Development of the Global Appraisal of Individual Needs-Quick, version 3 (Q3) Janet C. Titus, Ph.D. Presented August 17, 2011 Chestnut Health Systems Normal, IL

1.Describe the development (“life story”) of the Q3 2.Describe how a pilot study and feedback from the field influenced the development 3.Present the “final” Q3 Goals of this presentation are to…

Progressive Continuum of Measurement (Common Measures) Screening to Identify Who Needs to be “Assessed” (5-10 min) – Focus on brevity, simplicity for administration & scoring – Needs to be adequate for triage and referral – GAIN Short Screener for SUD, MH & Crime – ASSIST, AUDIT, CAGE, CRAFT, DAST, MAST for SUD – SCL, HSCL, BSI, CANS for Mental Health – LSI, MAYSI, YLS for Crime Quick Assessment for Targeted Referral (20-30 min) – Assessment of who needs a feedback, brief intervention or referral for more specialized assessment or treatment – Needs to be adequate for brief intervention – GAIN Quick – ADI, ASI, SASSI, T-ASI, MINI Comprehensive Biopsychosocial (1-2 hours) – Used to identify common problems and how they are interrelated – Needs to be adequate for diagnosis, treatment planning and placement of common problems – GAIN Initial (Clinical Core and Full) – CASI, A-CASI, MATE Specialized Assessment (additional time per area) – Additional assessment by a specialist (e.g., psychiatrist, MD, nurse, spec ed) may be needed to rule out a diagnosis or develop a treatment plan or individual education plan – CIDI, DISC, KSADS, PDI, SCAN Screener Quick Comprehensive Special More Extensive / Longer/ Expensive

What is the GAIN-Q (v. 2)? minute instrument used to briefly assess multiple mental health, substance abuse, and environmental problems Used in a variety of settings, including SAP, juvenile detention, child welfare, health clinics, and EAP Used to support brief interventions

Current GAIN-Q content Items cover 7 content areas – General Factors – Sources of Stress – Physical Health – Emotional Health – Behavioral Health – Substance-Related Issues – Service Utilization Optional section – Reasons for Quitting (focused on substance abuse)

Current GAIN-Q item formats Most items focus on behavior or experiences during the past year. – yes/no items At the end of most sections and in the “Service Utilization” section, items focus on the past 90 days. – number of days items

Current GAIN-Q results Results support efforts to sort individuals into three groups: – those who probably do not have problems requiring attention – those who have mild problems that might be appropriate for a brief intervention – those who are in need of a more detailed assessment and/or specialized treatment.

What are its strengths? Length Range of topics Ability to efficiently triage individuals Two narrative reports – Quick Recommendation and Referral Summary (QRRS) – Personal Feedback Report (PFR) for individuals for whom a brief intervention may be appropriate

What are its weaknesses? Lacks scales to support analyses or outcomes related to change over time. Item response choices do not provide information about lifetime problems or problems that have occurred in finer gradations of time within the past year. Current Personal Feedback Report focuses only on substance use and does not address the other content areas of the GAIN-Q. Only about 60% of the items can be directly imported into the GAIN-I.

Redesigning the Q: Blueprint topics 1) Q as a series of short screeners 2) Cover more ground 3) Retain and refine 4) Rescale response sets 5) Expand Personal Feedback Report 6) Option for screening and brief intervention intertwined

1) Q as a series of short screeners Each section of the GAIN-Q3 starts with a 5-6 item “screener” The screener items are from the corresponding full-length GAIN-I symptom scales. For full-length GAIN-I scales that have several subscales… at least one item from each subscale will be on a screener (all sub-domains represented).

1) Q as a series of short screeners Items were selected based on Rasch measurement modeling. Each set of items is optimal for screening (goal of over 90% sensitivity). Screener scores are good estimates of scores obtained on the corresponding full-length GAIN symptom scales (goal of correlation over.90 with full scales). Each screener ends with several “number of days” items (in the past 90).

2) Cover more ground Vocational Problems Screener (School/Work) Health Problems Screener Sources of Stress Screener General Victimization Screener (Risk Behaviors) Internalizing Disorder Screener Externalizing Disorder Screener Substance Disorder Screener Crime & Violence Screener

3) Retain and refine Sources of Stress Index – personal and environmental stressors Service Utilization – services received during past 90 days – costs to society during past 90 days Demographics

4) Rescale response sets Replace the “yes/no” response set with the GAIN- I’s recency scale (“When was the last time…?”): – Past month – 2-12 months ago – 1+ years ago – Never This will support analyses of outcomes related to change over time and analyses of lifetime problems or problems that have occurred in finer gradations of time within the past year.

5) Expand Personal Feedback Report For each GAIN-Q area in which an individual reports a problem, items focused on reasons/readiness to change behaviors will be asked. Responses will be used to support a motivational intervention.

6) Measure to support brief intervention When an individual reports a problem in any particular area, items to support a brief intervention in that area are administered. Assessment generates a summary of the results (Q3RRS) as well as a Personal Feedback Report to be used with the individual for a brief intervention. Report content – symptoms reported – frequency of symptoms from P90 items – reasons/readiness for changing behavior Reports will be editable.

GAIN-Q (v. 3) as best of both worlds Retaining strengths – Length – Range of topics – Efficiently categorize – Narrative reports Addressing weaknesses – Response sets to capture lifetime/more recent behaviors – Items support analyses of change over time – More in-depth PFR – 90% of items directly imported into GAIN-I

Pilot Study – Winter sites participated Participation was voluntary. Pilot sites had varying levels of GAIN experience Sites were provided with: – GAIN-Q administration and interpretation web training – GAIN-Q pilot ABS accounts In return, sites were asked to: – Collect at least 10 GAIN-Q pilot interviews – Provide feedback during the pilot on the GAIN-Q instrument, Q-ICP, and Q-ABS accounts Sites will complete a formal feedback survey at the completion of the pilot project.

Lessons Learned Pilot Study Analyses and User Feedback Add items/split items Reasons for change well endorsed, add long-term More detail on victimization/abuse Decision rules for administering reasons/readiness Special populations Feedback from the field CSAT - homelessness, pregnancy, military service and veterans status, sexual orientation From pilot to “final”, 129 changes.

GAIN-Q3 (3.1.2) Multipurpose assessment used to identify and address a wide range of life problems among adolescents and adults in both clinical and general populations Used in diverse settings - employee assistance programs, student assistance programs, health clinics, juvenile and criminal justice programs, child welfare programs, mental health and substance abuse treatment Overall aim of the Q3 - triage (quickly sort people) For participants whose results indicate mild problems, the Q3 system provides the means to conduct a brief intervention based on the principles of motivational interviewing. Used as its own follow-up assessment

Heart of the Q3 Nine separate screeners (4 to 8 items long) Measure problem recency (“last time”) for past month, past 90 day, past 12 month, and lifetime behaviors

Life Impact Measures Collection of four measures that provide a unique lens on the costs associated with life problems and the benefits associated with improving one’s life situation. Quality of Life Index Problem Prevalence Index Quarterly Costs to Society Index Life Satisfaction Index

Life Impact Measures Values vary according to complexity in a participant’s life – As the complexity of life problems increases, measures of problem prevalence and quarterly costs to society should increase, – As complexity decreases, quality of life and life satisfaction should increase The Life Satisfaction Index is a standalone measure; the other three Life Impact measures are constructed from information pulled from each of the main sections of the Q3.

Building Blocks of the Q3 The set of nine screeners composes the most basic form of the Q3. Adding successively more items to this base creates additional versions of the Q3.

Q3-Lite The most basic form of the assessment Consists only of the nine screeners, measuring only the recency of the participant’s behaviors Also provides a measure of the participant’s quality of life Takes about 20 minutes to administer

Q3-Standard Enhanced with supplementary items (the median number per section is 6) that record information on the frequency of the participant’s behaviors during the preceding 90 days. Provides more detailed outcome measures than the Q3- Lite - additional information can be used to monitor the participant’s progress when the Q3 is used as a follow-up assessment Includes indices on the participant’s prevalence of problems, quarterly costs to society, and life satisfaction Takes about 35 minutes to administer.

Q3-MI (Motivational Interview) Further enhanced with reasons and readiness items For any life area that screens as problematic, Q3 interviewers have the option of collecting information on the participant’s reasons and readiness to change their behaviors. Information is used during the Q3 brief intervention (conducted either during the assessment session or at a separate meeting) Time required to conduct the screening and brief intervention varies depending on the number of life areas the participant reports as problematic – on average, Q3-MI takes about 45 minutes to administer; Q3-MI and brief intervention takes about 60 to 75 minutes on average.

Administration and Clinical Reports Q3RRS Q3ICP Q3PFR VR (validity report)

Current Development Status Done/Final Touches Q3 instrument, ABS admin Q3ICP, Q3QRRS, VR Training – Moodle, in- person presentations QA/certification model Evaluation materials Site profiles In Development Brief intervention Q3-PFR