Staff of homeless assistance agencies who work with chronically homeless people are often expected to help them apply for SSI. Without special training, such staff may be only slightly more successful than homeless people themselves in completing an application that SSA will approve on initial submission.
Case workers need to know precisely what information SSA is looking for, and what specific facts to include for different disabling conditions. They also need to know where to get the relevant information, and how to access it.
Case workers across the country have learned by doing, but systematic efforts also exist to train case workers. We look at the outcomes of one major effort of this type--the SAMHSAs SSI/SSDI SOAR initiative--which began in 2005 and continues today. A variation on the theme of case worker training is development of specialized staff whose only job is to help people apply for disability benefits. We look at three examples of specialized staff--in Portland, Maine, in Chicago, and in Los Angeles.
3.1.1. Results of SOAR
SOAR is designed to improve access to SSI and SSDI for people who are homeless or at risk for homelessness and who also have a disabling condition, specifically mental illness or co-occurring mental illness and substance use disorders. SOAR works at two levels. At the systems level, SOAR offers technical help and strategic planning assistance to bring social service providers, advocates for the homeless, and state and local public agencies together to modify existing practices. At the direct care level, SOAR trains staff in participating states who will then train others--case managers, social workers, and other staff working with homeless people--to give them the information and skills needed to help their clients get SSI or SSDI (Dennis, Lassiter, Connelly, and Lupfer, 2011). The training curriculum,Stepping Stones to Recovery, was developed specifically to train case workers to assist with SSI/SSDI applications (Perret and Dennis, 2009).
Fourteen states began participating in SOAR participation in 2005, 11 more in 2006, and ten in 2007. A formal evaluation of SOARs first three years (Kauff et al., 2009) selected six states--three from each of the first 2 years--for in-depth case studies of the SOAR implementation process. The evaluation collected evidence on the number of SSI/SSDI applications submitted by SOAR participants and their rates of success. Rates of submission and success in the six case study states varied considerably. In the five case study states for which the evaluators were able to get information on applications submitted and their rates of success, the number of submitted applications ranged from 20 to 187, and rates of success ranged from 26 percent to 100 percent.7
By the end of 2011, 48 states had received SOAR training and technical assistance and most had projects functioning in at least some communities. Outcomes as of June 2011 for the 44 states that had projects with at least 1 years experience, and that could supply data, show that cumulatively these projects had submitted almost 15,000 applications since 2006, of which on average 71 percent were approved on initial application, ranging from 48 percent to 100 percent
Time to decision from receipt of the application at an SSA office averaged 101 days and ranged from 33 days to 234 days). Even the least successful of these projects, at 48 percent approval on first application, achieved a three-fold improvement on the average rate of 10-15 percent that homeless applicants experience when they do not get help with their applications.
The best performance by a SOAR project was Philadelphias Homeless Advocacy Project. It obtained 99 percent approval in an average of 32 days for 742 applications over a period of 4 years. At the other end of the spectrum were projects that achieved 67 percent approval in 136 days, 61 percent approval in 156 days, and 58 percent approval in 133 days. Evidence from the SOAR implementation study (Kauff et al., 2009) suggests that both approval rates and time to decision were helped by support from SSA and DDS directors who modified their practices to reducebottlenecks and increase communication with clients advocates.
3.1.2. Promising SOAR Practices
SOAR training and technical assistance are well-established a website (http://www.prainc.com/SOAR) and technical assistance center sponsored by SAMHSA. Numerous documents available through this website describe SOAR techniques and promising practices for improving the success of SSI applications. We limit ourselves in this brief to listing the practices discussed by Dennis, Perret, Seaman, and Wells (2007) and Perret and Dennis (2009):
Focus on initial applications. Do not wait for an application to fail and then rely on an appeal--doing so may add months or years to the process. Assemble the right documentation at the beginning.
Become an applicants representative. By having an applicant complete an SSA-1696 form, a case worker may become the applicants representative, legally entitled to speak for the applicant, receive mail, and appear at SSA offices as needed, whether the applicant can be located or persuaded to come in or not. This form allows two-way communication between the case worker and SSA and between the case worker and DDS.
Avoid consultative examinations if at all possible. Get the proper medical documentation from the applicants source of treatment before submitting an application. It rarely helps the applicant if SSA asks for a consultative examination.
Work closely with hospitals and other health care providers. Close relationships help get the proper records. They also enable cross-training, so that case workers know what records are likely to contain, and medical staff learn what SSA is looking for and can start providing appropriate documentation, especially of functional impairment.
Reach out to medical records departments. Medical records are often lengthy, highly detailed, and difficult to extract. Case workers need to know what information they might contain and how to ask for and get what they need without receiving masses of irrelevant material.
Establish ongoing communication with SSA and DDS. Both SSA and DDS can set up procedures that substantially enhance the odds that a homeless persons application will more smoothly and expeditiously through the disability determination process. Options include:
- Flagging applications from homeless people,
- Establishing a special person or unit that handles applications from homeless people,
- In big cities, designating particular local SSA offices that will handle all applications from homeless people, and
- Reserving one or more days a month during which a particular SSA office will work only with homeless people.
Informal arrangements also exist (e.g., building a personal relationship with a particular SSA staff member), who expedites all applications from homeless people if he knows they are coming. But formal ones are better, as they survive changes in staffing.
Create a summary report. Write a report or letter that pulls out and organizes all the relevant facts and document the functioning of the individual as it relates to his or her ability to work, and have an acceptable medical source sign it.
3.1.3. Specialized Staff
Many communities took steps on their own to facilitate the SSI application process for homeless people, often before SOAR began. Establishing positions for staff specializing in SSI applications is an important strategy. As will be seen in our three examples, all of which began before SOAR,8 specialized staff and units employ many of the promising practices just described to increase their chances of success.
Portland, Maine Department of Human Services. More than a decade ago, the City of Portland began funding a position within its Department of Human Services that is specifically responsible for helping people qualify for SSI/SSDI. The same staff person has occupied the position since its creation and is very successful for a number of reasons, not least of which is her tenure in the position. A large proportion of the people she assists are homeless. She spends a lot of time with potential applicants to get extensive detail about their illnesses, treatment, and work histories. She develops trusting relationships with clients, and they disclose information to her that they might not otherwise reveal on applications.
It takes her about 2 weeks to pull together the information needed for the SSI/SSDI application. During a potential applicants first visit, they complete an assessment form, set up visits to health care providers and anyone else the applicant needs to see, and arrange a meeting for filing the application. All of these appointments are scheduled very close together. She also establishes herself as a client representative and uses her office address as a mailing address for all applications. This helps her stay on top of communications and information requests from SSA so these do not get lost or ignored. Longstanding collaborative working relationships with the local SSA and state DDS offices are another important element in how this position functions. Local SSA staff are very cooperative and appreciate the way this position functions to smooth out the application process.
These components together establish continuity of contact (with applicants and with the SSA offices). As a result, the whole process takes approximately 3 months to get SSAs initial decision from the time the person first appears and asks for assistance. Portlands approval rate for initial applications is about 42 percent, compared with 10-15 percent for homeless people nationally who apply on their own without case workers or advocates. Over 50 percent of 2008 applications were awarded initially and did not need to go to appeal and a hearing. Furthermore, most applications from Portland that go to a hearing do ultimately get approved. This staff person also does reinstatement applications for people who have lost their benefits because they either did not appear for necessary appointments or were institutionalized or incarcerated.
Portlands staff person provides training to shelter staff, case managers, and representatives from other agencies to help them identify people who are likely to qualify for SSI and not refer people to her office who have little chance of qualifying, as this leads to disappointment all around. The largest sources of referrals for assistance are the county General Assistance office, Portlands homeless access and resource center, refugee services, and Healthcare for the Homeless and mental health care providers. About 80 percent of people initially referred for assistance with SSI applications actually submit applications.
Chicago, HHO. HHO has been doing SSI eligibility work for years, and has a standardized procedure for case workers to use, as well as a person with extensive experience whose job it is to supervise preparation of SSI applications. Staff members have also attended SOAR training and help train case workers in other agencies. HHO staff think SOAR is a good model, but that everything depends on local relationships. In their case, one SSA office in Chicago is very helpful and they use it as much as possible. HHO is in a good position to help its clients establish eligibility because, as a Federally Qualified Health Center (FQHC) and behavioral health care provider, it has access to a lot of the medical information needed. Not only does it have its own health records for the client, but Cook County Hospital is cooperative in sending over records for care received there. Many patients served by Cook County Hospital come to HHO for continuing care once they leave the hospital or emergency room, rather than explicitly for the purpose of establishing benefits eligibility, but their relationship with HHO helps HHO determine their eligibility for benefits.
Los Angeles, B.E.S.T. collaboration of public and private agencies. B.E.S.T. began on July 1, 2009, following at least 5 years during which the Los Angeles County Department of Health Services (DHS) developed very successful benefits advocacy techniques and practices, including a streamlined approach to data retrieval.9 During the time a person is enrolled in the B.E.S.T. project, an integrated services team works together to document eligibility for disability benefits and coordinate the SSI/SSDI application process. The same team also coordinates direct health and behavioral health care. B.E.S.T. is based at the Center for Community Health, located in Skid Row and run by JWCH Institute, an FQHC offering integrated medical, behavioral health, dental, eye, and clinical pharmacy services. The Institute has served the homeless Skid Row population for a long time. The team includes JWCH staff, staff from county public agencies, and non-profit service-providers.
B.E.S.T. assists participants in all aspects of the SSI/SSDI application process, including tracking the clients whereabouts, obtaining identification, providing transportation, and managing retrieval of health and mental health records. Local SSA offices and California DDS are crucial partners in the B.E.S.T. project. A June 15, 2011 report indicated that, in the 16 months between December 1, 2009 and March 31, 2011, 863 participants were enrolled in B.E.S.T. Of the 503 applications submitted to SSA for these enrollees, 393 had received a decision and 110 were still being reviewed when the report was written. An additional 83 applications were being prepared for submission. Of the 393 with decisions, 334 (85 percent) were approved on first application, with an average length of time from submission to approval of 50 days. This compares favorably with SOAR outcomes, which in 2010 were 73 percent approvals and 90-day average time from submission to approval. The average total time from enrollment in B.E.S.T. to SSA approval was 120 days.10