Successfully Implementing SOAR: Lessons Learned from Six States

What Is SOAR?

The SOAR initiative aims to improve access to SSI/SSDI benefits for individuals who are homeless. Communities do not receive any direct funding to implement SOAR but instead receive federally funded technical assistance (TA) from a small business contractor. Agencies that have provided funding for the TA include HHS Substance Abuse and Mental Health Services Administration (SAMHSA) and Health Resources and Services Administration as well as the Department of Housing and Urban Development. States submit an application to receive SOAR TA. As of January 2010, all but 16 states had successfully applied for and received federally funded SOAR TA. This TA includes:

Strategic planning to help states develop policies and procedures that will aid those who are homeless in obtaining SSI/SSDI. TA helps social service providers, advocates, and state and local agencies work together to determine how to create an effective system for obtaining SSI/SSDI. Participating organizations typically include the Social Security Administration (SSA), Disability Determination Services (DDS), state health and mental health agencies, state homeless services coordinating councils, and local providers of homeless and mental health services. These stakeholders develop a strategic action plan that describes which staff will contribute to SOAR and what role they will play in the initiative. The plan also specifies how the initiative will be supported and sustained and how cross-agency relationships will be developed or strengthened.

Training for staff who work with homeless individuals on how to support them through the SSI/SSDI application process. SOAR employs a train-the-trainer model in which states identify a few individuals to receive training from the TA contractor on the Stepping Stones to Recovery (SSTR) curriculum. These individuals then conduct in-state trainings on the SSTR curriculum for front-line workers  that is, case managers, social workers, and other staff who work directly with individuals who are homeless. In-state training participants are typically staff from homeless shelters and service organizations, mental health agencies, and health care facilities. SSA and DDS sometimes participate in these trainings to provide input on developing high-quality applications.

The SSTR curriculum emphasizes several key strategies that may increase and expedite SSI/SSDI application approvals. Strategies include serving as an applicants representative during the application process (and thus as a point of contact for SSA and DDS) and working closely with health care providers to obtain medical documentation. Other key strategies include submitting a summary report with the application to help the DDS medical examiner verify an applicants claim and working closely with SSA and DDS to ensure that the application is complete before submission.

Follow-up support to help communities expand their efforts and learn from the successes and challenges of other communities. Each state receives ongoing TA and monitoring of strategic action plan implementation for one to two years. The TA contractor also disseminates promising practices and maintains a website with materials and tools for use by SOAR communities.

Why Is SOAR Important?

SSI and SSDI provide critical financial support to low-income individuals with disabilities. Beneficiaries who are homeless can use the cash assistance from SSI/SSDI to access housing as well as medical and mental health services through Medicaid. To be eligible for benefits from either program, individuals must provide enough documentation to allow the state DDS to verify a medical and functional disability.

The precariousness of their living situations, along with the nature of their disabilities, makes it difficult for individuals who are homeless to complete the SSI/SSDI application process. Many adults who are homeless have no consistent source of medical care and lack trusting relationships with providers who can document their disability for the SSI/SSDI application (OToole et al. 2002). Mental health and substance abuse disorders may limit physical and cognitive functioning and impair a persons ability to make decisions and keep appointments (Macnee and Forrest 1997), both of which are necessary to complete the SSI/SSDI application process. The lack of a stable address and fragile social support networks can prevent medical providers and SSA or DDS staff from contacting applicants to obtain missing information or otherwise follow up on an application. Indeed, it is estimated that only 15 percent of new SSI applications submitted by homeless individuals nationwide are initially approved, compared with nearly 30 percent of applications submitted by others (Rosen et. al. 2001; Social Security Advisory Board 2006).

What Can Communities Do to Facilitate Successful Implementation of SOAR?

In 2007, ASPE contracted with Mathematica to conduct a study of SOARs implementation. The goals of the study were to (1) provide a comprehensive description of SOAR processes, (2) identify factors associated with successful implementation of SOAR, and (3) determine whether and how the initiative could be strengthened. The study focused on six states that had a range of experiences implementing SOAR: Massachusetts, New Jersey, Ohio, Pennsylvania, Utah, and Virginia. The primary source of data for the study was in-depth, in-person interviews with SOAR stakeholders in each state as well as focus groups with individuals who participated in an in-state SSTR training. The findings reported in this brief are based on information gathered from these six states.

The study identified eight factors associated with successful implementation of SOAR in the case study states (Table 1). Case study states that struggled least to implement SOAR exhibited all eight factors, while the two states that struggled most exhibited only one or none of the factors. By focusing on these factors at the outset, communities that are launching new initiatives may be more likely to succeed. In addition, communities that have struggled to implement SOAR may recognize critical factors that are missing in their initiatives and make needed improvements.

Our findings from case study states suggest that there are several ways states can lay the groundwork for successful implementation of SOAR:

Identify agencies and individuals with the time and commitment needed to provide strong, consistent leadership for SOAR. As part of the TA application, states are required to identify the agencies that will be involved in the initiative and to designate a state leader to coordinate SOAR activities within the state. Throughout the initiative, the state leader is expected to facilitate communication between stakeholders and troubleshoot challenges. State leaders are often senior staff from the state department of mental health, the states interagency council on homelessness, or the SAMHSA-funded Projects for Assistance in Transition from Homelessness (PATH) program. Because they dont receive direct funding for SOAR, state leaders must carve out time for SOAR amid their other roles and responsibilities.

In the case study states, identifying an appropriate state leader at the outset helped to get SOAR up and running more quickly and to foster consistent leadership throughout the initiative. In several case study states, the agencies and individuals named as the leaders in the TA application did not emerge as the operational leaders of SOAR. The initial application request for SOAR TA was directed to each states Homeless Policy Academy team leader.^[1]  The members of this team often named themselves as the SOAR leaders either as a formality (never intending to assume leadership) or without a firm grasp of what SOAR leadership would entail. In these states, it took time for an effective operational leader to emerge after the strategic planning process began. States that implemented SOAR well had state leaders with a genuine commitment to SOAR, an understanding of SOARs goals and potential benefits (both to homeless individuals and to their own agencies), and time to dedicate to SOAR despite other responsibilities.

Develop strategies to obtain support for SOAR at the highest levels of management among all stakeholders. Support from their agency management and direct supervisors empowered state leaders to dedicate the time and energy needed to coordinate SSTR trainings, troubleshoot challenges, and facilitate communication between stakeholders. Without such support  and particularly in the absence of financial support to conduct SOAR activities  state leaders were less able to treat the initiative as a priority. In states where SOAR leaders changed jobs or left their agencies, buy-in from the state leaders agency and direct supervisor helped to ensure that the initiative did not flounder during the transition to new leadership. Such buy-in also helped ensure that some level of institutional knowledge and enthusiasm for SOAR remained. Gaining buy-in at the highest possible levels within other agencies that participated in SOAR also was essential to sustaining the initiative.

Engage SSA and DDS staff early at both the regional and local levels (including line staff, their supervisors, and senior management). Active participation by SSA and DDS in all phases of the initiative helped to ensure that SOAR application processes and procedures were fully developed and fit well within local SSA and DDS office practices. The more deeply SSA and DDS were engaged in SOAR, the more beneficial it was to the initiative. Communities in which SSA and DDS were most engaged had the commitment of regional and local office staff, including line staff, their supervisors, and senior management. Despite federal regulations and federal and state oversight, SSA and DDS regional and local offices have some autonomy over practices and procedures, and they may adapt them to facilitate SOARs objectives. In states that implemented SOAR well, SSA and DDS offices contributed to the initiative in three key ways:

• Participating in strategic planning and in-state trainings. SSA and DDS staff participated in the strategic planning process, attended in-state trainings, and provided ongoing feedback on application quality and outcomes to front-line workers and SOAR leaders.
• Flagging applications submitted through SOAR. A SOAR flag notifies SSA and DDS staff that they can contact the front-line worker who helped file the application if they have questions. Flags also help staff to contextualize the application and track SOAR outcome data. In some states, a flag was simply a cover sheet attached to a paper application or a note in a DDS electronic record. SSAs online application system does not have a field to record that the application was submitted through SOAR, and creating such a field would require changes to SSAs software at the federal level. However, some states developed work-arounds (for example, flagging a case as homeless and writing SOAR in a comments field).

  SSA and DDS can support SOAR by participating in strategic planning and in-state trainings, flagging applications submitted through SOAR, and designating specific staff to process applications flagged as SOAR.

• Designating specific staff to process SOAR applications. Assigning specific staff to process SOAR applications allowed front-line workers to develop relationships with specific SSA or DDS staff who understood the challenges homeless individuals face in the SSI/SSDI application process. It also enabled front-line workers to contact SSA and DDS more easily with questions about particular applications or the application process in general. Some SSA and DDS staff reported that designating workers to process SOAR applications reduced application processing time. But this practice did present some challenges. In particular, it was sometimes difficult to maintain designated staff due to turnover. Some SSA and DDS offices also perceived that the volume of SOAR applications was too low to justify specialized staff. Some dealt with this challenge by designating a staff member to handle all SOAR applications in addition to a reduced regular caseload.

Establish formal procedures to ensure regular structured communication between stakeholders. The success of SOAR heavily depends upon developing and maintaining strong interagency partnerships. Partners must work together to develop application procedures, monitor progress, and continuously improve the initiative. In the case study states, ongoing communication between SSA, DDS, social service agency staff, and SOAR leaders was essential to solidifying interagency partnerships, advancing SOAR, and overcoming challenges. Informal communication that occurred because of existing relationships between stakeholders often was not enough to propel the initiative forward. To foster regular structured communication, several states conducted formal monthly or quarterly meetings of stakeholders. These meetings provided an opportunity to discuss any challenges to completing applications, gather feedback on the quality of applications, and provide ongoing training. Furthermore, they helped motivate stakeholders to continue the initiative and provided a forum to celebrate successes.

Select individuals with some knowledge of the SSI/SSDI application process or experience as a trainer to become in-state SSTR trainers. Individuals who became in-state trainers had a variety of professional backgrounds and job titles. About two-thirds were social workers, case managers, and benefits specialists, and the rest were mostly supervisors and program managers. Generally, in-state trainers who were case managers or benefits specialists from active SOAR stakeholders were more likely to remain involved in SOAR  that is, to continue to conduct trainings and provide follow-up support for training participants  because they were invested in the initiative, had agency-level support to implement SOAR, and could identify with the challenges and potential returns of integrating SOAR concepts into their jobs. Often, others did little more than facilitate a few in-state trainings.

However, prior knowledge of the SSI/SSDI application process or experience as a trainer appeared to be more important than profession or job title in conducting high-quality trainings. In-state trainers who had some familiarity with homelessness and the SSI/SSDI application process were well-positioned to train front-line staff in the SSTR curriculum. Trainers who had no previous experience with the application process required more support to become competent trainers and, in some case study states, never conducted any trainings.

Dedicate staff  within a state agency or a set of local agencies  exclusively to providing SSI/SSDI application assistance through SOAR. Front-line workers could best apply the skills they learned from the SSTR curriculum when they had support from their supervisors to dedicate sufficient time to SOAR. Completing applications through SOAR can take a substantial amount of time, and supervisors did not always afford staff this time, particularly in the face of budget cuts that affected client-to-staff ratios and placed competing responsibilities on staff.

Given time and resource constraints, the SOAR model seemed to have the most potential when agencies dedicated one or more specialists to providing application assistance, allowing other front-line workers to maintain their current responsibilities. Four of the six case study states were able to dedicate benefits specialists by shifting responsibilities around within agencies or by obtaining funding for newly created staff positions. Two states used PATH monies to fund full- or part-time benefits specialists because state leaders saw SOAR as congruent with PATHs goals and because SAMHSA (the agency that funds PATH) supported using PATH funds for this purpose. One state welfare agency created new positions focused exclusively on benefits assistance, hoping that these positions would ultimately allow the state to recoup General Assistance expenditures.^[2] In the other state, a city agency redirected funds, awarding a contract to implement SOAR to a community-based agency with which they had partnered on a previous homeless initiative.

Pilot SOAR in one to three local communities. Given the time and effort it takes to develop a strategic action plan and build cross-agency relationships, states are encouraged to pilot SOAR initiatives in one to three local communities before rolling out the initiative statewide. Case study states that did so were able to hone their approach, troubleshoot challenges, learn from their early experiences, and then spread the initiative to other sites. Those that attempted to implement SOAR in more than three sites right after the strategic planning process  and particularly those that attempted to implement SOAR statewide  had more difficulty coordinating activities and maintaining communication.

Systematically track outcomes from the beginning of the initiative. SOAR is intended to make SSI/SSDI benefits more accessible for individuals who have disabilities and are homeless, thereby improving their quality of life. To assess the extent to which it is succeeding, two types of outcome measures would be useful: (1) short-term outcomes focusing on the immediate results of the application process (for example, the application approval rate and the time between initial application and approval) and (2) long-term outcomes for applicants who acquire benefits (for example, applicants personal income, housing status, access to health care, and overall health). However, states are encouraged, but not required, to report any performance indicators or outcomes associated with SOAR.

Case study states that systematically tracked outcomes from the beginning of the initiative were better able to monitor progress and troubleshoot challenges. Tracking outcomes led to a sense of accountability among stakeholders and helped them see the results of their work, which encouraged them to continue with the initiative. Without this information, SOAR leaders, front-line workers, and staff from SSA and DDS were unable to determine whether SOAR was having a positive impact on their clients and were therefore less motivated to sustain the initiative.

Recently, the TA contractor developed a software program to help communities track and report SOAR outcomes data. The SOAR Data Tracking Program (available at www.prainc.com/soar/) allows front-line workers to electronically enter and save data they collect during the application process. The program can be used to generate various reports and compile and transmit data from multiple sites to a central location, using file encryption to protect confidential data. This software program may be the best option for communities interested in tracking outcomes systematically.

Looking Ahead

A well-implemented SOAR initiative helps front-line staff better navigate the SSI/SSDI application process and may increase the application approval rate among individuals who are homeless. To date, 34 states (including the District of Columbia) have received federally funded TA to implement SOAR in their communities. Based on findings from the case studies, states have had varying degrees of success putting the critical components of the initiative in place. SAMHSA recently provided funding for the TA contractor to continue working with some of these states, to provide assistance to the remaining 16 states and 6 U.S. territories, and to develop a web-based SSTR curriculum. The lessons described in this issue brief and in the full report can play an important role in the next phase of the federal initiative, as states that have struggled to implement SOAR hone their approaches and states just beginning the planning process set their priorities.

In addition to providing funding for more TA, SAMHSA provided funding for Mathematica to conduct an independent evaluation of SOARs outcomes. This evaluation will build on Mathematicas experience conducting the implementation study by addressing the following questions:

• To what extent does SSTR training change the knowledge and practices of front-line workers, and do these outcomes differ for participants in in-person SSTR trainings versus web-based SSTR trainings?
• To what extent does SOAR increase the number of SSI/SSDI applications submitted by individuals who are homeless?
• To what extent does SOAR improve SSI/SSDI application outcomes?
• What environmental factors in a community (such as availability of homeless services) are associated with better application outcomes?
• What implementation factors (for example, strong and consistent leadership) are associated with better application outcomes?
• Are improvements in SOAR application outcomes associated with benefits for state or private service delivery systems (such as cost recovery for state General Assistance expenditures, Medicaid reimbursements for uncompensated medical care, or reduced SSI/SSDI application backlog)?

In the pending evaluation, Mathematica will collect a variety of data to document agencies investments in SOAR and will provide new, more specific information on SOARs effectiveness and the factors associated with positive outcomes.

References

Macnee, C.L., and L.J. Forrest. Factors Associated with Return Visits to a Homeless Clinic. Journal of Health Care for the Poor and Underserved, vol. 8, no. 4, 1997, pp. 437-445.

OToole, T.P., J. Arbelaez, C. Haggerty, and the Baltimore Community Health Consortium. The Urban Safety Net: Can It Keep People Healthy and Out of the Hospital? Journal of Urban Health, vol. 81, no. 2, 2004, pp. 179-190.

Rosen, J., R. Hoey, and T. Steed. Food Stamp and SSI Benefits: Removing Access Barriers for Homeless People. Journal of Poverty Law and Policy, March-April 2001, pp. 679-696.

Social Security Advisory Board. Disability Decision Making: Data and Materials. Washington, DC: Social Security Advisory Board, 2006.

Endnotes

1.  The Homeless Policy Academy Initiative, which began in 2001, was designed to help state and local policymakers improve access to mainstream services for homeless individuals and families. States formed Homeless Policy Academy teams consisting of senior state officials, including representatives from the governors office; staff from mainstream assistance programs; and local stakeholders such as providers, consumers, and local government representatives.

2.  SSA may enter into agreements under which states or local governments are reimbursed for basic needs assistance (such as General Assistance) provided while an eligible individuals SSI/SSDI application was pending. Currently, 39 states have interim assistance reimbursement agreements with SSA (http://www.ssa.gov/OACT/ssir/SSI09/ProgramDescription.html#2351).

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