SOAR Webinar: Medical Summary Report Summer Camp

(muttering) [Woman’s Voice] So sometimes, I don’t, basically, I didn’t want
you to worry too much. But you can still call and
be like, hey, I got this. (laughing) You know how you do that, right? (muttering) Hello, everyone, and
welcome to the sixth webinar in our FY 2019 webinar series, titled: SOAR Medical Summary
Report, Summer Writing Camp. My name is Kristen
Lupfer, project director of the SAMHSA SOAR TA Center, and I’ll be your moderator today. Before we begin, just a few
housekeeping items to review. This training is supported
by the Substance Abuse and Mental Health Services
Administration, or SAMHSA, and the US Department of
Health and Human Services. The contents of this
presentation do not necessarily reflect the views and
policies of SAMHSA or DHHS. The training should not
be considered substitutes for individualized care
and treatment decisions. As a reminder, your lines
will be muted throughout the entire webinar, the
webinar is being recorded, and will be available for download on the SOAR website soon after. You may download the presentation slides and other materials now
by going to the top left of your screen and clicking
file, saved documents. Or you can visit the SOAR
website at, click webinars on that left sidebar and you can choose today’s topic. If you’d like to follow
along with closed captioning, you can open the multimedia
viewer at the bottom right corner of this WebEx application
and select high contrast, if you have any visual challenges. At the conclusion of the
webinar, you’ll immediately see a brief evaluation, which we
kindly ask you to complete, and finally, we’ll save
all questions and comments until the end of the presentation, at which time we will review instructions for posing questions to the
panelists, via the Q&A box. So it’s our intention that
by the end of this webinar, you will understand why it’s
important to include an MSR with your SOAR-assisted
SSI or SSDI application, what information is relevant
to key sections of the MSR, and how to write quality
MSRs and get them reviewed with feedback via (muttering) submission. So to reach those objectives, we’ll begin this afternoon
with presentations from Dan Coladonato, a
project associate here at the SAMHSA SOAR TA Center, we’ll hear from Jennifer Ankton, the Disability Adjudication Supervisor with the Nevada Bureau of
Disability Adjudication in Las Vegas, and Shaun
Kostiuk, the Client Financial Services Manager and SOAR
local lead at Pittsburgh Mercy, will share his experience (muttering) medical center reports. And then finally, we’ll
have plenty of time for questions and answers, facilitated by the SAMHSA SOAR TA Center. So providing today’s welcome
today is Dr. Mark Jacobson, SOAR project officer and
public health analyst in the Office of Program
Analysis and Coordination at the Center for Mental Health Services in Rockville, Maryland. Mark? – [Mark] To all of you joining us today, on behalf of SAMHSA and the
Homeless Programs Branch of the Center for Mental Health Services, I would like to welcome you
to this SSI/SSTI outreach, access and recovery webinar, called SOAR Medical Summary
Report, MSR, Writing Camp. As many of you know, SOAR
helps states and communities increase access to social
security disability benefits, for eligible adults, and
now children and youth, who are experiencing or
at risk of homelessness and have a serious mental
illness, medical impairment, and/or a co-occurring
substance use disorder. Today’s webinar will focus
on how to write quality MSRs and why it’s important to include an MSR with your SOAR-assisted
SSI/SSTI applications. I’d also like to welcome
and thank our presenters, Dan, Jennifer and Shaun,
for your willingness to share your expertise with us. I’d like to turn it back over to Kristen, who will be moderating our webinar today. Kristen? – [Kristen] Thank you, Mark. All right, so, Dan Coladonato
is going to kick things off with an MSR Overview and New
Findings on its Effectiveness. Dan? – [Dan] All right, thank you, Kristen. Welcome to everyone
that’s attending today, it looks like we have
almost 500 people attending, so that’s really great to see. I’m also really happy to be
joined by Jennifer and Shaun, and to get perspectives from
the field, and also from DDS. So I’m gonna go over the
medical summary report, what’s in it, why it’s important, and go over some
statistics that we’ve found about its effectiveness
when used with SOAR-assisted SSI/SSTI claims. So the medical summary
report is really a letter, which describes the individual
that you’re working with, the individual that is
experiencing homelessness and has a disabling health condition, that also describes their
limitations in functioning associated with those either mental or physical health impairments. The medical summary report will support the medical records that
you collect and submit with your SOAR-assisted
SSI or SSTI claims. It doesn’t replace the medical records, but it supports and
summarizes and highlights the most important parts
of those medical records for DDS to examine. Like I mentioned before,
it provides a clear link between the applicant’s conditions and their functional limitations. In some communities, it can
take the place of the SSA-3373, which is the function
report, and this is the form that you probably see come to you, as the person’s representative,
and also to the claimant or the applicant once the
case gets transferred to DDS, this report will get sent out. And because the medical
summary report covers everything that’s included in this report, and usually a lot more, it
can sometimes take place of this form. The medical summary report
also becomes medical evidence, as part of the claimant’s
file at DDS and SSA, when it’s cosigned by what SSA considers an acceptable medical
source, and I will go over what those acceptable
medical sources are later. The medical summary report
can be sent directly to the DDS examiner assigned
to the person’s claims, or it can be hand-delivered
to SSA when you deliver the additional SSA forms
that you’re submitting as part of this whole process. And essentially, the
medical summary report is answering the question:
can this person work and earn substantial gainful activity, despite their conditions
that they’re experiencing, and the resulting functional impairments? So at the SOAR TA Center, we
have a really helpful tool available for you to use; this
tool is especially helpful when you, if you don’t have
experience writing reports like the medical summary report, some people might have
experience writing behavioral health assessments, as part
of your clinical practice, but if you’re not a clinician
and this is your first time really writing one of these reports, this Medical Summary Report
Interview Guide and Template can be a really, really
helpful tool for you to use when you’re getting started
writing these reports. So we have this, this will be available, as Kristen mentioned, you can download it as part of today’s presentation. It’s also available on
our SOAR Works website, in the library and tools section, at the top of the homepage of the website. So this tool really, it’s used to help you gather information that’s needed to write the medical summary report. It provides all the potential questions that you can use as a guide
when you’re interviewing your applicant, and it covers
all the different components of the medical summary
report and what to include, for each component, and
it gives you questions that are geared towards the
person’s functional limitations which is really one of
the most critical parts of the MSR is to include
those functional limitations, and how that person struggles
to function, day to day. So the questions are geared,
the context of the questions are geared towards the
individual’s ability to work, like I said, at the substantial
gainful activity level, and also provides you with
questions to distinguish between a person’s access and ability. And what we mean by that is
if someone is experiencing homelessness, and they’re
reporting that they’re unable to cook for themselves, is
that because the individual is living on the street
and doesn’t have access to a kitchen, or is it literally
that they’re not able to, they don’t have the
necessary skills to prepare and cook meals for themselves? Another example is if a
person is recording that they can’t take public transportation, is that because they don’t
have the money to take public transportation, or
is that because they get so overwhelmed when they’re on a bus, when they’re experiencing
their mental health symptoms, and they’re unable to
successfully navigate public transportation to get to work or medical appointments or
wherever else they need to go. And we strongly encourage
you to use this tool, and the template itself
will help you organize and write your MSR and make sure you’re covering all the different areas that the medical summary report includes. So we just have some general tips for writing the MSR as well. We suggest that you begin
collecting medical records for the individual that
you’re helping with this SOAR application, almost
immediately, if that’s possible. Depending on the person,
it might take a few rapport-building meetings
for you to have them sign their releases of
information to start collecting their medical records, but
the sooner that you can get those releases and request
those medical records, the better, because having
these medical records, a complete set of medical
records, will make it a lot easier to begin writing the
medical summary report. We recommend that you go
through all the medical records and organize them in chronological order, this will help you to really
start to see the onset of the individual’s conditions, either mental of physical, and how their, it has affected their functioning
from when they started to experience the symptoms
and the conditions, to the current date. We also recommend setting
aside blocks of time to begin writing the report
with no interruptions, and sit down with all the
information that you need in order to write the
medical summary report, which includes the
person’s medical records, as I stated, if there’s an intake packet that you have with your
SOAR program that gets sent to you with a referral
for a SOAR application, and your medical summary
report interview guide. So here are the different
components contained within the MSR, and I’m gonna go through each one of these
components and talk about what should be included
in each of the components. All right, so the introduction section. So within the introduction section, one of the most important
things that you want to include in the introduction
is any diagnoses or conditions that the individual has, that the individual has or
has been diagnosed with, currently or in the past, so
this will give DDS an idea of what they’re gonna start looking for in terms of: does the individual meet one of the SSA blue book listings, the listing of impairments? Within the introduction section, you’ll also want to include
a person’s demographics, a physical description,
any unique characteristics of the person, and then
also your observations, as the SOAR case manager,
how does the person present when you’re meeting with them? Do you observe any symptoms
of their mental illness or their physical impairment? This will really help DDS to
begin to see the individual as you do; you’re gonna
probably have a lot of contact with the individual
over the course of time that it takes you to
complete the application, so you’ll want to
include your observations of that person’s symptoms,
their mannerisms, and their behaviors. And then the personal
history section of the MSR, this will include childhood
and family information, education, and legal history. And I know Shaun’s gonna
also cover this a little bit, during his presentation. However, I just wanna touch on
a few different things here. In terms of the childhood
and family information, don’t really, excuse me, you
don’t have to necessarily tell the person’s entire story. You wanna basically include
information within this section about how their childhood
and their family background relates to any current
diagnoses or functioning. If you are gonna explore
the person’s trauma, if they’ve experienced
trauma and have subsequently been diagnosed with an
anxiety disorder like PTSD, you would wanna include,
you don’t have to go into great detail about the trauma, but you can just include it,
that they did experience that, and how did that affect
them over the years, and how does that affect them currently, in terms of their functioning, and the symptoms they experience. With someone’s education,
you wanna include what the last grade they
completed, any struggles or symptoms of their diagnoses
while they were in school? Were they involved in special education, did they have an IEP? You would want to include
that relevant information, and then with the legal history section, a brief overview of the legal history. You don’t have to
necessarily include all the, every, if a person has an
extensive legal history, you don’t have to include every time they were incarcerated, or
the dates of incarceration, that kind of thing, but you want to, we want to include any connections between the person’s symptoms and contacts that they had with the police. So, an individual is homeless and is experiencing active psychosis, and has continued interactions
with the legal system, and oftentimes gets taken
to jail instead of maybe taken to the hospital, that
would be what you would want to include in there,
and also if a person did receive psychiatric treatment, while they were incarcerated, you wanna include the dates, the provider, and information about the
treatment they received while they were incarcerated. The employment section of the MSR. So this is a really important
section to be as thorough as possible; I know
oftentimes if an individual is homeless and hasn’t
worked in quite a while, it can sometimes be challenging
to gather this information, but you want to be as complete
and as thorough as possible when you’re documenting
your employment history. You wanna describe the person’s past jobs, including how long they
stayed at each job, the different tasks they performed, and any struggle that they had at work, and why they left. Those are all really important to include, and also, how can we
connect the difficulties that they had on their jobs with their mental health symptoms, and
other health conditions? Because remembering that
in order to meet criteria for social security disability,
an individual not only has to have a disabling health condition, but it has to severely
impact their function level. So connecting their
difficulties in maintaining work with their mental health
symptoms is crucial. If you are able to
contact former employers, that is extremely helpful,
and you can include quotes, or a written statement from the employer, and also include quotes from
the applicant that you are serving and helping to
submit a SOAR application. You would also want to include an overview of their military service,
if the person is a veteran. So the substance use and
co-occurring disorders section of the MSR, this one is always, or not, I shouldn’t say always, but
it can be very challenging if the individual has been
homeless for a long time, maybe has a spotty treatment record, and also has a co-occurring disorder. So, the way DDS looks at
cases where the person has a substance use history
and a co-occurring disorder is that if the person’s
substance use is deemed to be material to the person’s disability, the benefits will be denied. However, the determination
does not necessarily require that the person be sober
at the time of application. However, it’s important to understand what is meant by materiality. So, if a person is clean and
sober and their functional impairment does not
exist, they would not be, while they’re clean and sober, the person would not
be considered disabled. So essentially, if the
person is experiencing severe depression while
they’re drinking alcohol, and then they stop drinking alcohol and their depression symptoms go away, that person likely would not be considered disabled by social security’s rules. If a person is experiencing
active psychosis while they’re using stimulants, and they quit using
stimulants and they’re sober for a period of time and
their psychosis goes away, likely that person would
not be considered disabled by social security’s rules. So what’s, and like I
said, I know this can be, I’ve done a number of SOAR cases myself, oftentimes the cases
that I have helped with, the individuals did have
co-occurring disorders, so it can be challenging. However, if you are able
to talk to the person about any periods of
sobriety that they’ve had, were they hospitalized for
extended periods of time, were they in longterm
psychiatric treatment? Were they incarcerated
for periods of time? Did they go to any substance
abuse treatment programs? And if you can try to talk
to the person about that, get dates and get those records, and use those records to try
to document if the person still had severe symptoms
of their mental illness while they were, during
these periods of sobriety. All right, and the physical
and psychiatric health treatment sections, for these sections, if an individual doesn’t have
a physical health condition, obviously this, you wouldn’t
need to include that section, but if they do, you wanna definitely discuss any diagnoses
that the person has been, has received over the years, and current, and also give a brief
picture of chronological treatment history for the individual, both with physical health diagnoses and psychiatric health treatment. You would want to include
specific quotes from the applicant and their medical records that illustrate their symptoms. Any observations of their behavior, both from you as the SOAR case manager, and also from all the treating providers. So what I would do when I was writing medical summary reports
and covering these topics is I would go through the medical records and make sure that I include,
for each treating provider, include what the diagnosis
was that was assigned, and what the symptoms
are that was observed, and also what treatment that was provided. And if it’s in the medical records, how the person responded
to that treatment. Did their symptoms get
better, did they seem to function better while
they received that treatment, and after they received that treatment, or did they not respond
well to the treatment, and their symptoms persisted? That would be the information
that you would want to include in these two sections here. And durational issues,
what we mean by that is how long has the, either
the physical health or the psychiatric health, diagnoses, when was it established and
how long has the persisted? And if there’s anything in
the medical records about how long it’s expected to persist, so is it expected to
last 12 months or more? That would be something
you would definitely want to include in these sections. And also a current mental status exam, DDS is, for mental health
cases, DDS is looking for a mental status exam
within the last 90 days. So, information about
functional limitations. This is arguably one of
the most important parts of the MSR, to make sure that
you’re covering completely and thoroughly; for mental health cases, there are four areas of mental functioning that DDS will be looking at to determine whether the person has
either marked or extreme limitations in those four areas. Within those areas, you’ll
also want to discuss any effects or side
effects of the medications that the individual is taking, and describe any supports
that the applicant receives, and compare those with lack of support. So for me, this came into play a lot when I was writing
medical summary reports, because I worked for an assertive
community treatment team, and we provided a very high
level of community support to the individuals that we served. We would sometimes see
them five days a week, three, four, five days a week, and we would provide
them a lot of support, everywhere from monitoring
their medications to taking them to community appointments, to trying to help them get back into work. Just a full range of services. And what I would find
is when I was writing the medical summary reports,
when I’m looking back at records before they
got into our program, they appear to function
at a much higher level with that extra support that we provided, compared to when they first
came into our program. So it’s important to note
what the person’s functioning looks like with extra support
that they’re receiving from either a community-based service or a family member or a friend. All right, and here are the
four areas of mental functioning that will be examined by DDS
for mental health claims. They are: understand,
remember, or apply information. Interact with others. Concentrate, persist, or maintain pace. And adapt and manage oneself. So understand, remember
or apply information. This includes the person’s
memory, a person’s ability to follow instructions on
either written or oral, a person’s ability to solve
problems, simple or complex. Under interact with others,
this involves an individual’s ability to get along
with others on the job, at home in the community, et cetera, the person’s ability to manage
their anger or frustration when corrected at work
or when given guidance or suggestions, a person’s, if there’s any avoidance behaviors or isolative behaviors that the individual is engaging in? That would be the information
that you would want to include in interact with others. And then concentrate,
persist, or maintain pace. This includes a person’s
ability to complete tasks, focus on details at work, at home, in the community, a person’s
distractibility at work. You would also wanna
include in this section if a person’s able to,
not only if they have concentration issues, but also, are they able to persist with tasks? Are they able to, if they’re working a job where even though the tasks
are simple involved in the job, are they able to persist
and complete those tasks and maintain the appropriate pace over an eight hour workday
or a six hour workday, whatever their previous
work schedule included? And adapt or manage oneself. This is a person’s ability
to attend to their hygiene, respond to change appropriately, regulate their emotions appropriately, set realistic goals for
themselves, et cetera. There used to be an area
of mental functioning that was just activities of daily living, and the individual’s ability
to complete those activities of daily living, but
they are now considered, throughout all these four areas. So you can include any
functional limitations within these four areas as it pertains to activities of daily living. So within each of these four areas, you wanna make sure
that you try to include as many examples as possible
of the functional limitations that the individual is
experiencing as a result of their disabling health condition. In order to meet the criteria
for the SSA disability, the person would have to
either have marked limitations in two of the four
areas, or extreme in one. So the more examples of
their functional limitations within these four areas
that you can provide, the better for DDS. And the last section of
the MSR is the summary and contact information;
this will tie together all the information that
you have previously provided for a concise picture of the individual. Some people like to restate
the diagnoses here, and just, just a nice, just one
paragraph summary conclusion. You’ll also wanna include
your contact information as the SOAR case manager,
so the DDS adjudicator knows who to contact if
they have any questions about the report, and
then also if you’re able to have it cosigned by an
acceptable medical source, and you can see here on the slide what’s considered an
acceptable medical source. That would be a physician,
or a PHD psychologist, PsyD psychologist, nurse practitioner, there’s a few different
categories of advanced practice registered nurses, a
physician’s assistant, or an audiologist. All right, and I also just
wanna mention that we have a number of MSR examples on our website. This is also in the
library and tools section of the SOAR Works website, and as you can see listed here, there’s pretty much every
mental health diagnosis that you might encounter;
I’m sure there’s not every single one on there,
but there’s a lot of them that you could review if you’re
working with an individual that has schizophrenia, you could, you can review that
medical summary report, and also, as you’re
getting started with your medical summary reports,
or even if you’ve already submitted a few, if you
want some extra support, you can send a redacted
medical summary report, just remove all the personal
information of your client, and you can send that to
us at the SOAR TA Center, and we can review those and
provide feedback on request. So don’t, don’t hesitate
to use that support if that’s something you feel you need. And the last thing that
I want to talk about is the effectiveness. So the medical summary
report can, it’s definitely the most, the longest thing
that you’ll have to do as part of the SOAR application. It does take time, collecting
the medical records, going through the medical records, writing the medical summary
report can be a lengthy process. But we want to provide
you with some statistics that we found, to show you
that the work is worth it. It is worth it, and what
we’ve found through examining over 23,000, almost 23,000 applications in our online application tracking system that we maintain, is
that the use of the SOAR critical components, including
the medical summary report, statistically increases the
likelihood of an approval, and reduces the days to
decision on initial application. We found in this, the 23,000 applications were tracked over the last 10 years. We found that applications
with an MSR were more likely to be approved, and also
having the co-signature on the MSR increased the approval rate by 13 percentage points, so
that’s pretty significant, and this was recently analyzed data, and we’re really happy to be
able to provide you with that, to show you that the good
work that SOAR practitioners across the country are
doing, including all the SOAR critical components and
the medical summary report, is really paying off for those individuals that are experiencing homelessness. So with that, I’m gonna wrap up my portion of the presentation, and
turn it back over to Kristen. – [Kristen] All right,
thank you so much, Dan. That was great; we really
appreciate your perspective and hearing about your
experience, as well. And so I’m going to turn
things over to Jennifer Ankton, with the Nevada Bureau of
Disability Adjudication, to talk about MSRs from a
Disability Determination Services Perspective. – [Jennifer] Thank you, Kristen, and thank you Dan, for
providing an excellent overview of the MSR and how it relates
to the social security disability program and
application process, provided a lot of information
that I think is essential to the disability application process. So some of the information
that I’m going to share may be, derivative of what Dan has shared, but I can go into a
little bit more detail. So basically, I will be
addressing the factors that are relevant to DDS, and if we go to the first slide, for the disability
adjudicator, a well written MSR should provide a brief
summary of the claimant’s medical impairment and
how their impairments inhibit their ability to
perform work-related tasks. The key components the DDS
reviewer is considering in review of the MSR is
the medical diagnosis and how it was established. We’re looking for any treatment history that they have received,
the type of treatment, and the response to treatment. And we want to know, wanna be
able to answer the question: how does their condition affect
their ability to function? Next slide. The summary of evidence
outlined in the MSR should be supported by the
objective medical findings, to include the signs
and laboratory findings that establish the MDI or
medically determinable impairment. Social security defines
signs as the anatomical, physiological or
psychological abnormalities that are observable,
such as gait disturbance, limited mobility, abnormal
behaviors in mood, deficits in memory or orientation. Laboratory findings are defined
as one or more anatomical physiological or psychological phenomena that is evident in diagnostic testing, such as medical imaging,
which would include X rays, MRI, CAT scans, EEGs, ECGs, blood tests and psychological testing. Next slide. In regards to the treatment history, the MSR should provide
some details of past and current treatment, showing
the longitudinal effects of the claimant’s impairment. Reports of treatment should be relevant to the impairments alleged. Pertinent treatment history
should include medications, mental and physical
therapy, hospitalizations, frequent ER visits and
surgical interventions. Statements regarding the
response to and/or changes in treatment and side
effects related to treatment can be useful in the
reviewer’s assessment as well. Next slide. As Dan mentioned, the
functioning is a critical piece of the disability adjudication assessment. Functional information
is a significant factor in assessing the severity
of one’s condition. Collateral information provided
in the MSR is typically a true reflection of the
claimant’s limitations. What we have found in
applicants’ submission of the daily activity forms
or the 3373 is that is not always a true reflection
of the limitations that they may have; some
of them will struggle with even knowing how
to answer the questions, and they may have limited
insight, so therefore they’re not going to answer the questions accurately. So if we’re not able to
get collateral information from a family member or a friend, I do find that information
provided by a case worker, someone that is actually
visiting with this claimant on a regular basis, and just
based on their observations on how they’re able to function, we find that to be a
more accurate assessment of any limitations that they may have. Some of the key functional
information to include for physical impairments
would be difficulty, difficulty in standing and
walking, for a length of time. In addition to that, if
someone has to use like a cane or a walker, mentioning
that if it’s needed to even get up from a sitting
position, if they need that assistive device to actually stand, or do they need it around the home, or if they need it just
outside of the home, that is a good piece of
information to include in that. If they have any weight
restrictions in lifting and carrying providing the specifics on that, if they can’t lift more than 10 pounds, that’s critical for us to know. And then indicating if there’s
any limitations in bending, stopping or kneeling. That is helpful as well. Limitations in hand function, that would be decreased strength,
do they have any weakness, difficulty grasping things,
if they have difficulty with their clothing
items, zippers, buttons, picking up objects such as a coin, if they talk about
dropping things frequently, not being able to hold
things in their hand, if they have difficulty
writing, that’s helpful as well. How long does it take them
to complete certain tasks, you know, such as cooking
and chores or, ah, in this situation that may
not be applicable to them. If they are homeless, and they don’t, ah, if that’s not applicable
to them, that’s fine. You can just indicate that or
leave that information out. Just, you know, indicate that
they’re not in a position, at this time, to do that. You know, we take that into consideration, and that’s not something
that will be critical to, ah, that specific person. Next slide. The key functional information to include for mental impairments,
as Dan mentioned before, some of the things that we’re looking at is difficulty with
attention and concentration. Do they need encouragement
to complete tasks? And that could be either
their personal care, or even to if you think
about encouragement as, do they even need encouragement
to apply for services, do they need to be encouraged
to seek into certain programs, or do you have to encourage
them to seek treatment? That information would be helpful. Are they able to follow
written and oral instructions? Think about if you’re meeting with them and you’re interviewing
them, do you have to repeat the question or reword the question so that they’re able to comprehend? Do you have to assist them
if they’re going to apply for services, are you
assisting them in completing, you know, forms out? Do they have difficulty
getting along with others? Are they isolated, are
they, has their condition affected their relationships,
as far as, you know, family or did it affect
their working relationships? And how do they respond
to stress or changes in their environment? And that definitely can
be your observations or observations made by, you
know, a mental health provider. I’ve even seen where certain
claimants may respond negatively if there has been
a change in who is actually treating them, like a therapist, so those types of
observations would be helpful to include as well; next slide? How is the MSR Beneficial to DDS? The MSR may assist the adjudicative team in determining the next appropriate action leading to an expedient
and accurate determination. If we have the MSR in file
when we receive applications, that is definitely a good
starting point for us. We are able to determine
at that time if there is a lack of treatment, will we
need to get an examination? And it provides us that
story that we need. Because when we’re presenting the case, we’re making our assessment in determining what that decision is going to be, and our writing, we’re
basically telling the story. So having that information
upfront gives us a head start on how to prepare that case,
and kind of prepare that story, particular to that claimant. The MSR can provide the
supporting collateral information that is missing from the medical
and not medical findings, and again, that was, non-medical
findings we do consider would be outside source statements, such as ADLs, third party ADLs, a lot of times we’ll look
for information because we don’t see them face to face, we’re looking for any
observational information that may have been done at
the social security office. So when, you know, as a social worker, case worker, when you’re
meeting with them, and they’re, in their presentation, if they’re disheveled
and if there is issues in regards to their
hygiene or orientation, if you’re able to provide
statements regarding that, that gives us a better
understanding of this person’s presentation or how they’re
functioning, basically. And like I said, the MSR
can provide a more accurate assessment of functioning. And one of the things
that we’re looking for are consistencies or inconsistencies, and a lot of times if we’re
looking at progress notes, if it’s related to mental health, if we’re looking at progress notes or medication review
notes, a lot of times, the information can be
kind of cut and paste, and we don’t get that accurate picture of how this person may be
responding to medication, you know, if they’re progressing. They can give us one more
statement, or, you know, claim they’re doing well or stable, but they may not make
a statement regarding what their presentation is each time. So if, so in that sense, we
will find some inconsistencies, but if we have one person
such as a case worker who is able to, you know,
based on their observations in working with them,
they’re able to provide that statement, that, we
will look at that statement as more credible than
some of the information that may be missing or
some of the statements that may not seem correct
in the medical evidence. And then just in closing,
I do want to say, I’m (muttering) now, but I have
17 years adjudicating claims and I really think this
is a great tool to use, and it’s extremely helpful
for the adjudicator, and I think it is the tool
to expedite the process. (muttering) – [Kristen] All right, thank you Jennifer, we really appreciate you taking the time, sharing your expertise, and really sharing the importance of that MSR to DDS. I wanna take a little clip of
your last few sentences there and play it for folks who
are wavering on whether they, they think it might be worth
the investment of time. So, with that, I’m going
to turn things over to Shaun Kostiuk, the Client
Financial Services Manager at Pittsburgh Mercy, in
Pittsburgh, Pennsylvania, to talk about Winning MSR Tips and Tricks. – [Shaun] All right, thank
you Kristen, thank you Jenn, thank you Dan; I’d like
to take a little different approach to things because we spent, we just got a lot of awesome
technical information about kind of the technical
side of how you’re writing your MSR and what the adjudicators and the folks at DDS are gonna
look at in their process. What I’m gonna try to do is
supplement that a little bit, but also, from the perspective
of someone who’s written multiple medical summary
reports, honestly, what are the approaches
that you need to take, what are things you need to look for? And not necessarily the process side, but like, like Kristen said,
what are the winning tips? What are things that, you know, how can you draw on your experience? Because we all got into social work for one reason or another. Probably not because we’re
mathematicians or accountants or engineers or scientists;
we’re really good with people. That’s why we’re in this field. So how do we leverage
the skills that we have to build an MSR? Also, knowing that we’re good with people, we might not be Pulitzer Prize
winning authors or writers, or have the greatest writing skills. Your big takeaway I want you
to hear loud and clear is: that’s okay, you don’t need to be a strong technical writer to write
a medical summary report. What I wanna do is take
a 30 second brain break from the technical side of
the medical summary report. So we all work with
people, in some capacity. Think about a family member,
a friend, a loved one, someone that you know really well, that you have a close relationship with. Someone you know how they operate, and when you see their behavior, if it’s out of the ordinary, you usually can diagnose
what the trigger is. What did they experience, or
what did something you said, or something you did, or
something that led to that change? And think about, so in
my case, I use my wife. When my wife gets quiet
and she goes to bed early, I know I have to think back on, oh, gosh, what did I say in the last 20 minutes that she’s, we’re separating on? Okay, because I know how she operates. So, and what makes that
relationship so special is we’re engaged with that person. So think about that
before you get overwhelmed about needing to write an MSR. I really wanna stress how important it is, the relationship you
have with that person, and how well-engaged
with that person you are, because that is going
to aid you immensely. Anyone can sit down and
collect medical records and pull stuff from there
and put it in a report, but it’s your level of
engagement with that person, to be able to elicit all
the really, really useful functional information in their history that is gonna supplement
the medical portion of it, that’s gonna help, honestly, it’s gonna make the MSR write itself. So just think about that, okay? And then take a deep breath. Okay, so we all wanna write an MSR. Congratulations, all right? Let’s follow the rules. First thing, like I just
said, don’t get overwhelmed. Rule number two is: refer
back to rule number one. Don’t get overwhelmed; you can write this. Anyone can do it, whether
you have a psychology degree, a math degree, high school diploma, GED, whatever, you can do this. And again, if you’re still
overwhelmed when you’re writing it, an MSR is not
gonna hurt someone’s claim. It can only supplement
the medical information that DDS is getting, okay? Only good things are gonna happen. And I said before, you know, we’re, many of us are case
workers, not English majors, not journalism majors. So, the other thing I
want you to think about, when you are sitting down to write an MSR, now that you’re calm and prepared
and you’re not overwhelmed at all to put together a
six or seven page report, also keep in mind the
person you’re in front of, everyone’s in a different situation. So lean on the engagement
piece and your skills on engaging people, and find
out what makes the person you’re working with, what
makes their situation unique? And then highlight that. And also, I think it’s also important, and one thing I’ve learned
listen to Jenn talk is, be aware of your blind spots. And what I mean by that
is a lot of us might have a strong history in mental health. Such as myself. and Dan, actually
just learned that you have years working at Actium,
I had the same experience. So I really appreciated
you addressing that. But I think a lot about
mental health symptoms, and when I see (muttering) folks that have a lot of physical health
issues as well, it’s almost, I don’t wanna say it’s a
deterrent, but I don’t know that I even give that as
strong of attention as I could, because I know I’m not
as strong in that area. But when you look at what Jenn just said, that’s really important. So know your blind spots. If you have someone
else, another colleague, who might know that area pretty well, don’t be afraid to ask a
question or two about it. Or if you have an
adjudicator DDS that you have a good relationship with,
don’t hesitate to give them a quick call and see if
they can afford five minutes to explain how that might be useful, or what would be important for them to know about that condition. So okay, so real quickly,
on the different sections when we look at the personal history, and like I said, I think
the biggest mistake I made when writing MSRs throughout the years, especially my first few months, is I felt that I needed to give this extremely long, detailed narrative so the
person knew every little detail about the individual I’m working with. And what I learned is: less is more. To echo what Dan said, just
include what’s relevant. If their childhood and
upbringing and family, if that’s not relevant to
their current condition and functional limitations, you don’t need to include all that. If the person moved 15
times because they were in the military, but that’s
not related to their condition, you don’t need to include all that. And again, touching on the
physical health history, if it’s unremarkable, if someone’s healthy and they have no history
of any medical procedures, surgeries, complications, any problems, one succinct sentence that says: John Smith’s physical health
history is unremarkable. That’s all you need to put. Okay, diving into substance abuse, like I have there, be honest. I think this is the one
section where, as a writer, if you’re working with someone who has a substance abuse disorder, it
can be a little intimidating, a little frightening,
because your natural instinct is you don’t wanna share what might be damaging to their claim, but be honest. That’s the one piece that if
you try to cover something up but it’s in the medical records, your credibility just went
out the window by doing that. So if you are working with someone who has a substance abuse disorder, first, again, document it and say it’s
there, but highlight what treatment this person received. Highlight periods when they’re clean, and if this is someone
who is frequently using or under the influence,
highlight when you see them and they are not that way,
and when they are clean, and if you see a difference in functioning when they’re clean, working with you, versus what’s in the medical
record, highlight that. One tip though: from
working with that person and reading the medical
records, if you’re not able to determine that the
substance use is not material, so if you can’t tell a difference from when, if they’re
functioning looks the same when they’re clean and
when they’re, excuse me, if it looks very different
and someone functions really, really, really well
when they’re clean and sober, and they have a lot of
symptoms when they’re under the influence, if you can’t
prove that’s immaterial, DDS is not going to be
able to do that either. So you might want to
have an honest evaluation of the person you’re working with. That can be a really hard
conversation to have, but education and that, again,
engagement with that person is really gonna help you there. So, work history. What’s super important,
I wanna stress here, how many people do you
know are really open and comfortable sharing things on the work that they’re not good at? Or things at the job
that they struggled with, or reasons they were fired from a job? No one, no one wants to share that. So keep that in mind when
you’re authoring this section. And I, you have to be delicate. Tease out that information, you know? Organically, we’re going
to be guarded about that, about why we lost the
job, or why we only stayed on the job for two months
or two weeks, or two days. And if someone is resistant,
if they’re real guarded about it, that’s okay, just, you know, you can move on to another section. But again, that’s where your
engagement with the person is really gonna be helpful,
and if you are delicate enough and strategic in how
you work with a person, they’re gonna come out and
give you what happened, and their side of the story,
and what you might learn from that is really
valuable, what happened, and you might see that their
insight into what happened might not be the same as
what reality tells us. For instance, it’s really
common, I work with people and they say they had a
supervisor or a coworker or coworkers who were out to get them, and they just had it out for them. And then you look and
say: ding, ding, ding. This person has an
accompanying anxiety disorder. Well yeah, it makes sense. It makes sense that you
have difficult relationships with your coworkers; lean on that, when you do your work history section. But again, when you’re
interviewing the person, be really open-ended. That’s the best way to
get important details. And then the functional areas, again, to me this is the bread and butter. I mean, I think the medical summary report is the secret sauce of
the SOAR application. And I think to me, the function areas are the bread and butter of your MSR. That is where you can really
succinctly pull together those really nice examples. What are you seeing? And when I meet with
folks for the first time, I tell them, I say hey, you know, when we meet, I’m gonna
ask you some questions. I’m gonna take some stuff down. Don’t be alarmed if I’m writing slower, or I’m writing a lot,
I’ll slow things down. I tell them, I say: I’m
gonna write a lot of quotes from you because the person
that makes the medical decision on your claim is never gonna meet you. I said: they’re never gonna see you. They might talk to you on
the phone one or two times. I said: so part of my role
is to be the eyes and ears of that person, to share with them things that your doctor might not
have written in a note, or might not be in a hospital record, or might not be in a therapy note. You know, I really want
to give them as much evidence as possible on why
working is difficult for you, or why you’re not able to work
because of your condition. So and again, that’s part of engagement. I think I start off with
that in my intakes of folks, and that really helps
anxiety levels go down. Because normally, think
about it, if you’re meeting with your doctor or a professional, and there’s this period of
silence because someone’s taking notes, it gets
a little off-putting, a little intimidating, but again, if you can tell them
right off the bat, hey, this is why I’m doing it, sometimes people go the
total opposite direction, and they’ll say: oh my goodness, I can give you so many quotes. Let me tell you about this,
let me tell you about this, let me tell you about this time. And you really build a good relationship with the person that way. The other thing about the functional area that’s so important is when you’re working with someone and there’s not a lot of, and they might have very limited evidence, or maybe the evidence isn’t that strong, again, we’re all in social
work, we’ve all worked with people throughout the years that, from our observations, you
kind of look at the person and you say: I know that this person, I just know that they would
have a lot of trouble working, and I know there’s a
reason they can’t work, and sometimes it’s where we’re educated and we’re able to pinpoint
out those folks and why, but if it’s not in a medical record, that’s where the MSR
really strengthens that. It’s our opportunity
to support that person and share all those reasons,
those non-tangible reasons, to put it in writing
and show a third party: hey, this and this and
this and this and this. All these things are the
reasons this person can’t work. These are all the
symptoms the person faces. Because you also have to
keep in mind, when folks meet with doctors or therapists,
there’s naturally still a level of, you know, social desirability. There’s things that you
don’t want to share, things you struggle with. But when you’re working
with your SOAR worker, and you’re just an open
ear and someone has a good relationship with you, they’re gonna open up and
tell you all sorts of things. So we’re really in a really nice position to get a lot of that great detail. So okay. What I’m gonna dive into
now is a few case studies. And this was difficult in
narrowing it down to two, but I want to share with you two cases that really stood out to
me, and kind of the approach I took in writing their MSR, and why I believe their
MSR was so helpful. So the first case study, his name’s David. At the time we worked
together, he was a 27 year old single white male; his
diagnosis was major depressive disorder with generalized
anxiety disorder/social phobia. But what’s really
important, he had a really, really, really limited treatment history. And when I say limited,
I mean he had one crisis mobile team called to his
home once in his adult life, one evaluation at an
emergency room, and he was currently engaged in mobile
mental health treatment. Mobile mental health is, in
Pittsburgh it’s individual therapy, only the
individual therapist comes to a person’s home once a
week to do that therapy, rather than be clinic-based. So it didn’t have a lot to work with. What’s also really important
I want to point out is his medical summary
report, since he did not have a treating psychiatrist,
it was not signed by an accepted medical source. So that’s something else
that was in play here. So I really had to rely
on my observations, my engagement with this young man, and where we were fortunate
is he lived with his sister. His sister was very supportive, they’d lived together their entire lives, moved around a lot and it
was unbelievably helpful to have her there, because
when this gentleman presented, and I introduced myself,
he put his head down and looked at the floor; he
did not verbally respond to me. He limply extended his
hand so I could shake it. When I would ask him
questions, he would look at me and freeze up and immediately
look at his sister, and wait for her to respond
to my question for him. That’s how severe this man’s anxiety was. We learned more about
the function information, and it turned out he’d
worked twice in his life, but both times were due to nepotism. They were facilitated by family members. The one time he went to an interview because a family friend owned this garage that he was interviewing for,
but he told me he locked up and would not respond to any questions that the gentleman asked him. The manager who owned
the shop knew the family and decided to take a chance on him, just because he knew the family. None of that is gonna
be in a medical record. So it was really important
to get those stories and those really succinct
examples from him and from his sister. More importantly, another
thing he dealt with is he only left the house
once a week with his sister, to go to the grocery store. And they both said that he would
just stay right by her side and he would have, if
he went down an aisle, and she were to say to him: hey, go down and get a can of black beans. He would go down the canned goods aisle, and stand there, and if there
were two different brands of black beans, the
anxiety of choosing between the store brand and the
Bush’s brand would be too much for him to make a decision,
and he would stay there until his sister came and picked him up. So when I talked, so again,
I know I’m hitting hard on engagement and observation, but it’s so critically important. So getting back to the medical
summary report on this guy, again, not a lot of medical evidence, but when I say it was heavy
on observation examples, that’s what I’m, ah,
it really, really was. But it turned out he was
approved for SSDI in 54 days. No consultative examination
was ordered for him, and they agreed with
the alleged onset date that we put on the application, and the medical summary report and the supporting documentation, he ended up getting over
$11,000 in retroactive benefits. So that’s a case that stands
out that I really like. And we’re gonna flip to the other side. I’ll be a little quicker
with this gentleman. Gentleman’s name is Keith, at
the time we worked together, he was a 60 year old single white male, also diagnosed with major
depressive disorder, with incipient, pre-senile dementia and severe alcohol use disorder,
which was in remission. It was different, this
gentlemen is obviously, he was much, much older, he also had a very long work history. Keith very proudly was a
steelworker for 27 years, worked in the mills for the
better part of three decades. And when he lost that position,
he then went back to work as a security guard for 10
years, and that position ended in 2017 when he was hospitalized. So this gentleman worked for the better part of four decades. Finding out a little more
information about his work history when he worked as a security
guard, he worked overnights. And he sat behind a desk in
an office building downtown, where no one else was there, and his job consisted of
sitting behind a desk, watching a monitor, and
rounding in the parking lot, or parking garage once every few hours. So the first thing I picked up on there is he had no interaction
with people whatsoever. Prior to that, working at the mill, he shared with me again, that’s
a lot of independent work, and he was very heavily
using alcohol at that time. So again, he had symptoms
that he was dealing with at that time, but he was
coping and using alcohol. So all this kind of goes
in the Rolodex of my brain, and how can I leverage that
later on down the line? So, going back to January
’17, I have on the note here, that’s the first time he had an encounter with mental health treatment
was when he was 60 years old, after he worked for 37 years. So how the heck are we
gonna prove this guy is permanently disabled if
he has no treatment history? But it turned out, between
the symptoms we got, he had one inpatient hospitalization, the record were phenomenal,
it turns out a family friend found him in his home,
this gentleman, Keith, lived in the home of his deceased parents, so he had only ever lived in this home, turned out that he had been
laid off for two months, he had lost 40 pounds over
the course of two months, because he was not eating,
and he was so depressed, his home was completely squalor. There was rotten food in the refrigerator, as I said before, lost tons of weight, his hygiene was horrible,
so he was treated in the hospital on a
302, then had a step down at a diversion and acute
stabilization unit, and that’s when him and I met. That’s when him and I met and we worked together on his application. So in Keith’s case, his MSR was signed by a treating physician,
and he was also approved for SSDI benefits in 57 days. No consultative examination needed. And again, he had a very nice award amount of almost $1,900 a month. His first payment was
two months post approval. Because he had that
five-month waiting period. So I think in this case,
they agreed with the January onset date and his first payment
came out in June of 2017. So okay, so now that
we’re all warm and tingly from some case studies, I
have probably a thousand more I could share, even when Dan was talking, I had four other examples I
wanted to throw out there, but for the sake of time, I’ll save them. But a couple important things, what’s just as important
as knowing what to include and what to look for
when you interview people and what do you put in MSR,
are things you definitely don’t wanna do; like I said before, don’t jeopardize your
credibility by giving an opinion or exaggerating. It’s a report; it’s not an editorial. It’s not your opinion of somebody. It’s what you can see
and what you can prove. Also, very, what could
be a rookie mistake, don’t ask every question
on the interview guide. I think there’s at least a
billion questions on there. If you want to save yourself
from being overwhelmed, certainly don’t do that. That’s a really, really
comprehensive guide, and there’s a lot of great
questions and great approaches to take, but it’s not
meant to be mandatory to ask all those questions. I said before, don’t leave off quotes. Quotes are insanely important. Also, what is important is being succinct. Like I said before, when I
first started writing MSRs, I was writing 10, 11, 12 pages. In the first section, where I cut down, was in the personal history, because I was writing two
pages of personal history, per medical summary report,
and really I needed, oh, I don’t know, a paragraph, maybe two. So that was, it was lump
I took when I started, but that’s okay. And again, I talked about:
don’t try to be too technical. Having technical language
and technical writing is not a replacement for content. Keep that in mind. Layman’s terms are perfectly acceptable, and I’m sure you can ask an adjudicator, they’re probably refreshing
after sitting down and reading medical
terminology all day long, probably a layman’s report is pretty nice. A nice little break from things. And also, when you’re
sitting down to work on it, if you’re stuck, what we
laugh about with my staff all the time is, all the staff will, he’ll leave his office, come into mine, and he’ll say: Shaun, I just
wrote the same paragraph seven times and deleted it
over and over and over again. Because, and I’m sure we’ve
all been in that situation. If you’re stuck, don’t
stare at a blank screen. Just move on to a different section. If you’re stuck on substance use history, because the person is currently using, and you don’t know how to
succinctly highlight sobriety, then go to the functional areas,
go to the personal history. Go anywhere but the substance use section that you’re stuck on and have been looking at for 30 minutes. Also, when you’re writing,
to complement what Dan said before: use your own writing style. There’s no proscribed method
that you have to set down and follow when you’re writing this. We all have different approaches, we all are comfortable in different ways. One thing I do is when I
do an intake with someone and I know that they’re
going to be a good candidate, I immediately upon finishing my intake, I open up an MSR and I
hurry up and I blaze down as many quotes and
observations as I can remember, and anything that’s gonna
be helpful, I write down, because guess what? I’m probably gonna forget in five minutes. But when I open that MSR a week from now, after I meet with him a second time, that’s gonna come back so quickly. And it’s a really good opportunity just to keep all those things you see. Because again, people present
differently from time to time. Also, when you think about functioning, think about the persistence area. And if you have someone
who is missing appointments with you, you can tie
that back to their ability to manage themselves,
and their persistence. If they are having difficulty
keeping an appointment with you to help them get benefits, it’s an apples to apples
comparison on them being able to get to work to make money, doing a job. So leverage anything you get. And okay, very quickly, just
some things to remember. And again, I’ve pounded
this home, and I’m sorry for being so repetitive,
but when in doubt, focus on the person’s functioning. If you look at someone
and you think this person is gonna have a lot of difficulty working, but it’s not in the
medical record, well, why? Observe it, write it down, make sure the adjudicator knows that. Also, when in doubt, if
you’re more technical, refer to the blue book;
it’s very concrete. It lays out there: this
is what we look for, based on the condition or
conditions you’re claiming. I can’t, again, can’t speak
enough of what’s available on the toolkit, on the SOAR Works website. There are oodles and
gobs and gobs and gobs of insanely helpful resources there. Whether it’s from the technical end or from example medical summary reports. And again, these aren’t meant
to be done in one sitting. So, you know, when you’re gonna write, be in the right mental
state, make sure you’re clear-headed, make sure
your schedule is clear and blocked off, to write. Make sure you’re free of distractions. And if you get a half an hour in, and you start hitting a brick wall, then know when to say when. You know, when to sit down and say: okay, I’m gonna pick this back up
tomorrow, or two days from now when I’m thinking a little clearer. And again, I touched on this earlier, make sure you talk to, if it’s applicable, make sure you talk to a person’s supports, or their family members,
because the amount of firsthand information
they can share with you is so valuable, and you’re not gonna get that from a medical record. So, I’m trying to think of
if there’s anything else that’s important; I know that
when Jennifer talked about a consultative examination,
also keep in mind, you might have the best MSR in the world, and you still might be called for a consultative examination. When you’re there, though,
keep in mind a lot of folks, especially with schizophrenia
or psychotic disorder, their symptoms might not
come out in 20 minutes, or 30 minutes, so if you
feel that you’ve been rushed at a consultative examination,
I really recommend either try and delay that
exit, or if you were just inappropriately shoved
out the door too quickly, call the adjudicator and
let them know what happened. Very quickly, I had a
gentleman I worked with who, I timed from the minute he was called back from the waiting room until he was done with his consultative
examination was six minutes. It is impossible to do a
mental status examination, based on the questions they have in front of them, in six minutes. So I called the adjudicator. The adjudicator then referred
me to the complaint department at DDS, to the complaint
management technician, who knew the examiner I was calling about before I even gave the person’s name, and what ended up
happening is they ordered another examination, took the
gentleman to the examination, and it was a different examiner, and he was approved benefits. So just a little tip. When I, again, going back to functioning. So, I am gonna turn it
back over to Kristen, our facilitator, and I apologize
if I spoke too quickly. I had a lot of things I wanted to, kind of wanted to share with you. But in case I wasn’t clear enough, I am the champion of
functioning and observations. When it comes to writing
my medical summary reports. So thanks, everybody. – [Kristen] All right,
thank you so much, Shaun. That was a fantastic presentation. We really appreciate
hearing your experience and your tips, so I know a lot of folks will have some questions,
and so we definitely have a lot of time left to address those. So if you haven’t already,
you can pose your question to the panelists now by
typing into the Q&A panel, on the right-hand side
of your screen there. And we will kick things
off with a question that came in for Shaun, and
for anyone else to jump in. How do you work with your
staff to ensure quality MSRs? – [Shaun] Okay, thanks
Kristen; great question. So again, one thing I said before is I am, I do really support that
people have different ways of managing their work in
different writing styles. So the first thing I do
is, as tempting as it is when folks take the training course, to try to jump in and give them tips, is I keep my door shut
and I shut my mouth, and I let individuals’ own
learning styles take over. And then I read it when they’re done. So I let the folks take their best, their first draft at it,
and then before they’ve sent the first application, we meet and we go over the medical summary report together. And it’s so much easier that
way, because it empowers the person to use their
skills and their observations. And it’s helpful that I don’t
know anything about the case, except for the medical
summary report in front of me. And then we use that just to coach, what are some areas that look really good? What are some areas where we could probably cut out some detail,
or what are some areas that would be helpful to supplement? Or it might be something as simple as: make sure you cite your source here. So that’s an ongoing thing. Most folks I work with, after a couple of medical summary reports,
get pretty comfortable. The other thing I also have
had some of my staff do is send their medical summary
reports to the TA center. Because the gang there
gives fantastic feedback. And I will admit, Kristen,
I apologize, I do cheat and do that sometimes when
I’m a little bogged down with extra work, but it’s
a great, great resource. – [Kristen] No apologies necessary. That’s what we’re here
for, and thank you so much for reminding people about that resource. And I just wanna say
as an addition to that, if you are interested in sending in your medical summary reports to
the TA Center for review, just make sure you redact them for us. Do a find and replace in your document and change out the person’s name, delete their social security
number and date of birth from the top, so that you’re
not sharing any personal, identifiable information;
so we just want to read an anonymized report and
give you feedback on it. All right, thanks, so the
next question I think Jennifer can definitely speak to. So this provider is wondering: how far back do we go with
the medical treatment history? – [Jennifer] Okay, thanks Kristen. It depends on if it’s a concurrent claim. Such as if they’re applying
for the SSD and SSI, onset is important, so we
want to be sure that if their, for instance, if their onset was in 2015, we will want to know if they
were receiving treatment at that time, and we will
request that information. And if they had, typically
for the onset day, we would wanna go back at least one year, up to that onset date, if there is medical evidence available. For SSI applications, it is
typically one to two years. I suggest if there, if
you’re speaking of a mental impairment, if they had received,
if their hospitalizations were 10 years ago and they
showed a period of stability, based on treatment, or say,
I would suggest providing that information, because
that gives us the history. If, you know, if we have
evidence that’s showing now that they’re stable, but for
some reason maybe they had another psychotic break,
or maybe their medications were no longer working, we
would need something to show, okay, this is their history. If it’s available, I
would suggest providing that information so at
least a reviewer will have some knowledge of their history. I hope that answers the question. – [Kristen] Yeah, absolutely, thank you. That’s very helpful. – [Jennifer] Okay. – [Kristen] All right, so
our next question comes from Tony in Utah, wondering
about any tips on getting medical records for people with no income. Because medical records can be expensive. – [Jennifer] Okay, well– – [Kristen] For any of our panelists, too. Yeah, Jennifer, thanks. – [Jennifer] Okay, you
know, if you’re not able to get the medical records, of course, social security is going
to request those records, and we would pay for the cost
of obtaining those records. So in that situation, an MSR
would be helpful, you know, at least to provide something
with the application. If it’s just the MSR and
they’re not able to get the medical records,
indicating that is helpful, and then, you know, DDS
will request the records. – [Shaun] And then, just to
piggyback off what Jenn said, from the provider perspective,
one, medical records departments usually have a
negotiated social security rate, which is much, much,
much, much, much less than the first party rate;
usually around $28, $30. So it’s a reduced rate,
but what we always do is, in the TA Center, the
toolbox has the very nice, succinct letter to medical
records departments, requesting that those fees are waived. So if you request those, if
you’re the representative, and you request those records
on the person’s behalf, you can always negotiate with the provider to see if they’ll waive those fees. – [Dan] Yeah, and I can also just add, thank you Jennifer and
Shaun, for your comments, this is Dan, yeah, I’ve
had a few occasions where I’ve gone to request medical records for individuals and the
medical records department were trying to charge a
fee, and usually it can be really simply resolved by just calling the medical records
office and either talking to a manager or even the
person that’s processing your request, and if you
explain that the individual is homeless and has zero income, more often than not, I’ve been
able to get those records, the fees waived; so
it’s just another layer of advocacy that you’re able to provide for the individual that you’re
helping with the application. – [Kristen] Thank you all,
and I had just one more thing I’ll add is that it’s
different in every state, but there are a number
of states that have laws that regulate the costs
that can be charged for obtaining medical records. And so in some states, it is individuals who have low income or can’t afford it, or individuals who are
applying for disability, those fees are waived. And they’re not always
waived across the board. Medical records departments
need to be reminded of the law in their particular state, so if you wanna check with
us at the SOAR TA Center about what those laws
might be in your state, we can let you know. Yeah, so, excellent. So the next question that came in, this is kind of a combination
of a few questions, is: should I still write an MSR, even if it isn’t cosigned by a doctor? – [Shaun] Yes, absolutely,
a thousand times yes. Refer back to the first case study, the young gentleman I worked
with who wasn’t even seeing a treating physician at the time. Without the MSR, I have no
doubt he would have been denied. There’s so much useful
information in an MSR, for adjudicators to
rely on, and obviously, Jennifer can speak more to this as well, but yes, yes, always yes. – [Jennifer] Yes,
definitely, I’ve actually had this conversation with a
couple of adjudicators here. If it is not signed by an AMS, we still consider it evidence. And again, it can be critical in the case, in that it’s based on your observations, it’s based on your interactions, and again, if you are working
with the family members or whatever, and they’ve
provided you some information, it is definitely helpful,
and it is evidence that we look at, we read
it, we make note of it, and we consider it. – [Kristen] All right, fantastic. There were some followup questions about: what is an acceptable medical source? So physicians,
psychiatrists, psychologists, advanced practice registered nurses and physician’s assistants
are all accepted medical sources for
that diagnostic purpose. However, like we’ve heard
from all of our panelists, anyone can write a medical summary report and it’s absolutely
still important evidence to be considered. So, thank you all for that,
and for those questions related to that. So we also have a question
about, ah, how to get medical professionals to sign off, if they are afraid of liability issues. So kind of talking to
and collaborating with an acceptable medical
source in order to get them to cosign the MSR; a strategy for that? – [Shaun] When I approach a prescriber, or an acceptable medical
source about this, what I always do is the
first thing I say is: this doesn’t hold you liable for anything. What you’re agreeing to
by signing off on this is that a review of the
individual’s case was done, and you generally agree with
everything that is written in that report; there’s no liability, there’s no, we’re not
asking for an opinion on if you feel this person can work or not. So, I try to nip that, it’s
the very first thing I say to someone before I ask them
to read it and sign off on it. – [Dan] And I can just
add to what Shaun said, that there’s been a few
occasions where I’ve been assisting an individual with
an outside psychiatrist, that claims usually, I
was fortunate that I did, we did have a psychiatrist in house, so it wasn’t really an issue
having them sign off on it, but I did assist a few
individuals that had outside psychiatrists and doctors, and sometimes they express
some hesitation signing the medical summary
report on the first visit, because they didn’t have any
longitudinal contact with the individual, so I would, if
the person was okay with it, I would go to their doctor’s
appointments with them, sit in in the examination
and explain to the doctor exactly what I was trying
to do to help the individual with the application, and
then see if they were a little more comfortable with
me, taking the person to like subsequent appointments,
maybe two or three additional appointments, followup appointments, and then after they were
able to see the person a little bit more and talk
to them about their symptoms and their diagnosis,
they were more willing to sign off on the medical summary report, and like Shaun said,
agree with the information that I wrote in there, so
that would be another tip I would suggest. – [Kristen] Yeah, thank you both. I’ll just add one more
thing, and also add a link to the chat box, so people can access it. We have a resource on
the SOAR website called: What Medical Providers
Need to Know about SOAR and the Medical Summary Report. And it helps to just kind of
explain what are SSI and SSDI, who is eligible, what is SOAR, you know, what is this that we’re asking
you to look at and review? So, that can be a helpful
tool for folks, as well. All right, our next question is: have you ever shown a
completed MSR to an applicant? And if so, how did you do that? – [Shaun] I haven’t, no. – [Dan] Yeah, I haven’t either. I haven’t, I’ve worked
with a few individuals that have asked to see
their medical records that I helped them collect, and sometimes what I would
do is just kind of write a summary of all the medical records, but obviously people have
a right to their records, if they want it; I’ve never
actually shown an individual that I’ve helped with a SOAR application the medical summary report, either. – [Shaun] Yeah, and also to
piggyback on what Dan said, same thing, I’ve had
folks ask me for copies of their records that I’ve collected as part of their application. That is a big HIPAA no-no. Because they were released
to us for an explicit purpose of applying for benefits;
we’re not permitted to rerelease them for any purpose. Except to social security as
part of their application, but we’re not permitted to give copies of someone’s records to themselves. If they want them, they
would need to follow the same protocol and
request them for themselves. – [Kristen] All right,
great, thanks for that. (muttering) All right, this next question
is about the information to include in the medical summary report. So this individual is wondering, if an applicant doesn’t remember the dates and names of employment
or their employers, is it okay to include any information in the medical summary report about their employment history? – [Jennifer] I can take
a stab at that question. – [Kristen] Yeah, thanks. – [Jennifer] And the, we
require a 15 year work history. And I know that could
be challenging for some, so if they haven’t had
any type of work history in the last 15 years, a
statement regarding that is fine. If they’ve had a sporadic work history, if they’ve done just temporary
types of assignments, they can indicate that,
if it was part time, and then that way, we can determine whether or not we need to
investigate it further, when it comes down to a decision, because we are able to run a query to see if they had
earnings that were at SGA, in the last 15 years, so
if there is a job that, for instance, they provided on the 3369 that is unclear to us if
they, if it was at SGA, and we can look at that
query to see the earnings that they received; so again, we’re only looking at if
they worked full time, if it was at SGA, in the last 15 years. If they only worked a
couple weeks at a time, we don’t need that information. If they worked for various
temporary agencies, you can indicate a statement like that, just indicating maybe they
worked two to three weeks at a time, and maybe
didn’t work for another two or three months; we’re
only concerned about any type of full time employment performed in the last 15 years, and
they don’t have to have precise dates, if they can
just remember the years that they’ve worked, and
what’s important to us is the actual requirements of that job. So, you know, if the
physical requirements, any type of, it was a
customer service related job, interactions that they had, that’s really what’s important to us. – [Dan] And Jennifer, this is Dan, I actually have just a
followup question for you that I think would be
helpful for participants, and it’s a question that I
get a lot from the field. What if an individual that you’re helping with an application is
reporting that they worked full time for a number of years, but it was an under the table job? How should SOAR case managers address that in the employment history section? – [Jennifer] The same way, if it was, you would consider their earnings. So if they were paid less than SGA, then you would indicate that. We’re able to look at
self-employed earnings, if they’ve reported it, if
they’ve applied for tax, you know, filed for
taxes, that’s the only way we can verify it, you know,
the social security system. But we do get people that have worked under the table and a lot
of times, it’s not SGA. So you would still just wanna know, okay, what did you earn,
were you, you know, if you were paid 100, $200 a week, you know, depending on the
year, it may not have been SGA, and so it wouldn’t be applicable. But a statement regarding that is fine. – [Dan] Great, thank you. – [Jennifer] You’re welcome. – [Kristen] All right,
so this next question is kind of about process: so
how do you manage the time waiting for medical
records, reviewing them, interviewing, writing it, getting
in touch with the provider to sign, all within the two month slot, so the 60 days for application submission? – [Shaun] Well, I can
jump in quickly on that. Keep in mind, the 60-day
application time frame doesn’t start until you
protect the filing dates, so you can have your intake
send out for all the records, and there’s gonna be a delay
waiting for those records to come in, and once
you review the records and you feel that it’s going to be a case you’ll move forward with, at
that time, you can protect the filing date and your
60 days starts there. And that’s a lot of
times a lot of the wait, is just waiting for records to come in. After that, things can
move along pretty quickly, depending on just how
you, again, how you manage your own tasks, your own work. – [Dan] Next, I could also
add to what Shaun said, and I agree with what he shared, and also, if your process is you’re
going to set the protective filing date right from the start, and then you’re going to
request the medical records right away and write the
medical summary report within that 60-day period,
what you can do is you can make sure that the medical
summary report is moving along. You know, and then you can
also, like the medical records, if some of them haven’t come
in within that 60-day period, hopefully they will, usually
I think the most it would take would be 30 to 40 days
is what it took for me for some treatment sources,
but if all of them haven’t come in you can just make
sure you’re communicating with the DDS adjudicator that
your case gets assigned to, and just let them know that
you’re gonna be submitting X, Y and Z treatment sources,
and then this additional one, you haven’t received yet,
but if it does come in before they get it, you’ll send it over to them. So that’s usually how I would handle that. – [Shaun] Yeah, and also keep
in mind with the timeframes that the application doesn’t
instantaneously go to DDS when you submit it to the field office. So your MSR doesn’t need to be complete at the time you submit the application. It’s cheating a little
bit, but if you know it’s going to be done shortly after, you usually have a little
bit of time from the time you submit the app until it’s
on an adjudicator’s desk. – [Jennifer] And I would
suggest, if you have not been able to submit the
MSR once it’s been assigned to an adjudicator, just
providing the functioning information would be extremely helpful. And again, because that’s
based on your observations, over observations from
family members or friends, that can provide that insight. I think submitting that information alone would be extremely helpful,
even if you have not had, you know, an opportunity to
review all of their records, or had someone be able
to sign off on that. But just the summary
of, you know, basically, of what, where they are
currently, you know? As far as functioning and what’s in store. If you’re planning, you
know, if they have pending appointments or something
like that, to let us know, or again, just even provide the history. If they’ve had treatment in the past, and you haven’t been able
to request those records, but it still gives us some
insight into that claimant. – [Kristen] Great; thank you all. So we have just a few minutes left. I wanted to give our
panelists an opportunity for any last words or bits
of advice you wanna share before we close out for the afternoon. (overlapping muttering) – [Dan] Oh, go ahead
Shaun, you can go first. – [Shaun] Okay, thanks Dan. – [Dan] I was just thinking
when Shaun was sharing his success stories that, I
meant to share this during my portion of the presentation, but I recently was working
with a SOAR provider, she’s the SOAR-trained case
manager in northern California and she works for a mental health agency, however, she was actually helping her son, who has a combination of
physical and mental health conditions and a lot of
functional impairments, really severe physical
illnesses in addition to his mental health conditions, and she was helping him
with the SOAR application, due to him being at risk of homelessness. And she sent me an email just last week, saying that after she
submitted the MSR to DDS, they got an approval back within a week. So she was just really happy. She also took advantage of sending in the medical summary report to the
SOAR TA Center for review. Which I think is a really
good quality assurance measure in the beginning, when
you’re getting going. Hers was really well-written,
so I didn’t have to provide her with much feedback,
but it was just another success story that I kind of
wanted to leave everyone with, a little bit of hope, in terms of writing medical summary reports
and submitting them as part of your SOAR applications. All right Shaun, all you. – [Shaun] All right,
just two quick thoughts. One is, especially if you,
this is your first time that you wanna sit down and write an MSR, I can’t stress enough,
just don’t get overwhelmed. I mean, we can all write them. Again, this isn’t a technical report. You know, and if you need
to be re-centered, I mean, A, if you’re spinning
you wheels, take a break. Either step away from your desk
or go to a different section or just ground yourself
and again, think about if you were writing this
report for your mother, or your father, or your child, and that really helps, at least for me, really helps focus on what’s functional, what’s relevant, and what’s
really important to include. If you’re able to focus that way, it really helps, I’ve
found it really helps, really helps me focus and
it almost writes itself. I think with the observations, one thing I don’t think I highlighted was: make sure you’re specific in what you see. I would really avoid
general statements that, you know, this person has
difficulty doing tasks around the house, or this person, ah, has bad hygiene. Well, what does that look like? And that’s something that can be addressed in the very first paragraph, you know? Mr. John Smith presents
wearing soiled clothes. Is extremely malodorous, has matted hair underneath a baseball cap, has a beard with food debris in it. Has shoes with holes in them. Has fingernails that are
approximately an inch in length and are yellowed. That helps the person actually see what the person is looking like, and it’s a lot more clear than: someone doesn’t have good hygiene. So be, I know I hammered
home give examples, but give specific examples. That really helps, it
really helps the imagery, when you’re writing. – [Jennifer] One of the
things that, I’m sorry, one of the things that I
meant to mention earlier, was regarding, and I think Dan
talked about it a little bit, the side effects of medications. It would be, you know,
it’s a good practice to make statements regarding that. What we’ll see sometimes
is someone’s taking pain medication as well as medications for a mental disorder. The side effects alone of the
medication can be limiting, you know, their functioning. If they’re heavily sedated or fatigued, sometimes it’s impossible
for them to even get through a normal workday, because
the medications required for them to be asymptomatic is so heavy. So, you know, consider that as well. And another thing that I think people miss is that like we, we’ll
discover a condition within the medical evidence
that is clearly disabling, but it wasn’t shared. So think about that as
well, if there’s mental and physical conditions
that this claimant may have, please inform us, or you know, if they, because what we’ll see is sometimes, especially with the floor
claims, the mental history, and it’s just the focus on that. And then they could have
severe physical conditions, that were not mentioned. So just remember those things as well. – [Kristen] Excellent, all right. Thank you so much to
our fantastic panelists. We are out of time; if we
didn’t get to your question, we’ll pose your unanswered
questions to the panelists and we’ll follow up with you with that. So please take a moment to
complete the evaluation, which you’ll see upon exiting the webinar, and your responses will help to inform future webinar topics. So, again, on behalf of
the SAMHSA SOAR TA Center, we’d like to thank again our presenters and everyone who joined
today’s important webinar, and don’t hesitate to contact us any time for more support with writing MSRs. And have a great rest of your day. Thanks, everyone. – [Jennifer] Thank you.

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