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–Harvey Funai, M.S.W., Program Manager, Referral and Monitoring Agency, Division of Alcohol and Substance Abuse, Washington Department of Social and Health Services

In 1993, the Washington State Division of Alcohol and Substance Abuse (DASA) was awarded additional Federal grant funding from the Center for Substance Abuse Treatment to enhance the services provided by their Referral and Monitoring Agency (RMA). With this additional funding, DASA is working to accomplish several important objectives that will improve services to individuals disabled by chemical dependency in Washington State. The award resulted in hiring additional staff, co-located with the RMA, for the "SSI Managed Care Project."

This Project serves a population with severe long-term alcohol and drug addictions, unemployed and often homeless, who have multiple service needs. In determining that these individuals are disabled, the Social Security Administration (SSA) has decided that alcoholism and/or addiction to other drugs is "material to the finding of disability."

This means that, although the recipient may have other impairments, he or she would not meet the SSA's definition of disability without consideration of the alcoholism or other addiction. This also means that, were the use of addictive substances to end, the individual would no longer be considered disabled.

Washington State's SSI Managed Care Project uses a case management system. Each recipient is assigned to a monitor who acts as an advocate and case coordinator in dealing with the many social service agencies that serve the client. Underpinning the Washington State model is a computerized tracking system that enables the agency to follow the recipients efficiently, and allows a quick response to changes in a patient's status.

Identification of Potentially Eligible Individuals

One significant requirement of the SSI Managed Care Project grant is to carry out activities that will assist potentially eligible people to appropriately access SSI funding plus related treatment and medical services. The intent is to reach those individuals who are repeatedly cycling through an uncoordinated, publicly funded group of programs, including detoxification services, courts, jails, hospital emergency rooms and intensive care units, involuntary psychiatric detention and evaluation, emergency shelters, and ambulance services. Services for this repeating population cost taxpayers millions of dollars, often without ultimately promoting recovery.

To date, the Project has provided specialized training to more than 350 people concerning the SSI drug addict or alcoholic (DA/A) disability determination process and on services available to assist with the SSI application. This includes staff of social service agencies, chemical dependency assessment and treatment programs, public assistance offices, and staff of hospitals and other agencies serving those with chronic addiction problems.

Housing

Housing, particularly drug- and alcohol-free housing, is an essential component of any program of recovery and vocational rehabilitation. Identifying housing resources for DA/A clients involved with the RMA is an important part of the work funded by this grant.

At this point, Managed Care Project staff have met with 54 selected housing providers around the State, establishing protocols and procedures for referring clients to the most appropriate and best quality housing available. A Statewide directory of drug- and alcohol-free facilities and other low-income housing is being steadily compiled as a useful by-product of this effort. The directory is being made available to other agencies serving this population.

Professional Representative Payees

Clients in the RMA program are required to receive their benefits through payment to a third party, called a representative payee. As an important part of this grant, the project staff is developing professional representative payee services to help clients manage their limited funds.

We have initiated meetings and discussions with 23 potential professional representative payees. Contracts are currently in place in eastern, central, and western Washington, and others are being developed. The Managed Care Project has also developed a project-funded position to test the alternative of providing payee services from an outstation in a downtown Seattle SSA office.

Vocational Case Management Services

Current research indicates that getting involved with some kind of vocational services concurrently with treatment is a positive objective for many RMA clients. The grant is providing funds for increased staff to carry out active vocational case management of DA/A clients (in the form of three "vocational liaison" positions). The vocational liaisons provide direct client services to those recipients who have completed or are doing well in substance abuse treatment. They also have been building working relationships with the providers of vocational and employment services in the community.

The "Vocational Opportunities Training and Education" (VOTE) program has been partially funded through DASA since 1987. VOTE is a pre-employment training program tailored specifically for the recovering population. The program is delivered in a comprehensive, highly structured 7-week setting. Students receive ten college credits for course completion. These services are now available to SSI DA/A clients in Tacoma and Seattle, and will soon also be available in central Washington.

Follow-up studies of individuals completing the VOTE program have shown a convincing pattern of greater success in obtaining and retaining employment than for those not receiving such services. The VOTE recipients also achieve a much higher average level of pay.

Evaluation

The Managed Care Project also provides for a professional evaluation of program outcomes for RMA program participants. Experience with this population has provided us with direct evidence that the treatment and vocational services we offer clients work, and that the monitoring and advocacy services we provide are effective. But this is the first time a systematic effort has been made to measure the success of our program in getting this population into a stable recovery, and, ultimately, back to work.

Profiles of Program Success

One recent success story–"Bob Doe"– shows how a client can come a long way in less than 2 years. What really made a difference for Mr. Doe was the consistent support provided by the whole treatment team–his RMA monitor, treatment program staff, The Department of Vocational Rehabilitation, the Managed Care Project vocational liaison, and his instructors at the Seattle Career Institute. Mr. Doe's medical needs, including some badly needed dental work, were also funded and attended to during his period of recovery. This kind of continuum of care makes the difference for many clients of the Referral and Monitoring Agency.

"Bob Doe" had his initial RMA intake interview in February of 1993. He was regularly using cocaine and alcohol at that time. In May 1993, Mr. Doe went to an inpatient treatment program; he entered outpatient follow-up on July 19, 1993. While he was still active in outpatient treatment, we referred this patient to the State Division of Vocational Rehabilitation (DVR). He completed an orientation at DVR in early October 1993 and was approved for vocational rehabilitation services in November 1993. Mr. Doe was attending Alcoholics Anonymous meetings daily at this point.

After some explorations of vocational schooling with DVR, Mr. Doe was referred by his Managed Care Project vocational liaison to the Seattle Career Institute (SCI), a program based on the VOTE model described above. He had an orientation at SCI in June 1994 and completed this intensive 6-week program in early August. (This program has now been extended to 7 weeks.) He decided at that time that he would like to seriously look for work. He had prepared a professional-quality resume as part of his work at the Career Institute.

On August 15, 1994, Mr. Doe called the RMA to report that, following a 5-hour competitive exam, he had been hired by a local security service at a starting wage of $6.00 per hour. We followed up with Mr. Doe at the end of August and confirmed that he was working full-time and was very pleased with his employment. Mr. Doe now has 13 months of being clean and sober, and he reports that "the best thing about going back to work is that I feel useful to somebody again."

Other Success Stories

We have other success stories to share.

A former RMA client, 44 years old, who completed a DVR-sponsored certification program, now teaches computer science at a community college. The client came to the RMA in 1987 as a late-stage alcoholic with a 20-year history of abuse. After going through a long-term outpatient program, she has now attained more than 5 years of sobriety. She had carpal tunnel surgery while actively involved with the RMA; she also received mental health counseling as part of her treatment. This client's RMA monitor was very much involved with helping her access DVR services. This included attending a face-to-face staffing with the client and DVR counselor, as well as providing information from RMA files to support her application for services.

Another client, age 47, is now working 40 hours per week at the Seattle Veteran's Hospital earning $10.50 per hour. This client entered inpatient treatment in 1991, shortly after qualifying for SSI. His diagnosis was drug dependence with signs of dementia. He was using alcohol, heroin, and cocaine at the time of admission.

Inpatient treatment was followed by long-term outpatient aftercare and by vocational services with RMA monitoring and support. Regular face-to-face meetings with his RMA counselor, and coordination of services between the RMA and his therapist and vocational counselor in the Veteran's Administration recovery program, helped this client turn the corner from an abusive childhood and more than 30 years of polysubstance abuse.

In each of these cases, and many others, we feel the RMA monitor's consistent support and focus on recovery and employment has made a strong contribution to the client's success.

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