SSA requires that the documentation to establish diagnosis, duration, and disability come from acceptable medical sources, which are usually charts or records made by doctors or letters from doctors detailing the contents of those charts and records. If such evidence is not readily available--and it usually is not to chronically homeless people acting on their own--SSA may require an applicant to get a consultative examination to document the claimants impairment(s). Because doctors who do not know and have no history with the applicant usually perform these examinations, they are considerably less likely than the applicants own health care providers to be able to observe and document type, level, and duration of functional impairments, so the applicant is very likely to face denial of benefits.
Further complications arise because homeless people do not always go to the same provider for care or present with the same issues. They may also forget about some sources of care or fail to tell case workers about them, so documentation from those sources will never enter the application record. Most homeless peoples lack of a medical home or continuous primary care practitioner relationship complicates the effort to access the comprehensive information needed for SSI applications.
Officially, for medical records maintained at clinics or hospitals under a claimants name, Social Security number, or other identifying information, SSAs policy is to request all evidence available from those treating facilities to evaluate impairments, from the time at which a claimant alleges that his or her impairment began. In practice, though, getting enough of the right information about an applicant into SSAs hands to lead to a timely and positive decision is a serious challenge. This was emphasized by all of the people with whom we spoke about SSI eligibility processes during site visits, as well as people with whom we have been discussing these issues for years in communities throughout the country.
The most frequently heard challenges to successful SSI/SSDI applications from health care practitioners, case workers for homeless SSI/SSDI applicants, attorneys working on SSI/SSDI claims, and sometimes representatives of local SSA offices include:
Assembling evidence for the duration of medical conditions--Homeless people tend to use whatever health care provider is available when their need is urgent. They also move between communities and forget where they have received care, further complicating information retrieval. Records of the health care that chronically homeless people have received, and for what conditions, are often scattered among various clinics and hospitals and not easy to assemble. Further, the applicant for SSI may not have sought or received care for some conditions, especially mental illnesses. The doctor currently treating the applicant and being asked to document his or her health conditions(s) and their impact on functioning may have seen the applicant for only a few weeks or months--not enough to attest to a conditions duration or to understand all of the patients conditions and how they may interact to affect functioning.
If the applicants current doctors or health care facilities have not known a client for a year or have no records of the particular diagnoses in question going back that far, they can only attest to the length of time they have known the client in connection with the particular diagnoses. Many providers told us that their clients have to enter care and continue to attend a particular clinic, get services, and wait as long as it takes for the clinic to be able to certify that the required duration of their disabling condition has been met. If the health facilities involved are part of a larger health care system--say a county system with one or more hospitals and several clinics--SSI applicants may have received services for their condition(s) from more than one, and some of those services may go back far enough to document the required duration. But if those records are not electronically retrievable--and they usually are not--applicants may need to wait to apply until they have been in care long enough for their current primary care doctor to be able to document disabling condition(s) that have lasted or are likely to last at least a year.
Incorporating information from the people who know the applicant best--Often, the people who know the applicant best are outreach staff or case workers in homeless assistance agencies. They may write letters supporting an SSI application and include the facts about duration and functional impairment as they know them. While these third party letters are not medical evidence they can be helpful and are considered by SSA and DDS though not as highly as evidence that comes from an acceptable medical source.
The cost of retrieving medical records and other documentation--Sometimes there are charges for copying and sending medical records and other documentation. Homeless applicants rarely have the resources to pay these charges.
Communications between SSA offices and homeless applicants--SSA staff often have questions about an application and try to contact the applicant to resolve those questions or ask for additional information. Homeless people may be difficult to contact, and their applications may be denied if they continue to be unavailable to SSA staff and the needed information is not provided. Having a representative (a case worker or attorney facilitating the application) authorized to communicate with SSA about the application can avert many denials that occur for this reason.
Ignorance or confusion about past applications (successful and unsuccessful) for SSI/SSDI--We frequently heard from case workers and advocates that before coming for help, many of their homeless clients had already tried to apply for SSI/SSDI on their own. Case workers and advocates sometimes find that their clients chances of success in their current application improve considerably once information on past applications or enrollment is discovered, though clients may not be able to remember the information or provide it.