Global Appraisal of Individual Needs (GAIN): An introduction and Opportunity to Ask Questions Kate R. Moritz, M.A. & Michael L. Dennis, Ph.D. Chestnut Health Systems, Normal, IL Presentation at the Reclaiming Futures Leadership Institute, Asheville, NC, May 8, 2013. Supported by the Reclaiming Futures/Juvenile Drug Court Evaluation under Library of Congress contract no. LCFRD11C0007 to University of Arizona Southwest Institute for Research on Women, Chestnut Health Systems & Carnevale Associates The development of this presentation is funded by the Office of Juvenile Justice and Delinquency Prevention (OJJDP) through an interagency agreement with the Library of Congress – contract number LCFRD11C0007. The views expressed here are the authors and do not necessarily represent the official policies of OJJDP or the Library of Congress; nor does mention of trade names, commercial practices, or organizations imply endorsement by the U.S. Government. Available fromwww.gaincc.org/presentations.
Goals • Give an overview of the different GAIN measures, why/when they would be each be used and what the value added would be. • Illustrate with real data the diversity in the type and severity of problems, as well as how they vary by juvenile justice system involvement. • provide an opportunity to ask questions.
The Global Appraisal of Individual Needs (GAIN) is… • A family of instruments ranging from screening to quick assessment to full biopsychosocial and monitoring tools • Designed to integrate clinical and research assessment • Designed to support clinical decision making at the individual client level • Designed to support evaluation and planning at the program level • Designed to support secondary analyses and comparisons across individuals and programs
Chestnut’s GAIN Coordinating Center (GCC) • Chestnut Health Systems is a non-profit behavioral health care organization in Illinois • Chestnut’s GCC provides the following core services related to the GAIN family of instruments • Training, Quality Assurance , & Certification on the Instruments, Clinical Interpretation, and using the data for Program Management and Evaluation • Web applications and technical support for administration, clinical decision support, and data transfer to other electronic medical records or analytic files • Data cleaning, management, analytic support, technical reports, and articles
Designed to Provide a Continuum of Measurement(Common Measures) More Extensive / Longer/ Expensive Screener Quick Comprehensive Special • Screening to Identify Who Needs to be “Assessed” (5-10 min) • Focus on brevity, simplicity for administration & scoring • Needs to be adequate for triage and referral • GAIN Short Screener for SUD, MH & Crime • ASSIST, AUDIT, CAGE, CRAFT, DAST, MAST for SUD • SCL, HSCL, BSI, CANS for Mental Health • LSI, MAYSI, YLS for Crime • Quick Assessment for Targeted Referral (20-30 min) • Assessment of who needs a feedback, brief intervention or referral for more specialized assessment or treatment • Needs to be adequate for brief intervention • GAIN Quick • ADI, ASI, SASSI, T-ASI, MINI • Comprehensive Biopsychosocial (1-2 hours) • Used to identify common problems and how they are interrelated • Needs to be adequate for diagnosis, treatment planning and placement of common problems • GAIN Initial (Clinical Core and Full) • CASI, A-CASI, MATE • Specialized Assessment (additional time per area) • Additional assessment by a specialist (e.g., psychiatrist, MD, nurse, spec ed) may be needed to rule out a diagnosis or develop a treatment plan • CIDI, DISC, KSADS, PDI, SCAN
The More you Measure, the More you Find Source: CSAT 2010 AT Summary Analytic Data Set(n = 17,356)
Across Instruments the GAIN we have Set up shorter versions use subsets of items from longer measures and that predict them well Established a common web-based platform for computer assisted interviewing, clinical decision support, data entry, and data management Cleaned and pooled data to support local evaluation and provide practice based evidence for norms by age (under 18, 18-25, 26+), gender, and race, and to support secondary analysis by over 4 dozen independent researchers (see http://www.gaincc.org/psychometrics-publications/) Published power points for policy makers showing distributions and cross tabs related to key target populations, clinical outcomes and costs to society (see http://www.gaincc.org/slides )
GAIN ABS Web Application • HIPAA-compliant, web-based system hosted by Chestnut • records are accessible from anywhere with an internet connection • Chestnut handles all maintenance and regularly updates and adds new functionality • Allows for electronic administration of the GAIN • Includes automated item skips and calculations to reduce administration time • Includes detailed clinical reports that can be generated immediately after an assessment is completed
GAIN Short Screener (GAIN-SS) • Designedfor use in general populations or where there is less control to identify who has a disorder warranting further assessment or behavioral intervention, measuring change in the same, and comparing programs • Administration Time: 5 minutes • Mode: Self or staff administered • Scales: Four screeners used to generate symptom counts for the past month to measure change, past year to identify current disorders and lifetime to serve as covariates/validity checks • Internalizing Disorders (somatic, depression, suicide, anxiety, trauma, behavioral disorders) • Externalizing Disorders (ADHD, CD) • Substance Disorders (abuse, dependence) • Crime/Violence Disorders, and • Total Disorder Screener • Reports: Full Report and Summary Report • Language: Available in English and Spanish
GAIN SS Problem Profile * The first summary row is based on the sum of symptoms (0-20); The second is based on the areas with 1 or more symptoms (0-9) SAMHSA 2011 GAIN Summary Analytic Data Set (n=29,660)
Validation of Adolescent Co-Occurring from GAIN SS v. Records In 5 min, the 2 page GAIN SS predicted a similar rate to everything found in the clinical record over 2 years and was the best single source Source: Lucenko et al. (2009). Report to the Legislature: Co-Occurring Disorders Among DSHS Clients. Olympia, WA: Department of Social and Health Services. Retrieved from http://publications.rda.dshs.wa.gov/1392/
GAIN SS Total Screener Score Predicts Adolescent Level of Care About 41% of Residential are below 10 (more likely typical OP) About 30% of OP are in the high severity range more typical of residential Outpatient Median=6.0 Residential Median= 10.5 Few missed (1/2-3%) Source: SAPISP 2009 Data and Dennis et al 2006 16
The GAIN SS Predicts Recidivism in the Next 12 months Source: CSAT 2010 Summary Analytic Dataset (n=20,982)
GAIN-Q3 Designedfor use in targeted populations for more detailed screening, for screening in correctional settings or controlled environment, to support brief intervention, or for referral to further assessment or behavioral intervention, and for follow-up Mode: Generally staff-administered on computer (can be done on paper or self-administered with proctor) Response Set: Recency (“the last time” scale), breadth (lifetime, past year, past 90 days, past month for symptoms and utilization), and prevalence (past 90 days for behavior and utilization) Reports: Individual Clinical Profile, Personalized Feedback Report, Q3 Recommendation Referral Summary, Validity Report
GAIN-Q3 Versions GAIN-Q3-Lite (19 pages, 20 minutes) – 9 screeners & quality of life measure GAIN-Q3-Standard (26 pages, 35 minutes) – Q3-Lite plus days of behavior, utilization/cost and life satisfaction GAIN-Q3-MI (34 pages, 45 minutes) – Q3-Standard plus reasons & readiness for change to support motivational interviewing/problem solving for each area
GAIN Q3 Problem Profile (Adolescents) * The first summary row is based on the sum of symptoms (0-20); The second is based on the areas with 1 or more symptoms (0-9) SAMHSA 2011 GAIN Summary Analytic Data Set (n=29,650)
GAIN Q3 Summary Indices Beneficial Problematic *GSI groups are usually reversed (low satisfaction scores (0-2) are in the high problem group); here low satisfaction scores are in the low group, and high satisfaction scores are in the high group. Based on the absence of problems Ratings of satisfaction with several areas of life Functional Impairment Based mostly on Service Utilization Source: CSAT 2011 AT Summary Analytic Data Set (n=14,291)
GAIN-Initial (GAIN-I) Designed:to provide a standardized biopsychosocial for people presenting to substance abuse treatment using DSM-IV for diagnostic impressions and ASAM for placement and needing to meet common requirements (CARF, JCAHO, insurance,TEDS, Medicaid) for assessment, diagnosis, placement, treatment planning, accreditation, performance/outcome monitoring, economic analysis, program planning, Mode: Generally staff-administered on computer (can be done on paper or self-administered with proctor) Response Set: Breadth (past-year symptom counts for behavior and lifetime for utilization), recency (48 hours, 3-7 days, 1-4 weeks, 2-3 months, 4-12 months, 1+ years, never), and prevalence (past 90 days); patient and staff ratings
GAIN-I Versions GAIN-I Full (113 pages, 1.5 to 2.5 hours) – includes information on a wide range of life areas including background, substance use, physical health, risk behaviors and disease prevention, mental and emotional health, environment and living situation, legal, and vocational GAIN-I Core (77 pages, 1 to 2 hours) – covers the same life areas as the GAIN-I Full, but does not collect information on such topics as substance use treatment history, peak use of substances other than alcohol and cannabis in the past 90 days, specific lifetime health problems, or sources of treatment pressure GAIN-I Lite (56 pages, 1 hour) – covers the same life areas as the GAIN-I Core, but does not collect information on such topics as peak use in the past 90 days for any substances, lifetime arrest history, some risk behaviors, some victimization, and spirituality
GAIN-I (continued) • Scales: The GAIN-I has 9 sections (access to care, substance use, physical health, risk and protective behaviors, mental health, recovery environment, legal, vocational, and staff ratings) that include 103 long (alpha over .9) and short (alpha over .7) scales, summative indices, and over 3,000 created variables to support clinical decision-making and evaluation. • Interpretation: • Items can be used individually or to create specific diagnostic or treatment planning statements • Items can be summed into scales or indices for each behavior problem or type of service utilization • All scales, indices, and selected individual items have interpretative cut points to facilitate clinical interpretation and decision making • Examples: Will come back with data in a moment
GAIN ABS Reports for GAIN-I • Reports: • GAIN Recommendation and Referral Summary: a narrative report with editing capabilities for clinician to use for initial assessment summary, diagnosis, placement, and treatment planning • Individual Clinical Profile: Shows the severity of the client (low, moderate, high) on key indicators • Personal Feedback Report: Based on reasons for quitting and substance use items; used to support Motivational Interviewing and Motivational Enhancement Therapy • Validity Report: Identifies potential inconsistencies in a participant’s responses
GAIN Data Management Services • We also offer data management services to make the most of your GAIN data • Review your GAIN records for anomalies and return feedback to help you maintain accuracy of your data • Create and distribute analytic SPSS data files • Create and distribute a Characteristics and Outcomes Site Profiles report – which includes tables and charts displaying demographics, substance use patterns, lifetime severity, crime, risk behaviors, etc.
GAIN Training Model Includes training, coaching, monitoring and certifying staff on the GAIN family of instruments Provide training on standardized administration guidelines Provide advanced training on the assessment to support diagnosis, treatment planning, and program evaluation To promote sustainability, provide training on techniques for training others at the local agency
GAIN Administration Trainings • GAIN Short Screener Trainingis generally provided via self-paced online course available 24 hours/ 7 days a week*. • GAIN-Q3 Training is generally provided via distance learning* that includes online coursework, conference calls and webinars, and one-on-one coaching • GAIN-Itraining is generally provided via distance learning or in person that include presentations, small-group work, workshops, discussions, and practice and are followed by the same one-on-one coaching * Also available in person
GAIN Advanced Trainings GAIN Clinical Interpretation Trainingisgenerally provided via distance or in-person and is designed to learn how to better clinically interpret and more efficiently edit the results at the individual levels to support diagnosis, treatment planning and placement; it includes coursework, discussion, and iterative feedback on actual clinical reports. GAIN Program Management and Evaluation Training is generally provided via distance or in-person and is designed to learn how to better use data across clients and time to manage and evaluate programs in a more rigorous and efficient manner; it includes coursework, review of support materials, discussion, development and iterative feedback on a management and evaluation plan
Cultural Considerations Any assessment can only be as culturally sensitive as the treatment professionals who uses the tool. This places the responsibility of cultural sensitivity in assessment and treatment planning upon the interviewers and clinicians conducting the assessment and interpreting the information. It is important that the individual be assessed in his/or her primary language (for accuracy and ethical reasons). Need to consider local dialect and slang terminology that does not necessarily correspond with the version of the language used in the assessment
Cultural Considerations (continued) • Individuals may not know what comprises assessment or how it will be used or it may bring up old fears like school achievement testing anxieties. • Need to establish norms, validity, and real differences in how people respond to questions by gender, race, age and/or by clinical groups • Thelevel of acculturationcan impact a wide variety of areas such as choices of social networks, particular lifestyle and decisions on how to seek help..
Training Staff About Cultural Considerations Recognize the power of historical perspective (e.g., historical trauma, aculturation) Appreciate the impact of cultural explanations and stigmas Respect cultural variations, expectations, and communication Create an atmosphere of cultural safety and familiarity with pictures, sounds, colors, food and awareness of customs Show adaptability, flexibility, and respect
Cultural Considerations in Interviewing Adapting location Providing flexible scheduling Adjusting for language barriers Assigning appropriate interviewers Showing respect Making culturally sensitive adaptations to questions Acknowledging historical traumaif it comes up (but not assuming it applies to everyone in the group)
In Practice If you work with a population with strong cultural traditions, ask the client about their level of engagement in traditional culture as this could have a profound effect on their responses. The interviewer should make reasonable adaptations and accommodations while administering the GAIN as a semi-structured assessment in an effort to optimize respect, validity, reliability and efficiency with clients of any cultural background.
Bottom line Whether you use the GAIN or another assessment, you owe it to your clients to understand not only their symptomology/severity, but the cultural context of the symptoms associated with the individual. Look for common occurrences, but NEVER assume. You must continually span for cultural variability.
GAIN Data Collected from 1997 to 2011 on 22,967 Adolescents from 202 Sites NH WA ME MT VT ND MN OR MA NY ID WI SD WY MI RI PA IA NE CT OH NJ NV IN UT IL CA CO VA WV MO DE KS KY NC MD AZ TN OK AR NM SC GA GU AL MS TX LA AK FL HI PR VI
Juvenile Justice System Involvement Source: SAMHSA 2011 GAIN Summary Analytic Data Set: Adolescents 12-17 (n=22,976)
Demographic Characteristics Predominately male, Not-white, age 15 to 17 and from single parent households *Any Hispanic ethnicity separate from race group Source: SAMHSA 2011 GAIN Summary Analytic Data Set: Adolescents 12-17 (n=22,976)
Custody by Justice System Involvement *Other family, foster care, institution, emancipated, runaway **Includes shared custody, step parents and adopted Source: SAMHSA 2011 GAIN Summary Analytic Data Set: Adolescents 12-17 (n=22,976) 42
Substance Use Problems Source: SAMHSA 2011 GAIN Summary Analytic Data Set: Adolescents 12-17 (n=22,976)
Past Year Substance Severity by Justice Involvement Source: SAMHSA 2011 GAIN Summary Analytic Data Set: Adolescents 12-17 (n=22,976) 44
Victimization Severity Source: SAMHSA 2011 GAIN Summary Analytic Data Set: Adolescents 12-17 (n=22,976)
Severity of Victimization by Justice Involvement Source: SAMHSA 2011 GAIN Summary Analytic Data Set: Adolescents 12-17 (n=22,976)
Co-Occurring Psychiatric Problems Source: SAMHSA 2011 GAIN Summary Analytic Data Set: Adolescents 12-17 (n=22,976)
Past Year Mental Health Disorders Internalizing and Externalizing Disorders 32.8% (n=9,727) Neither 37.3% (n=11,059) Externalizing Disorders Only 20.6% (n=6,128) Internalizing Disorders Only 9.3% (n=2,770) Source: SAMHSA 2011 GAIN Summary Analytic Data Set: Adolescents 12-17 (n=22,976)
Mental Health Disorders by Justice Involvement Source: SAMHSA 2011 GAIN Summary Analytic Data Set: Adolescents 12-17 (n=22,976)
HIV Risk Behaviors in Past 90 Days Source: SAMHSA 2011 GAIN Summary Analytic Data Set: Adolescents 12-17 (n=22,976)