Sponsored by: Substance Abuse and Mental Health Services Administration U.S. Department of Health and Human Services April 2014 New Opportunities with SOAR: SOAR Fundamentals, Part I SSI/SSDI OUTREACH, ACCESS, AND RECOVERY SAMHSA SOAR TECHNICAL ASSISTANCE CENTER

Welcome  Abigail Lemon, MA  Senior Project Associate  SAMHSA SOAR Technical Assistance Center  Policy Research Associates, Inc.

Logistics  Recording  Downloading materials  Poll questions  Chat questions  Live Q&A

Webinar Call Agenda  One – Day SOAR Fundamentals Training  SOAR Fundamentals  SOAR Basics  Getting Started  Questions & Answers

POLL QUESTION #1

Preparing for SOAR Fundamentals

Local Implementation of Online Course  Preparation  Advertising the training  Sample training flyer  SOAR Online Course support  Weekly progress expectations  SOAR Fundamentals Training  One-day training  Follow-up Support  Local leads  SAMHSA SOAR TA Center

SOAR Fundamentals

Introductions  Local SOAR Leads  Program Participants Please tell us:  Your name and work location  What are your plans/goals for using SOAR in your work?  What do you need to learn today to get you there?

Logistics and Housekeeping  Take care of yourself  Restrooms and breaks  Ground rules  Cell phones  Ouch, Stretch, ELMO  Others?  Values and language  Parking Lot

SOAR  SOAR stands for SSI/SSDI Outreach, Access and Recovery  Focus is on people who are homeless or at risk for homelessness  Sponsored by the Substance Abuse and Mental Health Services Administration (SAMHSA) in collaboration with SSA since 2005  All 50 states currently participate; no direct funding provided to states

Why is SSI/SSDI Important for Individuals?  SSA disability benefits can provide access to:  Income  Housing  Health Insurance  Treatment  Other supportive services  For people with disabilities, SSI/SSDI can be a critical step towards ending homelessness and promoting recovery

Why is Access to SSI/SSDI Important for States & Localities?  People experiencing homelessness are frequent users of expensive uncompensated health care  Can recoup cost of this care from Medicaid for up to 90 days retroactive to date of SSI eligibility  States and localities can recoup from SSA the cost of public assistance provided during the application process  SSI, SSDI and Medicaid bring federal dollars into states, localities and community programs

Changing Lives Since 2005  19,008 persons experiencing or at risk for homelessness have been approved on initial application  65 percent approval rate overall  Compares to percent for unassisted applications from people who are homeless and 29 percent for all applicants  Approvals were received in an average of 100 days in 2013  Appeals can take a year or more; many people give up and do not appeal

Top Eight States  Served more than 4,000 persons  89 percent approval rate on initial applications  Approval rates are highest in places where more SOAR critical components are implemented

SOAR Technical Assistance Center  SAMHSA funds the SOAR TA Center to support states and communities  Offers virtual and on-site technical assistance  SOAR TA Liaisons are responsible for SOAR in multiple states  Get to know your SOAR TA Liaison  Reach out for help or answers to questions about any aspect of SOAR

Online Course Experience WowsWishes

Activity: Reasons for the Work We Do  This program is about:  Ending homelessness  Promoting recovery  Transforming lives  Discussion:  What brought you to this work?

SOAR Fundamentals Agenda  The Basics  Getting Started  Who is a SOAR applicant?  Engaging the applicant  State SOAR process  Forms  Medical Summary Report Refresher  Tracking Outcomes  Special Populations  Appeals  Now What?

SOAR Fundamentals Materials  PowerPoint slide handouts  Sample SSA Forms  MSR Worksheet  Sample Medical Summary Reports  Your State’s SOAR Process  Sample Application Packet  Any other materials that you want participants to have!

POLL QUESTION #2

SOAR Fundamentals: The Basics

SOAR Has Broader Goals Housing Access to treatment and other services Employment Opportunities Community Investment Decrease in adverse outcomes (incarceration & hospitalization) SOAR

SOAR Partners  Social Security Administration (SSA)  Federal agency that administers SSI/SSDI  Makes the non-medical decision  Disability Determination Services (DDS)  State agency under contract to SSA  Makes the medical/disability determination  Medical/treatment providers  Assessments/evaluations  Medical records  You!

SSI & SSDI: The Basics  SSI: Supplemental Security Income; needs based; federal benefit rate is $721 per month in 2014; provides Medicaid in most states  SSDI: Social Security Disability Insurance; amount depends on earnings put into SSA system; Medicare generally provided after 2 years of eligibility  The disability determination process for both programs is the same

Application Process Application Initiated at SSA SSA Determines Non- Medical Eligibility SSA Transfers Claim to DDS DDS Determines Medical Eligibility DDS Returns Record to SSA SSA Notifies Applicant

Criteria for Eligibility 1. Medically Determinable Physical or Mental impairment  Illness must either meet or be equivalent to the “listing” criteria used by DDS. Supporting information must be documented in medical records 2. Duration  The impairment tied to the illness(es) must have lasted OR be expected to last 12 months or more OR be expected to result in death 3. Functional Information  Applicants must demonstrate that significant functional impairment related to the illness(es) exists that impede their ability to work

Sequential Evaluation

Step 3 is Key!  Person can be found disabled at Step 3 and begin receiving benefits  If adequate evidence is presented that impairment meets the Listings and the applicant is unable to work  Connecting functional limitations to their inability to work with appropriate medical documentation is key

Documenting the Disability  Case managers need to collect medical records from all treatment sources  Applicant report  Collateral sources (friends, family, other service providers)  Common treatment providers  Two releases (agency and SSA-827) for each treatment source are signed so that the case manager can share these records with SSA and DDS  Used to meet the Listings  Organize your search!

Documenting the Disability  If medical records are not current, case managers may need to arrange for assessments to be done  Mental status exams must be done within 90 days of submitting application  DDS requires that the applicant has a diagnosis from a doctor (MD/PhD/EdD)

Make the Link to Work  The question DDS must answer is: “Can the person work and earn SGA?”  Disability must meet the criteria in the “Listings”  Must make the link between a person’s illness, his/her inability to function in a work setting

Functional Information  For mental illnesses, the applicant must demonstrate functional impairments that meet the Listings  Document all four areas  Activities of daily living  Social functioning  Concentration, persistence and pace  Repeated episodes of decompensation  Must demonstrate marked functional impairments in at least two areas

Functional Information  For physical impairments, the application must demonstrate significant limitations in meeting physical, mental, sensory and other requirements of work  A limited ability to perform certain physical demands of work activity (e.g. sitting, standing, walking, lifting, carrying, etc.) may reduce a person's ability to do past work and other work

Using the Blue Book Listings  AdultListings.htm  For each category of mental impairment:  General description of disorder  Section A – types of symptoms and impairments (diagnosis)  Section B – required “level of severity” (limitations in functioning)  Section C – medically documented history (longer period of documentation)  To qualify, an individual must:  Meet A + B  Or C

Criteria “A” – Blue Book Listings  Psychiatric evaluations  Physical health evaluations  Specialty physical health evaluations  Neurological reports  Laboratory results  Diagnostic tests  Neuropsychological tests  Psychological tests  Admission summaries  Discharge summaries

Criteria “B” – Blue Book Listing  Bio-psychosocial evaluation reports  Occupational therapy evaluation reports  Vocational evaluation reports  Psychiatric Rehabilitation Day Program notes  Supported housing progress notes  Functional descriptions  Medical Summary Report

Remember to Make the Link Diagnosis Part “A” of the Listing Functional Limitations Part “B” of the Listing Why the applicant is unable to work. The MSR helps illustrate the connection between A and B

The Secret to Approvals? A + B = Approval

Co-Occurring Disorders  If substance use is deemed "material" to a person's disability, benefits will be denied  Substance use is "material" when:  If a person were clean and sober, the functional impairment would not exist and the person would not be disabled  The determination does NOT require sobriety  Use past periods of sobriety (hospital, jail, treatment) to document symptoms that persisted

Medical Summary Report (MSR)  The MSR is a letter which describes the individual and his/her functional limitations and struggles  Supports medical records submitted  Helps DDS “see” the person you are working with  Illustrates the connection between the applicant’s functional limitations and the impairment  Answers the question: “Why can’t the applicant work?”  The MSR worksheet guides the case manager through the sections of the written report  The letter, not the worksheet, is submitted to DDS

Medical Summary Report  Medical Summary Reports are considered medical evidence if signed by a treating physician or psychologist  Even without a physician’s signature it is important for DDS’s determination of the applicant’s ability to work

POLL QUESTION #3

Getting Started

The Challenge  Limited resources  Limited time  A lot of people need our help  Applications involving mental illness and co- occurring substance use disorders are complicated

The SOAR Applicant Who can be helped by SOAR?  Adults who are experiencing, or at risk for, homelessness  And who have mental illness, co-occurring disorders or other physical disabilities or conditions Who is considered “homeless”?  Moving from place to place throughout the month  Living “doubled-up”  Living in uninhabitable housing, outside or in shelters  Living in unstable or non-permanent housing  Exiting jails or prisons and who have no stable place to live

Identifying SOAR Applicants

Using the Tool  Identify individuals who most need your assistance  Do not discourage anyone from applying for SSA benefits  Plan for alternative service or referral

Make the Tool Work For You  Consider adding your program acceptance criteria  Use in conjunction with other assessment tools  Consult with colleagues or the SOAR TA Center

Engaging Applicants  Create and maintain a safe space for you and the applicant  Keep your promises: Under promise and over deliver  Find out where the person spends his/her time  Develop ways to maintain contact, including someone to contact should you need to reach the applicant  Ask open-ended questions  Be mindful of non-verbal communication

Our State or Local SOAR Process  Attention Local/State Leads!  The next few slides cover the standard SOAR process; adapt these slides if your process differs from this  Add information about your local/state SOAR process here  How to set protective filings dates  When to contact SSA  How to communicate with DDS  Where to access records and assessments

Getting Started: Completing an Initial SSI/SSDI Application

Getting Started: Days 2 – 3 Complete and have applicant sign the SSA-1696 Appointment of Representative form

SSA-1696: Appointment of Representative  Permits communication with SSA and DDS about the applicant’s file  Case manager receives copies of all applicant communication from SSA and DDS  The most important tool for working with someone who is experiencing homelessness  “The Key to the City”  Neither the agency or the case manager is liable for the decision made by DDS  It is NOT the same as the representative payee  SOAR providers should check “waiving fees from all sources”

Getting Started: Days 2 – 3 Request LetterSSA-827Agency Release

SSA-827: Authorization to Disclose Information to SSA  Allows SSA and DDS to gather medical records and information from medical records departments  SOAR providers - use along with Agency Release Form when requesting medical records from every source (HIPAA Compliant)  All forms should be signed by the applicant  Available online

Getting Started: Weeks 1 – 2 SSA-3368: Disability Report Adult

SSA 3368: Adult Disability Report  Gathers basic information about the applicant’s work history, medical treatment and education  Helps DDS know which providers will have medical evidence for the application  DDS will request records from the medical sources listed  SOAR case managers can indicate in Remarks which records they will submit with the application  Complete online, use the paper version as a worksheet

Getting Started: Weeks 3 – 4 SSA-8000: Application for SSI

SSA-8000: SSI Application  Title XVI  Needs based so income and resources are counted  Longer application  The amount of pages may seem overwhelming but for many, resources are so limited that many of the pages will be blank  Don’t assume that the applicant does or does not have resources  Can be completed in person, by phone or submitted hard copy

Getting Started: Weeks 3-4 SSA-16: SSDI Application

 Title II  SSDI eligibility is based on work history  No resources and assets counted  Not necessary to establish need  Explores eligibility for other benefit programs (Worker’s Compensation, VA benefits, etc.)  SSA prefers online submissions  Establishes protective filing date for SSI applications

Remember the ‘Remarks’ Section  Found on the SSA-8000, SSA-16 and SSA-3368  Indicate that this is a “SOAR” claim if the person is experiencing or at risk of homelessness  Provide additional information that will clarify responses to questions on the forms  Reference the question number in the comments section along with the explanation

Getting Started: Weeks 5 – 8 Medical Summary Report (first and last pages)

Submitting the Application  Call the SSA SOAR Contact at least 1-2 weeks before the 60-day deadline, or earlier, to request an appointment to submit the completed application  hours before the SSA appointment, submit the combined Disability Application (SSA-16) and Disability Report (SSA-3368) online  Submit the completed application package using the SOAR Checklist for Initial Claims as a cover sheet

Submitting the Application

SOAR Application Checklist

Reminder! A Complete SOAR Packet Includes: 1. SOAR Checklist as a cover sheet for the completed application package 2. SSA-1696 Appointment of Representative form 3. SSA-827 Authorization to Disclose Information to SSA 4. SSA-8000 signed and dated by applicant 5. MSR signed by the SOAR provider as well as the applicant’s physician or psychologist 6. Copies of all medical records in chronological order 7. SSA-3368 and SSA-16 submitted on-line hours before turning in completed application package (Items 1-6)

Organizing Your Effort  Make a file for each applicant  Consider a folder with sections  Include a cover sheet  Section for medical records  Section for SSA/DDS Correspondence  Have files prepared in advance  Create a contact list for SSA reps, DDS adjudicators and medical records providers

QUESTION & ANSWER

Homework  Download the SOAR Fundamentals PowerPoint  Peruse the SOAR Leaders page  Password: SOARWorks  Enroll in the SOAR Online Course  Bring your questions!

Connect With Us Visit the SOAR website at Or contact: SAMHSA SOAR TA Center Policy Research Associates, Inc. Delmar, NY (518) 439 – 7415