Transcript Scoring and Interpreting the GAIN

Using the New GAIN Patient Placement
Summary to Support Individual Treatment
Planning, Placement and Program Evaluation
Marc Fishman, M.D., Johns Hopkins University and
Maryland Treatments Center, Baltimore, MD
Laverne Hanes Stevens, Ph.D., Chestnut Health Systems, Atlanta, GA
Michael L. Dennis, Ph.D., Chestnut Health Systems, Bloomington, IL
Workshop at the Joint Meeting on Adolescent Treatment Effectiveness, Baltimore,
MD, March 28, 2006. Preparation of this manuscript was supported by funding from
the Center for Substance Abuse Treatment (CSAT Contract no. 270-2003-00006) and
several individual grants. The content of this poster are the opinions of the author
and do not reflect the views or policies of the government. Available on line at
www.chestnut.org/LI/Posters or by contacting Joan Unsicker at 720 West Chestnut,
Bloomington, IL 61701, phone: (309) 827-6026, fax:(309) 829-4661, e-Mail:
[email protected]
This workshop will..
• Provide an overview of the evolution, strengths and limits
of ASAM’s patient placement criteria (Fishman)
• Outline the GAIN approach to integrating treatment
planning and placement, including the expanded
recommendations we are developing (Stevens)
• Summarize Chestnut’s work to developing real time
placement recommendations for line clinicians using the
CSAT adolescent treatment data set (Dennis)
Introduction the American Society
of Addiction Medicine’s (ASAM)
Patient Placement Criteria (PPC)
Marc Fishman MD
Johns Hopkins University
Maryland Treatment Centers
Evolution of the APC
PPC-1 (1991)
PPC-2 (1996)
PPC-2R (2001)
ASAM PPC-2:
Assessment Dimensions
1: Intoxication / Withdrawal Potential
2: Biomedical Conditions
3: Emotional / Behavioral / Cognitive Conditions
4: Readiness to Change
5: Relapse / Continued Use / Continued Problem
Potential
6: Recovery Environment
ASAM PPC
Levels of Care
Level 0.5:
Level I:
Level II:
Level III:
Early Intervention
Outpatient
Intensive Outpatient and
Partial Hospital
Residential / Inpatient
(includes therapeutic communities)
Level IV:
Hospital
(based on services – NOT length of stay)
ASAM PPC-2R
Adolescent Criteria
• Level II
– II.1: Intensive Outpatient (IOP)
– II.5: Partial Hospital / Day Program
• Level III
– III.1: Clinically Managed Low Intensity
Residential (e.g.., halfway houses)
– III.5: Clinically Managed Medium Intensity
Residential (moderate –long term treatment)
– III.7: Medically Monitored High Intensity
Residential/Inpatient (short term treatment)
ASAM PPC-2R Crosswalk
IV. Medically
Managed
Inpatient
I. Outpatient
II. Intensive
Outpatient
III. Residential
Withdrawal
No risk
Minimal
Some risk
Severe risk
Medical
No risk
Manageable
Medical
monitoring
required
24 hr acute
medical care
required
Emotional/
Behavioral
No risk
Mild severity
Moderate
24 hr psychiatric
care required
Readiness
To Change
Cooperative
Cooperative
but requires
structure
High resistance,
needs 24 hr
monitoring
Relapse
Potential
Maintains
abstinence
More
symptoms,
needs close
monitoring
Unable to
control use in
outpatient care
ASAM PPC: General Principles
• Unidimensional --> Multidimensional assessment
• Program driven --> Clinically / individually
driven treatment
• Fixed length -->
Variable length of treatment
• Fragmentation --> Integration of treatment
services
• Discrete Types --> Continuum of care
Strengths of PPC
• Real time placement decisions
• Justification of placement (regulatory,
reimbursement)
• Guide to common language for organizing
assessment data
• Guide to treatment needs and plan
• Shift to a more chronic model of care that
recognizes most people go through treatment
multiple times over a period of several years
before reaching sustained recovery.
Evaluation First and Continuous
Treatment
Proforma
Assessment
Standardized
Assessment
Treatment
Local Implementation
• Local variations in
– Availability of continuum of services
• Availability of certain levels of care
• Characteristics and services of actual local
programs in each levels of care
– Needs and expectations of client, referrors,
payors, regulators, and others (e.g. judges)
– Variation in provider programs, services,
capacity, culture
Limitations to PPC
• Inconsistency of interpretation and complex nature making
training and reliable implementation difficult
• Reliability of assessment data without standardized
instrumentation
• Operationalization of decision rules for placement
• Services are NOT consistently bundled by level of care
• Some services not level of care dependent
• Face valid, but limited outcome research
• Need to integrate with treatment planning for specific
services
The GAIN approach to integrating
treatment planning and placement
Laverne Hanes Stevens, Ph.D.,
Chestnut Health Systems, Atlanta, GA
How the GAIN Views Problem Sets
Recency
Prevalence
Breadth
Interpreting Problem Sets
Factor #1
Recency:
– Has this problem ever occurred and, if so, when
did it last occur?
– Things that happened in the past week or 90 days
will typically play a greater role in current
treatment than those that happened 4-12 months
or 1+ years ago.
Interpreting Problem Sets
Factor #2
Breadth:
• How widespread/diverse is the presentation of
clinical symptoms or pattern of service utilization?
• Typically more diverse presentations are associated
with higher severity.
• For clinical problems, the focus is on the past year
(or since the last interview in follow-up
assessments).
• For services, the focus is on the lifetime pattern of
service utilization.
Interpreting Problem Sets
Factor #3
Current Prevalence:
• How often has this happened in the past 90 days?
• Typically things that happen more frequently
(particularly if they interfere with responsibilities at
home, work/school or socially) are going to be
more important than those that happened only once
or twice.
GAIN Approach to ASAM
Level of Care Placement
• Rate the “Problem Recency” and “Treatment History”
– Three time perspectives: None, past or current
• First -- Determine treatment planning and service needs
based on the above rating.
• Then --Identify the level of care and/or local program that
best matches the cluster of service needs that are identified.
• Lastly -- Use information from average performance of
different levels of care with similar populations to make
choices where there is more than one possibility or trade-off.
Conceptualization of
Treatment Need and Placement
Problem Recency
None
None
Past
Current (past 90 days)*
1. No
Problem
2. Past
problem
3. Problems/No Tx
Past
Current
Treatment History
0. Not
Logical:
Check
understanding
of problem
or lying and
recode
(Consider
monitoring
and relapse
prevention)
(Consider initial or low invasive
treatment )
4. Problems w/past treatment
(Consider more intensive treatment
and re-intervention strategies)
.
5. Treatment
with no
current
problems
6. In treatment
with lowmoderate
problems
(Review for
step down or
discharge)
(Review need
to continue
or step up)
* Past week for B1. Detox/Withdrawal
7. In treatment
with severe
problems
(Review need
for more
intensive or
assertive levels)
Conceptualization of
Treatment Need and Placement
Problem Recency
None
None
Past
Current (past 90 days)*
1. No
Problem
2. Past
problem
3. Problems/No Tx
Past
Current
Treatment History
0. Not
Logical:
Check
understanding
of problem
or lying and
recode
(Consider
monitoring
and relapse
prevention)
(Consider initial or low invasive
treatment )
4. Problems w/past treatment
(Consider more intensive treatment
and re-intervention strategies)
.
5. Treatment
with no
current
problems
6. In treatment
with lowmoderate
problems
(Review for
step down or
discharge)
(Review need
to continue
or step up)
* Past week for B1. Detox/Withdrawal
7. In treatment
with severe
problems
(Review need
for more
intensive or
assertive levels)
Conceptualization of
Treatment Need and Placement
Problem Recency
None
None
Past
Current (past 90 days)*
1. No
Problem
2. Past
problem
3. Problems/No Tx
Past
Current
Treatment History
0. Not
Logical:
Check
understanding
of problem
or lying and
recode
(Consider
monitoring
and relapse
prevention)
(Consider initial or low invasive
treatment )
4. Problems w/past treatment
(Consider more intensive treatment
and re-intervention strategies)
.
5. Treatment
with no
current
problems
6. In treatment
with lowmoderate
problems
(Review for
step down or
discharge)
(Review need
to continue
or step up)
* Past week for B1. Detox/Withdrawal
7. In treatment
with severe
problems
(Review need
for more
intensive or
assertive levels)
Conceptualization of
Treatment Need and Placement
Problem Recency
None
None
Past
Current (past 90 days)*
1. No
Problem
2. Past
problem
3. Problems/No Tx
Past
Current
Treatment History
0. Not
Logical:
Check
understanding
of problem
or lying and
recode
(Consider
monitoring
and relapse
prevention)
(Consider initial or low invasive
treatment )
4. Problems w/past treatment
(Consider more intensive treatment
and re-intervention strategies)
.
5. Treatment
with no
current
problems
6. In treatment
with lowmoderate
problems
(Review for
step down or
discharge)
(Review need
to continue
or step up)
* Past week for B1. Detox/Withdrawal
7. In treatment
with severe
problems
(Review need
for more
intensive or
assertive levels)
Conceptualization of
Treatment Need and Placement
Problem Recency
None
None
Past
Current (past 90 days)*
1. No
Problem
2. Past
problem
3. Problems/No Tx
Past
Current
Treatment History
0. Not
Logical:
Check
understanding
of problem
or lying and
recode
(Consider
monitoring
and relapse
prevention)
(Consider initial or low invasive
treatment )
4. Problems w/past treatment
(Consider more intensive treatment
and re-intervention strategies)
.
5. Treatment
with no
current
problems
6. In treatment
with lowmoderate
problems
(Review for
step down or
discharge)
(Review need
to continue
or step up)
* Past week for B1. Detox/Withdrawal
7. In treatment
with severe
problems
(Review need
for more
intensive or
assertive levels)
Conceptualization of
Treatment Need and Placement
Problem Recency
None
None
Past
Current (past 90 days)*
1. No
Problem
2. Past
problem
3. Problems/No Tx
Past
Current
Treatment History
0. Not
Logical:
Check
understanding
of problem
or lying and
recode
(Consider
monitoring
and relapse
prevention)
(Consider initial or low invasive
treatment )
4. Problems w/past treatment
(Consider more intensive treatment
and re-intervention strategies)
.
5. Treatment
with no
current
problems
6. In treatment
with lowmoderate
problems
(Review for
step down or
discharge)
(Review need
to continue
or step up)
* Past week for B1. Detox/Withdrawal
7. In treatment
with severe
problems
(Review need
for more
intensive or
assertive levels)
Conceptualization of
Treatment Need and Placement
Problem Recency
None
None
Past
Current (past 90 days)*
1. No
Problem
2. Past
problem
3. Problems/No Tx
Past
Current
Treatment History
0. Not
Logical:
Check
understanding
of problem
or lying and
recode
(Consider
monitoring
and relapse
prevention)
(Consider initial or low invasive
treatment )
4. Problems w/past treatment
(Consider more intensive treatment
and re-intervention strategies)
.
5. Treatment
with no
current
problems
6. In treatment
with lowmoderate
problems
(Review for
step down or
discharge)
(Review need
to continue
or step up)
* Past week for B1. Detox/Withdrawal
7. In treatment
with severe
problems
(Review need
for more
intensive or
assertive levels)
Conceptualization of
Treatment Need and Placement
Problem Recency
None
None
Past
Current (past 90 days)*
1. No
Problem
2. Past
problem
3. Problems/No Tx
Past
Current
Treatment History
0. Not
Logical:
Check
understanding
of problem
or lying and
recode
(Consider
monitoring
and relapse
prevention)
(Consider initial or low invasive
treatment )
4. Problems w/past treatment
(Consider more intensive treatment
and re-intervention strategies)
.
5. Treatment
with no
current
problems
6. In treatment
with lowmoderate
problems
(Review for
step down or
discharge)
(Review need
to continue
or step up)
* Past week for B1. Detox/Withdrawal
7. In treatment
with severe
problems
(Review need
for more
intensive or
assertive levels)
Supplemental
ASAM
Worksheet
(GAIN I page 100)
Can document impression here
so it prints out in GRRS
SA treatment used for A, B4,
B5, and (if IOP/residential) B6
Can record problem recency
by treatment history rating
Can record comment to help
with treatment planning
Record preliminary placement
recommendations and any
comments about placement to
include at the end of the GRRS
The GAIN Recommendation and
Referral Summary (GRRS)
A text-based narrative in MS Word designed
to be edited and shared with specialists,
clinical staff from other agencies, insurers
and lay people.
G-RRS Organization & Content
(See Appendix F)
1.
Presenting Concerns and Identifying Information
2.
DSM-IV/ICD-9 Diagnoses
3. Evaluation Procedure
4.
Substance Use Diagnoses and Treatment History (ASAM
criteria A)
5. Level of Care and Service Needs (ASAM Six Dimensional
Criteria B)
6.
Summary Recommendation
7.
Staff Notes from Assessment (should be used and removed
during editing)
G-RRS Organization & Content
(See Appendix F)
1.
Presenting Concerns and Identifying Information
2.
DSM-IV/ICD-9 Diagnoses
3. Evaluation Procedure
4.
Substance Use Diagnoses and Treatment History (ASAM
criteria A)
5. Level of Care and Service Needs (ASAM Six
Dimensional Criteria B)
6.
Summary Recommendation
7.
Staff Notes from Assessment (should be used and removed
during editing)
Level of Care and Service Needs
Arranged by six dimensions of ASAM Criteria B:
1. Acute Alcohol/Drug Intoxication and Withdrawal Potential
2. Biomedical Conditions and Complications
3. Emotional, Behavioral, or Cognitive Conditions and
Complications
4. Readiness to Change
5. Relapse, Continued Use, or Continued Problem Potential
6. Recovery Environment
Prior Treatment Options Built into the GAIN
Recommendation & Referral Summary
B1 Intoxication/Withdrawal: Need for Detox Services
– Monitoring for change in intoxication or withdrawal symptoms
– Ambulatory detoxification services related to withdrawal
– Inpatient detoxification services related to current intoxication and
withdrawal
B2 – Biomedical: Need for Medical Services
– Monitoring for change in physical health (and medication compliance)
– The following specific accommodations for medical conditions
required to participate in treatment: List out
– A more detailed medical assessment (including nutritional guidance)
– Referral for the following specific medical services: List out
B3 Emotional/Behavioral: Need for Psychological Services
– Monitoring for change in mental health (and medication compliance)
– The following specific accommodations for psychological conditions
required to participate in treatment: List out
– A more detailed psychological assessment
– Referral for the following specific psychological services: List out
Prior Treatment Options… (Continued)
B4 Readiness to Change: Need for Motivational Services,
Coordination of Pressure and/or Access/Resistance Issues
– Monitoring for change in readiness for change
– The following assistance to help address treatment resistance: list out
– Individual motivational enhancement sessions
– The following specific services to help maintain motivation to stay in
recovery: list out
B5 Relapse/Continued Use Potential: Need for Risk Management
– Monitoring for change in relapse potential
– Relapse prevention skills groups
– Increased structure to reduce environmental risks of relapse
– The following specific steps to reduce continued use/relapse potential:
list out
B6 Recovery Environment: Need for Environmental Interventions and
Risk management
– Monitoring for change in recovery environment
– A residential or more structured treatment setting to temporarily control
environmental risks
– the following specific steps to reduce recovery environment risks: list out
– The following specific steps to take further advantages of sources of
support/personal strengths: list out
NEW
Recommendation Summary for
Supporting Clinical Decisions
Dimension B-1: Intoxication / Withdrawal
Treatment
Problem
No Problem
• No past / current
Past Problems
• Lifetime history of withdrawal
symptoms and no current problems
Current - Low/Mod Problems
• Any past week symptoms of withdrawal
and no current high severity problems
Current High Severity
• High on Current Withdrawal Scale in the
past week
• Any past week withdrawal symptoms
with daily opioid use or physiological
symptoms of withdrawal
No Treatment History
•
No past / current treatment
Past (Lifetime) Treatment History
•
Lifetime history of detoxification
services and no current treatment
Currently in Treatment
•
1 or more of the past 90 days in
detoxification
Conceptualization of
Treatment Need and Placement
Problem Recency
None
None
Past
Current (past 90 days)*
1. No
Problem
2. Past
problem
3. Problems/No Tx
Past
Current
Treatment History
0. Not
Logical:
Check
understanding
of problem
or lying and
recode
(Consider
monitoring
and relapse
prevention)
(Consider initial or low invasive
treatment )
4. Problems w/past treatment
(Consider more intensive treatment
and re-intervention strategies)
.
5. Treatment
with no
current
problems
6. In treatment
with lowmoderate
problems
(Review for
step down or
discharge)
(Review need
to continue
or step up)
* Past week for B1. Detox/Withdrawal
7. In treatment
with severe
problems
(Review need
for more
intensive or
assertive levels)
Example: Dimension B-1 / Cell 6 Text
The GRRS will print:
[NAME] has received detoxification services in the past 90 days
but is still using at a low frequency or having some withdrawal
symptoms in the past week. Based on the information provided,
the evaluator recommends: <<PROMPT: REVIEW, DELETE OR EDIT
ACCORDING T0 SPECIFIC NEEDS AND CLINICAL INDICATIONS>>
• Discussing the current and/or prior detoxification episodes with
[NAME] to review the experience (e.g., Did [he/she/name]
complete the prior detoxification program? follow-up
recommendation to go to treatment? achieve a period of initial
abstinence (at least 90 days)? Are there things that might be
adjusted to make it work as well or better this time? What is
[he/she/name] willing/able to do differently this time?)
• Requesting records from most recent detoxification
episode and reviewing those records to determine the
services previously provided, recommendations and
outcomes.
• Discuss [NAME]’s progress with current treatment team to
discuss areas of responsiveness and unresponsiveness;
compliance and noncompliance; and possible impact of
any physical or emotional problems that may be posing
challenges for detoxification.
• A review to determine whether to continue with current
detoxification services, re-admit or step-up to next level of
care.
• Restart or continue ambulatory or residential/inpatient
detoxification services
Dimension B-2: Biomedical Conditions
Problem
No Problem
• No past / current
Past Problems
• Past year mod/high on Health Distress
Scale; any disabilities; female w/history
of pregnancy; history of infectious
diseases; or any lifetime report of health
problems/issues
Current - Low/Mod Problems
• Any disabilities; female who became
pregnant in past 90 days (regardless of
outcome) or is currently pregnant, past 90
day infectious diseases or health problems
or need medical attention to attend
treatment
Current High Severity
• Had any health problems daily (45+/90)
or functional impairment weekly (13+/90)
Treatment
No Treatment History
•
No past / current treatment
Past (Lifetime) Treatment History
•
Any physical health treatment, or
current medication, or ever having seen
a doctor)
Currently in Treatment
•
Any physical health treatment in the
past 90 days or currently being treated
Conceptualization of
Treatment Need and Placement
Problem Recency
None
None
Past
Current (past 90 days)*
1. No
Problem
2. Past
problem
3. Problems/No Tx
Past
Current
Treatment History
0. Not
Logical:
Check
understanding
of problem
or lying and
recode
(Consider
monitoring
and relapse
prevention)
(Consider initial or low invasive
treatment )
4. Problems w/past treatment
(Consider more intensive treatment
and re-intervention strategies)
.
5. Treatment
with no
current
problems
6. In treatment
with lowmoderate
problems
(Review for
step down or
discharge)
(Review need
to continue
or step up)
* Past week for B1. Detox/Withdrawal
7. In treatment
with severe
problems
(Review need
for more
intensive or
assertive levels)
Example: Dimension B-2 / Cell 2 Text
The GRRS will print:
[NAME] reported a history of prior health problems, but not having
problems or treatment in the past 90 days. Based on the
information provided, the evaluator recommends: <<PROMPT:
REVIEW, DELETE OR EDIT ACCORDING T0 SPECIFIC NEEDS AND
CLINICAL INDICATIONS>>
• Discussing prior health problems and any prior medical care
with [NAME] to review the problem, the care received, and
potential impact upon treatment (e.g., Is there a relationship
between [NAME]’s medical issues and [his/her/Name’s]
substance use? To what extent might these health issues pose
challenges for the treatment of the substance use disorder? Are
there special needs that must be considered in order to
participate in substance use treatment?)
• Monitoring for change in physical health (and medication
compliance)
• Review of plan for what to do if these health problems reoccur in the future
Dimension B-3: Emotional-Cognitive-Behavioral
Problem
No Problem
• No past / current
Past Problems
• Reported lifetime history of being
bothered by emotional, trauma or behavior
problems, or diagnoses
Current - Low/Mod Problems
• Bothered by MH problems, functional
impairment, memories from the past,
attention problems or self-injury, at any
time in the past 90 days.
Current High Severity
• Had any emotional, trauma or behavioral
problems daily (45+ /90) or functional
impairment or self-harm weekly (13+/90)
or suicide plans/ means/attempts with any
functional impairment or self-harm
Treatment
No Treatment History
•
No past / current treatment
Past (Lifetime) Treatment History
•
Any mental health treatment, or
current medication, or ever having
seen a doctor
Currently in Treatment
•
Any mental health treatment in the
past 90 days or currently being
treated
Conceptualization of
Treatment Need and Placement
Problem Recency
None
None
Past
Current (past 90 days)*
1. No
Problem
2. Past
problem
3. Problems/No Tx
Past
Current
Treatment History
0. Not
Logical:
Check
understanding
of problem
or lying and
recode
(Consider
monitoring
and relapse
prevention)
(Consider initial or low invasive
treatment )
4. Problems w/past treatment
(Consider more intensive treatment
and re-intervention strategies)
.
5. Treatment
with no
current
problems
6. In treatment
with lowmoderate
problems
(Review for
step down or
discharge)
(Review need
to continue
or step up)
* Past week for B1. Detox/Withdrawal
7. In treatment
with severe
problems
(Review need
for more
intensive or
assertive levels)
Example: Dimension B-3 / Cell 5 Text
The GRRS will print:
[NAME] has received mental health treatment for emotional,
behavioral or cognitive problems in the past 90 days, but reports
not having problems in the past 90 days. Based on the
information provided, the evaluator recommends: <<PROMPT:
REVIEW, DELETE OR EDIT ACCORDING T0 SPECIFIC NEEDS AND
CLINICAL INDICATIONS>>
• Discussing past emotional, behavioral or cognitive problems
with [NAME] to review the need for future mental health
services, barriers to accessing them and any accommodations
needed to participate in treatment.
• Discussing how past emotional, behavioral or cognitive
problems and substance use problems may be related
• Develop follow-up plans related to mental health care (e.g.
Were arrangements made for continuing care? Does
[NAME] express willingness, have a plan and means,
and/or taken initial steps toward adhering to the follow-up
recommendations? Does [NAME] know what to do if
problems re-emerge?)
• Monitoring for change in emotional, behavioral or
cognitive condition, linkage to treatment, and
treatment/medication compliance
• The following specific accommodations for emotional,
behavioral or cognitive problems required to participate in
treatment: <list out>
Dimension B-4: Readiness for Change
Treatment
Problem
No Problem
No Treatment History
Past Problems
• Lifetime substance dependence, abuse,
induced disorders, weekly substance use,
hiding use or substance related family
problems
Past (Lifetime) Treatment History
Current - Low/Mod Problems
•
• No past / current
• Using in the past 90 days and one of the
following (mod/high resistance, low/mod
motivation, few reasons for quitting, not
completely ready to stop)
Current High Severity
• (Using in the past 48 hours, daily (45+/90)
or using opioids weekly (13+/90)) and one
of the following (high resistance, low
motivation, no reasons for quitting, not
completely ready to stop)
•
•
No past / current treatment
Lifetime substance use disorder
treatment, current medication, any recent
treatment
Currently in Treatment
Currently taking substance use disorder
meds; in substance use disorder
treatment in the past 90 days; currently
in substance use disorder treatment; or
others are putting on pressure to change.
Conceptualization of
Treatment Need and Placement
Problem Recency
None
None
Past
Current (past 90 days)*
1. No
Problem
2. Past
problem
3. Problems/No Tx
Past
Current
Treatment History
0. Not
Logical:
Check
understanding
of problem
or lying and
recode
(Consider
monitoring
and relapse
prevention)
(Consider initial or low invasive
treatment )
4. Problems w/past treatment
(Consider more intensive treatment
and re-intervention strategies)
.
5. Treatment
with no
current
problems
6. In treatment
with lowmoderate
problems
(Review for
step down or
discharge)
(Review need
to continue
or step up)
* Past week for B1. Detox/Withdrawal
7. In treatment
with severe
problems
(Review need
for more
intensive or
assertive levels)
Example: Dimension B-4 / Cell 7 Text
The GRRS will print:
[NAME] has received treatment for substance use problems in the
past 90 days, but is still experiencing severe problems. Based on
the information provided, the evaluator recommends:
<<PROMPT: REVIEW, DELETE OR EDIT ACCORDING T0 SPECIFIC
NEEDS AND CLINICAL INDICATIONS>>
• Discussing the current and/or prior treatment episodes with
[NAME] to review the experience (e.g., Did [he/she/name]
achieve a period of sustained abstinence? What is
[he/she/name] willing/able to do differently?)
• Discussing the Personal Feedback Report with [NAME],
(e.g. Use Motivational Interviewing to explore
consequences of [NAME]'s substance use? What are some
of [NAME]’s reasons for wanting to quit? What things are
a part of [NAME]’s typical pattern of use? When does
[NAME] have the most situational confidence for avoiding
substances?)
• Discussing with [NAME] the way substance use functions
in [his/her/name’s] life, (e.g. What things are usually
going on just prior to the decision to use drugs or alcohol?
What thoughts and feelings precede using? What effect
does substance use have on those thoughts/feelings? What
people, situations, or activities are associated with using
drugs or alcohol? What things might impact the likelihood
of continued use?)
• Discussing [NAME]'s goals, present level of motivation
for treatment and resistance to change, (e.g. Use
Motivational Interviewing to explore [NAME]’s goals for
substance use? What are some important reasons for those
goals? What steps are necessary to achieve those goals?
What things could prevent being able to attain those goals?
What are [NAME]’s points of ambivalence about
quitting?)
• Discussing [NAME]’s progress with current treatment
team to discuss areas of responsiveness and
unresponsiveness; compliance and noncompliance; and
areas of resistance and ambivalence; and any barriers to
treatment retention and compliance
• A review to determine whether to continue with current
level of care or step-up to next level of care.
Dimension B-5: Relapse Potential
Problem
No Problem
• No past / current
Past Problems
• Lifetime substance dependence, abuse, induced
disorders, weekly substance use, hiding use or
substance related family problems
Treatment
No Treatment History
•
Past (Lifetime) Treatment History
•
Current - Low/Mod Problems:
• Any past 90 day use or past month substance
dependence, abuse, induced disorders, weekly
substance use, hiding use or substance related
family problems, moderate/high risk on selfefficacy to resist relapse
Current High Severity
• (Using in the past 48 hours, daily (45+/90) or
using opioids weekly (13+/90)), high risk on
self-efficacy to resist relapse, and (past 90 day
use and low problem orientation)
No past / current treatment
Lifetime substance use disorder
treatment, current medication, or
urine/saliva/hair monitoring
Currently in Treatment
•
Currently taking substance use disorder
meds; in substance use disorder
treatment currently or in the past 90
days; or urine/saliva/hair monitoring
Conceptualization of
Treatment Need and Placement
Problem Recency
None
None
Past
Current (past 90 days)*
1. No
Problem
2. Past
problem
3. Problems/No Tx
Past
Current
Treatment History
0. Not
Logical:
Check
understanding
of problem
or lying and
recode
(Consider
monitoring
and relapse
prevention)
(Consider initial or low invasive
treatment )
4. Problems w/past treatment
(Consider more intensive treatment
and re-intervention strategies)
.
5. Treatment
with no
current
problems
6. In treatment
with lowmoderate
problems
(Review for
step down or
discharge)
(Review need
to continue
or step up)
* Past week for B1. Detox/Withdrawal
7. In treatment
with severe
problems
(Review need
for more
intensive or
assertive levels)
Example: Dimension B-5 / Cell 3 Text
The GRRS will print:
[NAME] reported substance use problems in the past 90 days and
no prior history of treatment for those problems. Based on the
information provided, the evaluator recommends: <<PROMPT:
REVIEW, DELETE OR EDIT ACCORDING T0 SPECIFIC NEEDS AND
CLINICAL INDICATIONS>>
• Referral to relapse prevention group or counseling
intervention to identify relapse triggers, develop a plan for
minimizing triggers, coping with those that do occur, and
what to do if [NAME] does relapse, (e.g. Does [NAME]
understand the nature of relapse and its triggers? What
people, places, things, thoughts or emotions are associated
with initiating substance use? What things might impact
the likelihood of relapse? Who will [NAME] call to help
get back on track?)
• Referral to cognitive-behavior therapy to develop skills for
coping with stress, managing thoughts and behaviors and
avoiding relapse
• Discuss with [NAME] the situations that pose a risk of
relapse, (e.g. Who are the people, places and things that
put [NAME] at high risk? How can high-risk situations be
avoided? What refusal skills does [NAME] already have
or need to develop? What will be [NAME]’s plan for
handling emergency risk situations?)
• Discussing [NAME]’s willingness to participate in a 12step or other recovery program (e.g. including getting and
actively working with a sponsor; working the 12 steps;
establishing a relationship with a home group; performing
a service at meetings such as set-up, literature, chairing a
meeting; or sharing their story at a meeting)
• Developing and discussing options for [NAME] to build or
enhance a non-using social support network; engage in
substance-free recreational activities; build situational
confidence; strengthen refusal skills; and cope with relapse
Dimension B-6: Recovery Environment
Problem
No Problem
• No past / current
Past Problems
• Lifetime history of homelessness, environmental risk
for home, school/work peers, or social peers,
victimization, drug related illegal activities.
Treatment
No Treatment History
•
Past (Lifetime) Treatment History
•
Current - Low/Mod Problems
• Past 90 day homelessness, unable to stay in the same
home, trouble at home, arguing/violence,
victimization, structured activities involving alcohol or
drugs, or any illegal activity to get substances or
under their influences.
Current High Severity
• Past 90 day illegal activity to get substances or under
their influences, victimization; or weekly (13+/90
days) homeless, with substance use in the home, or
structured activities involving alcohol or drugs; or
daily (45+/90 days) trouble with family or arguing.
No past / current treatment
Lifetime history of environmental
interventions targeting substance use
including: self help, recovery homes, IOP,
residential treatment, probation, parole,
detention, jail, electronic monitoring, or house
arrest.
Currently in Treatment
•
Past 90 day history of environmental
interventions targeting substance use
including: self help, recovery homes, IOP,
residential treatment, other controlled
environment where they could not come & go
as they please or being on probation, parole,
detention, jail, electronic monitoring or house
arrest.
Conceptualization of
Treatment Need and Placement
Problem Recency
None
None
Past
Current (past 90 days)*
1. No
Problem
2. Past
problem
3. Problems/No Tx
Past
Current
Treatment History
0. Not
Logical:
Check
understanding
of problem
or lying and
recode
(Consider
monitoring
and relapse
prevention)
(Consider initial or low invasive
treatment )
4. Problems w/past treatment
(Consider more intensive treatment
and re-intervention strategies)
.
5. Treatment
with no
current
problems
6. In treatment
with lowmoderate
problems
(Review for
step down or
discharge)
(Review need
to continue
or step up)
* Past week for B1. Detox/Withdrawal
7. In treatment
with severe
problems
(Review need
for more
intensive or
assertive levels)
Example: Dimension B-6 / Cell 4 Text
The GRRS will print:
NAME] reported current (past 90 days) recovery environment
problems and also reported receiving intervention for those
problems in the past. Based on the information provided, the
evaluator recommends: <<PROMPT: REVIEW, DELETE OR EDIT
ACCORDING T0 SPECIFIC NEEDS AND CLINICAL INDICATIONS>>
• Discussing the prior times in a controlled environment to review
the experience (e.g., Did [he/she/name] make changes in the
recovery environment or supports? Were other family members
involved in making changes? Did they have a follow-up
recommendation? achieve a period of initial abstinence (at least
90 days)? Are there things that might be adjusted to make more
permanent changes this time? What is [he/she/name]
willing/able to do differently this time?)
• Requesting records from prior service providers and
reviewing those records to determine the services
previously provided, recommendations and outcomes.
• Increased structure of environment to reduce exposure to
relapse triggers and increase support for recovery (e.g.
Placement in IOP or residential treatment; involvement in
substance-free structured activities in the community;
increased monitoring; substance-free vocational activities)
Dimension Recommendation Text
For each dimension, the GRRS will print text addressing 4 areas:
1. Client’s self-report summarized
2. Client Requests
3. Cell-specific Recommendations
4. General Recommendations for the Dimension
Self-Report Summarized
•
Problems: Things the client reported in terms of
symptoms and problems in that dimension
•
Treatment history: Lifetime service-utilization in
that dimension
•
Beliefs: Client attitudes, perceptions of problem
severity and need for help
List of Client Requests (Example from B-4)
[NAME] specifically asked for assistance with:
• Getting Treatment [S10a6]
• Making transportation arrangements [B9a1]
• Making child care arrangements [B9a2]
• Scheduling around work, school or family responsibilities
[B9a3]
• Paying for treatment [B9a4]
• Language, religious, ethnic or cultural issues [B9a5]
• Clothing [B9a6]
• Food [B9a7]
• Other issues:_________ [B9a99v]
Cell-Specific Recommendations (Example from B-4, cell 5)
[NAME] is currently receiving treatment for substance use, but
reports no substance use problems in the past 90 days. Based
on the information provided, the evaluator recommends:
<<PROMPT: REVIEW, DELETE OR EDIT ACCORDING T0
SPECIFIC NEEDS AND CLINICAL INDICATIONS>>
• Developing and discussing post-discharge or step-down plans
with [NAME], (e.g. Does [NAME] express willingness, have a
plan and means, and/or taken initial steps for adhering to
follow-up recommendations?)
• Discussing past substance use problems with [NAME] to review
the need for future services, barriers to accessing them and the
motivation to stay in recovery…..
General Recommendations for the Dimension
(Based on problems endorsed)
• Other: [ [XASB4v]; <list out others> / <list out others>]
• Refer to wrap-around or case management services [If [B9a199>0] or [B7=4, 5 or 6] or [B7a>59]]
• Discuss the external pressure for treatment, the consequences of
continued use or treatment drop-out, and potential need for
coordination of care w/external sources of pressure [If B4a-j>0]
• Discuss and set realistic expectations for how long [NAME] will
need to be in treatment and the potential need for continuing care
[If [B6<4] and [max of S9c-u>2]]
• Pair [NAME] with program graduate or experienced client to help
them understand the treatment process and expectations [If
[E5=0 or E5f=4] and [E6=0 or E6f=4] and [E7=0 or E7f=4]
and [S7=0]]
Developing Real Time Placement
Recommendations for
Line Clinicians
Michael L. Dennis, Ph.D.,
Chestnut Health Systems, Bloomington, IL
Current Summary Recommendation
• Summary of current systems client is involved in
and with which treatment needs to be coordinated
• Any level of care recommendation from GAIN
placement worksheet
• Prompt to :
– enter level of care recommendation
– comment on any special barriers to placement and what
might be done about them
– comment on need to coordinate care with other
treatment or agencies
• Signatures
• Staff notes from assessment
Strengths and Limits of Current Approach
• Strengths:
– Keeps decisions in the hand of clinicians and avoids
risk of regulator/funders questioning differences
– Recognizes the lack of evidence base for forcing
several decisions
• Weaknesses:
– Difficult to train and get staff to reliably implement
– Staff want advice
– Supervisors want tools for training/managing staff,
particularly when there is turn over
– It is difficult to do the needed outcome research on
placement rules unless they are made
reliably/consistently
Learning from Practice
• Used data collected from 7,269 adolescents interviewed
with GAIN version 5 as part of 89 CSAT adolescent
treatment grants since 2002
• Created a variable for each of the 8 cells in the GAIN
approach and reflected by the text we are developing for
the expanded GRRS
• Examined the distribution of the variables overall and by
level of care
• Used discriminant function analysis to predict the
probability of being in each level of care for similar clients.
• Used to combine information into a level of care
recommendation for line clinicians
• Characteristics of CSAT vs. TEDS public 2003 admissions
Geographic Location of Sites
NH
WA
MT
VT
ND
ME
MN
OR
MA
ID
NY
WI
SD
MI
WY
RI
IA
PA
NE
CT
OH
NV
UT
CA
IL
CO
KS
WV
MO
VA
OK
NM
MD
NC
AR
SC
MS
TX
AL
GA
Program
ART
EAT
SCY
TCE
YORP
LA
AK
FL
HI
DE
DC
KY
TN
AZ
NJ
DC
IN
PR
42%
16%
17%
Hispanic
100%
90%
80%
70%
60%
CSAT (n=7,226)
58%
Caucasian
15 to 17 years old
TEDS (n=153,251)
19%
18%
African American
12 to 14 years old
50%
30%
29%
Female
Mixed/Other
40%
30%
20%
10%
0%
Demographics
6%
23%
17%
20%
83%
73%
First used under
age 15
Prior Treatment
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Clinical Severity
82%
74%
33%
37%
TEDS (n=153,251)
CSAT (n=7,226)
Weekly use at
intake
50%
Past Year
Dependence
48%
53%
Criminal Justice
System
61%
53%
68%
Meth/amphetamines
100%
90%
80%
70%
60%
50%
40%
25%
82%
Marijuana/Hash
Heroin/Opiates
30%
57%
Alcohol
Cocaine/Crack
20%
10%
0%
Primary, Secondary or Tertiary SUD Problems
60%
8%
5%
4%
3%
7%
7%
TEDS (n=153,251)
Any Other
6%
2%
CSAT (n=7,226)
Any withdrawal symptoms past week
Severe withdrawal (11+ symptoms)
0.31
0.08
Sexually active in past 90 days
Major health problems
0.84
0.27
Any co-occurring psychiatric
0.79
Ever physical, sexual or emotional victimization
0.59
Doesn't acknowledge AOD problem
0.70
Doesn't acknowledges need for treatment
0.76
Regular alcohol use in recovery environment
0.70
Regular drug use in recovery environment
0.81
Any violence or illegal activity
0.82
Any past year violent crime
0.45
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Other ASAM Issues (not in TEDS)
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Level of Care
68%
Outpatient
71%
14%
Includes 9% in continuing
care after residential
treatment or detention
Intensive Outpatient
8%
18%
Residential
21%
TEDS (n=153,251)
CSAT (n=7,226)
100%
90%
80%
70%
60%
50%
40%
30%
20%
0%
10%
Level of Care
68%
Outpatient
71%
14%
Intensive Outpatient
Short Term Resid
(<30 days)
Includes 9% in continuing
care outpatient (CCOP) after
residential treatment or
detention
8%
9%
2%
TEDS (n=153,251)
9%
Long Term Resid
19%
CSAT (n=7,226)
Proportion of Adolescents in Each Cell*
0%
20%
40%
60%
80%
B1 Intox and Withdrawal
B2 Bio-Medical
B3 Psych-Behavioral
B4 Readiness for Change
B5 Relapse Potential
B6 Recovery Environment
0.
2.
4.
6.
Inconsistent
Past Problem
Cur Prob. w/ Tx Hx
Lo/mod Prob w/ Cur Tx
1.
3.
5.
7.
No Problem
Cur Prob. w/o Tx Hx
Past Prob w/ Cur Tx
High Cur Prob w/ Cur Tx
100%
Past month 3+
dependence
symptoms
Past month any
abuse/dependence
symptom
Lifetime SUD but
in CE 45+/90 past
days
Lifetime SUD in
past month
remission
No/Past use
Diagnostic Severity by Level of Care
100%
90%
CCOP
80%
70%
LTR
60%
50%
STR
40%
30%
IOP
20%
10%
OP
0%
7. High Cur Prob w/ Cur Tx
6. Lo/mod Prob w/ Cur Tx
5. Past Prob w/ Cur Tx
4. Cur Prob. w/ Tx Hx
3. Cur Prob. w/o Tx Hx
2. Past Problem
1. No Problem
0. Inconsistent
B1. Intox & Withdrawal Severity by LOC
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
CCOP
LTR
STR
IOP
OP
* Insufficient data (n<25)
7. High Cur Prob w/ Cur Tx
6. Lo/mod Prob w/ Cur Tx
5. Past Prob w/ Cur Tx
4. Cur Prob. w/ Tx Hx
3. Cur Prob. w/o Tx Hx*
2. Past Problem
1. No Problem
0. Inconsistent
B2. Biomedical Severity by LOC
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
CCOP
LTR
STR
IOP
OP
* Insufficient data (n<25)
7. High Cur Prob w/ Cur Tx
6. Lo/mod Prob w/ Cur Tx
5. Past Prob w/ Cur Tx
4. Cur Prob. w/ Tx Hx
3. Cur Prob. w/o Tx Hx
2. Past Problem
1. No Problem
0. Inconsistent*
B3. Psych-Behavioral Severity by LOC
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
CCOP
LTR
STR
IOP
OP
* Insufficient data (n<25)
7. High Cur Prob w/ Cur Tx
6. Lo/mod Prob w/ Cur Tx
5. Past Prob w/ Cur Tx
4. Cur Prob. w/ Tx Hx*
3. Cur Prob. w/o Tx Hx
2. Past Problem
1. No Problem*
0. Inconsistent*
B4. Readiness for Change Severity by LOC
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
CCOP
LTR
STR
IOP
OP
* Insufficient data (n<25)
7. High Cur Prob w/ Cur Tx
6. Lo/mod Prob w/ Cur Tx
5. Past Prob w/ Cur Tx
4. Cur Prob. w/ Tx Hx
3. Cur Prob. w/o Tx Hx
2. Past Problem
1. No Problem
0. Inconsistent
B5. Relapse Potential Severity by LOC
100%
80%
CCOP
60%
LTR
40%
STR
20%
IOP
0%
OP
* Insufficient data (n<25)
7. High Cur Prob w/ Cur Tx
6. Lo/mod Prob w/ Cur Tx
5. Past Prob w/ Cur Tx
4. Cur Prob. w/ Tx Hx
3. Cur Prob. w/o Tx Hx
2. Past Problem*
1. No Problem*
0. Inconsistent*
B6. Recovery Environment Severity by LOC
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
CCOP
LTR
STR
IOP
OP
Predicting Level of Care
• Discriminant Function Analysis using stepwise
analysis of the cells we have just reviewed, the
GAIN psychopathology scales & change
measures, and variables from Rand’s case mix
study (Morral et al., 2005).
• Final solution with 42 variables (see next slides)
allows us to predict where counselors around the
country would place a similar client in terms of
the best fit, and the probability of being in each
level of care.
-0.80
B2.2 Past Bio-Med
prob
B6.5 Past Recovery
environment Prob
B2.1 No Bio-Med
Prob
B5.7 Hi Severity
Relapse
potential/current TX
B4.6 Low/mod
Readiness for Change
problem/current TX
B4.7 High Severity
Readiness for change
issues/current TX
B5.2 Past Relapse
Problem
Most Influential Cells
OP
1.20
IOP
STR
0.70
LTR
CCOP
0.20
-0.30
Past Month (PM)/Past Year Psychopathology/ Psychopathy
OP
IOP
1.20
STR
LTR
0.70
CCOP
0.20
-0.30
-0.80
Substance
Problem Scale
(PM)
Substance
Crime & Violence
Behavior
Dependence Scale
Scale (PY)
Complexity Scale
(PY)
(PY)
1.20
0.70
Health Problems Scale (P90)
Treatment Resistance Index
Doesn't Acknolwedge AOD
prob
Current Withdrawal Scale (PW)
Self-Efficacy Scale
Treatment Motivation Index
Needle Frequency Scale (P90)
Emotional Problems Scale
(P90)
Problem Orientation Scale
Substance Frequency Scale
(P90)
Past 90 Day/ Week/ Current Change Scores
OP
STR
CCOP
0.20
-0.30
-0.80
IOP
LTR
Needs treatment for
non-common Drugs
Needs treatment for
Amphetamines/Meth
Days of tobacco use
(P90)
Needs treatment for
Heroin
Used drugs/alcohol
in past 2 days
Using daily (P90)
Days Drunk/High
most of day (P90)
Pattern of Substance Use
1.20
0.70
OP
IOP
STR
LTR
CCOP
0.20
-0.30
-0.80
1.20
0.70
Recent Arressts (P90)
Times admitted to detox
Currently in school
Current JJ involvement
Training Activity Scale (P90)
CJ System Index (P90)
Lifetime AA CA NA SR
participation
Currently in AOD Tx
Substance Abuse Tx Index
(P90)
Days in controlled environment
(P90)
Lifetime/ Past 90 Day/ Current Interventions
OP
STR
CCOP
0.20
-0.30
-0.80
IOP
LTR
Lifetime/ Past 90 Day/ Current Interventions
OP
IOP
STR
LTR
CCOP
1.20
0.70
0.20
-0.30
-0.80
Lifetime
Homeless/Runaway
Minority status
Age
How many people
live with
Predicted LOC by Actual LOC
100%
90%
CCOP
Actual Level of Care
80%
70%
LTR
60%
50%
STR
40%
30%
IOP
20%
10%
OP
0%
P_OP
P_IOP
P_STR
P_LTR
Miss-classification includes Predicted Level of Care
lack of availability
P_CCOP
75% correctly classified
Kappa=.51
Adding Text to Reflect Recommendation
and Likelihood of Alternatives
• Based on the above assessment, the evaluator
recommends that [NAME] be admitted to
Outpatient.
• <<Distribution of placement for similar clients is:
90% OP, 5% IOP, 0% STR, 2% LTR, 1%
CC_OP>>
Adding Management Tools for Clinical
Supervisors and Program Planners
• Summary of requests, cell placements and individual
treatment planning rates recommended, and kept vs.
modified or dropped to guide program planning
• Cross tabulations of predicted vs. actual placements to
identify gaps
• Running above by site, team or staff person to check for
potential training issues
• Ability to customize to identify local issues or programs.
Also will be doing analysis to see if placement into
expected level of care is associated with better outcomes
Next Steps and Timeline for Updating the GRRS
1. Development of a user interface
2. Expert panel to review content, rules and
recommendations in late May/June
3. Testing in the summer
4. Release by end of the year!
Acknowledgment
The content of this presentations are based on treatment & research funded by
the Center for Substance Abuse Treatment (CSAT), Substance Abuse and
Mental Health Services Administration (SAMHSA) under contract 270-200300006 using data provided by CSAT adolescent treatment grantees under the
Adolescent Residential Treatment (ART), Effective Adolescent Treatment
(EAT), Strengthening Communities for Youth (SCY), Targeted Capacity
Expansion (TCE), and Young Offender Re-entry Program (YORP) grants
(TI013313, TI013309, TI013344, TI013354, TI013356, TI013305, TI013340,
TI130022, TI03345, TI012208, TI013323, TI14376, TI14261,
TI14189,TI14252, TI14315, TI14283, TI14267, TI14188, TI14103, TI14272,
TI14090, TI14271, TI14355, TI14196, TI14214, TI14254, TI14311, TI15678,
TI15670, TI15486, TI15511, TI15433, TI15479, TI15682, TI15483, TI15674,
TI15467, TI15686, TI15481, TI15461, TI15475, TI15413, TI15562, TI15514,
TI15672, TI15478, TI15447, TI15545, TI15671)). 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 720 West Chestnut, Bloomington, IL 61701,
phone: (309) 827-6026, fax: (309) 829-4661, e-Mail:
[email protected].