Understanding SSAs Policy on Drug Addiction and Alcoholism

Understanding SSAs Policy on Drug Addiction and Alcoholism

Understanding SSAs Policy on Drug Addiction and Alcoholism The webinar will begin shortly. Audio: 1-888-323-4910 Passcode: 3741743 PIN: This was provided in your registration confirmation e-mail. If you experience difficulties, please stay on the line for an operator. Understanding SSAs Policy on Drug Addiction and Alcoholism and its Impact on Disability

Determinations Presented by: SAMHSA SOAR Technical Assistance Center Policy Research Associates, Inc. AND National Health Care for the Homeless Council This webinar is in part supported by Cooperative Agreement Number U30CS09746-04-00 from the Health Resources and Services Administration, Bureau of Primary Health Care (HRSA/BPHC). Its contents are solely the responsibility of the authors and do not necessarily represent the official views of HRSA/BPHC. Welcome and Opening Remarks

Sabrina Edgington Kristin Lupfer National Health Care for the Homeless Council SAMHSA SOAR TA Center Research Associates, Inc. Policy Webinar Instructions

Question instructions Muting Recording availability

Downloading documents Evaluation Agenda Welcome and Introductions Sabrina Edgington, MSSW, Program and Policy Specialist, National Health Care for the Homeless Council

Kristin Lupfer, LMSW, Associate Director, SAMHSA SOAR Technical Assistance Center, Policy Research Associates, Inc. Overview of DAA Ruling Michele Schaefer, Supervisory Team Leader, Office of Medical Listings Improvement, Office of Disability Programs, Social Security Administration Implications for DDS and Recommendations for Providers

Daette Quick, Certified Public Manager, Iowa Disability Determination Services Documenting Disability for Individuals who have a Substance Use Disorder Dr. Barry Zevin, MD, Tom Waddell Health Center, San Francisco Department of Public Health Submitting Applications for Individuals who have a Substance Use Disorder

Pam Heine, MSW, LSW, Senior Project Associate, SAMHSA SOAR Technical Assistance Center, Policy Research Associates, Inc. 13-2p: Evaluating Cases Involving Drug Addiction and Alcoholism (DAA) Presenter: Michele Schaefer

1996 Legislative Change Public Law 104-121 A claimant shall not be considered disabled if drug addiction or alcoholism is a contributing factor material to the determination that the individual is disabled. DAA Social Security Ruling 13-2p SSR 13-2p; Titles II and XVI: Evaluating Cases Involving Drug

Addiction and Alcoholism (DAA) Published on February 20, 2013 Effective March 22, 2013 DAA Social Security Ruling 13-2p, Cont. DAA SSR explains how we consider whether DAA is material 15 Questions in the SSR 6-Step DAA Evaluation Process DAA Definition We define DAA as

Substance Use Disorders DAA Does Not Include: Caffeine and nicotine disorders Use of prescription medications taken as prescribed Children who have medical conditions resulting from their mothers use of drugs or alcohol during pregnancy Occasional misuse of drugs or alcohol Substance-induced disorders

are not included in our definition of DAA. Exceptions: Substance-Induced Persisting Dementia Substance-Induced Persisting Amnestic Disorder DAA and Sequential Evaluation Adjudicators apply the sequential evaluation twice: Once to determine that the claimant is disabled considering all impairments

Second evaluation to determine whether the claimant would still be disabled if he or she were not using drugs or alcohol Burden of proof The burden of proving disability throughout the sequential evaluation process rests with the claimant. If DAA IS Material, then the Claimant IS NOT Disabled

DAA is Material When: The claimants only impairment is substance abuse or dependence; or The claimants other physical or mental impairment is, by itself, not disabling. For example, the claimant has a hearing impairment thats not severe. If DAA is NOT Material, then the Claimant IS Disabled DAA is NOT Material When:

Claimant has impairment(s) that is NOT affected by the DAA and is disabled; or Claimant has physical impairment(s) that is NOT affected by DAA, AND the vocational grid rules direct a finding of disabled; or Claimant has a permanent condition that resulted from drinking or taking drugs and it is a SEPARATE impairment DAA Evaluation Process Step 1 Does the claimant have DAA?

DAA Evaluation Process Step 2 Is the claimant disabled considering all impairments, including DAA? DAA Evaluation Process Step 3 Is DAA the only impairment? If DAA is the claimants only impairment, DAA is material and a denial is appropriate

DAA Evaluation Process Step 4 Is the other impairment(s) disabling by itself while the claimant is dependent upon or abusing drugs or alcohol? If the other impairment(s) is NOT disabling by itself, DAA is material and a denial is appropriate If the other impairment(s) IS disabling by itself, go to Step 5 DAA Evaluation Process

Step 5 Does the DAA cause or affect the claimants medically determinable impairment(s)? If DAA is not causing or does not affect the other impairment, DAA is NOT material. An allowance is appropriate. Step 5 Scenarios for Establishing that DAA Does NOT Cause or Affect the Other Impairments: Other disabling impairment has no relationship to the DAA

Claimant acquired a separate disabling impairment while using a substance DAA medically caused the other disabling impairment BUT other impairment is irreversible or could not improve to the point of nondisability DAA Evaluation Process Step 5 Contd If DAA does not cause or affect other impairments to be found nondisabling, DAA is NOT material and an allowance is appropriate If DAA causes or affects the claimants

other medically determinable impairment(s), proceed to step 6. DAA Evaluation Process Step 6 Would the other impairment(s) improve to the point of nondisability in the absence of DAA? Yes, DAA is material and a denial is appropriate No, DAA is not material and a allowance is appropriate

Question 14 -What explanation does the determination or decision need to contain? Findings: 1. Claimant has DAA 2. Claimant is disabled considering all impairments (including DAA) 3. Claimant would or would not be disabled in the absence of DAA Implications for DDS and Recommendations for Providers Daette Quick

Certified Public Manager, Iowa Disability Determination Services Supporting the Determination Adjudicators must provide sufficient information that supports their determination of materiality of DAA The claimant has DAA and at least one other medically determinable physical or mental impairment, The other impairment(s) could be disabling by itself , and The other impairment(s) might improve to the point of

non-disability if the claimant were to stop using drugs or alcohol. Non-Medical Sources Many claimants with Substance Use Disorders receive care from other non-medical sources Examples are: non-clinical social workers, caseworkers, voc rehab specialists, family members, school personnel, clergy, friends, past employers, licensed chemical dependency practitioners. Other medical sources include but are not limited

to: nurse practitioners, physicians assistants and therapists. Functioning Over Time Information from other sources can be essential to the finding of materiality by describing the claimants functioning over time (in times of use and abstinence) because it supplements the medical evidence of record Can describe how the claimant is performing or has performed activities of daily living Can detail claimants responses to normal stressors of daily living

Can provide information about independence of and ability to sustain work like activities Can provide information about ability to accept supervision and work appropriately with peers Can provide accurate description of level of function Key Information Per SSR 13-2p In many cases, evidence from other sources may be the most important information in the case record for these documentation issues.

When the information listed above is included in the Medical Summary Report, it assists with the determination of DAA materiality with information crucial to the determination of level of function when the claimant is and is not using drugs or alcohol. Documenting Disability for Individuals who have a Substance Use Disorder Dr. Barry Zevin, MD Tom Waddell Health Center, San Francisco Department of

Public Health Thinking About Disability in Homeless People Goals and approach to clinical care may be quite different than disability determination process Clinical process does have some similarity to disability determination process

Think holistically about patients functioning Explore why patient is homeless Explore underlying problems Explore consequences of homelessness Many patients show tremendous resilience but are unable to sustain functioning needed to work

Role of Clinicians Primary care providers and other continuity providers have advantage of observing patients over time As in other clinical tasks gathering and synthesizing information from other health care providers and collateral informants is essential Documentation in clinical setting has many purposes

Electronic health records create opportunities and challenges Help establish scope and consistency of problems may make creating a coherent narrative more difficult Documenting disability by assessing and recording patient functioning has many potential benefits to patients overall care Disability Due to Substance Abuse There is no doubt that substance use disorders of a high severity can cause severe functional disability

Policy that these disabilities do not qualify for benefits creates challenge for clinicians Knowledge of manifestations and natural history of substance use disorders is important in evaluating these patients It is not unusual for patients and clinicians less familiar with substance use disorders to attribute symptoms and functional limitations to addiction that are in fact caused by co-occurring

conditions Impairments Related to Substance Use Substance use disorders excluded by law as a basis for disability under SSI/SSDI. Comment whether patient would still be disabled even if substance use were to cease. Encourage treatment. Permanent or long-term sequelae of substance

abuse are considered in the system area in which they occur (e.g. Chronic liver disease in Digestive System section). Co-Occurring Disorders Personality disorders very frequent in substance abusers Very treatment resistant Degree of impairment underestimated by patients and providers

Ask about conflicts, consider patients style in the office conflicts with front office staff, other providers, family members, etc.

Explicitly point out violence history in anti-social PD patients and others PTSD, anxiety disorders, depression, ADHD, psychotic disorders Cognitive disorders due to developmental disabilities, traumatic brain injury, hypoxic episodes in OD, alcohol dementia Liver disease, heart disease, lung disease, chronic infectious disease, musculoskeletal disorders Chronic pain Strategies to Help Determine Lack of Materiality

Impairment preceded initiation of addiction Existence of permanent sequelae of alcohol or drug use Point out drug use as attempted self treatment of severe underlying problems Observation or review of reports of patient during periods of abstinence In program, In jail, etc.

Evidence supports rapid response of substance induced mental health disorders after abstinence - document this as factual Methadone or buprenorphine maintenance are not considered drugs of abuse and impairments that persist when patient is under treatment should qualify State explicitly as disability determination specialists may be unfamiliar Submitting Applications for Individuals who have a Substance Use Disorder Pam Heine, MSW, LSW SAMHSA SOAR Technical Assistance Center Policy Research Associates, Inc.

SOAR: An Active Role SOAR practitioners take an active role developing quality disability applications by: Becoming applicant's authorized representative (SSA 1696) Gathering and organizing required evidence received from applicant, medical providers (past and present), and other sources Submitting completed application which includes medical records and the SOAR Medical Summary Report (MSR) Describes severity of functioning over time Elevated to medical evidence when signed by an acceptable medical source, (i.e. MD, DO or PhD) Effective means to show applicants mental impairments pre-date or underly the substance abuse

Important Things to Know and Understand Read SSR 13-2p Definition of Alcoholism, Substance Dependence, and Substance Abuse

Co-occurring Mental Illness and Substance Abuse Understanding the Evidence - learn the details Stepping Stones to Recovery Training Good time to dust off that binder! Sample Descriptions Three Strategies After SSR 13-2p #1 Materiality

Medical provider documents that DAA is not material #2 Sobriety Take advantage of periods when the applicant has not been using drugs or alcohol Make a timeline

Careful review of record for doctors findings regarding the applicants limitations If possible, talk to applicant about drug or alcohol rehabilitation program After sober for one month, obtain statement from doctor regarding ability to work based on remaining health problems Three Strategies After SSR 13-2p #3 Medical Documentation and Other Evidence Educate treating sources about SSAs DA&A policy

Obtain opinion evidence from acceptable medical sources, and from sources who are not considered acceptable medical sources (see SSR 06-03) Emphasize the physical and other mental health impairments, including pain allegation (see SSR 83-14, SSR 85-15 and SSR 96-7p) Finally, always submit the SOAR Medical Summary Report

(MSR) where there is evidence of DA&A! Questions and Answers Facilitators: SAMHSA SOAR Technical Assistance Center Policy Research Associates, Inc. For More Information SAMHSA SOAR TA Center www.prainc.com/soar National Health Care for the Homeless Council www.nhchc.org

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