Understanding SSA ’ s Policy on Drug Addiction and Alcoholism

1. Understanding SSA’s 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.

2. Understanding SSA’s 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.

3. Welcome and Opening Remarks Sabrina Edgington National Health Care for the Homeless Council Kristin Lupfer SAMHSA SOAR TA Center Policy Research Associates, Inc.

4. Webinar Instructions • Question instructions • Muting • Recording availability • Downloading documents • Evaluation

5. 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.

6. 13-2p: Evaluating Cases Involving Drug Addiction and Alcoholism(DAA)Presenter:Michele Schaefer

7. 1996 Legislative ChangePublic 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.

8. 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

9. 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

10. DAA Definition We define DAA as “Substance Use Disorders”

11. 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

12. Substance-induced disorders are not included in our definition of DAA. • Exceptions: • Substance-Induced Persisting Dementia • Substance-Induced Persisting Amnestic Disorder

13. 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

14. Burden of proof The burden of proving disability throughout the sequential evaluation process rests with the claimant.

15. If DAA IS Material, then the Claimant IS NOT Disabled

16. DAA is Material When: • The claimant’s only impairment is substance abuse or dependence; or • The claimant’s other physical or mental impairment is, by itself, not disabling. For example, the claimant has a hearing impairment that’s not severe.

17. If DAA is NOT Material, then the Claimant IS Disabled

18. 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

19. DAA Evaluation Process Step 1 Does the claimant have DAA?

20. DAA Evaluation Process Step 2 Is the claimant disabled considering all impairments, including DAA?

21. DAA Evaluation Process Step 3 • Is DAA the only impairment? • If DAA is the claimant’s only impairment, DAA is material and a denial is appropriate

22. 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

23. DAA Evaluation Process Step 5 • Does the DAA cause or affect the claimant’s medically determinable impairment(s)? • If DAA is not causing or does not affect the other impairment, DAA is NOT material. An allowance is appropriate.

24. 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

25. DAA Evaluation Process Step 5 Cont’d • If DAA does not cause or affect other impairments to be found non-disabling, DAA is NOT material and an allowance is appropriate • If DAA causes or affects the claimant’s other medically determinable impairment(s), proceed to step 6.

26. 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

27. Question 14 -What explanation does the determination or decision need to contain? •  Findings: • Claimant has DAA • Claimant is disabled considering all impairments (including DAA) • Claimant would or would not be disabled in the absence of DAA

28. Implications for DDS and Recommendations for Providers Daette Quick Certified Public Manager, Iowa Disability Determination Services

29. 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.

30. 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, physician’s assistants and therapists.

31. Functioning Over Time • Information from “other” sources can be essential to the finding of materiality by describing the claimant’s 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 claimant’s 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

32. 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.

33. Documenting Disability for Individuals who have a Substance Use Disorder Dr. Barry Zevin, MD Tom Waddell Health Center, San Francisco Department of Public Health

34. 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 patient’s 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

35. 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

36. 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

37. 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).

38. 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 patient’s 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

39. 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

40. Submitting Applications for Individuals who have a Substance Use Disorder Pam Heine, MSW, LSW SAMHSA SOAR Technical Assistance Center Policy Research Associates, Inc.

41. 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 applicant’s mental impairments pre-date or underly the substance abuse

42. 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

43. 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 doctor’s findings regarding the applicant’s 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

44. Three Strategies After SSR 13-2p #3 Medical Documentation and Other Evidence • Educate treating sources about SSA’s 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!

45. Questions and Answers Facilitators:SAMHSA SOAR Technical Assistance Center Policy Research Associates, Inc.

46. For More Information SAMHSA SOAR TA Center www.prainc.com/soar National Health Care for the Homeless Council www.nhchc.org