Transcript Scoring and Interpreting the GAIN

Using the GAIN to Support Clinical
Decision-making for Preliminary
Diagnosis, Placement & Treatment
Michael Dennis, Ph.D.
Chestnut Health Systems,
Bloomington, IL
Presentation for the 12th Annual Southeast Conference on Co-occurring Mental and Substance
Related Disorders, June 9-11, 2005. Sponsored by the Mid-Florida Center Mental Health &
Substance Abuse Services Inc. 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]
Objectives
1. Background on the GAIN
2. Review GAIN Manual materials related to
clinical decision making on diagnosis,
placement and treatment planning ;
3. Summarize the GAIN approach to
integrating assessment, placement and
treatment planning
4. Provide an overview of the GAIN narrative
and technical reports designed to facilitate
clinical decision making.
Organization of this Presentation
•
Information is presented in a series of waves
•
Each wave further clarifies and gives more in-depth
information than the previous wave.
At first, what we
will be discussing
may seem like
pieces of a puzzle.
However, at the end of the
presentation, demonstration, and
small group exercise, all of the
pieces of the puzzle should be
clear!
Common problems with
existing assessment systems
• Assessment is often done with long, nonstandardized, and/or
overlapping measures in a redundant process.
• Measures do not translate directly to common clinical standards
for diagnosis, placement, treatment planning, or existing
epidemiological or economic data for comparison/evaluation.
• There are problems getting data back to use for immediate
clinical decision-making or even longer-term program planning.
• Workforce lacks the tools, training, supervision, and support to
collect the breadth of required information in an efficient,
reliable, and valid manner.
• Assessment system is inefficient and consumer unfriendly, with
patients having to answer the same questions multiple times in
order to access care.
• Lack of readily available common data set to provide
benchmarks to support needs assessment and program
planning/evaluation.
What is the 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.
The GAIN was developed through a 10-year collaboration
of researchers, clinicians, policy makers, and IT specialists
MA
CT
DC
CSAT
Co-occurring Disorder (CD) Studies
Cannabis Youth Treatment (CYT)
Adolescent Treatment Model (ATM)
Strengthening Communities for Youth (SCY)
Adolescent Residential Treatment (ART)
Effective Adolescent Treatment (EAT)
Young Offender Re-Entry Program (YORP)
Targeted Capacity Expansion (TCE) grants
Other Collaborators
RWJF Reclaiming Futures Program
Other RWJF Grantees
NIAAA/NIDA Other Grantees
Other Grants/Contracts
State, county, or agency systems
Other states, counties, or large agencies
proposing or considering it
It uses a Progressive Assessment Approach
• Screening to Identify Who Needs to Be Fully “Assessed”
– Focus on brevity, simplicity for administration
• Screening for Targeted Referral
– Assessment of who needs crisis or brief intervention (e.g., by SAP,
doctor) vs. more detailed assessment and specialized
treatment/referral
– Decision rules about where to send may be more complex (e.g.,
substance abuse, mental health, both)
• Comprehensive Biopsychosocial
– Used to identify common problems and how they are interrelated
– Requires more skill in administration and even more in interpretation
• Specialized Assessment
– The bio-psycho-social may identify areas where additional
assessment by a specialist (e.g., psychiatrist, school counselor) may
be needed to rule out a diagnosis or develop a treatment plan or
individual education plan
• Program Level Assessment
– For program management, evaluation, and planning
Administration/Logistical Features
• Administration can be done by paper/pencil, by computer, on
a stand alone PC, network, and the web (via other
contractors),
• HIPPA compliant data base,
• Data can be transferred to/from multiple MIS systems or
other providers,
• Computerized scoring, narrative interpretative reports,
intervention specific reports, validity and re-keying reports
are available,
• Has English and Spanish versions (varying in content) that
can take from 20 to 120 minutes, and
• It is designed for administration by a paraprofessional but so
that a range of behavioral, health and other professionals can
use/ interpret it with minimal additional questions.
Methodological Features
• It can be used and has norms available across age groups
and level of care,
• It has 103 scales with demonstrated reliability and validity
and over 3 dozen scientist doing further research on it,
• It is designed to be modularized so you can use all or parts
of it and transfer data (e.g, from screener to full
assessment),
• It has a clear training and certification program, has
technical assistance/support, and
• It is available at minimal out of pocket cost for to license
the GAIN ($100/site) and software ($1000/site),
• Formal training and certification program to support work
force development and provide technical assistance
Organization of the Full GAIN
A. Administration
(including records information, cognitive impairment, calendaring, referral
information, general instructions)
B. Background and Treatment Arrangements
(demographics, custody, access to care)
S. Substance Use
(including treatment readiness, relapse potential, withdrawal, abuse, and
dependence, treatment history, content and satisfaction with recent treatment,
current medication)
P. Physical Health
(including disabilities, current and childhood infectious diseases, allergies,
lifetime history, treatment history, current medication)
R. Risk Behaviors and Disease Prevention
(including needle and sexual risk behaviors, sexual preference, birth control,
tobacco use/dependence, fasting and exercise, testing and prevention classes)
Organization- Continued
M. Mental Health and Emotions
(including somatic, depressive, suicide risk, anxiety, traumatic distress,
ADHD, CD, personality disorder, treatment history, current medication)
E. Environment and Living Situation
(including housing, homelessness, public/emergency housing, use in home,
controlled environment, children status, living, vocational, and social risk,
violence towards others, traumatic victimization, other psycho-social
stressors, general social support, spirituality, general satisfaction)
L. Legal (Civil & Criminal)
(civil court involvement, illegal activities, status offenses, arrest history,
current criminal justice involvement, outstanding warrants and payments)
V. Vocational (School, Work, Financial)
(educational attainment/degrees, school problems and involvement, military
history, vocational attainment, work problems and involvement, current
vocational status, financial problems, pathological gambling, TANF
participation, personal and family income, HHS poverty index, drug/alcohol
expenses)
Z. End
(administrative time, comments, signatures, administrative ratings and
methods information, diagnostic impressions, special study information)
Chapter 5: Diagnosis
5.1 Diagnosis of Substance Related Disorders
– Includes information on terminology and its relationship to the GAIN,
detailed diagnoses, withdrawal, and substance induced-disorders
– Cross walk between GAIN items and DSM/ICD substances,
diagnostic criteria/codes, withdrawal patterns, and substance induced
health and psychological disorders
5.2 Supporting Non-Substance Axis 1 Disorders
– Includes information on other mood disorders, anxiety disorders,
disorders usually first diagnosed in infancy, childhood or adolescence,
and other Axis 1 disorders
– All statements evaluated in the GRRS/ICP are printed with formula
5.3 Other Axis 2, 3, 4 and 5 Diagnoses
– Including information on personality disorders by cluster, biomedical
conditions that might complicate treatment by ICD-9, severity of
victimization and other psycho-social stressors, and clinical ratings
(GAF, SOFAS, GARF – see p5-17, Exhibits 5-4 to 5-6)
5.4 Using the GRRS and ICP to Support Diagnoses
Chapter 6. Level of Care Placement
6.1 Continuum of Care
– Ideally there is a full ASAM continuum of care
– However, there are often local limits on what is available
6.2 Using the GAIN to Address ASAM Patient Placement
Criteria
– Crosswalk to ASAM Criterion A (Diagnosis) and dimensional
criteria (B1. Intoxication and Withdrawal Potential; B2. Biomedical
Conditions and Complications; B3. Emotional/Behavioral
Conditions and Complications; B4. Readiness for Change; B5.
Relapse Potential; and Recovery Environment)
– All statements evaluated in the GRRS/ICP are printed with formula
6.3 Using the GAIN Referral and Recommendation
Summary (GRRS) and Individual Clinical Profile (ICP)
to Support Placement Decisions
– Including general conceptualization of placement needs;
organization and use of the GRRS; organization and use of the ICP
Chapter 7. Individualized Treatment Planning
• Relationship Between Assessment and Treatment Planning
– Rating for service need in each ASAM area
– Treatment recommendations in each ASAM area (including
monitoring and none)
• Transitioning From Assessment to Planning
– Need to interpret and feedback
• Conceptualization of Core Problems
– Recency, breadth and prevalence
– History of and response to prior interventions
• Feedback and Targeting of Problems
– What they want vs. what you think or policy dictates
– Problem solving, simple, small relevant steps
– MET personal feedback report (PFR)
• Prioritizing General Areas for Treatment Planning
– Using the GRRS and ICP
After all of that work….
“…This is the part I always hate…”
General Issues in Clinical
Interpretation
General Issues in GAIN Interpretation
• The GAIN is just a self report, you should always consider
other information.
• About 3% of the clients will have severe enough cognitive
problems to limit its usefulness.
• An overlapping 5% will give answers that the assessor does
not believe (either due to cognitive limits or lying)
• Many clients (particularly adolescents and young adults) will
have inconsistencies because of difficulties with abstract
concepts and paying attention.
• Interpretation requires learning how to “synthesize” the
information.
Important Checks
When Relying on Self Report
• Over reporting
– Exaggeration to achieve an outcome (e.g., diversion from jail)
– Storytelling that is unlikely (e.g., claiming to have downed a fifth of
vodka by yourself)
– Endorsing everything but then appearing/claiming to be fully functional
• Suppression
– Symptoms may be low if currently receiving medication, treatment, or in
a controlled environment (e.g., taking SRI for depression and not
reporting enough symptoms to meet criteria; reporting no use because
they are in detention/jail)
– If condition is in remission or absent for the past 1+ years.
• Under reporting
– Watch for inconsistencies between a history of intervention with no
history of problems (e.g., 3 DUI’s, but claiming to have never driven
drunk)
– Contexts where there may be substantial penalties for acknowledging
problems (e.g., a work, criminal or juvenile justice setting; an interview
where privacy could not be established).
Clinical Planning Using the GAIN:
A three-legged stool
A. Clinical Judgment
Expected Pathology
Patterns: Clinical
interpretation can be based on
severity scales, which doublecheck reported symptoms
against the person’s life
problems, levels of
functioning and treatment
history.
B. GAIN Reports:
After you conduct the
GAIN interview, the GAIN
software can produce
reports (based on ICD-9 and
DSM-IV) that you can use
for supporting substance
diagnoses on Axis One and
other diagnoses on all five
DSM axes.
C. Additional Diagnostic Information:
Information from collaterals, prior treatment,
psychiatrists, and other health professionals is
collected on page 99 for your consideration.
A. Clinical Judgment
A. Clinical Judgment
-Expected Pathology
Patterns: Clinical
interpretation can be based on
severity scales, which doublecheck client-reported
symptoms against the client’s
life problems, levels of
functioning, and treatment
history.
B. GAIN Reports:
After you conduct the
GAIN interview, the GAIN
software can produce
reports (based on ICD-9 and
DSM-IV) that you can use
for supporting substance
diagnoses on Axis One and
other diagnoses on all five
DSM axes.
C. Additional Diagnostic Information:
Information from collaterals, prior treatment,
psychiatrists, and other health professionals is
collected on page 99 for your consideration.
Expected Patterns of Psychopathology
Higher scores associated with the
prescription of alcohol and drug
abuse medication (methadone,
naltrexone, antabuse,
buprenorphine) and/or substance
induced legal, mental health,
physical health, and withdrawal
problems
Higher scores associated with greater overall
dysfunction (e.g., dropping out of school,
unemployment, financial problems, homelessness)
General Individual Severity Scale (GISS)
Substance Problem Scale
Substance Issues Index (SII)
Substance Abuse Scale (SAS)
Substance Dependence Scale (SDS)
Behavior Complexity Scale
Inattentiveness Disorder Scale (IDS)
Hyperactivity-Implusivity Scale (HIS)
Conduct Disorder Scale (CDS)
Higher scores associated with psychopharmacological
behavioral health treatment (e.g., Ritalin, Adderall, lithium),
special/alternative education, school or work problems,
gambling and other evidence of impulse control problems,
and/or anti-social/borderline personality disorders
Higher scores associated with mental
health treatment (e.g., anti-depressants,
selective serotonin reuptake inhibitors
(SSRI), monoamine oxidase inhibitors
(MAOI) sedatives) and/or a history of
traumatic victimization, and/or high
levels of stress
Internal Mental Distress Scale
Somatic Symptom Index (SSI)
Depression Symptom Scale (DSS)
Homicidal/Suicidal Thought Index (HSTI)
Anxiety/Fear Symptom Scale (AFSS)
Traumatic Distress Scale (TDS)
Crime/Violence Scale
General Conflict Tactic Scale (GCTS)
Property Crime Scale (PCS)
Interpersonal Crime Scale (ICS)
Drug Crime Scale (DCS)
Higher scores associated with arrests, detention/jail time,
probation, parole, size of drug habit
Supplemental
Diagnosis
Worksheet
(GAIN I page 99)
Add additional diagnosis by
number, name or both so they
print out in the GRRS
Can also add course specifiers
Can check any of the Axis 4
psycho-social stressors
Can make past-year and past
90-day Axis V ratings
Can document any additional
sources of information
considered (e.g., records,
collateral report, diagnosis by
a prior doctor)
Interpreting Problem Factors
Requires a consideration of 3 factors:
• Recency
• Breadth
• Current Prevalence
Let’s look more closely at each of these.
Interpreting Problem Factors
(con’t)
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 Factors
(con’t)
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 Factors
(con’t)
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
• Determine treatment planning and service needs based on
the above rating
• Identify the level of care and/or local program that best
matches the cluster of service needs that are identified
• 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
1. No Problem
Past
Treatment History
Current
Not Logical:
Check
understanding
of problem or
lying and
recode
Past
2. Past problem
(consider
monitoring and
relapse prevention)
5. Treatment with
no current
problems (review
for step down or
discharge)
Current (past 90 days)
3. Problems
(consider initial or low invasive
treatment )
4. Problems w/past treatment
(consider more intensive
treatment and re-intervention
strategies)
6. In treatment with reduced
problems (review need to
continue or step up)
7. In treatment with problems
(review need for more intensive
or assertive levels)
Conceptualization of
Treatment Need and Placement
Problem Recency
None
None
1. No Problem
Past
Treatment History
Current
Not Logical:
Check
understanding
of problem or
lying and
recode
Past
2. Past problem
(consider
monitoring and
relapse prevention)
5. Treatment with
no current
problems (review
for step down or
discharge)
Current (past 90 days)
3. Problems
(consider initial or low invasive
treatment )
4. Problems w/past treatment
(consider more intensive
treatment and re-intervention
strategies)
6. In treatment with reduced
problems (review need to
continue or step up)
7. In treatment with problems
(review need for more intensive
or assertive levels)
Conceptualization of
Treatment Need and Placement
Problem Recency
None
None
1. No Problem
Past
Past
Treatment History
2. Past problem
(consider
monitoring and
relapse prevention)
Current
Not Logical:
Check
understanding
of problem or 5. Treatment with
no current
lying and
problems (review
recode
for step down or
discharge)
Current (past 90 days)
3. Problems
(consider initial or low invasive
treatment )
4. Problems w/past treatment
(consider more intensive
treatment and re-intervention
strategies)
6. In treatment with reduced
problems (review need to
continue or step up)
7. In treatment with problems
(review need for more intensive
or assertive levels)
Conceptualization of
Treatment Need and Placement
Problem Recency
None
None
1. No Problem
Past
Past
Treatment History
2. Past problem
(consider
monitoring and
relapse prevention)
Current
Not Logical:
Check
understanding
of problem or 5. Treatment with
no current
lying and
problems (review
recode
for step down or
discharge)
Current (past 90 days)
3. Problems
(consider initial or low invasive
treatment )
4. Problems w/past treatment
(consider more intensive
treatment and re-intervention
strategies)
6. In treatment with reduced
problems (review need to
continue or step up)
7. In treatment with problems
(review need for more intensive
or assertive levels)
Conceptualization of
Treatment Need and Placement
Problem Recency
None
None
1. No Problem
Past
Past
Treatment History
2. Past problem
(consider
monitoring and
relapse prevention)
Current
Not Logical:
Check
understanding
of problem or 5. Treatment
history, but no
lying and
current problems
recode
(review for step
down or discharge)
Current (past 90 days)
3. Problems
(consider initial or low invasive
treatment )
4. Problems w/past treatment
(consider more intensive
treatment and re-intervention
strategies)
6. In treatment with reduced
problems (review need to
continue or step up)
7. In treatment with problems
(review need for more intensive
or assertive levels)
Conceptualization of
Treatment Need and Placement
Problem Recency
None
None
1. No Problem
Past
Past
Treatment History
2. Past problem
(consider
monitoring and
relapse prevention)
Current
Not Logical:
Check
understanding
of problem or 5. Treatment with
no current
lying and
problems (review
recode
for step down or
discharge)
Current (past 90 days)
3. Problems
(consider initial or low invasive
treatment )
4. Problems w/past treatment
(consider more intensive
treatment and re-intervention
strategies)
6. In treatment with reduced
problems (review need to
continue or step up)
7. In treatment with problems
(review need for more intensive
or assertive levels)
Conceptualization of
Treatment Need and Placement
Problem Recency
None
None
1. No Problem
Past
Past
Treatment History
2. Past problem
(consider
monitoring and
relapse prevention)
Current
Not Logical:
Check
understanding
of problem or 5. Treatment with
no current
lying and
problems (review
recode
for step down or
discharge)
Current (past 90 days)
3. Problems
(consider initial or low invasive
treatment )
4. Problems w/past treatment
(consider more intensive
treatment and re-intervention
strategies)
6. In treatment with reduced
problems (review need to
continue or step up)
7. In treatment with 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
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
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
B. GAIN Reports
A. Clinical Judgment
-Expected Pathology
Patterns: Clinical
interpretation can be based on
severity scales, which doublecheck reported symptoms
against the person’s life
problems, levels of
functioning and treatment
history.
B. GAIN Reports:
After you conduct the
GAIN interview, the GAIN
software can produce
reports (based on ICD-9 and
DSM-IV) that you can use
for supporting substance
diagnoses on Axis One and
other diagnoses on all five
DSM axes.
C. Additional Diagnostic Information:
Information from collaterals, prior treatment,
psychiatrists, and other health professionals is
collected on page 99 for your consideration.
The GRRS and ICP
• GAIN Referral and Recommendation 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.
• Individual Clinical Profile (ICP) – A 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).
GAIN Recommendation and Referral
Summary (GRRS)
•
•
•
•
When starting a report, you can use the client name, initials or
another term supplied by the person running the report
Can use the site’s organizational name or another term supplied
by the person running the report
The GRRS comes out in a MS Word Document file (*.rtf) that
can be read, edited and saved by most word processing
programs.
The report includes three types of prompts identifying areas
where counselors:
1.
•
2.
3.
Often add additional information or comments from other sources of
information (e.g. psychiatrist or collateral input).
Must reconcile and finalize potentially conflicting diagnoses
Must make preliminary treatment planning recommendations
The ICP report parallels the GRRS, but provides more detailed
information to supplement it and/or to cross reference back to
the GAIN for more information.
GRRS - Continued
•
The GRRS summarizes data collected and follows existing
rules; it is a tool to feed into and support clinical judgment –
not to replace it.
•
The GRRS can only generate reports using the data collected.
•
Therefore, a GRRS based on the full (90-120 minute) version
of the GAIN contains more details (e.g., name of school,
employer, probation officer) than a GRRS based on the core
(60-90 minute) version of the GAIN.
•
Sites can add in questions that are not in their core version, but
that they want to have for the GRRS.
•
Sites can also remove sections of the report they do not want
and/or modify some of the labels (e.g., signature lines).
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)
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 client’s 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
When editing: Review staff notes to add any additional details and finalize text
2. DSM-IV/ICD-9 Diagnoses
Self-Report Based Measures and Codes for 5 axes of DSM
(Summary of current treatment, medication, allergies and other
sources of information to aid interpretation)
Axis 1. Substance use disorders, major depression, generalized
anxiety, ADHD, CD, and pathological gambling; 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 drughealth interactions
Axis 4. Traumatic victimization, check for major Axis IV biopsycho-social stressors, and checks for other high-stress
events
Axis 5. Staff ratings of psychiatric, social/occupational, and
relational functioning
Diagnosis – Continued
• Other
–
–
–
–
–
–
–
Also reports the additional staff diagnoses reported on GAIN Diagnosis
page at the end of the GAIN
Ability to document Axis 5 GAF, SOFAS, GARF staff ratings for the
past year and the past 90 days
Ability to acknowledge other sources of information
Can collapse, modify or delete diagnoses
Prompt to reconcile and confirm diagnoses
ICP prints out the rules/reasons why each diagnosis, specifier and rule
out was given
The manual lists all diagnoses, specifiers and rule outs that were
checked, including the rules for when they are to be printed
When editing: Reconcile any differences, eliminate duplicates, decide whether to
keep, change or delete course specifiers, identify anywhere you need further
information to confirm or rule out.
3. Evaluation Procedure
• Describes the type of administration (e.g. oral admin by staff),
environmental context, ratings of the client’s behaviors during
the meeting, validity concerns and any additional source of
information reported on the GAIN’s diagnosis page
• Includes a 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)
When editing: Identify where information comes from, add any
comments and finalize paragraph.
4. Substance Use and Treatment History
(ASAM PPC-2R Criteria A)
•
•
Detailed text narrative: age of first use, preferred substance, and
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), the report will tell:
–
–
–
–
•
•
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 substances used (but for which diagnostic criteria
are not met) a prompt will be given to add substances 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).
When editing: Review and finalize SA Tx history paragraphs.
5. Placement (ASAM PPC-2R Criteria B)
• 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
When editing: Review and finalize each subsection, including the
initial treatment planning recommendations. Review list of
treatment planning recommendation at the end of ICP, decide
whether to use them, and where they should go.
6. 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
When editing: Given the client history and current service needs, make a
placement recommendation assuming all levels of care available.
Repeat this step considering only what is available in your
community. Add comments on any waiting list or other placement
issues and finalize the recommendation.
How the ICP Helps with the GRRS
• Identifies the criteria on which the diagnosis or
statement is made
• Examines scale scores in a given area to better
understand the severity of what is going on
• Gives complete breakout of demographics,
behaviors, service utilization
• Provides more detailed information for treatment
planning
Individual Clinical Profile (ICP)
Organization & Content
1. Identifiers
2. DSM-IV/ICD-9 Diagnoses
3. Demographics (including appearance, housing situation,
prior treatment, involvement in other systems, potential
validity concerns, staff notes)
4.
5.
6.
7.
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 a MS Access report, not intended for general
distribution and only reports on data that was collected
[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
> - greater
than
< - less than
CAPS – quote
from staff
or client
From Phillip ICP page 1
ICP Demographics section
lists out code and all values
Example of CodeResponse 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
ICP ASAM Flags bulleted out
Minimal Criteria for
placement in a level
of care and the 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
ICP ASAM Profile
ASAM Criteria
Scale Name
[basis]
Score or
- Skipped
* Bad Data
Scale triaged
into Low,
Medium, or
High Severity
Circle Score
and Connect
Dots
Scales file has
More information on
purpose, interpretation,
source, and
psychometrics
From Phillip ICP page 6
Example of Hand Scoring: Dependence Scales
Go to questions S9n-u
Past Month: Count the
number of 3s in S9n-u
(answer=1)
Lifetime: Count the
number of 1, 2, or 3s in
S9n-u (answer=6)
Most scorings are counts
of ‘yes’ answers or sums of
answers
From Phillip ICP page 6
Simple Behavior/Service 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 item number;
-- skipped,
RF refused
DK don’t know
From Phillip ICP page 9
Help with Treatment Planning
Compares Client
and Staff Urgency
Ratings from the end
of each section
Circle Score and
Connect Dots
Specific things the
client has asked for
Other Actions or
Things Typically
Expected by
Agencies or
Accrediting
Agencies
From Phillip ICP page 10
X
X
X
X
X
X
X
X
C. Other Sources
of Information and Tools
A. Clinical Judgment
-Expected Pathology
Patterns: Clinical
interpretation can be based on
severity scales, which doublecheck reported symptoms
against the person’s life
problems, levels of
functioning and treatment
history.
B. GAIN Reports:
After you conduct the
GAIN interview, the GAIN
software can produce
reports (based on ICD-9 and
DSM-IV) that you can use
for supporting substance
diagnoses on Axis One and
other diagnoses on all five
DSM axes.
C. Additional Diagnostic Information:
Information from collaterals, prior treatment,
psychiatrists, and other health professionals is
collected on page 99 for your consideration.
Additional Information
• GAIN-I and collateral questionnaires
• Information, treatment summaries and discharge
reports from other providers
• Validity Report identifying missing/refused items,
time, inconsistencies
• GAIN Scales file: 1000+ page electronic encyclopedia
in MS Excel with documentation for each GAIN scale,
subscale, index, created variable/text statements used
in the GRRS, ICP and our research to date
Ok, but how do you do it in practice?
“…I think you should be more explicit here in step two…”
Reprise of Key Steps to Editing the GRRS
Section 1. Review staff notes to add any additional details and finalize
text.
Section 2. Reconcile any differences, eliminate duplicates, identify any where you need further information to confirm or rule out.
Section 3. Identify where information comes from, add any comments
and finalize paragraph.
Section 4. Review and finalize SA/Tx history paragraphs.
Section 5. Review and finalize each subsection, including the initial
treatment planning recommendations.
Section 6. Given the client history and current service needs, make a
placement recommendation assuming all levels of care
available. Repeat this step considering only what is available
in your community. Add comments on any waiting list or other
placement issues and finalize the recommendation.