SOAR Fundamentals Introductions Local SOAR Leads Program Participants

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 10 -15 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 Wows Wishes

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 Power. Point 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!

SOAR Fundamentals: The Basics

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

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 Applicatio n Initiated at SSA Determine s Non. Medical Eligibility SSA Transfers Claim to DDS Determine s Medical Eligibility DDS Returns Record to 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/Ph. D/Ed. D)

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 http: //www. ssa. gov/disability/professionals/bluebook / Adult. Listings. 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 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

Getting Started

The Challenge Limited resources Limited time A lot of people need our help Applications involving mental illness and cooccurring 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”? q Moving from place to place throughout the month q Living “doubled-up” q Living in uninhabitable housing, outside or in shelters q Living in unstable or non-permanent housing q 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 Letter Agency Release SSA 827

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

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 24 -48 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 http: //www. ssa. gov/applyfordisability/

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 24 -48 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

Medical Summary Report Refresher

Critical Components Serving as the appointed representative Collecting and submitting medical records Electronically submitting applications and medical evidence whenever possible Collaborating with physicians for assessments and medical information Collaborating with SSA and DDS Submitting a Medical Summary Report

The Importance of the Medical Summary Report Critical component of the SOAR model Provides a vivid picture of the individual for the DDS examiner who never sees them Provides a clear link to the functional impairment Often takes place of the SSA-3373 Function Report Helps to avoid the limited space and check-boxes of these forms Is medical evidence when co-signed by a physician or psychologist Can be sent directly to the DDS examiner or hand delivered to SSA Receives positive feedback from DDS examiners around the country

Tips for Writing Collect medical records after Releases of Information are signed Go through medical records and organize in chronological order Set aside several hours at a time to begin writing the report with no interruptions Sit down with all information -- medical records, intake packet, completed MSR worksheet (personal, medical, employment and substance use history) and any current mental status exams

Components of the MSR Reference Section Introduction Personal History Diagnostic and Treatment Information Link to Functional Impairment Summary Contact Information

Introduction Section Demographics Physical description – hygiene, grooming, dress, make-up, any unique characteristics Include diagnoses and impairment information Help the DDS examiner “see” the individual as you do!

Diagnoses and Treatment Psychiatric and physical Chronological treatment history Specific quotes from the applicant or record that illustrate diagnosis Observations of behavior Durational issues Current mental status exam

Link to Functional Impairment Critical to connect symptoms/effects of illness with marked functional impairments To the extent possible in all four functional areas Demonstrate impact of illness(es) on ability to work Medication – effects and side effects Support and effect of support Compare with lack of support

Make the Link The MSR is the link that connects the diagnosis to the limitations that the applicant experiences Being able to document this link is very important in order to demonstrate the applicant’s inability to engage in substantial gainful activity Diagnosis Limitations in Functioning Why can’t the applicant work?

Medical Summary Report Worksheet Tool for gathering information needed to write the MSR Open-ended questions � Tell me about … � How often … � When was the last time … Functional questions � Context of questions – SGA � Distinguish between access and ability Do not turn the worksheet in to DDS!

Summary and Contact Information Ties all information together for a concise picture of the individual Contact – names and numbers Co-signed by case manager, treating physician/psychologist

MSR Samples & Support Visit the SOAR website for MSR samples and abbreviated versions The SOAR TA Center will review redacted MSR letters and provide feedback upon request

Worth the Effort The overall process of applying for benefits is time-consuming Putting forth the initial effort for an earlier, more successful outcome may seem difficult, but it is worth the effort! Programs with higher outcomes submit medical summary reports

Tracking Outcomes

Online Application Tracking (OAT) https: //soartrack. prainc. com A web-based program that allows case managers to keep track of their outcomes � Free � Easy to use � Accessible from any web browser � Nothing to download On a secure server HIPAA compliant � No personal identifying information is collected

Registration

Outcomes in OAT Outcomes for initial applications & appeals � Approval rates � Time to decision � Critical components Optional outcomes � Housing � Employment � Medicaid and other public benefit reimbursements

Applicant Identification (ID) No personally identifiable information Alpha-numeric ID � First 2 letters of first name � Last 2 digits of the birth year � First 2 letters of last name � Last 4 digits of the Social Security Number Case workers should record Applicant ID in the case file for cross reference

Example: Summary Report

Special Populations

Special Populations Veterans Children Justice-Involved Persons

Veterans and SSA Benefits q The definition of disability and application process is different for VA and SSA benefits q q q Discharge status is not a factor in SSI/SSDI determination Those denied for VA benefits may still be eligible for SSI/SSDI Veterans can access SSA benefits while they are waiting for VA benefits Veterans who receive a partial disability rating and limited VA benefits may also receive supplemental SSA benefits Health insurance associated with SSA benefits can be important for Veterans without VA health care SSA has special provisions for expediting disability applications for Wounded Warriors, that also apply to appeals

VA Staff and SOAR Staff are encouraged to participate in SOAR training and assist with SSI/SSDI applications May disclose VA records to SSA if Veteran signs the appropriate release (SSA-827) Can assist in gathering documentation, completing the SSI/SSDI application forms, and referring the Veteran to a SOAR representative, if needed May not serve as Authorized Representative (SSA-1696) or Representative Payee (SSA-11), but can be listed as a contact who knows the Veteran

How Do Children Qualify for SSI? Four main criteria considered: Disability � � Income � Parent/household income Resources � A medically determinable physical or mental impairment, which results in marked and severe functional limitations and which can be expected to result in death or which has lasted for a continuous period of not less than 12 months How does the child’s functional abilities compare to the functional abilities of a child of the same age who does not have the physical and/or mental impairments? Parent/household resources Citizenship/Immigration status

Justice – Involved Persons Warrants (other than escape) should not hinder a person from applying or receiving payment A person can apply for benefits while incarcerated Prior history of incarceration alone does not make someone eligible for benefits

Engagement Tips for People in Correctional Settings Jails and prisons have distinct cultures Anticipate how this culture or “code” affects behavior and functioning in prison Expand skills to engage individuals in this culture Life experience affects engagement Engagement involves creating a safe space

SSA Appeals Process

SSA Appeals Process 1. Initial determination 2. Reconsideration Federal Court Review 4. Appeals Council Review Administrative Hearing 5. Federal Court Review Reconsideration 3. Administrative Hearing Initial Determination

Appeal Online http: //www. socialsecurity. gov/pgm/appeal. html

Reconsideration First level of appeal in most states, except for these areas: � Alabama, Alaska, California (Los Angeles North & WB), Colorado, Louisiana, Michigan, Missouri, New Hampshire, New York, & Pennsylvania Request for Reconsideration needed to initiate the appeals process Must be filed within 60 days of the date of the denial notice, plus an extra 5 days for mailing Three forms to file: � � � Request for Reconsideration Disability Report - Appeal Authorization to Disclose Information

Reconsideration DDS takes an entirely new look at the case and makes a new determination on a person’s disability � New disability examiner/analyst and new reviewing physician Many ways to support a claim at this stage: � Complete more detailed Disability Report - Appeal � Revisit the steps in the SOAR model to develop the claim for Reconsideration

What To Do If the Deadline Has Passed? The applicant can appeal if he/she has “Good Cause” for missing the deadline Ask SSA to accept late filing by giving “good cause” or reason for the delay � Related to applicant’s disability � Limited English proficiency and/or education � Failure to understand the requirements � Failure to receive denial notice within 5 days of the date on the notice � Unusual or unavoidable circumstances such as hospitalization

Appeal vs. New Application Starting a new application results in: � The loss of the earlier protective filing date and potential loss of months of back benefits Requesting reconsideration: � Preserves the protective filing date and potential eligibility for months of back benefits Be sure the applicant knows the difference and is making an informed choice!

Know the Reason(s) for Denial Request the electronic folder (CD) from SSA or the Office of Disability Adjudication and Review (ODAR) Review the CD to ascertain evidence on file and rationale for denial Review earnings record to make sure there are no SGA earnings Make note of errors, omissions and plan your strategy

Administrative Hearing Administrative Law Judge (ALJ) Hearing If denied at Reconsideration or you are in a prototype state File appeal online within 60 days of decision Review the claim, including the evidence used to deny the claim Submit new evidence if applicable Plan to attend the hearing

On the Record (OTR) Review A written request asking that the ALJ make a favorable decision based on the evidence in the case record � � You are requesting a decision based on new evidence that has become available since the DDS denial � A favorable decision is the only decision possible through an OTR review Otherwise there is no decision and the hearing process goes forward as though the OTR never happened Can be as big as a catastrophic worsening of the claimant’s condition, or as small as an onset date that was entered incorrectly Can be requested by the claimant or SOAR representative but is often done through a screening process by the ODAR Attorney Adjudicators in an effort to

Now What?

Next Steps Get started on your first application Reach out to your colleagues, local leads and the SAMHSA SOAR TA Center for assistance Keep in close communication with your SSA and DDS representatives Attend local SOAR steering committee meetings Track your outcomes in OAT

Your State SOAR Team Attention Local Leads! Add your information below: State Team Lead contact information Local Lead(s) contact information