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GAIN SCORING AND CLINICAL INTERPRETATION: Using the GAIN for Diagnosis, Level of Care Placement and Treatment Planning.

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Presentation on theme: "GAIN SCORING AND CLINICAL INTERPRETATION: Using the GAIN for Diagnosis, Level of Care Placement and Treatment Planning."— Presentation transcript:

1 GAIN SCORING AND CLINICAL INTERPRETATION: Using the GAIN for Diagnosis, Level of Care Placement and Treatment Planning

2 Objectives At the conclusion of this session, participants will be able to utilize the GAIN tools for the purpose of: –Forming diagnostic impressions based on DSM-IV-TR (APA, 2000) criteria –Making and supporting placement decisions based on ASAM Patient Placement Criteria –Prioritizing general areas for treatment planning –Utilizing the information to facilitate effective communication with specialists, (e.g. medical or psychiatric referrals) who we work with, but outside of the immediate treatment system, by using the standards and language of their professions.

3 Organization of This Presentation Information is presented in a series of 3 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!

4 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

5 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 6.3Using 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

6 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

7 After all of that work…. …This is the part I always hate…

8 General Issues in Clinical Interpretation

9 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.

10 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 DUIs, 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).

11 A. Clinical Judgment Expected Pathology Patterns: Clinical interpretation can be based on severity scales, which double- check reported symptoms against the persons 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. Clinical Planning Using the GAIN: A three-legged stool

12 A. Clinical Judgment -Expected Pathology Patterns: Clinical interpretation can be based on severity scales, which double- check client-reported symptoms against the clients 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

13 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) 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 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 arrests, detention/jail time, probation, parole, size of drug habit

14 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)

15 Interpreting Problem Factors Requires a consideration of 3 factors: Recency Breadth Current Prevalence Lets look more closely at each of these.

16 Interpreting Problem Factors (cont) 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.

17 Interpreting Problem Factors (cont) 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.

18 Interpreting Problem Factors (cont) 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.

19 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

20 Conceptualization of Treatment Need and Placement Problem Recency NonePastCurrent (past 90 days) Treatment History None Past Current 1. No Problem 2. Past problem (consider monitoring and relapse prevention) 3. Problems (consider initial or low invasive treatment ) Not Logical: Check understanding of problem or lying and recode 4. Problems w/past treatment (consider more intensive treatment and re-intervention strategies) 5. Treatment with no current problems (review for step down or discharge) 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)

21 Conceptualization of Treatment Need and Placement Problem Recency NonePastCurrent (past 90 days) Treatment History None Past Current 1. No Problem 2. Past problem (consider monitoring and relapse prevention) 3. Problems (consider initial or low invasive treatment ) Not Logical: Check understanding of problem or lying and recode 4. Problems w/past treatment (consider more intensive treatment and re-intervention strategies) 5. Treatment with no current problems (review for step down or discharge) 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)

22 Conceptualization of Treatment Need and Placement Problem Recency NonePastCurrent (past 90 days) Treatment History None Past Current 1. No Problem 2. Past problem (consider monitoring and relapse prevention) 3. Problems (consider initial or low invasive treatment ) Not Logical: Check understanding of problem or lying and recode 4. Problems w/past treatment (consider more intensive treatment and re-intervention strategies) 5. Treatment with no current problems (review for step down or discharge) 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)

23 Conceptualization of Treatment Need and Placement Problem Recency NonePastCurrent (past 90 days) Treatment History None Past Current 1. No Problem 2. Past problem (consider monitoring and relapse prevention) 3. Problems (consider initial or low invasive treatment ) Not Logical: Check understanding of problem or lying and recode 4. Problems w/past treatment (consider more intensive treatment and re-intervention strategies) 5. Treatment with no current problems (review for step down or discharge) 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)

24 Conceptualization of Treatment Need and Placement Problem Recency NonePastCurrent (past 90 days) Treatment History None Past Current 1. No Problem 2. Past problem (consider monitoring and relapse prevention) 3. Problems (consider initial or low invasive treatment ) Not Logical: Check understanding of problem or lying and recode 4. Problems w/past treatment (consider more intensive treatment and re-intervention strategies) 5. Treatment history, but no current problems (review for step down or discharge) 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)

25 Conceptualization of Treatment Need and Placement Problem Recency NonePastCurrent (past 90 days) Treatment History None Past Current 1. No Problem 2. Past problem (consider monitoring and relapse prevention) 3. Problems (consider initial or low invasive treatment ) Not Logical: Check understanding of problem or lying and recode 4. Problems w/past treatment (consider more intensive treatment and re-intervention strategies) 5. Treatment with no current problems (review for step down or discharge) 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)

26 Conceptualization of Treatment Need and Placement Problem Recency NonePastCurrent (past 90 days) Treatment History None Past Current 1. No Problem 2. Past problem (consider monitoring and relapse prevention) 3. Problems (consider initial or low invasive treatment ) Not Logical: Check understanding of problem or lying and recode 4. Problems w/past treatment (consider more intensive treatment and re-intervention strategies) 5. Treatment with no current problems (review for step down or discharge) 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)

27 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

28 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

29 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

30 A. Clinical Judgment -Expected Pathology Patterns: Clinical interpretation can be based on severity scales, which double- check reported symptoms against the persons 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. B. GAIN Reports

31 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).

32 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 sites 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.Often add additional information or comments from other sources of information (e.g. psychiatrist or collateral input). 2.Must reconcile and finalize potentially conflicting diagnoses 3.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.

33 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).

34 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)

35 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 clients verbatim words (IN CAPS). Prompts to add any additional information related to: –reason for referral, –custody arrangements, –living situation, –current address, –parents' marital status, –addresses of relevant parents/guardians When editing: Review staff notes to add any additional details and finalize text

36 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 drug- health interactions Axis 4. Traumatic victimization, check for major Axis IV bio- psycho-social stressors, and checks for other high-stress events Axis 5. Staff ratings of psychiatric, social/occupational, and relational functioning

37 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.

38 3. Evaluation Procedure Describes the type of administration (e.g. oral admin by staff), environmental context, ratings of the clients behaviors during the meeting, validity concerns and any additional source of information reported on the GAINs 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.

39 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.

40 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.

41 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.

42 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

43 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.ASAM placement flags 5.ASAM placement profile worksheet 6.Behaviors and Service Utilization 7.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

44 [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

45 ICP Demographics section lists out code and all values Example of Code- Response label From Phillip ICP page 3 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

46 ICP ASAM Flags bulleted out Minimal Criteria for placement in a level of care and the basis for printing the statement From Phillip ICP page 5 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

47 ICP ASAM Profile From Phillip ICP page 6 Scales file has More information on purpose, interpretation, source, and psychometrics ASAM Criteria Scale Name [basis] Scale triaged into Low, Medium, or High Severity Score or - Skipped * Bad Data Circle Score and Connect Dots

48 Example of Hand Scoring: Dependence Scales From Phillip ICP page 6 Go to questions S9n-u Lifetime: Count the number of 1, 2, or 3s in S9n-u (answer=6) Past Month: Count the number of 3s in S9n-u (answer=1) Most scorings are counts of yes answers or sums of answers

49 Simple Behavior/Service Utilization Measures From Phillip ICP page 9 Organized by Section of the GAIN; Gives item number; -- skipped, RF refused DK dont know Left side gives behaviors in the past 90 days Right side gives utilization in the past 90 days

50 Help with Treatment Planning Compares Client and Staff Urgency Ratings from the end of each section Specific things the client has asked for Other Actions or Things Typically Expected by Agencies or Accrediting Agencies From Phillip ICP page 10 Circle Score and Connect Dots X X X X X X X X

51 A. Clinical Judgment -Expected Pathology Patterns: Clinical interpretation can be based on severity scales, which double- check reported symptoms against the persons 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. C. Other Sources of Information and Tools

52 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

53 Ok, but how do you do it in practice? …I think you should be more explicit here in step two…

54 Reprise of GRRS Exercise 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.

55 Exercise with Phillip 1.Gather the following materials: –Phillip case (GRRS, ICP, validity report, GAIN) –Pull out last sheet of GRRS (staff notes), and last sheet of ICP (treatment planning worksheet) –GAIN manual and/or CD if you have them 2.Identify small group leaders and membership 3.Choose a note taker who will edit the GRRS 4.Pick someone to report out 5.Do exercise: try to move through it quickly, focusing on getting the GRRS edited with the materials readily available and making notes to rule out or get other information where there are concerns. 6.When we come back together, we will.. –Ask each group to talk about a given section, ask if other have different or other suggestions –Next group does next section, and so forth –Discuss local issues related to service system and other paperwork


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