1. Improving Access to SSI/SSDI: The Maryland SOAR Program NAMI Maryland 2016 Annual Conference October 14, 2016

2. Excerpted from…. Perret, Y & Dennis, D. STEPPING STONES TO RECOVERY: A TRAINING CURRICULUM FOR CASE MANAGERS ASSISTING ADULTS WHO ARE HOMELESS WITH SOCIAL SECURITY DISABILITY AND SUPLEMENTAL SECURITY INCOME APPLICATIONS. DHHS Pub. No. SMA 06-Rockville, MD: CMHS, SAMHSA, 2006

3. The Federal Disability Programs: SSI and SSDI

4. SSI and SSDI: The Basics SSI: Supplemental Security Income (Title 16) –Federal benefit that provides income ($733 per month in 2016) to individuals that are low-income and disabled, blind, or aged –Medicaid in Maryland SSDI: Social Security Disability Insurance (Title 2) –Federal benefit that provides income (dependent on earnings put into SSA system) to individuals with qualifying earnings history and that are disabled –Medicare provided after two years of eligibility in most instances SSA –Both programs are administered by the Social Security Administration (SSA) with disability evaluated by state contracted agency – Disability Determination Services (DDS)

5. The Problem Only about 30% of all applicants are typically approved on initial application Only about 10-15% of homeless adults who apply are typically approved on initial application Appeals take years and many potentially eligible people give up and do not appeal

6. Barriers to Accessing SSI/SSDI Complexity of process Medical records do not address functional impairments and inability to work Knowledge of the disability determination process and disability programs Communication at all levels of the process (community providers, SSA, DDS) Possible inconsistent treatment history

7. Why is access to SSI/SSDI so important for individuals? SSI/SSDI can provide access to: –Housing –Income –Health insurance Preventing or ending homelessness Promote recovery for people with disabilities

8. Determining Disability

9. SSA Definition of Disability “The inability to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment that can be expected to result in death or that has lasted or can be expected to last for a continuous period of not less than 12 months.” Basically asking: Can you work?

10. Sequential Evaluation Process Is the claimant engaging in SGA? Is the impairment(s) severe? Does the impairment(s) meet/equal listings? Does the impairment(s) preclude the ability to perform past relevant work? Does the impairment(s) preclude the ability to perform other work?

11. Listings for Mental Impairments (SSA Blue Book) Organic Mental Disorders Schizophrenia, Paranoia, and other Psychotic Disorders Affective Disorders Intellectual Disability Anxiety-Related Disorders Somatoform Disorders Personality Disorders Substance Addiction Disorders Autistic Disorder and Other Pervasive Developmental Disorders

12. Example Listings: ‘A’ criteria Depressive syndrome characterized by at least four of the following: a. Anhedonia or pervasive loss of interest in almost all activities; or b. Appetite disturbance with change in weight; or c. Sleep disturbance; or d. Psychomotor agitation or retardation; or e. Decreased energy; or f. Feelings of guilt or worthlessness; or g. Difficulty concentrating or thinking; or h. Thoughts of suicide; or i. Hallucinations, delusions, or paranoid thinking

13. Example Listings: ‘B’ criteria I II III IV Marked restrictions of activities of daily living Marked difficulties in maintaining social functioning Marked difficulties in maintaining concentration, persistence, and pace Repeated episodes of decompensation (each of extended duration)

14. Changes to mental health listings: January 17, 2017 1. Update listing names to reflect terms used in DSM-5 2. Addition of new adult mental health listings: o 12.11 Neurodevelopmental disorders (conditions characterized by an onset in childhood/adolescence) o 12.13 Eating disorders o 12.15 Trauma- and stressor-related disorders (such as PTSD) 3. New emphasis on the importance of social workers, case managers, and outreach workers in providing longitudinal evidence about functional impairments

15. Changes to mental health listings: January 17, 2017 4. Changes to the four areas of functioning: o Understand, remember, or apply information o Interact with others o Concentrate, persist, or maintain pace o Adapt or manage oneself 5. Activities of daily living (ADLs) will no longer be a separate category, and SSA will view ADLs as a primary source of information about all four of the areas of functioning For example: Difficulties in an ADL task may result from difficulty in understanding what to do, trouble concentrating on the task, being unable to engage in the task around others, or becoming so frustrated in the task that the person loses self-control in the situation.

16. Medical Summary Report

17. Things to remember… Medical evidence is the heart of disability determination Only physicians and psychologists can make diagnosis Often medical records do not sufficiently document functioning Family/other health care professionals can provide valuable information on functional impairment Writing a medical summary report which provides a comprehensive picture of the applicant can be very effective

18. Content of Medical Summary Report Reference Section Introduction Personal History Diagnostic and Treatment Information Functional Descriptions Summary Contact Information

19. Importance of Functional Descriptions Impact of person’s impairment(s) Based on collection of personal, medical, and collateral information Clearly explains: –Nature of impairment –How/if linked to illness –Impact on functioning and life, especially regarding ability to work

20. Example Functional Description (ADLs) Bob exhibits significant restrictions in his activities of daily living. His mood fluctuations, intrusive worry, and low motivation negatively impacts his ability to get out of bed in the morning. He reports that he knows how to cook, but has little motivation to do so. He does not go grocery shopping for himself because he finds it difficult to be in the store with other people. He gets easily frustrated with having others around him and he cannot tolerate it if the store does not have the exact item he is looking for.

21. SSI/SSDI Outreach, Access, and Recovery (SOAR)

22. What is SOAR? Strategy to help states and communities increase access to SSI and SSDI benefits for individuals who are homeless or at risk of homelessness and diagnosed with a severe mental illness National program sponsored by SAMHSA with programs in all 50 states and Washington, DC Increases provider role and engagement Aims to serve those who are most vulnerable Focuses on obtaining benefits as an aid to recovery, not an end in itself

23. How Is This Model Different? Case managers actively assist applicants and collate evidence, including obtaining medical records and producing a medical summary report Focuses on the initial application – “Get it right the first time!” and avoids appeals whenever possible Only those who have been SOAR trained can submit applications under SOAR, thus ensuring high quality applications Processes are in place to expedite SOAR cases at DDS Robust data is collected and approval rates/processing times are closely monitored Brings together SOAR partners, including community providers, DDS, SSA, BHA, DPSCS

24. SOAR Eligibility Must be 18 or older Must be homeless or at risk of homelessness Must have a severe mental health issue Must be unable to work because of mental health issues Cannot have an SSI/SSDI case already pending at the Hearing Level Must be referred to, assessed by, and prepared to work with a SOAR-trained case manager

25. Maryland SOAR Outcomes Over 1,100 applications submitted through SOAR with overall approval rate of over 80% Approval rate for initial SOAR claims is 85% in an average processing time of 77 days Many applicants have previously had claims denied prior to using the SOAR process Over $4.5 million federal dollars are estimated to have been brought into the state through the SOAR program

26. Resources For more information visit: –SSA Web site www.ssa.govwww.ssa.gov –Blue Book Listings: www.ssa.gov/disability/professionals/ bluebook/ – SOAR Web site www.soarworks.prainc.comwww.soarworks.prainc.com –Changes to mental health listings: C - 4 https://soarworks.prainc.com/article/ssa-revises-mental- health-listings

27. Presenters’ Contact Information E. Caroline Mason Medical Relations Director Disability Determination Services 410-308-4336 Elizabeth.C.Mason@ssa.gov Caroline Bolas Director: SOAR Initiative Behavioral Health Administration 410-402-8350 Caroline.bolas@maryland.govbolas@ Bilqis Rock Lead SOAR Specialist Health Care for the Homeless 443-703-1323 brock@hchmd.org