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News and Notes   |    
Psychiatric Services 2006; doi: 10.1176/appi.ps.57.6.895
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The receipt of disability benefits is crucial for people who are homeless. Benefits from two major federal programs—Supplemental Security Income (SSI) and Social Security Disability Insurance (SSDI)—often provide the foundation from which individuals can take the first steps toward recovery and employability. However, the application process requires extensive information and documentation, especially in regard to establishing disability. For homeless applicants, who may not have access to paperwork that confirms their identity and medical history, the requirements can be especially difficult.

In response to requests from frontline staff who work with homeless populations, especially adults who have serious mental illnesses, the Substance Abuse and Mental Health Services Administration (SAMHSA) has developed a 200-page guide—Stepping Stones to Recovery: A Case Manager's Manual for Assisting Adults Who Are Homeless, With Social Security Disability and Supplemental Security Income Applications. The manual speaks directly to case managers, because of their critical role in ensuring the success of the application. However, the guide is useful for anyone undertaking the application process, even those with virtually no knowledge of federal disability benefits programs.

The manual emphasizes the importance of establishing direct communication with the claims representative at the Social Security Administration's (SSA's) field office and with the disability examiner at Disability Determination Services (DDS), the state agency that contracts with SSA to perform disability evaluations. By speaking directly with the individuals who will process the claim, case managers become better informed about the necessary documentation, which can reduce the time required to make the determination and can result in more accurate determinations.

Of the ten chapters, chapter 3 is especially useful. It provides an overview of how to apply for benefits—there are four ways—and the documentation needed to complete an application. A checklist of nearly 50 documents that may be required, from a birth certificate to a burial contract, is presented, along with guidance about how and where to obtain critical items. Some of the required documents are letters, and an appendix provides useful samples—for example, a summary report from the case manager and a letter from a former employer. Another appendix contains copies of all the application forms described in the manual and instructions for completing them.

In chapter 6, "Documenting Disabilities," the focus is on claims based on mental illness and mental illness in combination with other disorders. The important concept of functional impairment is explained from the perspective of the DDS, which looks for documentation of disability in four areas: activities of daily living; social functioning; concentration, persistence, or pace in task completion; and repeated periods of illness, each of extended duration. The manual gives examples of how best to describe and document specific disabilities in the application process. Guidelines for retrieving copies of medical records include advice on how to educate overburdened medical records staff about the types of information needed by DDS so that records staff will be more likely to copy and send relevant documents.

Occasionally a case manager may believe an applicant's case would be strengthened with the addition of results from a new medical or psychological test. A discussion with the disability examiner may result in a consultative examination, known as a CE—a medical test ordered and paid for by DDS. The manual details the process of requesting and obtaining a CE. Case managers are advised about how to deal with potential problems, such as when a clinician unfamiliar with the applicant is assigned to conduct the examination.

An extensive chapter provides a detailed overview of the appeals process that may be undertaken when an initial SSI or SSDI application is denied—from completing and filing the Request for Reconsideration form through an appeal in federal court. It outlines the range of considerations an applicant should review before obtaining an attorney, and it provides guidelines for case managers who represent claimants at appeal hearings before SSA administrative law judges.

Three final chapters explain how to assist an applicant in obtaining his or her benefits promptly once a disability determination is made and how to ensure that the benefits will be used to meet the applicant's needs. The manual provides tips on preparing for the posteligibility interview in the SSA office and on verifying that the DDS has calculated the correct amounts of ongoing and retroactive benefits. Beneficiaries' rights and use of a representative payee are discussed.

The manual was prepared as part of SOAR (SSI/SSDI Outreach, Access, and Recovery), SAMHSA's technical assistance and training initiative to help increase access to SSA disability benefits for homeless people. The document was written by authors from Policy Research Associates with feedback from case managers, consumers, public policy professionals, federal staff, and others who specialize in the field. It is available on the SOAR Web site at http://pathprogram.samhsa.gov/soar.

Discharge planning for prisoners with mental illnesses:Best Practices: Access to Benefits for Prisoners With Mental Illnesses, an issue brief by the Bazelon Center for Mental Health Law, describes innovative approaches being used in numerous state and county corrections systems to ensure that inmates in jail and prison who have mental illnesses have prompt access to income support, medical care, and other services that they need to successfully reenter the community when they are released from incarceration. The types of approaches described include screening on entry to a correctional setting, planning for reentry, setting up interim medical coverage, implementing specialized postrelease follow-up, and simplifying the complex process of obtaining federal disability benefits, Medicaid, and other entitlements. Contact information for the programs is provided. The 12-page issue brief is available on the Bazelon Center's Web site at www.bazelon.org.

Fact sheet on the Massachusetts health care reform plan: In April 2006 Massachusetts Governor Mitt Romney signed into law landmark legislation that would provide nearly universal health care coverage to state residents. The bipartisan legislation to cover the state's uninsured population combines the concept of individual responsibility (through an individual mandate on the purchase of health insurance) with government subsidies to ensure affordability. Full implementation of the plan is expected by July 1, 2007. A two-page fact sheet released by the Kaiser Commission on Medicaid and the Uninsured describes components and implications of the plan and its financing mechanisms. Key questions, such as whether the mandated plans will be affordable for consumers, are answered. The fact sheet is available on the Kaiser Commission's Web site at www.kff.org/uninsured.

Sharp increases in Medicaid spending on outpatient drugs: Medicaid spending for outpatient prescription drugs increased by 20 percent per year on average from 1997 to 2002—from $11.6 billion to $23.7 billion—according to a new study by the Agency for Healthcare Research and Quality (AHRQ). The increase reflects a rise in the number of prescriptions for enrollees—from 301 million prescriptions in 1997 to 429 million in 2002—and rapid uptake of newer classes of drugs, which are often more expensive. The increase also reflects growing spending for disabled adults, including persons with low incomes and those with serious mental illnesses. The number of Medicaid enrollees taking antidepressants rose by 50 percent—from 2.5 million in 1997 to 3.7 million in 2002—which helped fuel a 130 percent rise in Medicaid spending for those drugs during the period. Psychotherapeutic drugs, including antidepressants, constituted the largest category of drugs prescribed to enrollees in 2002. Spending on drugs for disabled adults grew 97 percent—from $5.3 billion in 1997 to $10.3 billion in 2002. Disabled adults accounted for 47 percent of the Medicaid enrollees who were prescribed antidepressants—an increase of 37 percent between 1997 and 2002. "Trends in Prescription Drug Expenditures by Medicaid Enrollees" was published in a special supplement to the May 2006 issue of Medical Care. For more information, contact AHRQ at 301-427-1539 or 301-427-1865.

Children's Partnership plan for insuring more children: Despite the success of Medicaid and the State Children's Health Insurance Program (SCHIP) in reducing the number of uninsured low-income children by one-third in the past decade, more than eight million children remain uninsured. Seventy percent of uninsured children are eligible for public health coverage. A report by the Children's Partnership that was funded by the Kaiser Commission on Medicaid and the Uninsured outlines a set of reforms to move forward on children's coverage by employing new enrollment "doorways" that will give low-income families the opportunity to enroll their children at convenient public access points that are routine parts of their lives, such as schools, hospitals, and facilities for certain means-tested public programs. The cost associated with these investments in children's health coverage is modest, the report notes. The report makes ten recommendations that require a combination of both state and federal actions. The 34-page report, Opening Doorways to Health Care for Children: 10 Steps to Ensure Eligible but Uninsured Children Get Health Insurance, is available on the Kaiser Commission's Web site at www.kff.org/uninsured.

Evidence supporting systems of care: After enrolling in systems of care, children and adolescents with serious mental health needs spend less time in inpatient care, experience fewer arrests, show improvements in their overall mental health, and do better in school, according to a new data analysis by the Substance Abuse and Mental Health Services Administration (SAMHSA). A system of care is a coordinated network of community-based services and supports that are organized to meet the challenges of children and adolescents with serious needs. The SAMHSA data suggest that systems of care save taxpayers money. Compared with traditional mental health service delivery, systems of care save $2,777 per child in inpatient costs annually and juvenile justice systems $784 per child annually. These and other data related to key outcomes, such as reductions in suicide-related behaviors and reductions in juvenile detentions or incarcerations, are available on SAMHSA's Systems of Care Web site at www.systemsofcare.samhsa.gov.

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