Strengthening Applications: The Medical Summary Report

1. Strengthening Applications: The Medical Summary Report Presented by: National SOAR Technical Assistance Center Policy Research Associates, Inc. Under contract to: Substance Abuse and Mental Health Services Administration U.S. Department of Health and Human Services

2. Webinar Instructions • Question instructions • Muting • Recording availability

3. Agenda The Importance of the Medical Summary Report Deborah Dennis, SOAR Technical Assistance Center Strategies for Writing the Medical Summary Report Ashley Wright and Corey Gephart, Park Center, Nashville, TN Collaborating with Physicians for Writing Reports Larry Klowden, Northwestern Memorial Hospital, Chicago, IL Supporting SOAR Trainees through Writing Workshops Jennifer Alfredson and Emily Palmer, Health Care for the Homeless, Milwaukee, WI Reviewing Medical Summary Reports for Quality Assurance Emily Carmody, North Carolina Coalition to End Homelessness, Raleigh, NC Questions and Answers Facilitators: National SOAR Technical Assistance Team

4. The Importance of the Medical Summary ReportDeborah DennisNational SOAR Technical Assistance CenterPolicy Research Associates, Inc.

5. SOAR Critical Components • Serving as the appointed representative • Collecting and submitting medical records • Electronically submitting applications and medical evidence whenever possible • Collaborating with physicians for assessments and medical information • Collaborating with SSA and DDS • Submitting a Medical Summary Report

6. The Medical Summary Report • A letter that provides information not found in most medical records • Provides a vivid picture of the individual for the DDS examiner who never sees them • Provides a clear link to functional impairment • Often takes the place of the SSA-3373 Function Report • Helps to avoid the limited space and check-boxes of these forms

7. The Medical Summary Report • Is medical evidence when co-signed by physician or psychologist who has seen individual • Can be sent directly to the DDS disability examiner or hand delivered to SSA • Receives positive feedback from DDS examiners across the country

8. Components of the Medical Summary Report • Reference Section • Introduction • Personal History • Diagnostic and Treatment Information • Link to Functional Impairment • Summary • Contact Information

9. Introduction Section • Demographics • Physical description – hygiene, grooming, dress, make-up, any unusual characteristics • Additional information – helps DDS examiner “see” the individual as case manager does

10. Developmental problems Physical/sexual abuse Childhood Educational Relationships Medical problems Substance use Current housing Employment history Personal History Quotes from the individual are very helpful!

11. Psychiatric Diagnoses and Treatment • Chronological treatment history • Specific quotes from the applicant or record that illustrate diagnosis • Observations of behavior • Durational issues • Current mental status exam

12. Link to Functional Impairment • Critical to connect symptoms/effects of illness with marked functional impairments • To the extent possible in all four functional areas • Demonstrate impact of illness(es) on ability to work • Medication – effects and side effects • Support and effect of support • Compare with lack of support

13. Summary and Contact Information • Ties all information together for a concise picture of the individual • Contact – names and numbers • Co-signed by case manager, physician/psychologist

14. Medical Summary Report Worksheet • Serves as a helpful framework for writing the report • Pulls together information collected using: • Substance Use Worksheet (Module VII) • Applicant Assessment Worksheet (Module X) • Functional Information Worksheet (Module XI) • Breaks into workable sections • Use as a template for your work in the field

15. Samples and Support • Visit the SOAR website for samples and abbreviated versions • The SOAR TA Center will review redacted reports and provide feedback upon request

16. Worth the Effort • The overall process of applying for benefits is time-consuming • Putting forth the initial effort for an earlier, more successful outcome may seem difficult, but it is worth it for the person and for the case manager

17. Strategies for Writing the Medical Summary ReportAshley Wright and Corey GephartPark CenterNashville, TN

18. Steps/Strategies to Writing • Collect medical records after Releases of Information are signed. • Go through medical records and put them in chronological order. • Set aside several hours at a time to begin writing the report with no interruptions. • Sit down with all information, all Medical Records, Screening Packet (personal, medical, employment and substance use history) and any current Mental Status Exams.

19. Medical Summary Report Personal History Education Employment Relationship Substance Abuse Functional Information Activities of daily living Social functioning Concentration, persistence and pace Episodes of decompensation (if applicable) Introduction • Observations • Diagnosis/symptoms • How impairments interfere with ability to work Medical Records • Summarize all mental health & medical records • Include doctors that treated client, diagnosis & medications • If inpatient, include admission & discharge dates

20. Collaborating with Physicians for Writing ReportsLarry KlowdenNorthwestern Memorial HospitalChicago, IL

21. Northwestern Memorial Hospital • Northwestern Memorial Hospital - Downtown Chicago, IL • Academic Medical Center • Northwestern University Medical School • NU Graduate Psychology Program • Teaching environment with large residency and psychology Ph.D. programs • Stone Institute of Psychiatry • Comprehensive services – emergency, inpatient, outpatient, housing • Multi-disciplinary approach

22. Stone Institute of Psychiatry

23. SOAR Implementation • Designed through QI initiative • Key issue - who would prepare Medical Summary Report? • Approached head of residency program and supervisor of psychology students • They agreed MSR preparation was excellent learning opportunity

24. Preparing Medical Summary Reports • Staff assignments for Medical Summary Report • If resident is medicating the person, resident completes MSR • MSRs for other individuals are prepared by psychology students under the supervision of licensed psychologist • In certain situations, SOAR Coordinator can complete MSR and outpatient clinic Medical Director will co-sign • Staff identified to prepare MSR are notified as early as possible but at least 30 days prior to required completion date

25. Multi-Disciplinary Staff • Staff roles take advantage of multi-disciplinary licensed staff • Primary clinician (usually licensed therapist) – responsible for identifying individuals appropriate for SOAR application • Case managers and mental health workers -- identified as SOAR Coordinators; given overall responsibility for SOAR application • Resident or psychology student prepares MSR

26. Benefits and Challenges Benefits: • MSR is prepared by MD or psychologist • SOAR Coordinator focused and able to handle more cases Challenges: • Requires greater coordination – trainees schedule varied and complicated • Quality control – large number of residents, limited opportunity for review and trainee turnover

27. Supporting SOAR Trainees through Writing WorkshopsJennifer Alfredson and Emily PalmerHealth Care for the HomelessMilwaukee, WI

28. Why Did We Do It? • Completed a county-wide survey • Talked about community needs within our Community Collaborative • Concluded that many people were trained in SOAR, but not using it due to fear or worry about writing an MSR

29. The Idea • To give practical guidance and information about writing an MSR • To give participants time to practice writing • To allow participants to complete a full MSR by the end of the workshop

30. The Setup: Who To Invite? • Limited the workshop to a small group of people- only 8 • Participants must have already been through Stepping Stones to Recovery • Participants were to have an actual client that they were writing an MSR for

31. The Setup: Workshop Structure • Trainers had regular contact with participants about 2 months in advance • Reviewed how to set a Protective Filing Date • Reviewed tips for the application • Reviewed collection of information through records collection and interviews • Spread workshop over 2 weeks • Met 3 hours each week

32. The Setup: Workshop Structure • Reviewed MSR sections: introduction, personal history, psychiatric history, functional information (ADLs; social functioning; concentration, persistence and pace) • Gave following sections as homework: work history, substance abuse history, physical health history, episodes of decompensation

33. The Setup: Workshop Structure • Each section was set up and introduced similarly: • Watch the video with Andrea for that section • Read the example MSR section • Gave tips and advice on writing the section • Allowed time for participants to write the section • Discussed the writing in peer pairs and as a group

34. What Worked Well? • Discussing the SOAR process over 2 months was helpful to participants to go through the whole process with guidance • Splitting the training over 2 weeks gave participants an opportunity to write in between; giving homework was helpful • Participants said that they felt they could now “do” the SOAR process on their own • Participants said that they better understood how to write the MSR

35. What Would We Change? • 3 hours each week was not enough time; 4 hours per week would probably work • Giving homework was helpful and a challenge. Participants did not write as much on their own as they did in the group • Splitting the training up was a great idea, but many people did not show up the second week • Participants suggested a formal follow-up after the MSRs were written to review them as a group

36. What Would We Change? • Choosing a client was a challenge for participants. Some suggestions: • Increase the time for discussion from 2 months • Mention the MSR training right after a Stepping Stones to Recovery training and begin the process right away • Have 3 face-to-face meetings: one 2 months prior to the workshop and then the two workshops

37. Reviewing Medical Summary Reports for Quality AssuranceEmily CarmodyNorth Carolina Coalition to End Homelessness Raleigh, NC

38. SOAR Case Worker Certification • NC Coalition to End Homelessness (NCCEH) created process in September 2009 • Slow to start, but beginning to gain momentum as NC creates more dedicated SOAR case worker positions in the state • Currently have 3 case workers certified and 3 in process • Starting in 2010- all PATH Benefits Specialist positions in NC must be certified through NCCEH

39. Why Create A Certification Process? • Provides a way to recognize SOAR case workers who use their SOAR training • Provides an opportunity for state lead to monitor Medical Summary Reports for quality assurance • Reinforces SOAR process by using SOAR checklist for applications and reporting outcomes

40. Becoming SOAR Certified in NC Two Stages of Certification: STAGE 1 -- Provisional Status • Attend the two-day SOAR training for caseworkers • Complete at least one SOAR application using Quality Review Checklist • Submit copy of Medical Summary Report and Quality Review Checklist to NCCEH • Submit SOAR outcomes form to NCCEH • Complete SOAR Caseworker Certification Exam STAGE 2 – Fully Certified • Complete 5 additional applications • Submit copies of all medical summary reports, quality review checklists and outcomes to NCCEH for review • Complete self-assessment and evaluation of SOAR values, skills and experience

41. SOAR Case Worker Certification:Medical Summary Evaluation • Identifying information of applicant (REQUIRED) • Full Name • Date of Birth • Full Social Security Number • Introductory paragraph that provides a clear physical description (REQUIRED) • Personal History • Childhood description including any abuse history • School history • Work history • Relationship history • Homelessness history • Medical History (REQUIRED if using physical impairment listing) • List of symptoms experienced and described by individual (using SSA listing for guidance) • Medical Treatment History (citing records obtained by case worker)

42. SOAR Case Worker Certification:Medical Summary Evaluation • Mental Health History (REQUIRED if using mental health listing) • List of symptoms experienced and described by individual (using SSA listing for guidance) • Mental health treatment history (citing records obtained by case worker) • Substance Abuse History (REQUIRED if substance abuse in med. records) • History of use (when started, point of heaviest use, periods of abstinence) • Explanation of how substance use does or does not impact symptoms including if substances are used to manage current symptoms • Functioning Information (REQUIRED) • Clearly defined paragraphs addressing specific examples of impairment in: • Activities of Daily Living • Social Functioning • Concentration, Persistence, and Pace • Repeated Episodes of Decompensation • Contact Information for SOAR Case Worker and Treating Physician (REQUIRED)

43. SOAR Case Worker Certification:Benefits • Improves Medical Summary Reports • Encourages case workers to use SOAR after training and recognizes their hard work • Provides state team lead with examples of good Medical Summary Reports for trainings and one-on-one technical assistance • Certification requirements for case workers are easy to include in job expectations for dedicated SOAR case worker positions

44. For More Information: Emily Carmody, LCSW North Carolina Coalition to End Homelessness Phone: 919-755-4393 emily@ncceh.org SOAR Case Worker Certification on website: http://www.ncceh.org/caseworkers/

45. Questions and AnswersFacilitator: Kristin LupferNational SOAR Technical Assistance CenterPolicy Research Associates, Inc.

46. For More Information on SOAR Visit the SOAR website at www.prainc.com/soar Or contact: SOAR TA Center Policy Research Associates, Inc.Delmar, NY518-439-7415soar@prainc.com