Schizophrenia & SSI Assistance San Francisco CAAP/ General Assistance Program

1. Thomas Neill, Ph.D. Manager of Client Health Services San Francisco Human Services Agency thomas.neill@sfgov.org Schizophrenia & SSI Assistance San Francisco CAAP/ General Assistance Program Thomas Neill, Ph.D. SF Human Services Agency

2. Thomas Neill, Ph.D. SF Human Services Agency Introduction • HSA Provides material support for individuals and families that includes programs such as CalWORKs, Food Stamps, Adult Protective Services, and Foster Care. • I develop and manage health services for a program that is part of the San Francisco Human Services Agency (HSA)

3. Thomas Neill, Ph.D. SF Human Services Agency Key Points • There is a significant population of individuals with schizophrenia who are not engaged in treatment. • These individuals generally live marginally with inadequate housing and health care and cope with chronic co-occuring illnesses. • I want to describe our efforts to engage these individuals and improve their quality of lives.

4. Thomas Neill, Ph.D. SF Human Services Agency General Assistance or County Adult Assistance Programs (CAAP) • Need based financial support for those with no other means of support • Fulfils state mandate, locally funded and controlled • Adults without dependent children • Welfare reform in 1998 added services • Welfare to work • Assistance with SSI/SSDI applications

5. Thomas Neill, Ph.D. SF Human Services Agency Characteristics of the Setting • Large population • Current enrolment: 7,300 • Annual unduplicated: 12,500 • Non-clinical setting • Clients come for financial support • Health needs of population largely unknown • Opportunity to engage clients who would not otherwise seek health services

6. Thomas Neill, Ph.D. SF Human Services Agency Client Characteristics • Long-standing functional impairments in both vocational & social arenas • Aging population: 42% 50+yrs; 70% 40+yrs • Untreated medical, dental and behavioural health conditions • Over-reliance on emergency services; Clients lack ongoing care & critical medical evidence • Limited ability to describe difficulties • Provide incoherent accounts of history of illnesses and treatment

7. Thomas Neill, Ph.D. SF Human Services Agency Clients with Schizophrenia on CAAP • No accurate data on prevalence in the welfare population • Anecdotal information shows that many clients have prominent delusional thinking. • Clients with unrealistic employment goals or prominent paranoia in welfare to work program • Psychosis identified in work readiness screening and SSI case management

8. Thomas Neill, Ph.D. SF Human Services Agency Stigma Limits Engagement • Common presentation, clients with prominent delusions and no insight • Denial preserves self-esteem • SSI and Disability – Interpreted as an indication of defect and lack of worth • Overcoming stigma of SSI/Disability • Empathize with delusional thoughts • Engage with intermediary goals – improve quality of life • Support clients' vocational aspirations

9. Thomas Neill, Ph.D. SF Human Services Agency CAAP SSI Case Management • Goal: Identify clients with disabilities and assist them through the SSA application process • Staffing Model • Clinicians screen for disability and provide medical evidence • Case managers complete application material and research histories • Outreach workers bring clients to missed appointments

10. Thomas Neill, Ph.D. SF Human Services Agency Scale of Program • Average Available Staff FY0809 • Case Managers 12.5 FTE • Physicians 2.3 FTE • Psychologists 2.6 FTE • FY0809 Transitioned to SSI/SSDI/CAPI 504 Clients • Current: 1,817 Clients identified as possibly eligible for SSA Disability Benefits

11. Thomas Neill, Ph.D. SF Human Services Agency Sample Client 1 (Applied 2008) • Age 61 AfAm woman, formerly homeless • Prominent paranoid and grandiose delusions, disorganized speech • Conflict with others in SRO • No known treatment history; Limited primary care • Fired first CM and PhD in CAAP SSI CM • Behavior directed by delusions • Challenge to engage • Awarded thru use of collateral data • Housing provider & limited medical records

12. Thomas Neill, Ph.D. SF Human Services Agency Sample Client 2, (Applied 2007) • Age 46, male, SF native, lives w/ family friends • Symptoms: flat affect, command hallucinations, paranoia, uncomfortable around others • Missed appointments • Behavioural problems in school, no records • Father gave him beer age 8, onset of regular alcohol and stimulants in adolescence • Substance use treatment age 30-36 • Currently drinks 4 beers/day, denied stimulants

13. Thomas Neill, Ph.D. SF Human Services Agency Sample Client 2, Slide 2(Applied 2007) • Psychiatric treatment • 6 psychiatric ER visits in last 10yrs • BIB police, threatening others • Psychotic symptoms, sometime with and sometimes without stimulant use • Began outpatient treatment in 2007 • Initial claim denied finding that he would be more functional without current alcohol use. • Awarded on appeal with documented continued symptoms in absence of stimulant use

14. Thomas Neill, Ph.D. SF Human Services Agency Keys to Success - Network • Onsite to be close to clients • Stay Connected to Clients • Community Treatment Providers • Non-clinical staff who work with our clients: CAAP eligibility workers, housing providers & support services, shelter case manager's, etc. • Outreach workers • Hold CAAP Benefits

15. Thomas Neill, Ph.D. SF Human Services Agency Key Community Partners • SSA District Office • Exchange information • Manage flow of claims • State Department of Social Services • Developing closer relationship with Disability Determination Section • Department of Health • Provides access to Electronic Medical Records to Research Treatment Histories • Coordinate programs for this clientele

16. Thomas Neill, Ph.D. SF Human Services Agency Challenges to Show Disability • Co-occurring substance use • Alcohol & opioids do not cause psychosis • Request that DDS reevaluate co-occuring alcohol or opioid use as reason for denial of claim • Limited treatment history cited as reason for denial despite consultative exam documenting signs and symptoms of schizophrenia • Economic & legal challenges for clients whose symptoms lead them to homelessness and avoidance of needed care

17. Thomas Neill, Ph.D. SF Human Services Agency Challenges to Stability • Maintaining Housing - Need for increased money management • Psychotic symptoms often lead to homelessness and further deterioration • Need help from SSA • Require money management for clients with risk of homelessness • Reconsider funding for money management programs – possible partnerships with HSA & DPH