# Presentation: 239308

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

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

## 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

## 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

## 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

## 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

## 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)

## 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

## 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

## 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

## Sequential Evaluation

**Sequential Evaluation**

- Step 2—Does the person have a severe impairment?

- Step **3—Does** the impairment meet or equal the listing requirements?

**Step 4—Does the impairment allow for past relevant work to be done?**

**Step 5—Can the person do any other work, considering age, education, work history?**

- Person is working at SGA level.

- Person is not working or is **working** at less than SGA level.

**Person has no severe impairment.**

- Person has **severe** impairment.

- Impairment does not meet or equal the listing **requirements**.

- Impairment meets or equals the listing **requirements**.

- Person can do past  work.

- Person **cannot** do past  work.

**Yes**

- No

**Denied**

**Denied**

- Denied

**Denied**

**Approved**

**Approved**

**Step** 1—Is the person working?

- 29

## History of SSA’s Consideration of Substance Use

- 1961:  Substance use disorders considered under category of “personality disorders”
- 1972:  Beginning of SSI as well as SSA’s Drug Addiction and Alcoholism (DA & A) program
- Required those receiving SSI to have representative payee and to be in substance use treatment

## 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

## What Does Material Mean?

- To determine if substance use is material to one’s 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.

## 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

## 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, DON’t ASK!
- Often, trying to manage sequelae of early trauma  leads to substance use

## Early Trauma (continued)

- Questions to get at early trauma:
- When you did something your parents didn’t 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?

## 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?

## 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 didn’t graduate)?
- Were there any grades that you found you needed to do some extra work or needed  extra help?  If yes, what were they?

## 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 weren’t so tough?

## 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?

## 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

##     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

## 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 don’t 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?

## 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, Korsakoff’s syndrome, AIDS-dementia, etc.

## 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.

## 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 .

## 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 can’t sleep or do anything he used to be able to do

##  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”

##   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@hereintown.net