Using the New GAIN Patient Placement Summary to Support Individual Treatment Planning, Placement and Program Evaluation Marc Fishman, M.D., Johns Hopkins

Using the New GAIN Patient Placement Summary to Support Individual Treatment

Planning, Placement and Program Evaluation

Marc Fishman, M.D., Johns Hopkins University and Maryland Treatments Center, Baltimore, MD

Laverne Hanes Stevens, Ph.D., Chestnut Health Systems, Atlanta, GA

Michael L. Dennis, Ph.D., Chestnut Health Systems, Bloomington, IL

Workshop at the Joint Meeting on Adolescent Treatment Effectiveness, Baltimore, MD, March 28, 2006. Preparation of this manuscript was supported by funding from the Center for Substance Abuse Treatment (CSAT Contract no. 270-2003-00006) and

several individual grants. 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: (309) 827-6026, fax:(309) 829-4661, e-Mail:

[email protected]

This workshop will..

• Provide an overview of the evolution, strengths and limits of ASAM’s patient placement criteria (Fishman)

• Outline the GAIN approach to integrating treatment planning and placement, including the expanded recommendations we are developing (Stevens)

• Summarize Chestnut’s work to developing real time placement recommendations for line clinicians using the CSAT adolescent treatment data set (Dennis)

Introduction the American Society of Addiction Medicine’s (ASAM) Patient Placement Criteria (PPC)

Marc Fishman MD

Johns Hopkins University

Maryland Treatment Centers

Evolution of the APC

PPC-1 (1991)

PPC-2 (1996)

PPC-2R (2001)

ASAM PPC-2: Assessment Dimensions

1: Intoxication / Withdrawal Potential2: Biomedical Conditions3: Emotional / Behavioral / Cognitive Conditions4: Readiness to Change5: Relapse / Continued Use / Continued Problem

Potential6: Recovery Environment

ASAM PPCLevels of Care

Level 0.5: Early Intervention

Level I: Outpatient

Level II: Intensive Outpatient and Partial Hospital

Level III: Residential / Inpatient

(includes therapeutic communities)

Level IV: Hospital

(based on services – NOT length of stay)

ASAM PPC-2R Adolescent Criteria

• Level II– II.1: Intensive Outpatient (IOP)– II.5: Partial Hospital / Day Program

• Level III– III.1: Clinically Managed Low Intensity

Residential (e.g.., halfway houses)

– III.5: Clinically Managed Medium Intensity Residential (moderate –long term treatment)

– III.7: Medically Monitored High Intensity Residential/Inpatient (short term treatment)

ASAM PPC-2R Crosswalk

I. OutpatientII. Intensive Outpatient III. Residential

IV. Medically Managed Inpatient

Withdrawal No risk Minimal Some risk Severe risk

Medical No risk Manageable Medical monitoring required

24 hr acute medical care required

Emotional/ Behavioral

No risk Mild severity Moderate 24 hr psychiatric care required

Readiness To Change

Cooperative Cooperative but requires structure

High resistance, needs 24 hr monitoring

Relapse Potential

Maintains abstinence

More symptoms, needs close monitoring

Unable to control use in outpatient care

ASAM PPC: General Principles

• Unidimensional --> Multidimensional assessment• Program driven --> Clinically / individually

driven treatment• Fixed length --> Variable length of treatment• Fragmentation --> Integration of treatment

services• Discrete Types --> Continuum of care

Strengths of PPC

• Real time placement decisions

• Justification of placement (regulatory, reimbursement)

• Guide to common language for organizing assessment data

• Guide to treatment needs and plan

• Shift to a more chronic model of care that recognizes most people go through treatment multiple times over a period of several years before reaching sustained recovery.

Evaluation First and Continuous

ProformaAssessment

Treatment StandardizedAssessment

Treatment

Local Implementation

• Local variations in– Availability of continuum of services

• Availability of certain levels of care• Characteristics and services of actual local

programs in each levels of care– Needs and expectations of client, referrors,

payors, regulators, and others (e.g. judges) – Variation in provider programs, services,

capacity, culture

Limitations to PPC

• Inconsistency of interpretation and complex nature making training and reliable implementation difficult

• Reliability of assessment data without standardized instrumentation

• Operationalization of decision rules for placement• Services are NOT consistently bundled by level of care• Some services not level of care dependent • Face valid, but limited outcome research• Need to integrate with treatment planning for specific

services

The GAIN approach to integrating treatment planning and placement

Laverne Hanes Stevens, Ph.D.,

Chestnut Health Systems, Atlanta, GA

How the GAIN Views Problem Sets

Recency

Prevalence

Breadth

Interpreting Problem Sets

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.


Factor #2Breadth:• 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.


Factor #3Current 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

• First -- Determine treatment planning and service needs based on the above rating.

• Then --Identify the level of care and/or local program that best matches the cluster of service needs that are identified.

• Lastly -- 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 Past Current (past 90 days)*

Treatm

ent History

None P

ast Current .

1. No Problem

2. Past problem (Consider

monitoring and relapse prevention)

3. Problems/No Tx (Consider initial or low invasive

treatment )

0. 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 low-moderate problems

(Review need to continue or step up)

7. In treatment with severe problems

(Review need for more

intensive or assertive levels)

* Past week for B1. Detox/Withdrawal


Problem Recency


Treatm

ent History

None P

ast Current .

1. No Problem




treatment )



recode













Problem Recency


Treatm

ent History

None P

ast Current .

1. No Problem




treatment )



recode













Problem Recency


Treatm

ent History

None P

ast Current .

1. No Problem




treatment )



recode













Problem Recency


Treatm

ent History

None P

ast Current .

1. No Problem




treatment )



recode













Problem Recency


Treatm

ent History

None P

ast Current .

1. No Problem




treatment )



recode













Problem Recency


Treatm

ent History

None P

ast Current .

1. No Problem




treatment )



recode













Problem Recency


Treatm

ent History

None P

ast Current .

1. No Problem




treatment )



recode












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

The GAIN Recommendation and Referral 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.

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)

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)

Level of Care and Service Needs

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

Prior 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

Prior 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

NEW Recommendation Summary for

Supporting Clinical Decisions

Dimension B-1: Intoxication / Withdrawal

Problem

No Problem• No past / current

Past Problems• Lifetime history of withdrawal

symptoms and no current problems

Current - Low/Mod Problems• Any past week symptoms of withdrawal

and no current high severity problems

Current High Severity• High on Current Withdrawal Scale in the

past week• Any past week withdrawal symptoms

with daily opioid use or physiological symptoms of withdrawal

Treatment

No Treatment History• No past / current treatment

Past (Lifetime) Treatment History• Lifetime history of detoxification

services and no current treatment

Currently in Treatment• 1 or more of the past 90 days in

detoxification


Problem Recency


Treatm

ent History

None P

ast Current .

1. No Problem




treatment )



recode












Example: Dimension B-1 / Cell 6 Text

The GRRS will print:

[NAME] has received detoxification services in the past 90 days but is still using at a low frequency or having some withdrawal symptoms in the past week. Based on the information provided, the evaluator recommends: <<PROMPT: REVIEW, DELETE OR EDIT ACCORDING T0

SPECIFIC NEEDS AND CLINICAL INDICATIONS>> • Discussing the current and/or prior detoxification episodes with

[NAME] to review the experience (e.g., Did [he/she/name] complete the prior detoxification program? follow-up recommendation to go to treatment? achieve a period of initial abstinence (at least 90 days)? Are there things that might be adjusted to make it work as well or better this time? What is [he/she/name] willing/able to do differently this time?)

• Requesting records from most recent detoxification episode and reviewing those records to determine the services previously provided, recommendations and outcomes.

• Discuss [NAME]’s progress with current treatment team to discuss areas of responsiveness and unresponsiveness; compliance and noncompliance; and possible impact of any physical or emotional problems that may be posing challenges for detoxification.

• A review to determine whether to continue with current detoxification services, re-admit or step-up to next level of care.

• Restart or continue ambulatory or residential/inpatient detoxification services

Dimension B-2: Biomedical Conditions

Problem

No Problem• No past / currentPast Problems• Past year mod/high on Health Distress

Scale; any disabilities; female w/history of pregnancy; history of infectious diseases; or any lifetime report of health problems/issues

Current - Low/Mod Problems• Any disabilities; female who became

pregnant in past 90 days (regardless of outcome) or is currently pregnant, past 90 day infectious diseases or health problems or need medical attention to attend treatment

Current High Severity• Had any health problems daily (45+/90)

or functional impairment weekly (13+/90)

Treatment

No Treatment History• No past / current treatmentPast (Lifetime) Treatment History• Any physical health treatment, or

current medication, or ever having seen a doctor)

Currently in Treatment• Any physical health treatment in the

past 90 days or currently being treated


Problem Recency


Treatm

ent History

None P

ast Current .

1. No Problem




treatment )



recode














[NAME] reported a history of prior health problems, but not having problems or treatment in the past 90 days. Based on the information provided, the evaluator recommends: <<PROMPT: REVIEW, DELETE OR EDIT ACCORDING T0 SPECIFIC NEEDS AND CLINICAL INDICATIONS>>

• Discussing prior health problems and any prior medical care

with [NAME] to review the problem, the care received, and potential impact upon treatment (e.g., Is there a relationship between [NAME]’s medical issues and [his/her/Name’s] substance use? To what extent might these health issues pose challenges for the treatment of the substance use disorder? Are there special needs that must be considered in order to participate in substance use treatment?)

• Monitoring for change in physical health (and medication compliance)

• Review of plan for what to do if these health problems re-occur in the future

Dimension B-3: Emotional-Cognitive-Behavioral

Problem

No Problem• No past / currentPast Problems• Reported lifetime history of being

bothered by emotional, trauma or behavior problems, or diagnoses

Current - Low/Mod Problems• Bothered by MH problems, functional

impairment, memories from the past, attention problems or self-injury, at any time in the past 90 days.

Current High Severity• Had any emotional, trauma or behavioral

problems daily (45+ /90) or functional impairment or self-harm weekly (13+/90) or suicide plans/ means/attempts with any functional impairment or self-harm

Treatment

No Treatment History• No past / current treatmentPast (Lifetime) Treatment History• Any mental health treatment, or

current medication, or ever having seen a doctor

Currently in Treatment• Any mental health treatment in the

past 90 days or currently being treated


Problem Recency


Treatm

ent History

None P

ast Current .

1. No Problem




treatment )



recode














[NAME] has received mental health treatment for emotional, behavioral or cognitive problems in the past 90 days, but reports not having problems in the past 90 days. Based on the information provided, the evaluator recommends: <<PROMPT: REVIEW, DELETE OR EDIT ACCORDING T0 SPECIFIC NEEDS AND CLINICAL INDICATIONS>>

• Discussing past emotional, behavioral or cognitive problems with [NAME] to review the need for future mental health services, barriers to accessing them and any accommodations needed to participate in treatment.

• Discussing how past emotional, behavioral or cognitive problems and substance use problems may be related

• Develop follow-up plans related to mental health care (e.g. Were arrangements made for continuing care? Does [NAME] express willingness, have a plan and means, and/or taken initial steps toward adhering to the follow-up recommendations? Does [NAME] know what to do if problems re-emerge?)

• Monitoring for change in emotional, behavioral or cognitive condition, linkage to treatment, and treatment/medication compliance

• The following specific accommodations for emotional, behavioral or cognitive problems required to participate in treatment: <list out>

Dimension B-4: Readiness for Change

Problem

No Problem• No past / currentPast Problems• Lifetime substance dependence, abuse,

induced disorders, weekly substance use, hiding use or substance related family problems

Current - Low/Mod Problems• Using in the past 90 days and one of the

following (mod/high resistance, low/mod motivation, few reasons for quitting, not completely ready to stop)

Current High Severity• (Using in the past 48 hours, daily (45+/90)

or using opioids weekly (13+/90)) and one of the following (high resistance, low motivation, no reasons for quitting, not completely ready to stop)

Treatment


Past (Lifetime) Treatment History• Lifetime substance use disorder

treatment, current medication, any recent treatment

Currently in Treatment• Currently taking substance use disorder

meds; in substance use disorder treatment in the past 90 days; currently in substance use disorder treatment; or others are putting on pressure to change.


Problem Recency


Treatm

ent History

None P

ast Current .

1. No Problem




treatment )



recode














[NAME] has received treatment for substance use problems in the past 90 days, but is still experiencing severe problems. Based on the information provided, the evaluator recommends: <<PROMPT: REVIEW, DELETE OR EDIT ACCORDING T0 SPECIFIC NEEDS AND CLINICAL INDICATIONS>>

• Discussing the current and/or prior treatment episodes with [NAME] to review the experience (e.g., Did [he/she/name] achieve a period of sustained abstinence? What is [he/she/name] willing/able to do differently?)

• Discussing the Personal Feedback Report with [NAME], (e.g. Use Motivational Interviewing to explore consequences of [NAME]'s substance use? What are some of [NAME]’s reasons for wanting to quit? What things are a part of [NAME]’s typical pattern of use? When does [NAME] have the most situational confidence for avoiding substances?)

• Discussing with [NAME] the way substance use functions in [his/her/name’s] life, (e.g. What things are usually going on just prior to the decision to use drugs or alcohol? What thoughts and feelings precede using? What effect does substance use have on those thoughts/feelings? What people, situations, or activities are associated with using drugs or alcohol? What things might impact the likelihood of continued use?)

• Discussing [NAME]'s goals, present level of motivation for treatment and resistance to change, (e.g. Use Motivational Interviewing to explore [NAME]’s goals for substance use? What are some important reasons for those goals? What steps are necessary to achieve those goals? What things could prevent being able to attain those goals? What are [NAME]’s points of ambivalence about quitting?)

• Discussing [NAME]’s progress with current treatment team to discuss areas of responsiveness and unresponsiveness; compliance and noncompliance; and areas of resistance and ambivalence; and any barriers to treatment retention and compliance

• A review to determine whether to continue with current level of care or step-up to next level of care.

Dimension B-5: Relapse Potential

Problem

No Problem• No past / currentPast Problems• Lifetime substance dependence, abuse, induced

disorders, weekly substance use, hiding use or substance related family problems

Current - Low/Mod Problems:• Any past 90 day use or past month substance

dependence, abuse, induced disorders, weekly substance use, hiding use or substance related family problems, moderate/high risk on self-efficacy to resist relapse

Current High Severity• (Using in the past 48 hours, daily (45+/90) or

using opioids weekly (13+/90)), high risk on self-efficacy to resist relapse, and (past 90 day use and low problem orientation)

Treatment


Past (Lifetime) Treatment History• Lifetime substance use disorder

treatment, current medication, or urine/saliva/hair monitoring

Currently in Treatment• Currently taking substance use disorder

meds; in substance use disorder treatment currently or in the past 90 days; or urine/saliva/hair monitoring


Problem Recency


Treatm

ent History

None P

ast Current .

1. No Problem




treatment )



recode














[NAME] reported substance use problems in the past 90 days and no prior history of treatment for those problems. Based on the information provided, the evaluator recommends: <<PROMPT: REVIEW, DELETE OR EDIT ACCORDING T0 SPECIFIC NEEDS AND CLINICAL INDICATIONS>>

• Referral to relapse prevention group or counseling intervention to identify relapse triggers, develop a plan for minimizing triggers, coping with those that do occur, and what to do if [NAME] does relapse, (e.g. Does [NAME] understand the nature of relapse and its triggers? What people, places, things, thoughts or emotions are associated with initiating substance use? What things might impact the likelihood of relapse? Who will [NAME] call to help get back on track?)

• Referral to cognitive-behavior therapy to develop skills for coping with stress, managing thoughts and behaviors and avoiding relapse

• Discuss with [NAME] the situations that pose a risk of relapse, (e.g. Who are the people, places and things that put [NAME] at high risk? How can high-risk situations be avoided? What refusal skills does [NAME] already have or need to develop? What will be [NAME]’s plan for handling emergency risk situations?)

• Discussing [NAME]’s willingness to participate in a 12-step or other recovery program (e.g. including getting and actively working with a sponsor; working the 12 steps; establishing a relationship with a home group; performing a service at meetings such as set-up, literature, chairing a meeting; or sharing their story at a meeting)

• Developing and discussing options for [NAME] to build or enhance a non-using social support network; engage in substance-free recreational activities; build situational confidence; strengthen refusal skills; and cope with relapse

Dimension B-6: Recovery Environment

Problem

No Problem• No past / currentPast Problems• Lifetime history of homelessness, environmental risk

for home, school/work peers, or social peers, victimization, drug related illegal activities.

Current - Low/Mod Problems• Past 90 day homelessness, unable to stay in the same

home, trouble at home, arguing/violence, victimization, structured activities involving alcohol or drugs, or any illegal activity to get substances or under their influences.

Current High Severity• Past 90 day illegal activity to get substances or under

their influences, victimization; or weekly (13+/90 days) homeless, with substance use in the home, or structured activities involving alcohol or drugs; or daily (45+/90 days) trouble with family or arguing.

Treatment


Past (Lifetime) Treatment History• Lifetime history of environmental

interventions targeting substance use including: self help, recovery homes, IOP, residential treatment, probation, parole, detention, jail, electronic monitoring, or house arrest.

Currently in Treatment• Past 90 day history of environmental

interventions targeting substance use including: self help, recovery homes, IOP, residential treatment, other controlled environment where they could not come & go as they please or being on probation, parole, detention, jail, electronic monitoring or house arrest.


Problem Recency


Treatm

ent History

None P

ast Current .

1. No Problem




treatment )



recode














NAME] reported current (past 90 days) recovery environment problems and also reported receiving intervention for those problems in the past. Based on the information provided, the evaluator recommends: <<PROMPT: REVIEW, DELETE OR EDIT ACCORDING T0 SPECIFIC NEEDS AND CLINICAL INDICATIONS>>

• Discussing the prior times in a controlled environment to review the experience (e.g., Did [he/she/name] make changes in the recovery environment or supports? Were other family members involved in making changes? Did they have a follow-up recommendation? achieve a period of initial abstinence (at least 90 days)? Are there things that might be adjusted to make more permanent changes this time? What is [he/she/name] willing/able to do differently this time?)

• Requesting records from prior service providers and reviewing those records to determine the services previously provided, recommendations and outcomes.

• Increased structure of environment to reduce exposure to relapse triggers and increase support for recovery (e.g. Placement in IOP or residential treatment; involvement in substance-free structured activities in the community; increased monitoring; substance-free vocational activities)

Dimension Recommendation Text

For each dimension, the GRRS will print text addressing 4 areas:

1. Client’s self-report summarized

2. Client Requests

3. Cell-specific Recommendations

4. General Recommendations for the Dimension

Self-Report Summarized

• Problems: Things the client reported in terms of symptoms and problems in that dimension

• Treatment history: Lifetime service-utilization in that dimension

• Beliefs: Client attitudes, perceptions of problem severity and need for help

List of Client Requests (Example from B-4)

[NAME] specifically asked for assistance with:

• Getting Treatment [S10a6]

• Making transportation arrangements [B9a1]

• Making child care arrangements [B9a2]

• Scheduling around work, school or family responsibilities [B9a3]

• Paying for treatment [B9a4]

• Language, religious, ethnic or cultural issues [B9a5]

• Clothing [B9a6]

• Food [B9a7]

• Other issues:_________ [B9a99v]

Cell-Specific Recommendations (Example from B-4, cell 5)

[NAME] is currently receiving treatment for substance use, but reports no substance use problems in the past 90 days. Based on the information provided, the evaluator recommends: <<PROMPT: REVIEW, DELETE OR EDIT ACCORDING T0 SPECIFIC NEEDS AND CLINICAL INDICATIONS>>

• Developing and discussing post-discharge or step-down plans with [NAME], (e.g. Does [NAME] express willingness, have a plan and means, and/or taken initial steps for adhering to follow-up recommendations?)

• Discussing past substance use problems with [NAME] to review the need for future services, barriers to accessing them and the motivation to stay in recovery…..

General Recommendations for the Dimension(Based on problems endorsed)

• Other: [ [XASB4v]; <list out others> / <list out others>]

• Refer to wrap-around or case management services [If [B9a1-99>0] or [B7=4, 5 or 6] or [B7a>59]]

• Discuss the external pressure for treatment, the consequences of continued use or treatment drop-out, and potential need for coordination of care w/external sources of pressure [If B4a-j>0]

• Discuss and set realistic expectations for how long [NAME] will need to be in treatment and the potential need for continuing care [If [B6<4] and [max of S9c-u>2]]

• Pair [NAME] with program graduate or experienced client to help them understand the treatment process and expectations [If [E5=0 or E5f=4] and [E6=0 or E6f=4] and [E7=0 or E7f=4] and [S7=0]]

Developing Real Time Placement Recommendations for

Line Clinicians

Michael L. Dennis, Ph.D.,

Chestnut Health Systems, Bloomington, IL

Current 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

Strengths and Limits of Current Approach

• Strengths:– Keeps decisions in the hand of clinicians and avoids risk

of regulator/funders questioning differences– Recognizes the lack of evidence base for forcing several

decisions

• Weaknesses:– Difficult to train and get staff to reliably implement– Staff want advice– Supervisors want tools for training/managing staff,

particularly when there is turn over– It is difficult to do the needed outcome research on

placement rules unless they are made reliably/consistently

Learning from Practice

• Used data collected from 7,269 adolescents interviewed with GAIN version 5 as part of 89 CSAT adolescent treatment grants since 2002

• Created a variable for each of the 8 cells in the GAIN approach and reflected by the text we are developing for the expanded GRRS

• Examined the distribution of the variables overall and by level of care

• Used discriminant function analysis to predict the probability of being in each level of care for similar clients.

• Used to combine information into a level of care recommendation for line clinicians

• Characteristics of CSAT vs. TEDS public 2003 admissions

Admin

Geographic Location of Sites

ART

EATSCYTCEYORP

AK

AL

ARAZ

CA CODC

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

UTVA

WA

WV

WY

PR

VT

WI

IL

KY

MA

CT

DC

Program

Admin

Demographics

30%

19%

58%

16%

6%

17%

83%

18%

42%

17%

23%

20%

73%

29%0% 10

%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Female

African American

Caucasian

Hispanic

Mixed/Other

12 to 14 years old

15 to 17 years old

TEDS (n=153,251)

CSAT (n=7,226)

Admin

Clinical Severity

82%

33%

50%

48%

53%

37%

61%

53%

68%

74%0% 10

%

20%

30%

40%

50%

60%

70%

80%

90%

100%

First used underage 15

Prior Treatment

Weekly use atintake

Past YearDependence

Criminal JusticeSystem

TEDS (n=153,251)

CSAT (n=7,226)

Admin

Primary, Secondary or Tertiary SUD Problems

57%

82%

8%

4%

7%

6%

60%

5%

3%

7%

2%

25%

0% 10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Alcohol

Marijuana/Hash

Cocaine/Crack

Heroin/Opiates

Meth/amphetamines

Any Other

TEDS (n=153,251)

CSAT (n=7,226)

Admin

Other ASAM Issues (not in TEDS)

0.31

0.08

0.84

0.27

0.79

0.59

0.70

0.76

0.70

0.81

0.82

0.45

0% 10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Any withdrawal symptoms past week

Severe withdrawal (11+ symptoms)

Sexually active in past 90 days

Major health problems

Any co-occurring psychiatric

Ever physical, sexual or emotional victimization

Doesn't acknowledge AOD problem

Doesn't acknowledges need for treatment

Regular alcohol use in recovery environment

Regular drug use in recovery environment

Any violence or illegal activity

Any past year violent crime

Admin

Level of Care

68%

14%

18%

8%

21%

71%

0% 10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Outpatient

Intensive Outpatient

Residential TEDS (n=153,251)

CSAT (n=7,226)

Includes 9% in continuing care after residential

treatment or detention

Admin

68%

14%

9%

9%

8%

2%

19%

71%0% 10

%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Outpatient

Intensive Outpatient

Short Term Resid(<30 days)

Long Term ResidTEDS (n=153,251)

CSAT (n=7,226)

Level of Care

Includes 9% in continuing care outpatient (CCOP) after

residential treatment or detention

Admin

Proportion of Adolescents in Each Cell*

0% 20% 40% 60% 80% 100%

B1 Intox and Withdrawal

B2 Bio-Medical

B3 Psych-Behavioral

B4 Readiness for Change

B5 Relapse Potential

B6 Recovery Environment

0. Inconsistent 1. No Problem

2. Past Problem 3. Cur Prob. w/o Tx Hx

4. Cur Prob. w/ Tx Hx 5. Past Prob w/ Cur Tx

6. Lo/mod Prob w/ Cur Tx 7. High Cur Prob w/ Cur Tx

Diagnostic Severity by Level of Care

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

No/

Pas

t use

Lif

etim

e S

UD

inpa

st m

onth

rem

issi

on

Lif

etim

e S

UD

but

in C

E 4

5+/9

0 pa

stda

ys

Pas

t mon

th a

nyab

use/

depe

nden

cesy

mpt

om

Pas

t mon

th 3

+de

pend

ence

sym

ptom

s

CCOP

LTR

STR

IOP

OP

B1. Intox & Withdrawal Severity by LOC

0%10%20%30%40%50%60%70%80%90%

100%0.

Inc

onsi

sten

t

1. N

o P

robl

em

2. P

ast P

robl

em

3. C

ur P

rob.

w/o

Tx

Hx

4. C

ur P

rob.

w/ T

x H

x

5. P

ast P

rob

w/ C

ur T

x

6. L

o/m

od P

rob

w/ C

ur T

x

7. H

igh

Cur

Pro

b w

/ Cur

Tx

CCOP

LTR

STR

IOP

OP

B2. Biomedical Severity by LOC

* Insufficient data (n<25)

0%10%20%30%40%50%60%70%80%90%

100%0.

Inc

onsi

sten

t

1. N

o P

robl

em

2. P

ast P

robl

em

3. C

ur P

rob.

w/o

Tx

Hx*

4. C

ur P

rob.

w/ T

x H

x

5. P

ast P

rob

w/ C

ur T

x

6. L

o/m

od P

rob

w/ C

ur T

x

7. H

igh

Cur

Pro

b w

/ Cur

Tx

CCOP

LTR

STR

IOP

OP

B3. Psych-Behavioral Severity by LOC


0%10%20%30%40%50%60%70%80%90%

100%0.

Inc

onsi

sten

t*

1. N

o P

robl

em

2. P

ast P

robl

em

3. C

ur P

rob.

w/o

Tx

Hx

4. C

ur P

rob.

w/ T

x H

x

5. P

ast P

rob

w/ C

ur T

x

6. L

o/m

od P

rob

w/ C

ur T

x

7. H

igh

Cur

Pro

b w

/ Cur

Tx

CCOP

LTR

STR

IOP

OP

B4. Readiness for Change Severity by LOC


0%10%20%30%40%50%60%70%80%90%

100%0.

Inc

onsi

sten

t*

1. N

o P

robl

em*

2. P

ast P

robl

em

3. C

ur P

rob.

w/o

Tx

Hx

4. C

ur P

rob.

w/ T

x H

x*

5. P

ast P

rob

w/ C

ur T

x

6. L

o/m

od P

rob

w/ C

ur T

x

7. H

igh

Cur

Pro

b w

/ Cur

Tx

CCOP

LTR

STR

IOP

OP

B5. Relapse Potential Severity by LOC


0%

20%

40%

60%

80%

100%0.

Inc

onsi

sten

t

1. N

o P

robl

em

2. P

ast P

robl

em

3. C

ur P

rob.

w/o

Tx

Hx

4. C

ur P

rob.

w/ T

x H

x

5. P

ast P

rob

w/ C

ur T

x

6. L

o/m

od P

rob

w/ C

ur T

x

7. H

igh

Cur

Pro

b w

/ Cur

Tx

CCOP

LTR

STR

IOP

OP

B6. Recovery Environment Severity by LOC


0%10%20%30%40%50%60%70%80%90%

100%0.

Inc

onsi

sten

t*

1. N

o P

robl

em*

2. P

ast P

robl

em*

3. C

ur P

rob.

w/o

Tx

Hx

4. C

ur P

rob.

w/ T

x H

x

5. P

ast P

rob

w/ C

ur T

x

6. L

o/m

od P

rob

w/ C

ur T

x

7. H

igh

Cur

Pro

b w

/ Cur

Tx

CCOP

LTR

STR

IOP

OP

Predicting Level of Care

• Discriminant Function Analysis using stepwise analysis of the cells we have just reviewed, the GAIN psychopathology scales & change measures, and variables from Rand’s case mix study (Morral et al., 2005).

• Final solution with 42 variables (see next slides) allows us to predict where counselors around the country would place a similar client in terms of the best fit, and the probability of being in each level of care.

Most Influential Cells

-0.80

-0.30

0.20

0.70

1.20B

5.2

Pas

t Rel

apse

Pro

blem

B4.

7 H

igh

Sev

erity

Rea

dine

ss f

or c

hang

eis

sues

/cur

rent

TX

B4.

6 L

ow/m

odR

eadi

ness

for

Cha

nge

prob

lem

/cur

rent

TX

B5.

7 H

i Sev

erity

Rel

apse

pote

ntia

l/cur

rent

TX

B2.

1 N

o B

io-M

edP

rob

B6.

5 P

ast R

ecov

ery

envi

ronm

ent P

rob

B2.

2 P

ast B

io-M

edpr

ob

OP

IOP

STR

LTR

CCOP

Past Month (PM)/Past Year Psychopathology/ Psychopathy

-0.80

-0.30

0.20

0.70

1.20

SubstanceProblem Scale

(PM)

SubstanceDependence Scale

(PY)

Crime & ViolenceScale (PY)

BehaviorComplexity Scale

(PY)

OP

IOP

STR

LTR

CCOP

Past 90 Day/ Week/ Current Change Scores

-0.80

-0.30

0.20

0.70

1.20S

ubst

ance

Fre

quen

cy S

cale

(P90

)

Pro

blem

Ori

enta

tion

Sca

le

Em

otio

nal P

robl

ems

Sca

le(P

90)

Nee

dle

Fre

quen

cy S

cale

(P

90)

Tre

atm

ent M

otiv

atio

n In

dex

Sel

f-E

ffic

acy

Sca

le

Cur

rent

Wit

hdra

wal

Sca

le (

PW

)

Doe

sn't

Ack

nolw

edge

AO

Dpr

ob

Tre

atm

ent R

esis

tanc

e In

dex

Hea

lth

Pro

blem

s S

cale

(P

90)

OP IOPSTR LTRCCOP

Pattern of Substance Use

-0.80

-0.30

0.20

0.70

1.20D

ays

Dru

nk/H

igh

mos

t of

day

(P90

)

Usi

ng d

aily

(P

90)

Use

d dr

ugs/

alco

hol

in p

ast 2

day

s

Nee

ds tr

eatm

ent f

orH

eroi

n

Day

s of

toba

cco

use

(P90

)

Nee

ds tr

eatm

ent f

orA

mph

etam

ines

/Met

h

Nee

ds tr

eatm

ent f

orno

n-co

mm

on D

rugs

OP

IOP

STR

LTR

CCOP

Lifetime/ Past 90 Day/ Current Interventions

-0.80

-0.30

0.20

0.70

1.20D

ays

in c

ontr

olle

d en

viro

nmen

t(P

90)

Sub

stan

ce A

buse

Tx

Inde

x(P

90)

Cur

rent

ly in

AO

D T

x

Lif

etim

e A

A C

A N

A S

Rpa

rtic

ipat

ion

CJ

Sys

tem

Ind

ex (

P90

)

Tra

inin

g A

ctiv

ity

Sca

le (

P90

)

Cur

rent

JJ

invo

lvem

ent

Cur

rent

ly in

sch

ool

Tim

es a

dmit

ted

to d

etox

Rec

ent A

rres

sts

(P90

)

OP IOPSTR LTRCCOP

Lifetime/ Past 90 Day/ Current Interventions

-0.80

-0.30

0.20

0.70

1.20

LifetimeHomeless/Runaway

Minority status Age How many peoplelive with

OP

IOP

STR

LTR

CCOP

Predicted LOC by Actual LOC

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

P_OP P_IOP P_STR P_LTR P_CCOP

CCOP

LTR

STR

IOP

OP

Predicted Level of Care

Act

ual L

evel

of

Car

e

75% correctly classifiedKappa=.51

Miss-classification includes lack of availability

Adding Text to Reflect Recommendation and Likelihood of Alternatives

• Based on the above assessment, the evaluator recommends that [NAME] be admitted to Outpatient.

• <<Distribution of placement for similar clients is: 90% OP, 5% IOP, 0% STR, 2% LTR, 1% CC_OP>>

Adding Management Tools for Clinical Supervisors and Program Planners

• Summary of requests, cell placements and individual treatment planning rates recommended, and kept vs. modified or dropped to guide program planning

• Cross tabulations of predicted vs. actual placements to identify gaps

• Running above by site, team or staff person to check for potential training issues

• Ability to customize to identify local issues or programs.

Also will be doing analysis to see if placement into expected level of care is associated with better outcomes

Next Steps and Timeline for Updating the GRRS

1. Development of a user interface

2. Expert panel to review content, rules and recommendations in late May/June

3. Testing in the summer

4. Release by end of the year!

Acknowledgment

The content of this presentations are based on treatment & research funded by the Center for Substance Abuse Treatment (CSAT), Substance Abuse and Mental Health Services Administration (SAMHSA) under contract 270-2003-00006 using data provided by CSAT adolescent treatment grantees under the Adolescent Residential Treatment (ART), Effective Adolescent Treatment (EAT), Strengthening Communities for Youth (SCY), Targeted Capacity Expansion (TCE), and Young Offender Re-entry Program (YORP) grants (TI013313, TI013309, TI013344, TI013354, TI013356, TI013305, TI013340, TI130022, TI03345, TI012208, TI013323, TI14376, TI14261, TI14189,TI14252, TI14315, TI14283, TI14267, TI14188, TI14103, TI14272, TI14090, TI14271, TI14355, TI14196, TI14214, TI14254, TI14311, TI15678, TI15670, TI15486, TI15511, TI15433, TI15479, TI15682, TI15483, TI15674, TI15467, TI15686, TI15481, TI15461, TI15475, TI15413, TI15562, TI15514, TI15672, TI15478, TI15447, TI15545, TI15671)). 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].

Documents

Using the New GAIN Patient Placement Summary to Support Individual Treatment Planning, Placement and Program Evaluation Marc Fishman, M.D., Johns Hopkins