Improving Clinician Ratings of Money Mismanagement: Addiction's Impact.

Yale University, New Haven CT

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Abstract

DESCRIPTION (provided by applicant): The goal of this study is to improve upon the current procedure for determining when patients with psychiatric and/or substance abuse disorders are incapable of managing their funds by developing and validating the CAFI (Clinician Assessment of Financial Incapability), a brief clinician-rated instrument to "diagnose" incapability. Disabled people are harmed when their Supplemental Security Income (SSI) and Social Security Disability Insurance (SSDI) benefits are misspent, often on drugs and alcohol, leaving them without money for housing and other essentials. A representative payee may be assigned to patients who are incapable of managing their funds but the Social Security Administration (SSA) largely decides on payee assignment based on a single question answered by the patient's clinician. Clinicians are given no instruction to consider substance abuse, despite its importance in managing funds. This study involves a Pre-Pilot Phase during which candidate items will be developed and tested, an Instrument Development Phase and an Instrument Validation Phase. In the Pre-Pilot phase, candidate items for the CAFI will be developed by the research team and piloted with 15 clinicians. Then, in the Instrument Development Phase, three sets of assessments will be conducted: (a) questionnaires with the single SSA question and the candidate items for the CAFI will be completed by clinicians treating 120 inpatients and patients in day hospitals with histories of substance abuse, and will be completed again one week later to identify items with adequate test-retest reliability, (b) all-data assessments of patients'capability to manage their funds will be completed by independent third-party experts using the L.E.A.D. procedure (Longitudinal Expert Evaluation Using All Available Data) applied to pre-defined criteria, and (c) clinical rating scales administered to patients by a research assistant. Individual item analysis, test-retest reliability, exploratory factor analysis and backwards stepwise logistic regression will be used to cull a brief questionnaire (the CAFI) from the candidate questionnaire with items that best identify beneficiaries incapable of managing their funds (as determined by the all data approach). In the Instrument Validation Phase, the CAFI and the battery of assessments (all-data evaluation, and research assistant ratings) will be collected for 192 patients at baseline. The sensitivity and specificity of each of the clinician assessments (single SSA question and CAFI) vis a vis the concurrent all-data assessment will be determined and the accuracy of the single SSA question and the CAFI will be compared using a z-test of differences between coefficients. The convergent validity of the single SSA question and the CAFI will be determined by comparing the agreement of each with clinical measures collected by the research assistant. Twenty-four weeks later, follow-up assessments will be collected by the research assistant and third-party experts to determine the predictive validity of the single SSA question and the CAFI. Analyses of the role of substance abuse in money mismanagement will be conducted.