1 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 ). 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 or by contacting Joan Unsicker at 720 West Chestnut, Bloomington, IL 61701, phone: (309) , fax:(309) ,

2 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 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 minute GAIN-Initial (GI) designed to serve as a standardized biopsychosocial and integrated clinical research assessment tool A minute GAIN-Monitoring 90 days (GM90) for tracking change over time and program evaluation/clinical research.

3 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

4 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 & 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.

5 Location of CSAT Adolescent Treatment Grantees Using the GAIN Since 1997 ART ATM CYT Drug Court Earmark EAT SCY TCE YORP AK AL AR AZ CA CO DC DE FL GA HI IA ID IN KS LA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA WA WV WY PR SAC Grant States VT WI IL KY MA CT DC Program 3/06

6 All Adolescent and Adult, Clinical and Research Sites Using the GAIN since 1993 Indiana Kansas Mississippi Montana Nebraska Nevada North Dakota Arkansas Maine Oklahoma South Dakota Tennessee Alabama Idaho Minnesota New Mexico North Carolina West Virginia Georgia Iowa Louisiana South Carolina Utah Kentucky Alaska Virginia Pennsylvania Michigan Ohio Oregon Colorado New York Arizona Texas Florida Wisconsin Missouri Illinois California Washington Wyoming Number of Sites 1 to to to 88 Puerto Rico New Hampshire Delaware Hawaii Rhode Island New Jersey District Of Columbia Maryland Connecticut Vermont Massachusetts None (yet) 3/06 1+ Statewide syst. 1+ Statewide syst considering it

7 Collaboration to create an common infrastructure to help move the field towards evidenced based practice CSAT, NIH, Other Federal, State & Local Agencies Sites/Clinics & Their IT providers Chestnut, Optimos, & Consultants (often from sites) Researchers, Local & National Evaluators

8 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.

9 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.

10 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.

11 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. Where is the GAIN Going? (continued)

12 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

13 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

14 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