SOAR Webinar: Understanding and Documenting Opioid and Other Substance Use Disorders

– [Pam] Hello everyone, and welcome to the second
webinar in our fiscal year 2019 webinar series titled
Understanding and Documenting Opioid and Other Substance Use Disorders for SSI/SSDI Claims. My name is Pam Heine, Senior Project Associate
with the SOAR TA Center, and I will be your moderator today. Before we begin, just a few
housekeeping items to review. A disclaimer from SAMHSA. This training is sponsored
by the Substance Abuse and Mental Health Services Administration and the US Department of
Health and Human Services. The views, opinions, and content expressed in this presentation
do not necessarily reflect the views, opinions, or policies of the Center for Mental Health Services, the Substance Abuse and Mental Health Services Administration, or the US Department of
Health and Human Services. Just a few webinar instructions. As a reminder, your lines will be muted throughout the entire webinar. This webinar is being recorded and will be available for
download in about a week. You may download the
presentation slides now and other materials by going
to the top left of your screen and clicking on the file
icon, Save Document, or visit the SOAR website
at, click Webinars on the left side bar, and choose today’s topic. At the conclusion of the webinar, you’ll immediately be redirected
to a brief evaluation, which we kindly ask you to complete. And finally, we will save
all questions and comments until the end of the presentations at which time we will review instructions for posing questions to
panelists via the Q&A function. To just go over some of the objectives, it is our intention that
by the end of this webinar, you will have a better understanding of those key strategies for requesting and interpreting substance
use related medical records, also SOAR best practices for assisting SSI and SSDA applications with opioid and other substance use disorders, and also how to effectively document opiod and other substance use disorders using the Medical Summary Report, the MSR. So to just review today’s agenda, to help reach those objectives, we will begin this
afternoon with presentations from Dr. Melissa Neal who is a Senior Project Associate with the SAMHSA’s GAINS Center at Policy Research Associates
in Delmar, New York. Then we’ll have Amanda Starkey who is a Project associate
and subject matter expert on substance use disorders
here at the SOAR TA Center. And rounding things out with
a local SOAR perspective is Rachael Phillips who
is a SOAR specialist with the PATH program in Troy, Michigan. And then we’ll also end
with plenty of times for question and answers, which are facilitated
here at the TA Center. So providing today’s welcome is Robert Grace, the SOAR project officer with the Homeless
Programs Branch at SAMHSA. Bobby, would you like to do it yourself? – [Robert] Yes, thank you Pam. I’d like to thank all of you for joining us today, on behalf of the Substance Abuse and Mental Health Services
Administration, SAMHSA and the Homeless Program Branch of the Center for Mental Health Services I would like to welcome you to this SSI/SSDI Outreach,
Access and Recovery SOAR webinar called Understanding
and Documenting Opioid and Other Substance Use Disorders for SSI/SSDI Claims. SOAR helps states and
communities increase access to Social Security disability benefits. For eligible adults who
are experiencing or at risk of homelessness, and have
a serious mental illness, medical impairment and/or co-occurring substance abuse disorder. Today’s webinar we’ll
focus on the opioid crisis in the United States
and all types of people with disabilities who are experiencing or at risk of homelessness. We know that opioid
crisis has significantly impacted these vulnerable population, The SOAR provided some questions remain, for example, if someone
does have an opioid or other substance use disorder, what does it mean for their SOAR assisted, SSI/SSDI claim? Also, how do we effectively document substance use in the Medical
Summary Report, the MSR? This webinar will help
answer these questions and others, which impact SOAR applicants. I would like to welcome and thank our presenters for your
willingness to share your expertise with us. At this time I’ll turn
it back over to Pam, Pam Heine, who will
moderate today’s webinar. Pam? – [Pam] Thank you Bobby for providing today’s welcome, we appreciate it. So now I’ll turn the mic over to Dr. Neal, who will kick things off. Melissa, please speak
in your presentation. – [Melissa] Alright,
good afternoon everyone. Thank you so much to the SOAR TA Center for having me participate
in today’s webinar. I’ve been asked to provide a little bit of an overview of the opioid epidemic and some of the critical factors that are coming into
play when thinking about people who are in recovery
at midst the opioid epidemic. And first I’m just gonna
cover some statistics around how this epidemic is impacting us. One way that we look at
or quantify the epidemic is looking at drug overdose stats, and the centers for Disease
Control and Prevention, we also call this the CDC, they have shown that since 2000 the rate of deaths from drug
overdoses has increased 137% and when we look specifically at opioids we’ve seen a 200% increase in the rate of overdose deaths. And in 2016, which is the
most recent data available over 66% of drug overdose deaths involved some type of opioid. And so, I’m gonna go into some maps, you’ll see on the right
side of the screen a map, and these are produced by the CDC, you can go to their website
and access this for yourself, if you download the webinar slides you’ll see this link
and that will take you right to these really helpful maps. And on the CDC website
you can go year by year and watch how just across the country there is an incremental spread of opioid overdose across the nation, so that in 1999 you see
most of the country is blue, and in 2016 we see alarming areas of red, indicating high rates of overdose due to drug poisoning. Now, these maps do overall
overdose for all drugs, but again, a remainder,
over 66% of drug overdose stats in 2016 were due to opioids. In such a few more statistics around this epidemic in 2016 the number of overdose deaths involving opioids was five times higher than that in 1999, so when you think about that blue map and compare to the colorful map, the overdose deaths was
about five times higher. On average, about 115
Americans passed away every day due to an opioid overdose, and some of the contributors to this are in this graphics
also produced by the CDC and one thing I do like to point out to Social Service Providers is that we often here and there in terms of who’s bringing drugs
into our communities and how people are accessing drugs, but it’s important to consider that the first wave of opioid overdose stats came from misused prescription drugs, and so the reality is that many people’s substance use disorders
started in physicians offices, and that’s really important for providers to think about when they’re
trying to understand their clients’ history. See, the other thing
this graph access to ask is so what war on drugs? And so, since the early 70s we’ve had some really aggressive political campaigns talking about being top on crime and having a war on drugs
and that has resulted in a disproportionate
number of people of color incarcerated in state prisons
and jails and federal prisons, and when we look at the data many of them are incarcerated due to convictions
related to drug charges. And so, when we think about that and then we look at this data, we have to recognize that despite the war on drugs and many
people being incarcerated we still are wrestling with the reality that overdose deaths have not gone down, and the rate of substance use disorders has not gone down, and so this
is an important consideration to think about as you work with people of different races and ethnic backgrounds, that’s an important piece
of history to think about. Trauma is another aspect that we need to think about when considering recovery and amidst opioid epidemic, and trauma is very, highly prevalent, nearly 90% of U.S. adults have experienced a traumatic event based on DMS-5 Criteria many adults have experienced multiple traumatic event types. And just one way that trauma can impact us is through the development of PTSD, and so we see among U.S. adults about 8.3% will experience the symptoms
of PTSD in a lifetime. It’ll be no surprise that
trauma is very prevalent among our veterans who
have served in the military and going above and beyond thinking about those who’ve served in
Iraq or in Afghanistan, also people who served in the Vietnam War may still be dealing with the aftermath of traumatic events that occurred to them and those things could still be affecting their lives today. Another way that people experience trauma through their service in the military has been the experience of sexual assault, or sexual harassment,
and so statistics show about 23% of women report sexual assault while in the military, 55%
of women and 38% of men report sexual harassment during
their time in the military, and those are experiences that can result in trauma and the effects. So trauma affects us
each very individually, a lot of how we respond to trauma is based on physiological makeups,
and so brain development, stress response mechanisms,
immune system responses, all come together to shape how we each respond to trauma, so
as you work with clients you’re gonna see that one person may react to the exact same traumatic event in a very different way
than another client. The mental and emotional effects of trauma also vary widely, and so one person may resort to more of a
state of powerlessness, another person may show high levels of fear and constant state of alertness, so also that’s something to keep in mind that you’re interacting with clients, just the way that that trauma affects them is gonna show differently. And as I mentioned before, unresolved trauma can result in mental and substance use disorders, so that’s why trauma really
is an important thing to understand as you’re trying to explore your clients’ history,
and better understand what substance use
disorders are there and why, however, unresolved trauma also can result in suicide, chronic disease
and premature death, and it’s important I think for people who recognize the link between
trauma and chronic disease as, you know most people don’t think that those things go together. Some current trends in addressing some of these issues that I just covered, right now we do see a little bit more of a public health approach versus a criminal justice approach to addressing the substance use issues and
opioids epidemic overall, and much of these we hope is because there’s an increasing
evidence that documents that substance use
disorders are a disease, or a medical condition, and so society is, and many of our stakeholders
are increasingly recognizing that. And as result we are seeing more diversion from the criminal justice
system into treatment, for example there are even
now police departments that have programs for people
with substance use disorders can go to the police
department and be transported somewhere where they can receive treatment without facing the threat
of a criminal charge. So that is a very commencing trend, we’re also seeing that
victims and their families are more humanized and
when we contrast this to the crack cocaine epidemic
a couple of decades ago, we see that the people who
has substance use disorders and their families now are humanized more, and their stories are shared more broadly, and media has had a lot to do with that. Increasingly, media is elevating stories to really share the voices of people who have been impacted
by the opioid epidemic as well as help disseminate
some of the solutions that communities have been testing out and have known effective
in addressing opioid use in their communities. Another aspect to think about when we are considering
recovery and in the midst of the opioid epidemic is that
there are unique risk factors for service members’
families and their veterans, and the military culture
is very effective, very necessary for the
safety and the organization of people during their
time in the Military, however, those people
can also face challenges when they are transitioning back into their homes and their communities where the culture looks very different, and so we see veterans have challenges in making those transitions. You see high rates of
co-occurring disorders, many veterans report chronic pain, and we see an elevated risk of suicide among service members
veterans and their families. And so, as I mentioned
in the previous slide the military culture sometime has this unintended result
of decreased help-seeking and service members and veterans have said that by seeking treatment
they fear being seen as weak they fear that leadership
might treat them differently or fear that others might have less confidence in their abilities. And so as a result we do see high rates of co-occurring disorders among veterans, among people who have not
served in the military. Co-occurring disorders are high about 83% of adults with substance
use disorders have one or more co-occurring
mental health disorders. And so, we anticipate that
it’s gonna be the same or even higher among veterans due to their invisible wounds of war. However, it’s harder to give the numbers around that, right now what we know is 25 to 33% of veterans
with a substance use disorder also meet the criteria for
mental health disorders but that’s just among those
veterans who seek treatment, and the research shows that veterans are typically just
inclined to seek treatment when they are considering or they know they’re gonna be redeployed. And so what we know is there’s a large group of veterans out there who are not seeking treatment and so we don’t have a good measure of how many of them have a co-occurring substance use or mental health disorder. However, veterans are more likely to report the experience of pain and we do see that 45% of service members and 50% of veterans
report experiencing pain on a regular basis. This is about double the number of people in the general public that report pain on a regular basis, and
among service members we see about 11% report
misusing prescriptions with opioid pain medication being the most frequently misused. And so, this again is just
current service members so thinking about veterans and the fact that they report experiencing pain on a regular basis we know that veterans are prescribed opioids for years. We also, then, can take the next step and reasonably affirm that veterans may also be misusing
opioids pain medications. And so some of this is driven
by access to care issues, not all veterans are
eligible to receive VA care, not all veterans want to receive VA care, and the VA centers in different areas have varying capacity to provide services, so some VA centers are able to provide, or cover chiropractic
care as an alternative to opioid pain medication. Other VA centers aren’t able to provide those kind of services. So we see a lot of different access issues depending on where the person is located. Some successful approaches to reducing opioid use disorders among veterans include the Drug Monitoring Programs, increased access to
Medication Assisted Treatment, peer supports including veteran mentors, Veterans Treatment Courts and so forth. And finally, we’re gonna
look at, just briefly, at homelessness as an aspect of thinking about recovery amidst the opioid epidemic, and housing is a critical
social determinant of health, a person’s ability to be
housed is directly linked to recovery and wellness outcomes. What we see nationally
is about 1/3 of people experiencing homelessness
also report having an alcohol or drug problem. 2/3 of people experiencing
homelessness have had more of an official
substance use disorder during their lifetime. 75% of people experiencing
homelessness have also had a co-occurring substance use and mental health disorder. And the most disturbing statistic here is that 81% of overdose deaths among people experiencing homelessness are related to the use of opioids. And some of the promising practices for working with people
experiencing homelessness have been incorporating
the housing-first approach, so having those programs for someone is just placing housing
without requiring them to be sober first or to
go to treatment first, or to complete any
other requirement first. They’re just placed
housing and then supported to consider or to enter treatment later, and most of these programs are supportive housing with case management or other wraparound services. Many of the most promising
housing-first programs have provided permanent supportive housing versus transitional and
that’s because this group that is experiencing homelessness and substance use disorders typically has been dealing with this chronically and need a lot of time
and a lot of support to really stabilize and to make progress on their path to recovery. Other effective housing-first approaches incorporate peer support,
so having these people who have lived the
experience, providing some of these case management services and really helping people along their way on a day-to-day basis has been effective. Many of our housing programs also are using more informed
program requirements, so their structures and the way that the program is run supports stability, knowing that if that
person can stay stable they’re more likely to recover, and they’re more likely
to see improved outcomes in terms of their substance
use and mental illness. Another focus is that more of these program requirements
have a recovery focus, and so when someone is
not complying with rules, or expectations of the program there’s more of a recovery focus rather than a punitive approach when trying to address the person’s behaviors. So this is the end of my presentation where we have just touched on trauma, risks to service members and veterans, and homelessness as three things to think about when considering recovery amidst the opioid epidemic. And now, I’m gonna transition things over to Amanda Starkey
with the SOAR TA Center. – [Amanda] Thank you Melissa. Hi everyone, thank you again for joining us on this
important presentation, my name is Amanda Starkey
and I’m a Project Associate at the SAHMSA SOAR TA Center. Before joining the TA Center in 2007 I worked as a SOAR Case Manager in a few different organizations throughout Michigan and Colorado, and I helped represent about 200 or so applications on the SOAR process. So throughout all of those applications that I helped represent,
I saw a common challenge when it came to co-occurring disorders. In my portion of the presentation I’d like to provide more insight into SSA and DBS’s decision making process and key strategies for
drastic co-occurring disorders and Medical Summary Report. So first, let’s talk about the DAA. The Social Security
Administration uses the term DAA to describe drug addiction or alcoholism. So Special Security Administration uses the term not otherwise prescribed, and that means that the side effects from prescribed opioid can be considered an accessory to a disabling condition, so they’re only looking at drug addiction and alcoholism and the effects of it when they are non-prescribed substances. So, under SSA’s role the
DAA is not considered to be a disabling condition, so drug addiction and alcoholism beyond what is prescribed by treatment provider is not considering
a disabling condition. However, SSA and DBS are not blind to the reality that in a lot of cases a legitimate mental disorder accompanies the drug or alcohol addiction, so SSA is aware that
co-occurring disorders exist and they do recognize this. So our job as SOAR Case Managers is to present evidence that
will as clearly as possible distinguish the effects of mental illness from the effects of drug or alcohol abuse. So what does SSA mean by materiality? Current SSA laws state that
substance use is found material to a person’s disability,
SSA benefits will be denied. Materiality refers to the extent of which substance abuse contributes to the applicants’ impairment, so if the applicant
still experiences severe impairments that result in significant functional deficit and an inability to earn and maintain a substantial gainful activity level work
during periods of sobriety then the substance abuse will not be considered material to their disability. SSA law also state that the applicant has the burden of proving disability throughout the unique
sequential evaluation process used per DAA cases, so beyond this sequential evaluation
that we learn about in our SOAR fundamentals training, SSA uses another sequential evaluation to determine the materiality
and the eligibility for benefits when
conditions are accompanied by drug abuse or alcoholism. So this means that enough evidence needs to be provided in the records and other submitted material to clearly illustrate that the applicant meets or exceeds the requirements to
move on to the next step or be approved to step
five or six of these new sequential evaluation which we’re going to talk about on the next slide. As SOAR provider, it’s
our job to clearly present the information that supports disability. So I took a picture of the
actual sequential evaluation that SSA uses to analyze
drug or alcohol use with disability and I’m
just going to walk us through the steps. So in step one SSA asks the question does the claimant have DAA? If the answer is no the evaluation is not necessary because
they don’t need to make a determination on if
the drug or alcohol use is material if it does not exist. If the answer is yes, the
claimant will move on to step two. Step two asks, is the claimant disabled? If the answer is yes,
that they are disabled, the application will
go on to the next step, if even without the substance use or with the substance use the applicant still is able to earn
substantial gainful activity they wouldn’t be considered disabled and they wouldn’t need to be evaluated under this sequential evaluation, their case would just be denied. Step three asks, is DAA
the only impairment? So this question is
pretty straightforward, if they DAA is the only thing that’s preventing this person from being able to work then their case will be denied, because Social Security does not consider DAA as
a disabling condition. If the answer is no, they
have other impairments to go along with the DAA,
it’ll move on to step four. So step four asks the question, is the condition along
disable the claimant while actively using? So, for example, if someone
meets the listing criteria of a physical impairment but they continue to use not prescribed opioids to treat the pain from that impairment, they could still be considered disabled and they could be allowed on the case, because whether they use opioids or not they still have the physical disability that meets the listing criteria. If the answer is no, they could be denied. Step five asks, does
the DAA cause or affect the claimant’s medically
determinable impairment? If the answer is no, then
the case will be allowed. So they have the medically
determinable impairment, and DAA is not the cause of this, so their case can be allowed. If the answer is yes, the DAA does cause their impairments but the
impairments are irreversible or could not improve to the point of non-disability even
if they stopped using the drugs or alcohol, the
case can still be allowed. So only time that the case would move on to the next step is if the
drug abuse or alcoholism is clearly affecting
the claimant’s medically determinable impairment,
and it’s not clear whether those impairments
would be irreversible or if they were not to improve. So then it moves on to the sixth step on the sequential
evaluation for materiality, and that asks the question, would the impairment improve to the point of non-disability in the absence of DAA? If the answer is yes,
it will be determined that DAA is material to
the person’s disability and the application will be denied. If the answer is no, even with the lack of drug addiction or
alcoholism the impairment will not improve enough to be considered non-disability, the case will be allowed. So I think this is a new perspective for SOAR providers who
haven’t seen this before, it gives us a better
understanding of exactly what SSA and DBS needs to understand when they’re presented with a case with a co-occurring disorder. Which leads us to this slide, so it’s really important to understand what you need to know, so we need to show that the person
meets the threshold of their drug addiction or alcoholism not being material to their disability based on the sequential evaluation stats. So it’s good to have a
strong understanding of this before we move forward and
working with our claimant. So we as you can do this is
to ask the right questions, collect information from
a variety of sources, a robust compilation of evidence from both medical and non-medical sources will help to clearly illustrate the applicant’s substance use and the extent to which that substance use
impacts his or her life. You can use the Medical
Summary Report interview guide to do this, I’ve included a picture of the section on substance use from that MSR interview guide on the right side of the slide, and you can use this to
help guide your questioning and find some more information
on the person’s use history. And most importantly,
this allows the applicants to tell his or her story. A Medical Summary Report
is a really unique opportunity for the applicant to tell his or her authentic story. A lot of times we get
the most valuable details when the applicant is
offered the opportunity to speak openly without judgment, and it’s our goal as SOAR providers to understand and clearly detect the applicants’ story,
this is their only chance a lot of times, to tell
the disability examiner what’s really going on in their life, and the impact mental illness
and substance use has had. So things that are important to know before we get there with writing the MSR when it comes to the
substance use section. So what does the person use? It’s really good to get
that out in the open to know what you’re working with. What drugs or alcohol
does the person prefer and what have they used in the past, what purpose does this serve? if a person is feeling depressed and they’re using a stimulant,
how does he or she respond? what about someone who is using opioids to help them become numb to PTSD symptoms, so these are really good
details to understand, and a lot of times this isn’t provided in the clinical record, it takes us having a good open-ended conversation with our clients to truly understand what purpose the drug use or alcohol use has in their lives. How does it interact with symptoms? So if he or she is using to self-medicate what triggers the need to use? I worked with a client who had intermittent explosive
disorder a few years ago, and he used heroin to
help suppress his rage, and that was a really important part of the story for us to tell, and it wasn’t in his clinical record. How does it impact their
physical and mental impairment? Does the drug addiction or alcoholism exacerbate the symptoms of their physical and mental impairments? Or does it help lessen their symptoms? I mean, how is it relevant
to their disability? So a lot of times the opiod uses the response to an injury, chronic pain or mental anguish that the
applicant is experiencing. It’s important to
understand that’s relevant in relation to the applicants’
disabling condition, and to clearly detect this in
your Medical Summary Report. So I’ve come across a common
scene for more advancing, about the applicants substance use and mental health history, so the Department of Corrections Records they have great examples of functioning during periods of sobriety. So, were behavioral services needed during incarceration episodes? anything can garner from
jail or corrections records is helpful here to talk
about what’s going on with the person’s functioning
when they’re sober. In neuropsych evaluations we’re going to talk more about this
the next few slides, but I wanted to mention it here also, because they can help distinguish underlying issues that might be related to brain functioning that otherwise wouldn’t be noted in
their clinical records, or could be chucked up to side effects of the drugs or alcohol
that the applicant is using. So those are some medical
sources of information, collateral sources you can talk, of course, to the applicant,
or their case manager. Shelters are really good source for collateral information,
in my experience working as a SOAR Case Manager, shelter managers provided really great collateral details about the applicants’ functioning and their
substance use pattern, and how they’re functioning
after an all-night stay in the shelter when
maybe they’ve come down from the drugs or alcohol, what are they like in the morning. The shelter managers can provide a really nice depiction of
their behavior and functioning. So family and close friends
are also good sources of information about the
role substance use plays in the applicant’s life. Of course you need to get a signed release and permission from the applicants to talk to support people, but they can provide some behind the scenes details about the person’s history and their current use pattern. So the Medical Summary
Report interview guide is a really important tool we can use as SOAR providers to garner
the right information from our applicants for
writing a very effective substance use history section in the Medical Summary Report. There’s sample questions provided for you, just remember to keep your questions open-ended, like tell me more about, or how do you feel when, we wanna create a safe environment where the applicant feels able to truly open up to us as their SOAR providers and advocates. And follow-up to get a clear picture, so sometimes this involves
revisiting conversations at a later date, is something too much? Or you don’t think you’re
getting the true picture of what’s really going
on, maybe bring it up in the next interview. Hey, I remember you said this last week, let’s talk more about that now. Maybe you can get some more details that the applicant wasn’t
willing to share previously. And using the clinical
record to help ask questions, so sometimes applicants
can’t remember time-frames, and the good thing about clinical records is they’re always dated, so you know what period of their life the substance use was happening in. Another good use of clinical records is to look for toxicology reports, so if you see a toxicology
report in ER records that shows substance use
not initially discussed, so for example, someone tested positive for methamphetamines in
their ER toxicology report you can say, hey I saw your ER report from 2014 that’s showing me you tested positive for
methamphetamines, can you tell me about what was going on then? It might trigger some memories, and encourage the applicant
to be open with you. So I just wanted to give
a short story about that, I was working with a client last year, and she told me that she was sober for several years on the mid-2000, she’s been previously addicted to crack-cocaine, but
she said she got sober in the 2000s when she was raising her son. So I looked over her clinical record, and I kept seeing positive
toxicology screens for cocaine, so I brought this up to her, like, you know I know we talked about it, and you said you were sober
between 2008 and 2012, but your records are showing
positive tox screens, and her response was,
“Oh yeah, I was sober, ” just partied on the
weekend at that time.” So that was her story to tell, and it also gave me some insights into her understanding of sobriety, and her mental state at
the time of our interviews. So you’ve collected all the evidence, you have the clinical record, you had an interview with the applicant and asked them what their
substance use history was like, and now is time to present the information in chronological order in the Medical Summary Report. So it’s important to
start with initial use and word forward. So asking questions or
describing what was going on when the applicant first started using, was there any type of family trauma, abuse or neglect happening, that led the applicant to use hard drugs or alcohol for the first time, and then you want to go on to discuss how the relationship with drugs or alcohol has progressed over time, so what happened since that initial use, does the person use
chronically or on a binge basis Do they go through periods of sobriety and relapse and what happened
to trigger those relapses? This are all really important details that we can include
in our substance use history section of our
Medical Summary Report. When you wanna use the clinical record to find more clues, like I said, ER notes, case management notes, group therapy notes,
are really good pieces of information to look
for clues about this. In group therapy you can
see how the person responds on a group study during
periods of sobriety, are they outgoing or do
they keep to themselves and have trouble opening
up in a group study? SO throughout your substance
use history section you want to continue to make the links between symptoms and sobriety, it’s important to clearly describe what symptoms as mental
illness are present during periods of sobriety, the clinical and criminal justice records are great resources for this information. So if someone had an extended stay at a psychiatric hospital for a week or so case notes and nursing
notes about their behavior on the floor during that time can be really valuable details to include in your report
because they were sober during the time that
they were hospitalized, likewise for periods of incarceration, if they had to seek treatment for behavioral health in jail, it’s important to note that in the report because these are most likely periods of sobriety where the
applicant still needed psychiatric treatment. And it’s our job to
advocate for our consumers, it’s our unique and very
special responsibility to help them tell their story, our Medical Summary Report is maybe the only piece of evidence available that explores the complexities of the co-occurring disorders beyond just short clinical notes
from treatment providers. And you need to use your knowledge of materiality to frame your writing, so think about how SSA
evaluates materiality and their sequential evaluation and apply that to the
section on substance use in your Medical Summary Report, and constantly ask yourself if your report is answering the question of, does the applicant still
experience symptoms during periods of sobriety. These are all great, they’re great strategies
I’ve used over the years as a SOAR practitioner
to help support my cases and I just wanted to end my portion of this presentation with a brief example of someone I worked with in about 2012. So this man was named Chris,
he was a middle-aged man, who was referred by his case manager at the local Community Mental Health Center where I worked as the SOAR specialist. He was staying in a shelter, and he spent most of his time at the Day Center. So this guy came in, in his referral and he had a really long
history of mental illness, he had physical impairments, he walked with a limp and used the cane, he had an intellectual impairment that was supported by
special education records going back to the 1970s, and he was recently sober about nine months after 20 plus years of
alcohol and drug dependence mostly with crack and cocaine
addiction and alcohol. His main diagnosis was bipolar disorder, so before I met with him, he was denied five times prior to engaging in the SOAR program, so I was a young SOAR practitioner and super optimistic, and I knew I was gonna help this
guy, so we got to work. Right off the bat my direct observations, it was really obvious he
had some odd behaviors and slight problems with
his balance and speech, he would slur some
words, even with the use of a cane he had some balance issues. I tried my best to do some
compassionate interviewing and providing a safe
environment during our chat, and eventually I asked if he’d be willing to participate in a
neuropsychological evaluation to explore some of the symptoms I noticed. He agreed, he was little hesitant, but he agreed and I worked
with his case manager to help get the evaluation scheduled through the Community
Mental Health Center. So, after his neuropsych eval, I received the report back and the results
were pretty fascinating. So on one of the tasks he was asked to copy a simple picture of some shape, and he actually drew a mirror image of the shape, and the report confirmed that this is indicative of
a neurocognitive disorder. Back then, it was called then organic brain disorder in the report. So neuropsychologist wrote in the report, that due to his past alcohol abuse his brain chemistry was
irreversibly changed. So that goes back to that
sequential evaluation where even though he stopped
drinking for nine months he has irreversible damage
from his substance use that will not improve over time. So I obviously included this new record and the information from it into his Medical Summary Report, and his case was approved in 70 days, he received $12,000 in
retroactive benefits, and he had $1,340 ongoing monthly SSDI benefit after that. This gave him validation, he felt crazy all these years applying to benefits and getting denied when he
knew something was wrong. This validated that he really did have a diagnosis that was worthy
of a disability decision and he was more committed to treatment, he got housing and he
continued his recovery with case management, and another bonus in this situation is that his therapy team gained insights into his condition based in the finding
neuropsych evaluation, which is all around a
really positive outcome to a man who spent years in
a really stressful situation. So this concludes my
portion of the presentation, and I’m going to turn in
over to Rachael Phillips, who is a SOAR Case Manager at Community Housing Network
in Troy, Michigan. – [Rachael] Thanks Amanda. And thanks again to the SOAR TA Center for having me here for this webinar today. Today I’m gonna go over some strategies and tips that I’ve used to help complete some successful SOAR claims, for clients who have
co-occurring disorders. I’m gonna start by
providing some information and statistics about the area that I work in, here in
Troy, which is a suburb of Detroit, Michigan. And these statistics
are from 2016 and 2017, you can see them here on the screen, but I wanna really highlight the fact that there’s been a 61% increase in opioid-related deaths, and 5,720 individuals who are currently, or I’m sorry, not currently but in 2017 receiving outpatient
treatment for opioid abuse. And as we know Dr. Neal
kinda covered this earlier in her presentation, this
really disproportionately affects those who are
experiencing homelessness, and that is a mayor part of working as a SOAR practitioner
is helping those folks. Here at Community Housing Network I work on the PATH team, and for those who are not familiar with PATH, we provide outreach and SOAR assistance to people who are
experiencing homelessness or at risk of homelessness, we
focus on the most vulnerable, chronically homeless or who have a high vulnerability index. We meet with folks where they’re at, so that could be outside at a park, a parking lot, under a viaduct, it’s really everywhere and anywhere, and that’s how I receive
my referrals for SOAR. As a SOAR specialist here,
I review our referrals, I screen for further eligibility, and then I implement the
SOAR critical components of collecting the medical evidence, and doing the SOAR gather interviews, connecting people to other resources and services and if needed we refer per appeal and legal aid. Okay, so some of the most successful strategies that I’ve used to help our clients who have
co-occurring disorders throughout the SOAR process are isolating periods of sobriety in
the medical documentation, and Amanda kinda touched this
throughout her presentation, but this is super important when you’re reviewing medical
records to really go through and look at those inpatient treatment dates and identify the marked symptoms that are occurring throughout those dates. So using the Blue Book analysis that’s offered through
the SOAR TA website, they provide that, and kinda going through and seeing what symptoms need to be marked in order to help this
client get an approval from the determination examiner, so identifying those inpatient treatments, and marking those symptoms
while they’re there, also looking for past urinalysis, toxicology reports and
any of the blood tests, or metabolic panel exams can really help to identify dates and
specific time periods where that individual was not using but still experiencing their
symptoms of mental illness. And also, looking for
the mental status exams are huge cause it will have
those marked symptoms on there. The interview process is another place where I really try to pull out some of the things that
wouldn’t necessarily be noted in someone’s case notes from their medical treatment provider, so it’s a little bit of
relationship building and engaging in meaningful conversations regarding that individual’s substance use asking when the substance’s use began, what’s triggers the use, and what symptoms they’re experiencing throughout those periods of sobriety
can be really huge, and Amanda said on her
presentation as well is getting their story is really important, I even sometimes create a timeline based on their self-report
so that when I am reviewing their medical documentation,
I have that information to kinda crosscheck and be like, okay I know that this person said that this was going on in
their lives at that time, and they weren’t using so I’m gonna really try and dig through those records and see what I can find
as medical evidence to support that. And I keep that timeline with me in their file so that anytime I can go back in and kind of add to it if they remember certain information or marks when they get new records in and crosscheck it again
with that information. Utilizing the Medical Summary Report, again is your best friend, linking their trauma to their substance use or other diagnoses is really huge, it’s been mentioned a lot
throughout this webinar, but SOAR really provides the opportunity for us to tell their
story and for the examiner to get to know the person behind the stack of papers that are, you
know, coming to them for this determination. The self-reports are super helpful within the Medical Summary Report, and when the medical
documentation is lacking or not thorough and they don’t have a very strong treatment history, utilizing community
partners for collateral information and collateral ladders has been a huge help for me as a SOAR practitioner as well. There’s been many times that we’ve contacted local shelters, parole officers, case managers, or people who are involved in like faith based organizations, to provide information for that person of what they are like
when they’re not using, or if they do use and they’re not using when they wake up in the morning, then what’s their attitude,
what’s their mood like then, how are they interacting with folks, and this has been a huge
help for individuals where the medical documentation may not be as strong. So a couple, I have two case studies today that I want to talk about, and both of these individuals have
co-occurring disorders. The first one, a 35-year old female PATH program participant, Jane. Jane was diagnosed with
borderline personality disorder, major depressive disorder,
generalized anxiety disorder and health substance use disorder as well. She was utilizing a methadone treatment at the time of her
referral and she was also referred actually by her methadone treatment coordinator for SOAR. Throughout the SOAR process, Jane was able to provide really thorough
information regarding her use and part trauma
and what triggered the use, which really helped in
developing her application, and her Medical Summary
Report, and ultimately Jane was approved by
explaining these experiences within the Medical Summary Report, and isolating those periods of sobriety within her medical records, we were able to meet the listing
criteria and Jane’s SSI application was approved, and that was a pretty quick turnaround
on that one I believe, I don’t have the exact date but I remember that was a pretty quick one. Oops. I went ahead a little far. My second case study here is for John Doe, John was a 31-year old male
PATH program participant, John had a intermittent
explosive disorder, major depressive disorder,
generalized anxiety disorder, and a potential
traumatic brain injury. So, he had a substantial
history of substance use and even reported some current use as a means of coping with
his mental health symptoms. This particular case required
a really extensive review of his medical records in order to isolate those symptoms during periods of sobriety, particularly during periods of inpatient hospitalization
and rehabilitation, which he had several of. So, throughout the interview process, John was able to share that he would be triggered to use after experiencing some of the symptoms of his
mental health diagnosis, and often used those substances as a way of coping with his illnesses, injuries, and conditions. So that, including all of this information in his Medical Summary Report, and highlighting those periods of sobriety within his medical documentation, John’s application was
also approved for SSI. So these are just a few ways that as a SOAR practitioner you can work with your clients who have
co-occurring disorders, and really throughout the necessary things that you would need to
help them get approved. And that wraps up my portion
for the day, thanks again. – [Pam] Thank you so much everyone, Dr. Neal, Amanda and Rachael for your really informative presentations. We have a bunch of
questions come in already, but if you’d like to ask your question just please type it into the Q&A box on the right-hand side of your screen, That’s how we’ll be taking questions. If we don’t get to an answer, we’ll be sure to distribute these to the panelists for response after the webinar, just in case
we don’t get to everything. We did get some really great questions, and again, some came in
before the presenters were finished, so I hope that maybe these were answered already. So, I’m gonna go ahead
and pose this question, and I think Amanda then maybe
Rachael will comment on it. So, do you have any tips for this, when using a function
report and I’m thinking that your presentation really discuss the value of the substance use history section of the MSR,
could you comment on that if folks are also submitting
a function report, and making sure that an
MSR is included with that, can you talk about that a little bit? – [Amanda] Sure, this is Amanda. That’s a good question,
so the function report does not address substance use history, so this would be a good opportunity to make use of the remarks section and you can discuss their
functional impairment during specifically periods of sobriety, and I think that’s the best
way to incorporate this into a function report. If there are questions that ask about their
day-to-day functioning and they seem to be worse during periods of sobriety you can
make sure to carry that over into the remarks section as well, and say, when the person is sober they have trouble getting out of bed because they’re so depressed, sometimes they’ve done cocaine just to get through the day, to get things done, something like that. So I would suggest really utilizing that remarks section
in the function report. Rachael do you have anything to add? – [Rachael] No, I think you about covered it on that one. – [Pam] Thanks. I think that’s a great tip to use the remarks section to add information about periods of sobriety, when symptoms are present, that’s really great. So, if you’re submitting function reports along with an MSR, you know, highlight this information and remarks ’cause we know that the DDF
adjudicators will read that. Here’s another question, and Amanda, you might wanna start taking this, and Rachael jumps in, ’cause Amanda your case study did address this to some extent that this has to do with if someone has liver disease due to alcoholism which is again another irreversible condition that’s not gonna get better, so someone has a liver disease due to alcoholism and the liver disease will not improve, will they be denied? – [Amanda] Yeah, that goes back to the controlled evaluation of materiality, so
again, the liver disease is not expected to improve even with the absence of substance use, so they will not be denied per record, denied per benefit, based
on their substance use because of that, if they meet all of the requirements for disability the substance abuse won’t play a role in the determination
because they are going to have this chronic condition either way, it’s not going away if they stop using alcohol. – [Rachael] That’s a good response, really I think there’s a big misconception too if a condition would may be caused by alcohol or other drugs
that they would be denied, but, you know, like other conditions that would be looked at separately and, you know, to see if the person maybe met the listing for liver disease how bad is it, how severe is it. So that’s really great to get, kinda get out there. But you may see that, you know, you may see hepatitis C
that was caused by drug use, you may see some other conditions as well, so Social Security will evaluate that by looking under the appropriate listing of impairments for that. – [Pam] Thanks for that. So, I think this was Amanda who was successful in getting the neuropsych eval, what advice would you get to SOAR Case Managers who would like to get
neuropsych evaluations, but the applicant has
no insurance for that. Do you wanna talk about
your particular case, or any strategies for maybe getting funding for a neuropsych, if you think that could really be
helpful for their treatment and their disability case. – [Amanda] Yeah, so I
think this neuropsych evals in general are
really really valuable pieces of evidence, but I also understand that they are expensive and nearly impossible to come across if you don’t have insurance. In the case study I was referring to, Michigan had a specific program for people experiencing homelessness that offered health insurance, so he did have insurance that covered it. When I worked in Denver there wasn’t a program like that and
we teamed up with a local university, University of Colorado, and their psychology department performed the neuropsych eval on a very reasonable sliding fee scale based on income. We also set grant money aside on their admin costs to pay for neuropsych evals for a
non-profit organization if we deemed them to be
necessary for the case. – [Pam] Great, so those are the tips and places to go to help fund some of these more expensive evaluations and needed testing. Here’s a good one that I think Rachael and Amanda, you’ve both seen for many of your SOAR applicants, are there strategies to counter frequent emergency room reports of intoxication, it seems like these reports, ER are used to seeing him there for alcohol and not noting other symptoms, so when you
get emergency room records and you’re just seeing the person treated for maybe alcoholism or maybe an overdose, or something else. How do you discuss those in your MSR? How do you talk to the
applicant about these? Especially, it says here if the report says that the
client is, quote unquote, normal, or no other symptoms are discussed other than maybe just for intoxication. – [Rachael] I can go
ahead and try answer that. This happens a lot with
a lot of those folks that I work with, and
what I really try and do is when those, when I read all of those emergency reports and see that maybe oh this is all happening within a two month range, and then it kinda calms down for a little bit, I try and have those conversations
with the client and asks them what was
going on at this time and see maybe did they go talk to their Community Mental Health provider at that time, and see
if those records maybe offer a different perspective
of what was going on, but at the very least, again, getting their story to see if you can advocate for them within their
MSR and let them know what was going on with the MSR and their mental health goes and not just the substance use. – [Amanda] That’s a good advice, Rachael. So dig a little deeper,
find other documentation, like you said, use other
collateral information, talk to the applicant
about what was going on at the time, I think that’s really great ’cause that’s often what happens, and you wanna make sure
that those are explained by finding out what was going on with that person at that time. – [Pam] Here’s another MSR question, I think perfect for
both Rachael and Amanda. I have been told by SSA that
a well-written MSR is good, but without a doctor’s signature on the MSR is not
meaningful documentation, is this true? And if so, what are our options? Amanda do you want to take that one first? – [Amanda] Sure, so this is
common question that comes up as a recurring theme SOAR
Technical Assistance, so it’s not considered medical evidence if it isn’t co-signed by a
qualified medical professional, but it is considered collateral evidence, which speaks to the functioning portion of the person’s application so you can still use your MSR as
a really powerful tool to talk about the person’s
functional impairments and particularly their
functional impairments during periods of sobriety if they have a co-occurring disorder. So it can be used to flesh out part B of the listing requirement but you do a need a doctor’s signature or a treatment provider’s signature if you want the MSR to serve as criteria for part A of the listing. – [Pam] Very good, cause that is also on, again a misconception about
how valuable the MSR is, even though is an unsigned one, because it’s a valuable
functional information that it has, but you’re right to stablish your diagnosis on, there must be a, you know, signed, or to give it to, give it
medical evidence weight it must be signed. Great, Melissa shared a
really great statistics on the numbers of adults who’d experienced a traumatic events, you know, about 90% of adults have experienced
a traumatic event and often many experience
multiple traumatic events. So again, in understanding
this and in the high percentage that individuals who are experiencing homelessness, I think it was 75%, how important is it to be able to help the applicant understand how their substance use history may impact their disability case? So this is really Amanda and Rachael, like how do you have that conversation with the applicant about that? So that they are open and honest with you about sharing their usage and, you know, again how you help them explain it to you so that you can describe it in your MSR? Is that often a difficult conversation? – [Amanda] I can jump in here and in my experience I’m
usually just very honest with them when I bring up the subject of substance use and tell them I’m not here to get you in trouble, but helping me understand what’s going on with substance use and your mental health is how we are going to make
this application successful. So that way when we’re
having those conversations that generally allows them to open up a little bit more and
understand I’m not here, this is not a punitive thing, you know, we’re working together on this and I’m really trying to
figure out what’s going on and I make it very clear
that the timeframes are important for the sake of getting that information from
their medical records versus getting their story from their own perspective as well. – [Pam] That’s really good. Okay. This is a question for Amanda, ’cause you have mentioned that you use clinical records for finding more clues like ER, case management
and group’s therapy records, so the question was in regarding to the group’s therapy notes, this person said, “I had
a previous SOAR applicant “who when they requested his medical “records were told that they could “only release notes on group’s therapy “with the court order. “Is there a way around this?” So I don’t know if it’s a
state-by-state type of question that we can look into but, Amanda, I mean did you find them easy to get
when you were in Michigan? – [Amanda] So, in Michigan and Colorado I don’t recall having a problem giving group therapy notes,
it was a private practice, sometimes I would have trouble getting individual therapy notes, so I think that might be a case-by-case
kind of situation that we could work through
together with strategy for talking to that record’s department. – [Pam] That’s good to know, so the person who asked the question feel free to call, email the TA Center and we can see if we can look into
that a little bit for you, if those would be very helpful either for your case and the person who was taking the group therapy, I guess in those comments. Okay, here is a question that is kind of along the line,
I mean we see this a lot, what about a claimant who likely has DAA but suffered a disabling injury due to his DAA and is now disabled. So it sounds like while the person was maybe intoxicated they were injured, and that injury may meet a listing, how would that, would social security look at DAA to deny them? Amanda did you wanna take that, that’s similar to the, either
your case study too maybe. – [Amanda] Yeah, so this is similar if they have a condition, even if it was caused
by drug or alcohol use, it doesn’t disqualify them from being eligible for
benefits, it doesn’t matter how the person acquired their disability, if they have a disability that’s going to prevent them from being able to engage in substantial gainful activity for at least 12 months, then they are eligible for SSI or SSDI benefits. – [Pam] I think that’s good, yeah. Great answer for that. This question came in,
it pertained to Melissa’s information about veterans, the use of TRICARE, the question was, does TRICARE cover residential services and I though maybe if Melissa, you have some information on this that you can share we could get a response at the TA Center but did you wanna talk about that at all? Is that something you’re, you know about? – [Melissa] I actually
would need to follow up with one of our other team
members to give that answer. – [Pam] Okay, yeah. So we were able to get per the TA center that TRICARE is a member of health plans that provides arranged coverage, so to find out about the eligibility for residential services
that we encourage you to contact TRICARE at their website ’cause there you can
look into the individual plans, but again, yeah if it’s something you, the questioner wants
more information on, just email the TA Center
and we’ll get back to our subject matter expert on that. And then there is also, Melissa made a comment
about not all veterans can have access to the
VA, which is correct and we just wanted to share that because, again, Jen Elder at the TA Center answered that and so that
is a common misconception that everyone who has
served in the army forces will have access to health care by the VA, so with eligibility enrollment
for VA health services. Anyway, just wanted to kinda clear that up so they questioner has an understanding that Melissa’s statement was correct, Melissa did you wanna talk any more about veterans and access to health care? – [Melissa] No, I think
that you covered that, and again, I reiterate
what you mentioned about reaching out and trying to learn what is available specifically on an individual basis as
what people can access really can vary based
on where they’re located and what those VA Centers
and hospitals have to offer, so yeah, it really is an individualized approach that you need to take. – [Pam] Okay, that’s great. Thank you for that. I have a few questions along those lines. Let’s see, I have a question here about trauma and again, Amanda and her presentation shared
the MSR interview guide that had that substance use,
substance history section that has a lot of open-ended questions but because Amanda and Rachael have a lot of experience
interviewing applicants with co-occurring disorders, and we see in Melissa’s statistics that a high percentage had
traumatic events in their past. What are some strategies,
Amanda mentioned, compassionate interviewing, what are some of your strategies for listening this information from applicants, knowing that you’re using this for their disability claim. Do you wanna talk a little bit about that? Some strategies for helping folks, again, understand why you’re asking about their trauma history, especially if it’s impacting their current functioning. – [Amanda] Sure, so during my intake process one of the key things I make sure to discuss with the applicant is, we need you to be as open and honest as possible so DDS can understand the true story of your life. Not very many people have the opportunity to prevent something as unique as the Medical Summary Report
for their disability cases. So this is a really good
opportunity to present this information in your own words, and it’s my job to help tell your story. And that seems to be a
pretty effective strategy. And just one example
as it relates to trauma and substance use from a case that I work, like, I think it was one
of my first store cases back in 2010. This man presented really
rough around the edges. He told me he’s done
every drug in the book, but liked alcohol the most. So he was getting into a lot
of fights on street corners. He just was really rough. He had a beard, he was scruffy, he just like presented
as a really tough guy. So we started talking
about his alcohol use, and we went back, he said
he was like seven or eight and he was sneaking beers out of his parents’ fridge at night. I stopped and I said “Seven or eight?” “That’s really young.” He’s like “Yeah, I was just a bad kid.” I was like, “You know, I know
seven and eight year olds “and I don’t think they have
that ability to be a bad kid.” Was there anything going on that made you want to try that beer? And he got really quiet. And he said “Well you know, my neighbor “used to make me come over
his house and help him “put stuff away, but that’s not really “what he was doing, that’s
what he was telling my parents “he was doing, and that’s when I started “drinking the beer.” So that’s all he shared
with me, but that was enough context clues to get the idea of what was really going on with him. So, I talked with his
case manager about it with his permission,
and they brought it up in their future
appointments, and he ended up working through it in therapy throughout this whole process,
and ended up opening up a little bit more to me,
and let me share this story with his application. And it gave me a really
new, and strong insight into the root cause of
his substance use history and how his use just
progressed so much over time. And it brought out a lot of anger and emotion in him as well. And I just think that if we can create an environment where someone
feels welcomed enough to share such personal details. He was 50 years old and he
said I’m the first person he ever shared that with before. So, it was just a really huge gift to me that he was willing to open
up about that from his end. And I know it was traumatic,
but I supported him and helped him connect
with his case manager and therapist so that they could provide the further support that he needed to work through that trauma. – [Pam] That’s perfect, and
that’s a great illustration in how important it is
for our case workers to develop those trusting relationships. It’s really how you’re gonna
get information that you know is gonna really help
their disability case, and really show the meaning
behind their substance use. So that’s a really great example. And also looping in his therapist as well. Really great to show that
you care, and you care about his mental health,
especially knowing how difficult it was to
share that information. It’s really great. Now we have another question
that probably has come up quite a bit in the work that you’ve done, Rachael and Amanda, is
how would you suggest addressing comments and records saying that a client is med seeking? You know, that suggests perhaps
it’s not legitimate pain, whether it’s physical pain,
or traumatic pain, right? Med seeking. Have you seen that in medical records? And how do you kind of explain that? And what kind of clue does that give you when and if you have seen
that in medical records that they’re just drug
seeking for pain medication? Something you’ve encountered,
or any suggestions in addressing that? – [Rachael] I think Helen said it before, but luckily, in my
experience, I’ve always had other records that kind
of overshadow that. So, I’m not too sure how to go about it if that’s the only thing
that they’re marking on the visit is just the med seeking, I’ve often found that there’s other things in those records that mark symptoms. And generally, med seeking would mean that they may not be using at that time. Well, if it does say med seeking, but they did maybe a toxicology report, and you’re seeing that,
you know, you might find a clean toxicology report on there, even when the records say med seeking, it’s just one of those situations that you might need to
dig a little bit further and kind of look at the
other evidence around. But like I said, in my experience, I’ve been pretty lucky to have
other supporting documents on those, I haven’t had one
where that’s the only one. – [Pam] Well that’s helpful,
look for other documentation. Again, the individual could
be in pretty serious pain, and there really could
be a reason for that related to their mental health diagnoses. That would be really good. We have a question here and it’s something we can talk about at the case center, but there was a request
for copies of your MSRs for Rachael and Amanda,
so that’s something we can talk about, and see
if we can’t take a look them, get them redacted, and see
if we can’t upload those with the PowerPoint. So we’ll look for those,
maybe that’s something that we can do. So I think people are
really interested in seeing how you do write your MSRs, specifically the session’s
use history section as well when you know that DAA is something that could be involved in their case. So, with that, we have
a few more questions that we’ll make sure that
we get answered offline. We may have to get some
more details on it. But again I just wanna thank
all of our presenters today for their wonderful and
informative presentation and taking time to answer some questions that SAMHSA SOAR community had. So again, I just want to thank everyone for joining us on this webinar. Don’t forget to do the evaluation and to have a good afternoon, thank you.

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