Title: Using the GAIN Recommendation and Referral Summary GRRS to Support Clinical Decisionmaking
1Using 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
3The Progression of Substance Use Problems
- Multiple Problem Clients
- Clinical Disorder
- Problem Use
- Frequent Use
- Bingeing
- Opportunistic Use
- Experimentation
- No Use
Severity
4Multiple 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
5Severity 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
6Objectives
- 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
7Part 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.
9CSATs 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
10Main 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)
11G-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
12General
- 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.
13General - 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)
141. 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
152. 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
16Diagnosis 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
173. 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)
184. 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)
195. 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
20Conceptualization of Treatment Planning Need for
Each ASAM area
21B1. 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.
22B2. 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.
23B3. 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).
24B3. 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
25B4. 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
26B5. 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
27B6. 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).
28B6. 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
296. 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
30Using 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
31Individual 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
32Notes 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
33ICP 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
34ICP 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
35ICP 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
36Simple 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
37Help 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
38GI 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)
39Key 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
40Validity 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
41Other 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.
42GAIN/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
43Part IIDownloading and Installing the G-RRS
application(see Dionnas presentation)
44Part IIIImplementing the G-RRS
45Implementation 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.
46Some 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?)
47Some 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
48Getting 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.
49Contact 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