Findings from a Study of the SSI/SSDI Outreach, Access, and Recovery (SOAR) Initiative. The SOAR Initiative

12/15/2009

SOAR is a multi-agency federal initiative that provides training and TA to states to develop SSI/SSDI advocacy initiatives. Its ultimate goal is to help case managers (1) develop the means to expedite processing of SSI/SSDI applications for homeless individuals and (2) improve the quality of the information submitted with the application in order to increase the likelihood of disability benefit award at initial application and to substantially reduce the processing time associated with the application. States do not receive direct financial resources from the federal government to implement the initiative, but do receive training and TA.[1]

States were initially invited to apply for SOAR training and TA through the Homeless Policy Academies sponsored by the Health Resources Services Administration (HRSA). The Homeless Policy Academy Initiative was designed to help state and local policymakers address the issues of chronic homelessness and the needs of families with children experiencing homelessness. Those states interested in receiving SOAR training and TA were required to submit an application that described their service system, leadership, and commitment to SOAR. A small business contractor provides the TA with funding from the Substance Abuse and Mental Health Services Administration (SAMHSA) and HRSA as well as from the Department of Housing and Urban Development (HUD). The TA contractor and federal partners together selected the states to receive the SOAR training and TA from those that applied. The TA that the contractor provides consists of three core activities:

  1. Strategic Planning.  The TA contractor assists states and communities with developing a strategic action plan to ensure that SOAR's critical program elements will be in place to maximize the award of SSI/SSDI benefits to individuals who are homeless. Up to 30 stakeholders participate in a two-day, professionally facilitated forum intended to lay the groundwork for the SSI/SSDI outreach initiative. Stakeholders include state mental health and substance abuse agencies, local homeless assistance providers, local SSA field offices, the state DDS, public hospitals and clinics, and a variety of other service providers that assist individuals who are homeless. The strategic action plan is intended to establish who and how many staff are to be devoted to the effort; how it will be implemented, funded, and sustained; and the nature of cross-agency relationships that will be developed or strengthened to facilitate the success of the initiative.
  2. Train-the-Trainer (TTT) Program.  After the state has developed a strategic action plan, it may send up to four staff members to attend a four-day SSTR training program. The SSTR curriculum is designed to make case managers more knowledgeable about the disability application process by providing information and tools needed to effectively guide applicants through the process. After completing the intensive training, state trainers are expected to return to their states and train state and local program staff who serve individuals who are homeless. State trainers receive assistance from the TA contractor as they plan their initial training sessions as well as feedback on session content and their training techniques based on observations by the TA contractor.
  3. Ongoing TA and Monitoring.  Each state receives ongoing TA and monitoring of action plan implementation for one year following its initial development. In addition, the TA contractor hosts a website with materials and tools for use by case managers.

The SOAR approach emphasizes several key components that hold promise for increasing and expediting initial SSI/SSDI application approvals, such as obtaining consent for case managers to become an applicant's representative during the application process; taking all possible steps to avoid the need for a CE; working closely with health care providers, SSA, and the state DDS; and drafting an effective summary report for inclusion with the application to help point the DDS medical examiner to the relevant evidence to support an applicant's claim. SOAR's approach also emphasizes the need for adequate staffing levels, staff training, and collaboration among stakeholders as well as the need to track and report on outcomes achieved by organizations implementing the SSTR curriculum.

Figure I.1 illustrates the inputs, activities, and potential outputs and outcomes of the SOAR initiative. Many of the relationships depicted in this model are reciprocal and less linear than depicted. Several inputs facilitate the implementation of SOAR. These include support from several federal agencies and departments including HUD, ASPE, HRSA, and SAMHSA. These federal entities have a long history of supporting the development of the SSTR curriculum and other homelessness initiatives. For example, SAMHSA supports the Projects for Assistance in Transition from Homelessness (PATH) program, which provides grants to states for community-based outreach, substance abuse prevention and treatment and mental health services, case management, as well as a limited set of housing services for people experiencing serious mental illness and are experiencing homelessness or at risk of becoming homeless. HRSA supports Healthcare for the Homeless, a grant program that provides primary care (including primary health care and substance abuse services, emergency care and referrals, outreach and assistance in qualifying for entitlement programs and housing) to homeless people. As another input for SOAR, staff of the TA contractor, who are specialists in the fields of homeless services, mental health, program development, and training, lend their expertise to states and local communities. Finally, participation by a diverse group of state departments and local service providers, many of which work with homeless populations, facilitates the entry of the SOAR initiative into their communities through their participation in the strategic planning process and training.

Several activities result from the inputs. In the logic model presented below, SOAR activities are those things the TA contractor does to introduce SOAR into a community. First, the TA contractor facilitates state planning forums during which all stakeholders plan for implementing SOAR in their community. During and after this process, the contractor works with state and local staff to identify the critical components of SOAR that will require the most attention in their communities. These components are listed below in Figure I.1. The contractor also works to facilitate dialogue and collaboration among SOAR stakeholders so that the critical components are implemented with minimal burden. This contractor then trains leaders from each state in the SSTR curriculum, provides ongoing TA support as needed, and serves as a resource to state agencies.

There are at least three observable outputs that results from the SOAR activities facilitated by the TA contractor. In the logic model below, outputs reflect states' efforts to implement SOAR and are what enable SOAR to achieve its intended outcomes (improve access to SSI/SSDI benefits for and quality of life among individuals who are homeless). First, state leaders are able to use the knowledge and skills they have learned from the TA contractor to train other case managers to implement the critical components. Second, communities in which case managers receive training build cross-agency collaborative relationships. Finally, state team leaders provide ongoing support and assistance to in-state trainers and case managers in providing application assistance to the target population.

Implementation of SOAR critical components may lead to several short-term outcomes. For example, SOAR communities may begin to develop an infrastructure to track administrative and client outcomes related to SOAR. (One of SOAR's critical components is assessment of results.)

Figure I.1.
SOAR Logic Model
Inputs SOAR Activities Outputs Outcomes:
Short-Term
Outcomes:
Long-Term
HHS (ASPE, HRSA, SAMHSA) TA contractor facilitates state strategic planning forums State trainers train case managers to implement SOAR critical components* States develop infrastructure to track administrative and client outcomes Sustain SOAR components in existing SOAR communities
HUD TA contractor trains in-state SOAR trainers inthe SSTR curriculum SOAR communities build cross-agency relationships Increase number of applicants for SSI/SSDI Supply SOAR clients with steady income
SSA TA contractor provides ongoing TA to states State leaders support case managers in providing application assistance to clients Reduce time lag between submission and approval of application Improve health outcomes and access to housing for SOAR clients
TA contractor   Increase SSI/SSDI approval rate on initial application States recoup General Assistance and emergency medical care expenditures
State/local providers of services to homeless clients with disabilities   Increase monitoring of client and administrative outcomes
  Expand and replicate SOAR
  Factors Mediating and Moderating Outcomes
(1) Existing relationships between stakeholders (2) Existing local infrastructure to serve homeless
* Critical components are (1) case managers, outreach workers, and/or benefits specialists trained and available to assist with applications; (2) maintain communications and contact with applicant; (3) case manager or other staff person becomes applicant's representative; (4) active role in obtaining applicant's medical records, past and present; (5) collaborate with physicians/psychologists for assessments and medical information; (6) community assessments focus on avoiding the need for consultative examinations; (7) electronic submission of application and medical information whenever possible; (8) collaborate with DDS and SSA; (9) quality review of applications prior to submission; (10) provision of representative payees; (11) employability strategy; (12) assessment of results.

Increased awareness of the need to assist those who are homeless obtain SSI/SSDI may encourage case managers to submit a higher number of SSI/SSDI applications. Possibly, case managers may have acquired the necessary techniques to help individuals submit timely and more complete applications, a change that may improve the SSI/SSDI approval rate by reducing the share of technical denials as well as decrease DDS processing time. Finally, case managers may have developed a greater understanding of the advantage to clients of following up with SSI/SSDI when appropriate (for example, to obtain more information if an application is denied).

Long-term outcomes of supplying SOAR clients with a steady income and improving access to housing and health care may follow the short-term outcomes. To date, long-term outcomes have been extremely difficult to measure, both because the data do not exist in many states and because such outcomes take time to realize. Thus, another long-term goal of SOAR is the increased monitoring of client and system outcomes. As interagency partnerships develop due to SOAR and positive short-term and long-term outcomes accrue, participating communities may sustain SOAR, and other communities may seek to replicate the initiative. In addition, states may begin to realize cost savings as they recoup General Assistance and uncompensated state Medicaid expenditures from SSA for those who are approved for SSI.

The short- and long-term outcomes may be mediated or moderated by both the existing infrastructure of SOAR stakeholders in each community and the existing relationships between those stakeholders. That is, the extent to which SOAR may result in positive outcomes depends, in part, on the starting point of each community. These mediators and moderators are especially relevant for determining the extent to which SOAR can be or has been sustained in communities.

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