Helping Adults Who Are Homeless Gain Disability Benefits: The SSI/SSDI Outreach, Access, and Recovery (SOAR) Program

More than two-thirds of homeless adults in 2009 had one or more disabilities, and mental and substance use disorders were among the most prominent (1). For persons with mental illnesses and other co-occurring disorders who are homeless, Supplemental Security Income (SSI) and Social Security Disability Insurance (SSDI) can provide a steady income and health insurance. Together, these benefits make it possible for many to secure housing, treatment, and other needed supports (2,3).

Many people who are homeless and potentially eligible for SSI and SSDI never apply for them (4). Only 10% to 15% of first-time applicants who do not receive active assistance in applying are approved (5). Nationwide, allowance rates for initial SSI and SSDI applications for adults aged 18 to 64 average 32%, whether or not the applicant is homeless (6). Denials are typically a result of the Social Security Administration's inability to contact the individual, missed appointments by the applicant, and a lack of adequate documentation to support the application (5,7).

People experiencing homelessness face many challenges when applying for disability benefits (5,8). They are more likely than those who have never been homeless to have serious mental illnesses as well as other disabilities, such as cognitive disorders, chronic physical health conditions, and substance use disorders (9). Disability that is due to mental illness or cognitive disorder is more difficult to document than other disabilities because of inconsistent treatment histories and difficulty in finding medical records for people who may have been treated in many places (5). People who are homeless may not remember when, where, or why they were treated. Many do not know, do not understand, or are reluctant to admit that they have a mental illness. Others mistakenly believe that they are already receiving SSI or SSDI (10). Furthermore, most case managers have neither the time nor the expertise to assist with disability applications.

The Substance Abuse and Mental Health Services Administration (SAMHSA) established the SSI/SSDI Outreach, Access, and Recovery (SOAR) Technical Assistance (TA) Center to address these barriers by helping states and communities increase access to SSI and SSDI for adults with disabilities who are homeless or at risk for homelessness. In 2005, 41 states were invited to apply for SOAR TA because they had identified increasing access to disability benefits as a priority in their state plans to end homelessness (11). Thirteen states were selected from the first group of applicants, 14 states in 2006, and ten more in 2007. In 2009, SAMHSA funding allowed the remaining states to participate and provided ongoing support to all participating states. SAMHSA provides SOAR technical assistance through a contract with Policy Research Associates, Inc. Technical assistance under the SAMHSA contract is provided to states at no charge. No state or community receives federal funding specifically targeted to participation in SOAR, and SSI and SSDI beneficiaries are not charged a fee for assistance received through SOAR.

In each state, SOAR TA included three components. First, state and local strategic planning helped forge collaborative relationships and develop community-based plans to increase access to SSI and SSDI in pilot communities. States identified key stakeholders to attend a strategic planning meeting, including staff from local, area, or regional offices of the Social Security Administration and staff from the states' Disability Determination Service. During the meeting, plans were developed to implement SOAR and address barriers at the state and community levels.

The second component was training. The SOAR training curriculum provided case managers with techniques to develop more complete disability applications (12). Using a “train-the-trainer” model, new trainers in each state were observed by the SOAR TA team to ensure fidelity to the curriculum.

The third component was ongoing TA. Over time, the SOAR TA team identified core components of the SOAR process and reinforced their use. TA addressed challenges in implementing SOAR, maintaining momentum, and sustaining and expanding SOAR programs.

There has been limited research on interventions to expedite and increase access to benefits for people who are homeless (13). An evaluation of Homeless Outreach Project and Evaluation (HOPE), a program of the Social Security Administration, reported an allowance rate for SSI, SSDI, or both disability applications of 41% (7). A preliminary evaluation of two SOAR sites found that SSI and SSDI approval rates rose after implementation of SOAR (11). To provide more information on the potential of such interventions, this study collected information about outcomes of SSI and SSDI applications assisted by SOAR beginning in 2005. The data collection plan was approved by the Policy Research Associates, Inc., institutional review board.

Methods

SOAR TA staff worked with each state to implement a data collection system to record outcomes of SSI and SSDI applications assisted by SOAR-trained case managers. In 2007 an outcome tracking database was created and made available to anyone who wanted to use it. A few states adapted their homeless management information system to track outcomes. All states were encouraged to collect data about the number of initial disability decisions, the number of approvals or denials, and the number of days from submission to decision. Aggregate data were collected by the state or locality and provided annually to SAMHSA's SOAR TA team.

States also were encouraged to keep track of how long applicants had been homeless before receiving SOAR assistance and the date the person obtained housing. States were asked to report any retroactive Medicaid or general assistance fund reimbursement as well as any collaboration they developed with hospitals, jails or prisons, or state or county general assistance programs.

A total of 48 states plus the District of Columbia had received SOAR TA as of 2010. Data were collected from states that had been receiving SOAR TA for at least one year, which excluded seven states that had implemented the program more recently. Four states and the District of Columbia were unable to implement a data collection process or had not sustained the SOAR program. Thus data were received from 37 of the 42 states (88%) that were expected to report outcomes. The data are cumulative; each state reported outcomes of applications submitted since they began implementing SOAR one to four years earlier.

Results

As of June 2010, the 37 states reported assisting 8,978 persons with SSI and SSDI applications (Table 1). Of those, 6,558 initial applications were approved, for an allowance rate of 73%. The average time to approval was 91 days, but there was wide variation among the states. Social Security Administration allowance rates and time to decision vary by state independent of the SOAR initiative. Thus variations among states in Table 1 may not be due solely to differences in implementation of SOAR.

Some states gathered additional information about individual and systemic outcomes. These data point to encouraging trends. For example, 16 states reported that at the time of their application, individuals assisted had been homeless for an average of two years, indicating that the program is reaching people who are chronically homeless. Ten states reported that 81% of SSI and SSDI applicants were housed by the time benefits were approved.

Eleven states reported significant cost savings through Medicaid reimbursement or federal reimbursement to their general assistance programs. Utah reported that their general assistance program in Salt Lake City recouped close to $500,000 in two years. In Michigan, one hospital recouped $219,382 from Medicaid in one year for 15 previously uninsured individuals. Eleven states initiated collaborations with hospitals, including agreements with medical records departments for expedited records at no cost, easy access to needed assessments, and grant funding to support local SOAR programs.

Case managers in states with the highest allowance rates reported using the SSA-1696 Appointment of Representative form, one of the cornerstones of the SOAR model. This form allows them to receive correspondence from the Social Security Administration and act on the applicant's behalf during the application process. Of the 21 states that reported data about use of the form, the SSA-1696 was used for 92% of all applications assisted.

Discussion

The SOAR program substantially increased access to SSI and SSDI benefits for people with disabilities who had experienced or were at risk for homelessness. The allowance rate for SSI and SSDI applications assisted by SOAR (73%) far exceeded the allowance rate (32%) for all persons who apply for disability benefits from the Social Security Administration and estimates of the allowance rate (10% to 15%) for homeless applicants who are not assisted during application. In addition, the average length of time between initial application and decision was shorter among applicants assisted by SOAR than among all applicants (91 versus 120 days).

The SOAR experience indicates that the application process for Social Security Administration benefits must be reframed as a collaboration between states and communities to achieve financial stability for their most vulnerable residents rather than an effort by an isolated person with disabilities experiencing homelessness. Moreover, a collaborative, multilevel effort to increase access to these benefits is an essential foundation for recovery from chronic homelessness for people with mental illnesses and other co-occurring disorders.

Research conducted thus far has several limitations. Although the latest data are persuasive, it is challenging to show definitively that results of applications among homeless persons assisted by the SOAR model differ from those among homeless persons who did not receive assistance. Further research could determine more precisely the SOAR model's added value.

In addition, research could identify the relative contribution of the core components of SOAR, individually or in combination, to increased allowance rates. Results from several states and communities also indicated that SOAR provided a substantial financial advantage to states, counties, hospitals, and other general and behavioral health care providers. In the case of states and counties, for example, the Social Security Administration can reimburse disability or general assistance funds starting from the date of SSI eligibility. For hospitals and other health care providers or for public payers responsible for state or county Medicaid or uninsured care, the federal Medicaid benefit that typically accompanies SSI can reimburse for care up to 90 days before the date of SSI eligibility. These benefits also provide future ongoing health insurance and income support critical to improved health. More rigorous research is needed to evaluate these impacts.

Future research should examine interventions such as SOAR longitudinally in specific communities to determine the impact of gaining access to disability benefits on applicants' life situation over time, such as the ability to acquire housing or changes in health status. Another important set of research questions could examine the cost of repeatedly unsuccessful applications by people who are homeless, including the costs of appeals and consultative exams, and the cost savings in staff time that accrue to the Social Security Administration and the state Disability Determination Service because of SOAR assistance.

Conclusions

The results of this study suggest that SOAR substantially increased access to SSI and SSDI for people with disabilities who experience or are at risk for homelessness. Expediting benefits can create a foundation for recovery that allows people who are homeless to find and maintain permanent housing, explore treatment options, and experience hope, achievements without which employment and self-sufficiency cannot be sustained.

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