We noted above that, for facilitating application review, it is better to have formal agency commitments to cooperation, rather than just personal relationships between case workers and eligibility technicians, although such relationships can be helpful as well. Not only will formal commitments survive staffing changes, but agencies that have formally agreed to work together will also be more likely to examine agency procedures and work together to modify any that are found to be counter-productive.
SOAR offers technical assistance to help states and communities improve the application process by changing their systems. SOAR brings social service-providers, advocates for the homeless, and state and local public agencies together for this purpose. The SOAR evaluation (Kauff et al., 2009) identified the structural and systems factors that seemed to affect the likelihood that initial SSI applications would succeed. They include support in SSA and DDS offices from the top levels through supervisory support for case managers or dedicated benefit specialists; structured interagency communication; and data collection on outcomes. As with all new service efforts that require collaboration across multiple government levels, agencies, and people (Burt and Spellman, 2007), SOAR goals are attained to the extent that implementers at all levels commit themselves to the work involved in changing their standard operating procedures, and follow-through on those commitments.
We focus on two examples of ways that agencies worked to improve medical data retrieval, and the medical data itself, in Los Angeles and Boston.
3.2.1. Accessing Medical Documentation
One of the major stumbling blocks for SSI applications for homeless people is the difficulty in documenting the duration and extent of disabling conditions. Homeless people usually do not have a medical home and seek medical care at the facility most convenient to them at the time they need care. Records are scattered in many facilities. Rarely has the medical professional being asked to complete SSI/SSDI documentation known the person long enough to be able to report that a condition has existed for a long time at a high level of functional impairment.
To improve this situation, in the early 2000s the Los Angeles County DHS assigned two highly experienced registered nurses to retrieve the needed documentation from the countys many public health care facilities. DHS runs the countys seven public hospitals and related clinics. All DHS hospitals use the same data software, Affinity, but each hospital has its own computer system and its own system for assigning patient numbers, none of which are linked or integrated across hospitals. For several years the nurses had to go to each hospital to search its patient records and then retrieve relevant data.
In June 2008, DHS succeeded in getting the nurses efficient access to all of the Affinity systems, by locating seven computers (one for each system) in one central place. This computer room greatly facilitated the process of verifying when and where people got care, and for what, although nurses still have to go to paper records to retrieve case notes. The new structure of data access made it a lot easier for the nurses to get the data for the case managers in various public and non-profit programs that were helping homeless people complete their SSI/SSDI applications. This capability sped up the process and provided the exact information to show when the persons disabling condition(s) began.
B.E.S.T. is responsible for facilitating the Los Angeles County Department of Public Social Services (DPSS) as it works to move more than 10,000 disabled General Relief recipients onto SSI. To support this process, central data rooms have recently been established in two more county hospitals as part of extensive countywide efforts to qualify more homeless people for SSI. Ten nurses are now stationed at DPSS, DHSs county hospitals, and the county jail to facilitate client recruitment and data retrieval to support SSI applications.
3.2.2. Improving the Medical Documentation Itself
Doctors are not usually thinking about documenting functional impairments when they make entries in medical charts. Yet for certain medical conditions common among homeless people, including mental illnesses, documentation of functional impairments is exactly what SSA needs to see in medical records before it can establish a finding of disability. In Los Angeles, DHS has found that recently-begun SOAR training plus improved data retrieval helps case workers in homeless assistance agencies to prepare successful SSI applications. However, case worker training is not enough. Even if case workers are able to access medical documentation, hospital records often do not provide the specific information that SSA needs before it can approve an application.
The DHS nurses stationed at county hospitals use the data retrieval structure just described to access billing records, which give them service use and diagnosis, along with a few other important facts. Notes in client medical records are not automated, so DHS nurses retrieve medical records and make hard copies of essential information. They also go one step further. Especially for recent treatment, they are able to contact attending physicians, clarify their perception of a patients condition and needed treatment, and have the physicians enter relevant notes into the case record. This updated record then becomes the documentation sent to SSA. The further advantage of these practices is that attending physicians gradually become aware of what they need to include in their medical notes, so the hard copy records are slowly improving.
BHCHP staff members invest significant effort in getting clients covered by SSI because of both the income stream and the Medicaid coverage that comes with SSI. BHCHP prepares medical documentation for SSI determination, and has become quite proficient at documenting conditions and functional impairments to comport with federal regulations, thus enabling its clients to qualify for SSI in short timeframes and with high rates of acceptance on first application. BHCHPs director and other clinicians whose experience has helped them develop techniques of successful medical documentation and have codified their recommendations in a highly informative and detailed guide disseminated by NHCHC (OConnell et al., 2007).
OConnell and colleagues recommend two basic strategies to support applications for disability benefits:
Refer explicitly to medical criteria for disability specified in the SSAs Listing of Impairments.
For patients whose impairments do not meet or equal the level of severity specified in a medical listing, document activities the patient can and cannot do. This strategy is most effectively accomplished in collaboration with a multi-disciplinary clinical team that includes a social worker and/or vocational counselor.
Recommendations for clinicians and health care agencies often suggest that a multi-disciplinary team be involved to cover some of the employment/impairment history elements and acknowledge that complying with these recommendations will be time-consuming. The payoff will be improved patient-provider relationships and clinical outcomes, as well as financial support for patients and Medicaid coverage for health care provided. The manual advises clinicians and agencies to:
Understand the disability determination process for SSI/SSDI and how medical evidence is used at each stage.
Understand the criteria DDS uses for each condition to determine that it is disabling; use the SSA publication Disability Evaluation Under Social Security (The Blue Book), which explains what SSA must see to find that a disability exists.
Write a letter explaining the assessment of the patients impairment. SSA privileges information from the treating source above other medical sources; failure to provide a letter will likely mean that SSA will ask for a consultative examination, which rarely leads to approving an application.
Build an ongoing relationship with the state DDS agency, whose staff may be willing to tell you what evidence they need for particular conditions to support a determination of disability.
Train all medical professionals to routinely record and highlight the existence of important criteria for each Blue Book listing relevant to the patient, as they do for vital signs.
Expand traditional educational and occupational history-taking to include how long jobs were held, what activities they entailed, what patients are and are not able to do now, current means of support, why they are unemployed or homeless, literacy level, education completed, and type of education.
Whenever possible, document a longitudinal history of the patients functional capacity, including difficulties with activities of daily living, tasks it is difficult for the patient to do, special barriers that exist, and (in)ability to sustain employment for a regular work week (6-8 hours a day, 5 days a week).