that they spend most of their social time
    with, the extent to which people in living,
    vocational and social circles were getting drunk,
    using drugs, committing illegal activity,
    fighting, vocationally engaged, had a treatment
    history, and considered themselves in recovery)
  • Sources of Social Support (if collected, open-end
    and closed list)
  • Personal Strengths (if collected, open-end and
    closed list).

28
B6. Continued
  • Spirituality (including religious affliation,
    strength and centrality of spiritual believes)
  • Satisfaction with Environment (extent satisfied
    with living situation, family, sexual partners,
    work/school, free time activities,
    coping/support)
  • Victimization (Lifetime history, severity,
    recency and current fears about being attached
    with a weapon, beaten, sexually abuse, or
    emotionally abused Prompt to comment on any
    reports/follow-up done)
  • Prompt to recommend one of the following
  • 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

29
6. Summary Recommendation
  • Summary of current systems clients is involved in
    and that treatment needs to be be coordinated
    with
  • 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

30
Using the ICP to help with the G-RRS
  • Identify the criteria on which the diagnosis or
    statement is made
  • Examining scale scores in a given area to better
    understand the severity or what is going on
  • Complete breakout of demographics, behaviors,
    service utilization
  • More detailed information for treatment planning

31
Individual Clinical Profile (ICP) Organization
  • 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 an access report, not intended for
    general distribution and only reports on data
    that was collected

32
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
  • gt - greater
  • than
  • lt - less than
  • CAPS quote
  • from staff
  • or client

From Phillip ICP page 1
33
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
34
ICP ASAM Flags bulleted out
Minimal Criteria for level of care and 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
35
ICP ASAM Profile
ASAM Criteria Scale Name basis
  • Score or
  • Skipped
  • Bad Data

Scale triaged into Low, Medium, or High Severity
Scales file as more on purpose, interpretation,
source, and psychometrics
From Phillip ICP page 6
36
Simple Behavior/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 page
number, item number -- skipped, RF refused DK
dont know
From Phillip ICP page 9
37
Help with Treatment Planning
Compares Client and Staff Urgency Ratings
Specific things the client has asked for
Other Actions or Things Typically Expected by
Agencies or Accrediting Agencies
From Phillip ICP page 10
38
GI Scales and Variable File
  • 1000 page electronic encyclopedia in MS Excel
    with documentation for each GAIN scale, subscale,
    index, created variable/text statements used in
    the G-RRS, ICP and our research to date
  • For each variable, documentation includes
  • Scale/variable name (and any related/earlier
    versions)
  • Time Period(s) covered
  • Section of the GAIN
  • Question (items, page in full version)
  • Scale measurement type (Cut-points for triage)
  • Purpose (s)
  • Short Description
  • Interpretation
  • Supplemental References on source, norms,
    psychometrics
  • Comments
  • GAIN V5 SPSS Syntax
  • Prior SPSS Syntax (if different)
  • Actual questions (from version 5)

39
Key Methodological Work Underway
  • ASAM placement recommendations based on expert
    and statistical models
  • Identification of multi-problem clusters or Code
    types
  • Modeling Change over time in relations to the
    treatment hinge and the cycle of relapse,
    treatment re-entry and recovery
  • Propensity score models to predict outcomes and
    serve as a synthetic average treatment
    comparison group

40
Validity Checks
  • Currently Available
  • Staff ratings of understanding,
    misrepresentation, appearance/behaviors during
    assessment, and context
  • Consistency Reports
  • Counts of missing/refused items
  • Out of normative responses on time, key items
  • Additional Scales in the Works
  • Inconsistency scale
  • Endorsing rare items (faking bad/general
    severity)
  • Not endorsing common items (faking good/a typical
    profile)
  • Predicting false negative relative to urine tests

41
Other Computer Generated Clinical Reports
  • GAIN-Q Referral and Recommendation Summary (GRRS)
    text based summary to support preliminary
    diagnosis and placement based on the GAIN-Quick
  • Personal Feedback Reports (PFR) text based
    summary to support the motivational interviewing
    component of MET/CBT based on the GAIN-I or
    GAIN-Q
  • Validity reports to identify areas for
    clarification and potential problems
  • Other site specific clinical reports (e.g.,
    pre-filling existing paperwork like a health
    assessment, TEDS report etc)
  • Data elements can be transferred into existing
    MIS and used in other reports/systems as well.

42
GAIN/ABS just part of aTrans-Enterprise MIS
Service Logs
Appt Tracking
School MIS
Mgmt Reports
Host MIS
Welfare MIS
Host Acct Sys
JJS MIS
Assessment Building System GAIN, Screener And
Other Measures
Host Lab
Evaluator or Data Manager GRL, Other Data
Cross Site Evaluation
43
Part IIDownloading and Installing the G-RRS
application(see Dionnas presentation)
44
Part IIIImplementing the G-RRS
45
Implementation Issues
  • While many staff will be very excited about
    having the G-RRS help them do paper work, there
    are several issues that will need to be resolved
    on a site-by-site basis.
  • We recommend starting with a small team of people
    (from multiple agencies if a complex project)
    that can try using the G-RRS and think through
    how it interacts with existing systems,
    requirements, and policies during a 4 to 8 week
    start up phase.

46
Some Likely Questions
  • Who will run the report? (Do they have the
    necessary hardware and software?)
  • How will the report get to the clinician that
    needs to use it?
  • How does this clinician get access to the ICP and
    full GAIN when they need it?
  • Where will the reports be saved (and what
    security safeguards are in place to protect
    documents with private health information)?
  • Does the report need a signature (e.g, from the
    person or persons responsible for finalizing the
    diagnosis, placement and treatment plans)? If
    so, who needs to sign it and by when?
  • When does the report need to be in the clinical
    file? (How does the report get into the clinical
    file?)

47
Some Likely Questions
  • Who edits the report/needs training on how to
    edit the report?
  • Where can the information needed to fill in the
    prompts be found? Does the site want to drop or
    change the wording of some prompts?
  • What parts of the report (if any) should be
    expanded or deleted routinely? (If deleted
    routinely, should they just be deleted from the
    template?)
  • Who needs to approve implementation of the
    report?
  • Who needs to be notified that the report will be
    implemented (e.g., records staff, counselors)?
  • Who will be the point person within the site to
    ask questions about the G-RRS? (typically a GAIN
    trainer, ABS administrator or clinical
    coordinator).
  • See also FAQs in hand out on install G-RRS
    applications

48
Getting Help
  • Manuals and forms on line at the Adolescent
    Program Support Site (www.chestnut.org/li/apss )
    or the generic GAIN (www.chestnut.org/li/gain )
    or ABS (www.chestnut.org/li/abs ) websites.
  • For questions related to installing or modifying
    the G-RRS or ABS in general, contact our ABS
    SUPPORT team at abssupport_at_chestnut.org or call
    Dionna Christian at 309-820-3543 ext. 83400.
  • For questions on administering the GAIN, specific
    GAIN items, interpreting the GAIN, or questions
    on QA, contact our GAIN SUPPORT team at
    gainsupport_at_chestnut.org or call Michelle White
    at 309-820-3543 ext. 83439.
  • For GAIN or ABS license questions, contact Joan
    Unsicker at junsicker_at_chestnut.org or
  • 309-820-3543 ext. 83413.
  • For GAIN, GRL, WAI or TxSI data submission
    questions, contact Melissa Ives at
    mives_at_chestnut.org or 309-820-3543 ext. 83408.
  • For other information or information on holding a
    future training in your area, to answer any
    questions not covered above, or if you have
    problems using any of the above contact
    information, contact Michelle White at
    mwhite_at_chestnut.org or 309-820-3543 ext 83439.

49
Contact Information
  • Michael L. Dennis, Ph.D.
  • Lighthouse Institute, Chestnut Health Systems
  • 720 West Chestnut, Bloomington, IL 61701
  • Phone (309) 827-6026, Fax (309) 829-4661
  • E-Mail mdennis_at_chestnut.org
  • Website www.chestnut.org/li/GAIN
  • GAIN Training Coordinator
  • Michelle White at 309-827-6026 or mwhite_at_chestnut
  • These slides are available from the Adolescent
    Program Support Site (www.chestnut.org/li/APSS )
    for CSAT/RWJF grantees
  • and GAIN site (www.chestnut.org/li/gain) for
    others
Write a Comment
User Comments (0)
About PowerShow.com