SOAR Medical Summary Report - Enhancing SSI/SSDI Applications

1. The SOAR Medical Summary ReportPlease stay on the line. The webinar will begin shortly.To download this presentation and other materials, click here: http://soarworks.prainc.com/article/soar-msr-webinar Use your phone to hear audio:Toll Free Number: (855) 749-4750Access code: 666 898 914Contact lguerin@prainc.com if you experience technical difficulties.This webinar is being recorded and will be available for viewing within 1 week of this presentation.

2. The SOAR Medical Summary Report Presented BY: SAMHSA 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

3. Welcome! Kristin Lupfer, Project Director SOAR Technical Assistance Center Policy Research associates, Inc. Delmar, New York

4. Webinar Instructions • Muting • Recording availability • Downloading documents • Evaluation • http://soarworks.prainc.com/article/soar-webinar-employment

5. Learning Objectives • Understand the importance of the SOAR Medical Summary Report and what it entails  • Learn ways that you can use the Medical Summary Report to help support SSI/SSDI applications you submit • Gain access to worksheets, samples and other tools to help support the writing of a Medical Summary Report

6. Agenda Medical Summary Report Overview • Jen Elder, Senior Project Associate, Policy Research Associates, Inc., Delmar, New York • Interviewing for and Writing the Medical Summary Report • Amanda Toral, Entitlement Specialist, Eleventh Judicial Criminal Mental Health Project, Miami, Florida • Daniel Perry, BEST Team Lead, Central City Concern, Portland, Oregon Disability Determination Services Perspectives • Brad Stanley, Medical Relations Officer, Disability Determination Services, Birmingham, Alabama Questions & Answers

7. Poll Question #1 Have you ever written a SOAR Medical Summary Report? a. Not yet b. Yes, less than 5 c. Yes, more than 5 d. Making plans to in the future

8. The SOAR Medical Summary Report: A Basic Overview Jen Elder, Senior Project Associate Policy Research Associates, Inc. Delmar, New York

9. The Importance of the Medical Summary Report (MSR) • SOAR Key Component • Applications submitted with a high-quality MSR increases the likelihood of an approval on initial application • Identified by USICH, VA, SSA, and SAMHSA as a Key Strategy for Connecting Individuals Experiencing Homelessness to SSI/SSDI • Interagency report released in July 2015 specifically describes the MSR as a critical component for successful applications • Often takes place of the SSA-3373 Function Report • Helps to avoid the limited space and check-boxes of these forms

10. What is an MSR? • A letter which describes the individual and his/her functional limitations and struggles • Supports medical records submitted • Helps DDS “see” the person you are working with • Illustrates the connection between the applicant’s functional limitations and the impairment • Answers the question: “Why is the applicant unable to work?” • Is medical evidence when co-signed by a physician or psychologist • Submitted to SSA/DDS according to your local SOAR Process

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

12. Introduction Section • Demographics • Physical description – hygiene, grooming, dress, make-up, any unique characteristics • Observations about behavior and mannerisms • Include diagnoses and impairment information • Help the DDS examiner “see” the individual as you do!

13. Personal History • Childhood and family information • Brief overview of their background • Past trauma that may relate to current diagnoses and functioning • Education • What was the last grade they completed? Did they have any struggles in school? • Employment history • Describe their past jobs – include how long they stayed at each job, the tasks they performed, any struggles they had at work, and why they left

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

15. Link to Functional Impairment • Critical to connect symptoms/effects of illness with marked functional impairments • To the extent possible in all four functional areas: • Activities of daily living (ADLs) • Social functioning • Concentration, persistence, and pace • Repeated episodes of decompensation • Demonstrate impact of illness(es) on ability to work • Medication – effects and side effects • Support and effect of support, compared with lack of support

16. Make the Link • The MSR is the link that connects the diagnosis to the limitations that the applicant experiences • Being able to document this link is very important in order to demonstrate the applicant’s inability to engage in substantial gainful activity Limitations in Functioning Diagnosis Why the applicant is unable to work

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

18. Medical Summary Report Interview Guide • Tool for gathering information needed to write the MSR • Open-ended questions • Tell me about … • How often … • When was the last time … • Functional questions • Context of questions – SGA • Distinguish between access and ability

19. Medical Summary Report Template • Use the MSR Template to organize and write the MSR • Agency Letterhead • Headings • Signatures

20. MSR Samples & Support • Visit the SOAR website for MSR samples in the SOAR Library! • The SOAR TA Center will review redacted MSR letters and provide feedback upon request

21. Poll Question #2 True or False? The Medical Summary Report is an untested strategy and we are not sure of its importance in supporting applications. a. True b. False

22. Interviewing and Writing for the MSR Amanda Toral, Entitlement Specialist Eleventh Judicial Criminal Mental Health Project Miami, FLorida

23. Tips for Interviewing • Face-to-face interviewing • Meeting in person allows for rapport building and an overall perspective • Over the phone or through someone else may not give the full picture of the individual • Environment • Both client and interviewer should be comfortable • Give options so that client can have a choice in where and when to meet • Don’t assume the client can come to you, arrange what works for both of you • Explaining the purpose of the interview • An explanation of what type of information you are looking for and what types of questions you are going to ask, making the client fully aware of the nature of the interview • Express that the more information you have, the better report you can write. However, let the client know it is ok if they are uncomfortable talking about something specific

24. Interview Questions • Interview Questions • Use SOAR worksheets (SOAR Tools and Worksheets | SOAR Works!) • Read them ahead of time! • Get comfortable being uncomfortable. Some questions regarding trauma for example, may lead to responses that you did not expect and may cause the client to react in a way you did not expect • Let the client talk • Loose conversation may still give you good information for your report and it will build rapport • Some responses may cause client to go off on another topic • Going “out of order” according to the medical summary outline is ok, the worksheets will keep you on track for what information you need to obtain • Body language and social cues • Pay attention to the client’s body language – for information for the report, but also to know if the client is losing interest in the conversation • Be aware of social cues that the client may not be comfortable

25. Interviewing, Continued • Multiple interviews • Be open to the idea of coming back for another interview • Sitting for hours to get the information may not be conducive to getting the right information • More time may be needed to build rapport for client to be comfortable sharing information • Taking notes • Ask if it’s ok to write while the client talks, don’t assume the client will be comfortable with it • Take notes on what the client is saying and what you observe • Don’t take everything you see or hear at face value • Interviewing available support system • If the client has a person in their life that knows them and supports them, ask if they are comfortable with you talking to that person • Interview family, friends, treatment team, etc. Information from third parties are just as beneficial as information from the client themselves.

26. Tips for Writing • Schedule time • Arrange time to write your report shortly after meeting with the client • Information is fresh in your head and will make the report easier to write • Allows you to write and complete in a timely manner, giving you amble time to request a doctor signature and have it prepared to send to DDS • Use quotes • Direct quotes from the client will allow DDS to see from the client’s perspective • Use medical records • Have medical records on hand when writing the MSR • Use information from the records to comment on past and current diagnoses and symptoms, to give a full picture of the clients presenting illness and how it has been present over time • Make sure to report when information is coming from the records (i.e. According to records from Jackson Memorial Hospital…)

27. Writing, Continued • Use input from support system and treatment team • Write about the information provided by others (family, friends, treatment team) • Make sure to comment on where this information is coming from (i.e. According to the client’s mother…) • Write in a clear and concise manner • Try not to give too much detail in one category or another so ensure that you are staying on topic • Medical jargon may be confused and unknown to the person reading it • Given explanations of symptoms instead of just listing them • Explain how the symptoms affect the persons ability to function • Get a second opinion • Ask a supervisor or co-worker to read over the report for errors • Someone who knows the client may be able to share their perspective • Someone who does not know the client can help to say whether or not they got a good overall picture of the client

28. MSR Sections to Focus On • Psychiatric History • We use bullet points in this section to list all facilities, clinics, programs, hospitals, and doctors the client has received services from • We provide information from what the client has told us about each, in addition to referencing information from the medical records we have collected • We write a couple sentences about each one, references when and for how long they received treatment, what type of treatment, diagnosis and medication information. • Listed in chronological order, showing just how far back the impairment has been present

29. MSR Sections to Focus On • Functional Information • We provide information in each section (ADLs, Social Functioning, Concentration, Persistence, and Pace, and Episodes of Decompensation) that relates to the Functional Report that is often requested by DDS • Focus on making the link! symptoms  limitations in functioning for that particular area of functioning  how this impairs work ability • Providing this functional information within the MSR, has often eliminated the need for the Function Report • Make note of this when talking to the DDS adjudicator. Let them know that you have an MSR and explain what information is in it. Some adjudicators we have worked with are unfamiliar with SOAR, have not seen an MSR before and are not aware that the information provided in the MSR is the information they ask for in the Functional Report

30. Co-Signatures • Getting an MSR co-signed • Talk to the psychiatrist right after your initial interview with the client • Let them know you will be working on an MSR for the client and would like their assistance, so that they can expect to hear from you again • Explain the purpose of the MSR, what information it will have and how it will benefit the application • Explain how a doctors signature holds more weight than yours alone, making the MSR medical evidence • Let them know their input is welcomed so they can review and sign the MSR • If you work with this psychiatrist often, build rapport, let them know you will be working together again • If you cannot reach the psychiatrist or feel that they are not receptive, work with the treatment team • Since you will be communicating with the treatment team for MSR information, discuss the MSR with them and let them know you may need assistance in presenting it to the doctor and getting it signed

31. Co-Signatures • If treating physician is someone other than an MD • Have the ARNP, or whomever is treating the client, sign the MSR; their signature still holds value • Explain that Social Security only considers medical evidence if signed by psychiatrists or psychologists, and discuss options for getting a co-signature • Some ARNPs work under an MD who may be willing to co-sign • No MD signature • Submit it anyway! Sometimes it can be difficult to even get the psychiatrist on the phone. The MSR is still good information, even if only signed by you

32. Contact Information • Amanda Toral, M.S. • Entitlement Specialist • Jail Diversion Program - SOAR Team • Phone: 305-548-5346 • Email: arubin@jud11.flcourts.org

33. Interviewing and Writing for the MSR Daniel Perry, BEST Team Lead Central City Concern Portland, Oregon

34. How BEST Uses MSRs • Provide detailed functional information • Replaces the SSA-3373 Function Report sent to DDS • Supplement medical records: • Connect functioning to conditions • Fill in gaps from records • Clarifies differences between treating sources • Paint a picture of the person and provide observations

35. Pre-Interview: Everyone is Different • Review available medical records • Look for missing information • Determine potential onset date • Become familiar with questions • Not every question needs to be asked to every client

36. Interview Tips: Set the Mood • Be intentional about the setting • It’s often best to meet alone • Private and comfortable • Be transparent – tell clients why you need the information • Do not be judgmental

37. Interviewing Tips: The Conversation • Treat the interview like a conversation – respond to what is being said • Show empathy • Reinforce strengths • Use basic conversation strategy to build rapport • Tailor the interview style to client • Generally avoid yes/no questions • Get only the detail that is needed, especially when dealing with sensitive topics • Be Curious!

38. Post Interview: Further Documentation • Write down detailed observations • Mental status exams make a great template • Follow up with additional records requests, if needed • Reach out to case managers, doctors, family members, etc. for collateral information

39. Time to Write • Start as soon as possible after the interview • Incorporate medical records into the functional information • Include direct quotes from the client (very useful!) and your detailed observations • Remember, every case is different: • Drop sections that do not apply • Be intentional about where you include the most detail • Fill in gaps from medical records

40. Contact Information • Daniel Perry • BEST Team Lead • Central City Concern • Phone: 971-271-6271 • Email: Daniel.Perry@ccconcern.org

41. Poll Question #3 What is a good interviewing technique? a. Pay attention to the applicant’s body language b. Meet in a private space c. Show empathy d. All of the above

42. Disability Determination Services Perspectives Brad Stanley, Medical Relations Officer Disability Determination Services Birmingham, Alabama

43. What are we looking for in the MSR submitted on SOAR claims? • Clear description of treatment in a logical and chronological order • History of hospitalization both in the past and current hospitalization or ER visits • Function, Function, Function

44. Medical Information • The MSR provides a snap shot look at the claimant’s treatment history. • Provides medical treatment details, showing the longitudinal effects of the claimant’s illness or impairments. • For disability examiners, provides a starting point to discuss the case with the Medical team to see what additional information may be needed in order for a decision to be made.

45. Function, Function, Function • Why should functional information be included in the MSR? • You have a unique opportunity to shed light on how a individual’s medical condition affects his or her daily activities. • Functional information shows how restrictive a impairment is on someone performing day to day task and even work related task. • Because we routinely do not see the claimant, you can provide insight to the claimants medical impairments but moreover how those impairments affect the claimant everyday.

46. What kind of functional information are we looking for? • We are looking for (Psychological): • How well does the claimant follow instructions • How does the claimant respond to change in their environment • Do they get along well with other • Do they require encouragement to complete task • Do they take longer to complete task • Concentration and attention

47. What kind of functional information are we looking for? • We are looking for (Physical): • Standing and walking problems • Fatigue • Lifting and carrying • Problems with bending or stooping • Problems using the hands (grasping, decrease strength)

48. Contact Information • Brad Stanley 
Medical Relations Officer • Disability Determination Services • Birmingham, Alabama • Phone: 1-800-292-8106, Ext. 112 • Email: Brad.Stanley@ssa.gov

49. Questions and Answers • Facilitated By: • SAMHSA SOAR Technical Assistance Center • Policy Research Associates, Inc. • Please type your question into the Q&A panel located underneath the participant tab, or • To ask a question by phone, please raise your hand by clicking the hand icon in the participant pod. We will unmute you so you can ask your question.

50. For More Information on SOAR • http://soarworks.prainc.com • SAMHSA SOAR TA Center345 Delaware AvenueDelmar, New York 12054(518) 439 – 7415 • soar@prainc.com • www.facebook.com/soarworks @SOARWorks