Planning for the Next Generation of the Global Appraisal of Individual Needs GAIN

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Planning for the Next Generation of the Global
Appraisal of Individual Needs (GAIN)

• Michael Dennis, Ph.D., David Smith, B.G.S.,
  Michelle White, Ph.D.
• Chestnut Health Systems, Bloomington, IL
• Think Tank Presentation for the Joint Meeting on
  Adolescent Treatment Effectiveness, Baltimore,
  MD, March 28, 2006, Federal Hill Room.
  Preparation of this manuscript was supported by
  funding from the Center for Substance Abuse
  Treatment (CSAT Contract no. 270-2003-00006). 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 [phone], fax[phone],
  e-Mail junsicker_at_Chestnut.Org

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Global Appraisal of Individual Needs (GAIN)

• The GAIN was developed through over a decade of
  collaboration
• between clinical researchers, practitioners,
  information
• technology specialists, funders, and regulators
  and is today in
• over 300 programs around the United States and
  Canada. Based
• on a progressive approach to assessment, the GAIN
  is a series of
• instruments that include
• A 5 minute GAIN-Short Screener (GSS) that can be
  used in general populations, for triage services,
  or as a denominator/measure of change in program
  evaluation
• A 20-30 minute GAIN-Quick (GQ) that can be used
  with targeted populations (e.g. SAP/EAP, JJ/CJ
  settings) to support a basic assessment, brief
  intervention, and/or referral to specialty
  treatment systems
• A 90-120 minute GAIN-Initial (GI) designed to
  serve as a standardized biopsychosocial and
  integrated clinical research assessment tool
• A 30-60 minute GAIN-Monitoring 90 days (GM90) for
  tracking change over time and program
  evaluation/clinical research.

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This think tank will..

• Summarize the evolution of the GAIN to date, the
  growth of the community using it, what it does
  well, and summarize where it is currently going
• Seek your input on three key challenges for the
  next generation of the GAIN
• Integrating Treatment Planning and Placement
  Recommendation
• Software Interface, Modules, Customization
• Workforce Training, Turnover, Sustainability

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Evolution of the GAIN

• 1993 GAIN 1.x created for NIDA Training and
  Employment Program (TEP) with adult methadone
  clients as an integrated clinical and research
  instrument based on ASI, IAP, DATOS, several
  existing scales
• 1996 GAIN 2.x revised for Drug Outcome Monitoring
  Study (DOMS) of all Chestnut Interventions
  adult and adolescent levels of care to focus more
  specifically on DSM, ASAM, JACHO/CARF and map
  onto epidemiological data based
• 1998 GAIN 3.x revised for Cannabis Youth
  Treatment (CYT) and Adolescent Treatment Model
  (ATM) in 18 sites to address problems in DOMS and
  incorporate GPRA versions 1 2
• 2000 GAIN 4.x revised to include several new
  modules to address specific NIDA and NIAAA
  research studies (not widely used)
• 2002 GAIN 5.x revised for Strengthening
  Communities for Youth (SCY) and CSAT adolescent
  treatment program to incorporate changes from
  version 4.x, reasons for quitting, treatment
  history process measures, GPRA versions 3 4,
  several state reporting requirements.

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Location of CSAT Adolescent Treatment Grantees
Using the GAIN Since 1997
NH
WA
VT
ME
MT
ND
MN
OR
MA
NY
ID
WI
SD
MI
WY
RI
IA
PA
CT
NE
OH
NJ
NV
DC
IN
UT
IL
CA
CO
WV
VA
DE
DC
KS
MO
KY
MD
NC
TN
AR
AZ
OK
Program
NM
SC
ART
ATM
GA
AL
MS
CYT
Drug Court
TX
LA
Earmark
AK
EAT
SCY
FL
TCE
YORP
SAC Grant States
PR
HI
3/06
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All Adolescent and Adult, Clinical and Research
Sites Using the GAIN since 1993
New Hampshire
Washington
Maine
Minnesota
Montana
Vermont
North Dakota
Oregon
Massachusetts
Wisconsin
Idaho
New York
South Dakota
Michigan
Rhode Island
Wyoming
Iowa
Pennsylvania
Connecticut
Nebraska
Nevada
Indiana
Ohio
New Jersey
Illinois
West Virginia
Utah
Colorado
Delaware
Virginia
Kansas
Missouri
District Of Columbia
Kentucky
California
North Carolina
Maryland
Tennessee
Oklahoma
Arkansas
South Carolina
Arizona
New Mexico
Mississippi
Alabama
Georgia
Number of Sites
Texas
Louisiana
None (yet)
1 to 14
Alaska
15 to 30
Florida
31 to 88
Hawaii
3/06
Puerto Rico
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Collaboration to create an common infrastructure
to help move the field towards evidenced based
practice
CSAT, NIH, Other Federal, State Local Agencies
Researchers, Local National Evaluators
Sites/Clinics Their IT providers
Chestnut, Optimos, Consultants (often from
sites)
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Common Values

• Want to improve the quality, effectiveness, and
  cost effectiveness of substance abuse treatment
  by providing an infrastructure to facilitate
  evidence based practice and applied research.
• Take advantage of growing knowledge base and
  shared resources to guide individual level
  clinical decisions and effectiveness.
• Collect data in a reliable, valid and efficient
  manner so that it can be used to support clinical
  decision making, administration, accreditation,
  program planning, evaluation and research.
• Use open software that is flexible enough to use
  from situations with no/low IT support to a more
  complex agency mapping it onto detailed polices.
• Maintain consistency of items, business rules,
  and data bases required to share clinical
  decision making tools and reports (which save
  money), and to pool the data in a reliable and
  valid way to facilitate the expansion of the
  knowledge base and
• To attracting additional sites, policy makers,
  evaluators, and researchers interested in using
  the system or improving our knowledge.

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Where is the GAIN Going?

• The number of programs using the GAIN has doubled
  every year for five years and is projected to
  continue to do so for the next five years as
  increasingly more regional/state systems strongly
  recommend, offer incentives for, and/or codify
  requirements to use the GAIN.
• Incorporation of computer adaptive testing to
  shorten the administration time and other complex
  statistical modules to improve validity and
  provide clinical guidance.
• Better integration of information across records
  from multiple sources (e.g., participant,
  collateral, urine) and/or over time.
• Better integration into existing clinical
  information systems related to diagnosis,
  placement, treatment planning, monitoring, and
  billing.

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Where is the GAIN Going? (continued)

• Demands for more specialized versions, different
  languages, self administration, and better
  modularization/set up for local customization
  (subsets, new items).
• Demands for easier ways to generate both canned
  and locally created reports to Word, Excel,
  Access and other languages.
• Demands for use in a range of platforms (laptop,
  LAN/WAN, Internet) including minimal/no set up
  accounts for sites with minimal IT
  infrastructure.
• Demands for tools to help local IT staff manage
  and update the applications in complex systems.
• Need for more robust and flexible software to
  meet these demands.

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Where is the GAIN Going? (continued)

• Development of work force development/quality
  control model, public domain manuals, other
  shared clinical resources, open syntax, data
  sharing with multiple applied researchers and
  evaluators.
• Secondary analysis of existing data to improve
  knowledge about what works for whom and to guide
  clinicians.
• Meta analysis of Adolescent Treatment
  Effectiveness Studies and Synthesis to related
  them to non-experimental outcome studies.
• Development of case mix and propensity score
  adjustments for non-experimental studies.
• Becoming a key piece of infrastructure in the
  move toward evidence based practice.

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Integrating Treatment Planning and Placement
Recommendation

• Challenge Staff have a difficult time
  consistently implementing approach to treatment
  planning and ASAM placement when they edit the
  diagnoses/reports in Word, the changes are not in
  the data set.
• Potential Strategies
• Expand the GRRS clinical narrative to provide a
  summary of what the client wants, general
  treatment planning recommendations, and specific
  recommendation based on their self reports, and
  preliminary level of care recommendations based
  on what their peers would do
• Create a tool in the new software for partially
  editing the diagnosis, treatment planning and
  placement recommendation in the system so that
  answers are save and available
• Produce simple cross tabs of what the computer
  recommended vs. what staff did that can be run
  overall, by site, staff person or type of client
  to identify training issues and for program
  planning

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Software Interface, Modules, Customization

• Challenge In the new GAIN Software we plan to
  provide instrument templates that will parallel
  current grant cores plus others that are
  optimized for assessment time, clinical
  reporting, mental health, criminal justice, etc.
  Adding additional customizability will also add
  complexity, cost and development time.
• Potential Strategies
• Develop an online tool to fine-tune these
  templates further and create new ones
• Include knowledge about the composition of
  scales and indices in this tool to protect the
  user from breaking important relationships
• Add the ability to add modules with additional
  questions at the end of a GAIN assessment in
  essence additional instruments

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Workforce Training, Turnover, Sustainability

• Challenge Many programs enjoy using the GAIN
  once it is in use, but when grant funding ends or
  trained and certified local trainers resign, they
  have a difficult time sustaining its use. They
  also have problems with planning issues related
  to which instruments to continue using, when, and
  why.
• Potential Strategies
• Offer packets or consultations on addressing
  sustainability based on the experiences of
  programs who have been successful in doing it
• Reduce barriers to initial implementation to
  retain staff longer, thus reducing turnover
  problems
• Addition of state or regional level
  certification/shared local trainers across
  programs to address turnover and training issues
• Proactive introductions between local programs
  using GAIN to encourage cross-program
  collaboration to improve sustainability
• Improve software tools to better identify which
  staff most need ongoing QA reviews