The success of SOAR depended on the extent to which stakeholders committed time and resources to the initiative, and on their willingness to collaborate. We identified at least four factors that influenced stakeholders' commitment to SOAR:
- Encouragement and support from state leads and partner organizations. Strong leaders marketed SOAR as an opportunity for stakeholders to advance organizational goals and worked persistently to engage reluctant partners. Dedicated staff sometimes supported state leads with this work; for example, stakeholders in one state credited a case manager's persistent legwork with building a strong regional partnership with DDS. Strong state leads looked at SOAR efforts holistically and helped troubleshot problems and identify ways to strengthen the initiative.
- Supervisory support for SOAR participation. Organizational leaders were more likely to encourage staff to dedicate resources to SOAR if it fit into an ongoing initiative (for example, a state's ten-year plan to end homelessness), and if the organization was not overburdened with other projects. Staff at all levels were more likely to participate when their supervisors were excited about the initiative.
- Correspondence between SOAR activities and stakeholders' core job functions. Improving the quality of SSI/SSDI applications is a natural goal for DDS and SSA, and helping clients get benefits is often part of comprehensive case management, particularly among those who specialize in benefits acquisition. For other stakeholders, making SOAR successful required work beyond their core responsibilities. State leads and trainers needed to dedicate time and energy to the initiative's success in organizations other than their own, with state leads working to build and maintain cross-agency relationships and trainers reaching staff from an array of organizations. Organizations and individuals often made an initial commitment to SOAR but then were forced to turn their attention to other more urgent organizational priorities. Some continued to contribute to SOAR even though it was not integral to their job; these staff typically had support from their supervisors and/or were personally enthusiastic about SOAR.
- Staff turnover. Across participating organizations, staff at all levels changed frequently, and turnover often hindered inter-agency collaboration. Turnover often meant that organizations lost expertise, enthusiasm for SOAR, and institutional knowledge. Collaboration was particularly stymied when state or local leads or staff that had used personal relationships to build collaboration with other organizations changed jobs. When champions of SOAR within a particular institution left, their replacements did not necessarily advocate for continued organizational support for SOAR. Turnover sometimes had a ripple effect, with partners becoming frustrated when another organization's involvement decreased.
At the strategic planning forums, which laid the foundation for future collaboration, stakeholders developed a work plan and agreed to communicate regularly about the initiative. Follow-up meetings and communication after the strategic planning forum, however, required leadership, either from the state lead or someone else. Some state leads did not clearly understand their role as the facilitator of continued communication between stakeholders. In most states, the TA contractor organized and played a role in recruiting stakeholders to participate in the strategic planning forum. Thereafter, state leads may not have realized that they had to take the reins in fostering ongoing collaboration, or that doing so would be timing-consuming and challenging. Without ongoing communication facilitated by a leader, partners expressed confusion over next steps and relationships had little opportunity to blossom.
Regular meetings between stakeholders were essential to develop lines of formal and informal communication, build on relationships, and overcome challenges. States that had mechanisms for ongoing structured communication were better able to keep partners engaged. For example, some states had quarterly meetings that brought together case managers, SSA and DDS staff, and senior leadership to share their experiences with SOAR and develop strategies for overcoming any challenges. These meetings provided an opportunity to hear positive feedback and solidify interagency relationships.
States in which stakeholders communicated regularly in a structured manner generally had more positive outcomes than others. Communication came most readily when stakeholders had partnerships prior to SOAR implementation, but successful state initiatives helped stakeholders strengthen existing relationships and build new partnerships.
Figures V.1 through V.4 illustrate the importance of collaboration to the utility of the SOAR model. They illustrate communication patterns before and after implementation of SOAR in, respectively, one community that was unable to demonstrate any application outcomes and one that demonstrated positive application outcomes. As the legend delineates, line types represent how frequently entities reported communicating with one another. Sometimes stakeholders' perceptions of how frequently they communicated differed, so we provide separate lines for each perspective; arrows show the direction of communication.
In the state depicted in Figures V.1 and V.2, most stakeholders reported a minimal or moderate level of communication before and after SOAR implementation. The state lead remained largely disconnected from other organizations. After SOAR implementation many stakeholders reported more frequent contact with SSA, but SSA did not report increased contact with any other entity.
In contrast, in the state depicted in Figures V.3 and V.4, communication among stakeholders increased noticeably after SOAR. Each stakeholder reported some level of communication with all other entities before SOAR implementation, but many stakeholders communicated more frequently with these groups after the initiative was in place. The state lead, who previously had a moderate amount of communication with all other parties, reported frequent communication with all stakeholders after SOAR implementation, and SSA and the in-state trainers also reported communicating more frequently with other participants. Neither figure includes case managers because members of this diverse group had varying levels of communication with other stakeholders. In the state depicted in Figure Y, however, case managers meet regularly with other stakeholders, including trainers, the state lead, SSA, and DDS.
Communication Before SOAR in State with No Outcomes
Communication After SOAR in State with No Outcomes
Communication Before SOAR in State with Positive Outcomes
Communication After SOAR in State with Positive Outcomes
The success of SOAR depends particularly on relationship building among state and local leads, SSA, and DDS field offices, medical providers, trainers, and case managers. In the following section we describe how and the extent to which each of these stakeholders developed relationships with the others and the contributions that each made to SOAR.
1. State and Local Leads
The role of the state lead in the SOAR model is multifaceted. Ideally, state leads work to (1) encourage initial and ongoing participation of stakeholders; (2) help stakeholders identify resources for SOAR; (3) facilitate ongoing stakeholder communication, informally and/or through regular meetings; (4) help organizations identify and overcome potential challenges of staff turnover; and (5) coordinate outcomes tracking and submit data to the TA contractor. Formal or informal local leaders could supplement this work, drawing on their local contacts and knowledge of the service system.
In practice, state leads varied considerably in the time and energy they dedicated to SOAR, and in the extent to which they were able to provide effective leadership. Fostering participation and collaboration was easier when strong partnerships already existed, and when the state lead was a respected community leader or held a relatively senior position within a prominent organization, particularly a state agency. For example, one state lead was the director of the state's Homelessness Task Force, and consequently had strong connections to a range of stakeholders, the stature to recruit new partners, time and energy to dedicate to strategic planning and partnerships building, and insights about how different partners could enhance SOAR. In contrast, some state leads lacked the time, resources, or sense of empowerment necessary to facilitate SOAR's success outside of their own organization. For example, one lead from the state PATH organization encouraged PATH grantees to dedicate staff time to SOAR and build collaboration between with SSA and DDS, but did little to engage other organizations, in part because the lead felt that she did not have the authority or clout to influence the activities of a different state agency. Some state leads made initial efforts to engage other entities, but did not follow-up after their initial efforts floundered.
While state-wide SOAR efforts generally struggled without a strong state lead, official or unofficial local leads were sometimes able to propel the initiative forward in their communities. For example, one state did not have state-level leadership for several months due to staff turnover but a motivated case manager supervisor in one community kept the initiative active during that time. While the SOAR model calls for a state and local lead in each pilot community during initial implementation, no state we visited had both consistent strong local and state leadership. However, if SOAR expands to multiple communities within more states, complementary state and local leadership may become more essential. Local leads would be responsible for community-specific partnerships and challenges, and state leads would coordinate efforts, identify and troubleshoot challenges, and facilitate relationships at the state or regional level (for instance, with SSA and DDS).
2. SSA and DDS
Cooperation between case managers and SSA and DDS is a SOAR critical component. Ideally, SSA and DDS staff will understand the challenges SOAR applicants face, accommodate those difficulties to the extent possible, and develop relationships with case managers to whom they can turn for additional information about applicants. Better access to applicants and case managers, along with improved application quality, can increase the number of applications approved and decrease processing times.
While SSA and DDS are large, bureaucratic entities, regional and local offices have some autonomy over practices and procedures, and have the potential to adapt them to facilitate SOAR's objectives. One way that SSA and DDS offices modified procedures was by flagging SOAR applications. A flag or notation on the application serves as a signal to agency staff that they can contact the SOAR case manager with questions, and helps them contextualize the applications. Flags also facilitate the tracking of SOAR outcome data. Some states developed a flag simply by using a cover sheet on paper applications or through an electronic data system. SSA's online application system does not have a field to record that the application is completed by a SOAR worker, and creating such a field would require changes to SSA's software at the federal level. However, states were creative about developing workarounds (for example, flagging a case as homeless and writing SOAR in a comments field). Stakeholders sometimes had different understandings of what homeless or SOAR flags meant. For instance, sometimes case managers defined anyone at risk of being unsheltered as homeless, but DDS and SSA had a more stringent definition of homelessness as being currently unsheltered. Miscommunication about what flags meant sometimes undermined partnerships. Strong leaders, however, were generally able to work with stakeholders to clarify definitions.
Another way SSA and DDS offices modified procedures was by designating specific staff to process SOAR applications. This provided case managers with a specific contact person who developed an in-depth appreciation for the challenges involved in navigating the SSI/SSDI application process for individuals who are homeless. Some SSA and DDS staff reported that designating workers to process SOAR or homeless applications improved processing time. But, this practice is not without challenges. In particular, it was difficult in some locations to sustain designated staff due to turnover. In addition, some SSA and DDS offices perceived that the volume of SOAR applications was too low to justify specialized staff. Some dealt with this challenge by designating staff who would be responsible for all SOAR cases in addition to a reduced regular caseload.
The extent to which SSA and DDS were willing to modify procedures by flagging applications or designating staff varied, often based on how worthwhile leaders perceived that SOAR would be to their agencies. While SOAR cases are a small percentage of all SSA applications, some office managers recognized that SOAR can help decrease overall workloads (if case managers submit higher quality applications and facilitate access to applicants) and were therefore eager to make small changes to accommodate SOAR. Generally, engaging SSA and DDS required the persistence of SOAR leadership and the marketing of SOAR's potential benefits, but state or local SOAR leaders did not always have the time to invest in these activities. SSA and DDS leaders were most receptive to SOAR when they saw the initiative as congruent with an existing organizational priority or initiative, or when they already had relationships with other SOAR partners. Generally, field offices were more proactive in making changes when regional offices communicated their support for SOAR.
Even when SSA and DDS offices did not formally modify procedures, SOAR often fostered more frequent contact between field office staff and case managers. When communication increased, field office staff reported receiving more complete applications, and stated that by connecting them to case managers, SOAR made the process of obtaining additional information easier. Case managers reported that they submitted better applications when they could contact SSA and DDS staff with questions, and when they received feedback on their applications.
3. Medical Providers
Collaboration with medical providers has the potential to enhance SOAR. Case managers and DDS rely on the medical community to provide records and perform CEs for SSI/SSDI applications. However, many medical providers are not aware of the criteria DDS uses to evaluate cases or of DDS's terminology, which is often different from providers' standard medical language. With greater awareness of the SSI/SSDI application process, medical providers could tailor their existing work and strengthen SOAR applications. In addition, application processing times have the potential to improve when DDS locates and receives medical records quickly. Further, medical providers could encourage their patients to apply for SSA benefits, not only because benefits would have a positive impact on the lives of their patients, but also because those who are approved for SSI/SSDI qualify for Medicaid, which can then reimburse medical providers for the cost of uncompensated care. The TA contractor reported that several states that were not included in our case studies developed partnerships with medical providers that led to cost recovery (see Appendix A).
Despite the potential benefits of engaging medical providers in the SOAR initiative, many states have not integrated the medical community into their efforts. Only two of the six case study states formally integrated medical providers into their SOAR initiatives. In one, the Veteran's Administration (VA) sent several case managers to a TTT session, and conducted three trainings for VA staff. In another, stakeholders have made extensive use of Healthcare for the Homeless (HCH), a grant program funded by the HRSA to provide 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 those who are homeless. In this state, HCH directs all SSI application issues to one doctorand-nurse team, which also conducts a benefits clinic once a week. DDS had recently begun using HCH doctors to perform CEs. This arrangement was expected to better serve homeless applicants because they frequently access care at the clinics and many have an established relationship with the medical doctors. The VA and HCH are two entities that could be engaged in SOAR at the national level; the relationships described here illustrate the potential benefits of closer collaboration. In some states, case managers routinely request copies of medical records from providers, but SOAR leaders have not tried to streamline this process or build more formal relationships. Providers often have different forms and releases required before medical records may be accessed and the process of completing these can be time-consuming. Developing a common form could streamline this process, but would require buy-in from a diverse range of providers. Case managers in other states do not pursue copies of medical records because providers give copies to DDS for free but require CBOs to pay for copies. In addition, they perceive DDS as the agency responsible for obtaining medical records and as being able to do so most efficiently. In many states, SOAR leaders are still concentrating on getting the more basic components of the initiative in place, such as arranging for in-state trainings and building relationships with SSA and DDS, and therefore have not yet focused on developing medical provider relationships.
The intent within the SOAR model is for state leads and trainers to collaborate on when, where, and to whom the in-state SSTR trainings should be delivered. For SOAR to be successful, stakeholders need to target trainings towards the appropriate case managers. Sometimes, however, decision making around in-state trainings was not collaborative. Rather, state leads dictated decisions around in-state trainings to the trainers, or trainers assumed sole responsibility for the in-state trainings without consulting the state lead. The former typically happened when stakeholder collaboration was weak, and the latter typically happened when state leadership was weak. A variety of models can foster collaboration between the state lead and trainers. In some states, the state lead was a trainer, or active trainers were part of the state or local lead's organization. When the state lead was a trainer or communicated closely with the trainers, the lead was aware of on-the-ground implementation issues and connected to case managers.
Another intent within the SOAR model is for trainers to provide ongoing assistance to case mangers after the in-state trainings to submit SOAR applications and work through early implementation challenges. Trainers varied in their ability to provide this type of assistance. Generally when followup did occur, case managers initiated contact and did so only when they had a prior relationship with the trainer. After the in-state trainings, case managers rarely contacted trainers with whom they did not already have a relationship. Trainers who were employed by the lead agency were more likely to develop relationships with other stakeholders because they were invested in the initiative and tended to have agency support. Trainers had more difficulty providing follow-up assistance and conducting on-going trainings when they were not employed by the lead agency, in part because of other demands on their time.
5. Case Managers
Case managers use the SOAR training to help individuals complete SSI/SSDI applications and navigate the application process. Peer support can bolster case managers' efforts to implement SOAR critical components and provide ideas and encouragement for addressing challenges. This support was most feasible when case managers were already connected through existing networks (for example, when case managers in different organizations were supported by the same funding streams or part of a larger umbrella organization). Some states held quarterly meetings that brought together case managers and SSA and DDS staff along with state leaders to share promising practices and troubleshoot any challenges. These meetings provided feedback on the application process and application outcomes and served as an opportunity to share in their success, which encouraged case managers and SSA and DDS to continue their work.
One of the most important relationships that can facilitate access to benefits for individuals who are homeless is that between case managers providing application assistance and SSA/DDS staff processing the applications. Case managers often had to take substantial initiative to develop relationships with SSA and DDS staff. Within a single locality or even a single organization, some case managers took the initiative to reach out to SSA and DDS staff and some did not. Case managers found it easier to develop relationships with SSA and DDS employees who were designated as SOAR contacts, or who attended in-state trainings. In most states, agency representatives regularly attended trainings, and case managers reported that learning more about DDS and SSA procedures from an agency representative was invaluable. In some localities, DDS and SSA representatives gave presentations at the trainings on how to prepare quality applications and foster ongoing communication with their respective agencies. In other localities they participated minimally, introducing themselves and adding a few comments about their agency's work.