SSISSDI for Homeless Adults who Have CoOccurring Disorders

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SSI/SSDI for Homeless Adults who Have
Co-Occurring Disorders

• Yvonne M. Perret, MA, MSW LCSW-C
• PATH Teleconference
• May 19, 2006

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Co-Occurring Disorders

• For this presentation, co-occurring disorders
  refers to substance use disorders and a diagnosis
  of other mental illnesses
• People with these disorders often have multiple
  other problems, including physical health
  problems
• In some instances, co-occurring disorders refer
  to a different combination of disorders

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SSI/SSDI A Brief Overview

• Social Security Administration (SSA) oversees
  both programs
• SSI
• Income benefit for people with disabilities,
  those who are 65 and over, people who are blind.
• Limited income, assets and resources
• Usually provides Medicaid
• Limited federal benefit rate 2006-603/month

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SSI/SSDI A Brief Overview

• SSDI
• Based on the earnings put into the Social
  Security System through FICA contributions
• Benefit amount dependent on amount of earnings
• Provides Medicare generally after two years of
  eligibility

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SSI/SSDI Similarities

• Both require non-medical and medical information
• Medical criteria are exactly the same
• Non-medical is different more complicated for
  SSI
• Process of eligibility determination is similar
  for both programs

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Medical Criteria for Eligibility for SSI/SSDI

• Individual must have medically determinable
  physical or mental impairment
• Impairment must have lasted or be expected to
  last 12 months or more or result in death
• Impairment must cause functional limitations that
  keep the individual from working Substantial
  Gainful Activity (SGA) (2006 defined as 860/mo.
  gross earnings)

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Functional Areas

• Activities of Daily Living Washing, dressing,
  bathing, using transportation, budgeting,
  housekeeping, using a phone, etc.
• Social Functioning Ability to communicate
  clearly with others also ability to tolerate
  being around and interacting with other people on
  a consistent basis

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Functional Areas (continued)

• Ability to maintain pace and persistence in the
  completion of tasks Concentration, memory,
  following directions, focus, repeated ability to
  do
• Periods of decompensation of extended duration
  Must have lasted at least 2 weeks or more 3 or
  more times in the last year

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Eligibility for SSI/SSDI

• After meeting non-medical criteria, individual
  must
• Meet diagnostic and durational criteria
• Show marked functional impairment in at least
  two of the four functional areas
• Marked defined as more than moderate
• To determine eligibility, DDS follows a
  sequential evaluation

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Sequential Evaluation
Step 1Is the person working?
Person is not working or is working at less than
SGA level.
Person is working at SGA level.
Denied
Step 2Does the person have a severe impairment?
Person has no severe impairment.
Person has severe impairment.
Denied
Step 3Does the impairment meet or equal the
listing requirements?
Impairment does not meet or equal the listing
requirements.
Impairment meets or equals the listing
requirements.
Approved
Step 4Does the impairment allow for past
relevant work to be done?
Person can do past work.
Person cannot do past work.
Denied
Step 5Can the person do any other work,
considering age, education, work history?
Yes
No
Approved
Denied
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History of SSAs Consideration of Substance Use

• 1961 Substance use disorders considered under
  category of personality disorders
• 1972 Beginning of SSI as well as SSAs Drug
  Addiction and Alcoholism (DA A) program
• Required those receiving SSI to have
  representative payee and to be in substance use
  treatment

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History (continued)

• 1994 To curb growth,
• Added SSDI to the SSI requirements for treatment
  and representative payee
• Limited receipt of SSI to 36 months
• 1996 In welfare reform law
• Changed consideration of substance use to whether
  or not it is material
• Remains the law today

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What Does Material Mean?

• To determine if substance use is material to
  ones disability, the following question needs to
  be answered
• If a person were to be clean and sober, would he
  or she still be disabled by another illness or
  impairment?
• If the answer is yes, the person more likely
  would be approved
• If no, the person would be denied.

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Deciding Material Requires Comprehensive
Evaluations

• Evaluations
• Must be longitudinal
• Must be comprehensive and address
• all relevant information
• Should be done with use of open
• ended questions whenever possible
• Must understand early and ongoing context
• of substance use

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Evaluations Essential Components

• I. Early history Possibility of early trauma
• Need to understand early trauma to help us
  understand ongoing substance use
• When asking about early trauma, we MUST be able
  to handle the responses effectively and ensure
  the safety of the individual
• If you cannot successfully open up these issues
  and ensure appropriate handling of the situation,
  DONt ASK!
• Often, trying to manage sequelae of early trauma
  leads to substance use

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Early Trauma (continued)

• Questions to get at early trauma
• When you did something your parents didnt like
  or thought was naughty, what would they do?
• When you were growing up, did any grown up or
  bigger person touch you in a way that made you
  feel uncomfortable or was private or just felt
  kind of strange? Can you tell me what happened?

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Early Trauma (continued)

• What was it like to be in your family? e.g.,
  some families are happy, some are sad, some
  angry, some tense, etc.
• How old were you when you started drinking (or
  using drugs)? What was going on in your life
  then?
• How old were you when you left home?

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Evaluations Essential Components

• Learning Experiences
• What was it like in school for you? How was the
  work? What about the schoolwork was tough? Was
  easy?
• What grade did you finish? Do you recall how old
  you were? What made you decide to leave school
  then (if didnt graduate)?
• Were there any grades that you found you needed
  to do some extra work or needed extra help? If
  yes, what were they?

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Learning Experiences (continued)

• How many other children were in your class
  usually? (This allows you to ask about special
  education without asking if the individual was in
  special education, as many folks deny this)
• Did you ever find that you needed to take a grade
  over again? If yes, what was going on? How
  come?
• Can you please read this for me? (Hand over a
  newspaper or something at a 6th grade reading
  level and ask to read a few sentences. Gets at
  literacy)
• What subjects did you find tough? Which ones
  werent so tough?

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Evaluations Employment History

• At what age did you first start working,
• For each job
• What did you do? What did you like? Dislike?
• What made you decide to leave?
• What was easy for you at this job? Difficult?
• Who did you get along with? Not get along with?
  Why?

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Evaluations Brain Hurt

• Ask often only about traumatic brain injury
• Need to ask more comprehensively
• Example Have you ever had an accident, or were
  in a fight, or got hit, or fell and were knocked
  out? Then, follow up with questions regarding
  evaluation and treatment

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Further Consideration of Material

• If has brain hurt, must have objective proof,
  e.g., abnormal EEG, abnormal CT scan,
  neuropsychological or other psychological testing
• Consider long-term effects of certain substances
  on the brain, e.g., alcohol

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Understanding of Current and Ongoing Substance Use

• If you could use any drug at all, what would it
  be? How come?
• What is it like for you when you dont use?
• If history of treatment, what happened that led
  to your using again?
• When in treatment, how do you feel?
• When use is reduced, what happens?

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Understanding of Current and Ongoing Substance Use

• If never in treatment, has anyone encouraged you
  to be in treatment? What has kept you from trying
  it?
• Depending on route of use and substance used,
  ensure assessment of further medical problems,
  e.g., HIV/AIDS, hepatitis, Korsakoffs syndrome,
  AIDS-dementia, etc.

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Example Fred Jones

• Fred Jones (not a real person)
• 38-year-old, single man who has been on the
  street for 5 years
• He was physically abused from ages 6-10 and was
  sexually abused by his uncle, Wally, from ages
  8-12. He has told no one of this.
• Fred finished 8th grade, was in special
  education, and repeated the 6th grade twice.
• He worked for a while between ages 22-25.
  Consistently was fired for hitting his bosses.

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Fred Jones (continued)

• Started drinking at age 9 on a regular basis.
  Uncle gave him beer. Age 12 Began smoking
  marijuana. Age 15 Alternated between
  marijuana, cocaine, and alcohol
• History of 6 psychiatric hospitalizations. Most
  recent January of this year. Intermittent
  outpatient treatment .

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Fred Jones (continued)

• History of diagnoses of bipolar disorder and
  major depression with psychotic features
• Moods are often up-and-down with no feelings of
  control over them.
• Often moods are accompanied by bizarre thoughts
  and hearing people talking about his past abuse
• Substance used is consistent with mood swings,
  e.g., when depressed uses cocaine when manic, he
  uses alcohol or marijuana
• During episodes of non-use, remembers his abusive
  past and finds he cant sleep or do anything he
  used to be able to do

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Would Fred Likely Be Eligible?

• Fred would likely be eligible because
• He has another serious mental illness that
  impedes his functioning
• Even when not using, impairing symptoms remain
• Ongoing symptoms of early trauma also impede
  functioning
• Substance use would likely not be material

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For further information

• Yvonne M. Perret, MA, MSW, LCSW-C
• Executive Director
• Advocacy and Training Center
• 1116 Bedford St.
• Cumberland, MD 21502
• 301-777-7987
• yperret_at_hereintown.net