2015-10993. Request for Information on Early Intervention Strategies for Serving Individuals With Disabilities

AGENCY:

Social Security Administration.

ACTION:

Request for information.

SUMMARY:

The Consolidated and Further Continuing Appropriations Act, 2015 (Pub. L. 113-235), provided us with money under section 1110 of the Social Security Act to begin the design, development, and implementation of an early intervention demonstration to test innovative strategies aimed at helping people with disabilities remain in the workforce. The President's FY 2016 Budget requested additional funds to support a complete demonstration project. In order to inform the development of that demonstration, this request for information (RFI) seeks recommendations on targeted design features related to improving employment and earnings outcomes for people with disabilities, specifically individuals with mental impairments. The input we receive will inform and complement ongoing interagency deliberations about the best use of funds for an initial demonstration project relevant to future policy discussions for the Social Security Disability Insurance (DI) and Supplemental Security Income (SSI) programs.

DATES:

Comments must be received by June 8, 2015.

ADDRESSES:

You may submit comments by any one of three methods—Internet, fax, or mail. Do not submit the same comments multiple times or by more than one method. Regardless of which method you choose, please state that your comments refer to Docket No. SSA-2015-0023 so that we may associate your comments with the correct docket.

Caution: You should be careful to include in your comments only information that you wish to make publicly available. We strongly urge you not to include in your comments any personal information, such as Social Security numbers or medical information.

1. Internet: We strongly recommend that you submit your comments via the Internet. Please visit the Federal eRulemaking portal at http://www.regulations.gov. Use the Search function to find docket number SSA-2015-0023. The system will issue a tracking number to confirm your submission. You will not be able to view your comment immediately because we must post each comment manually. It may take up to a week for your comment to be viewable.

2. Fax: Fax comment to [phone].

3. Mail: Mail your comments to the Office of Regulations and Reports Clearance, Social Security Administration, 3100 West High Rise Building, 6401 Security Boulevard, Baltimore, Maryland 21235-6401.

Comments are available for public viewing on the Federal eRulemaking portal at http://www.regulations.gov or in person, during regular business hours, by arranging with the contact person identified below.

FOR FURTHER INFORMATION CONTACT:

Susan Wilschke, Office of Retirement and Disability Policy, Social Security Administration, 6401 Security Boulevard, Baltimore, Maryland 21235-6401, [phone]. For information on eligibility or filing for benefits, call our nation toll-free number, 1-800-772-1213 or TTY 1-800-325-0778, or visit our Internet site, Social Security online, at http://www.socialsecurity.gov.

SUPPLEMENTARY INFORMATION:

Purpose

The DI program provides benefits for disabled workers and their families. We paid more than $141 billion in DI benefits to almost 11 million people in 2014. The SSI program guarantees a minimum level of income support to financially needy individuals who are aged, blind, or disabled. In 2014, we paid nearly $54 billion in Federal SSI benefits to more than 8 million people. Given the large number of individuals who rely on the DI and SSI programs to make ends meet and the interest in supporting employment efforts of those with disabilities, it is helpful for policymakers to have an evidentiary base from which to consider potential program improvements and innovations that can strengthen the ability of individuals with disabilities to work.

This request for information offers States, community-based and other non-profit organizations, philanthropic organizations, researchers, and other interested members of the public the opportunity to provide recommendations on effective approaches for improving employment and earnings outcomes for individuals with disabilities, specifically individuals with mental impairments. For the purposes of this RFI, “early intervention” means serving an individual with impairment before the individual is determined eligible for benefits in either the DI or SSI programs.

In light of research indicating that health problems often begin in advance of complete disability onset, and data showing that earnings often begin to decline well before benefits are awarded, we believe demonstrations on early intervention are merited and may lead to innovative approaches for assisting people with disabilities to succeed in the workforce. Our past demonstrations have identified certain interventions after the point of complete disability onset that can yield positive outcomes for beneficiaries, but earlier interventions, before an individual begins to receive DI or SSI benefits, may be more effective. While several demonstrations for existing DI and SSI beneficiaries have yielded positive results, such as increased earnings, they have not identified interventions that would return beneficiaries to substantial and sustained employment.

Public input responding to this notice will inform ongoing deliberations of a Federal interagency workgroup and a Federal Technical Advisory Panel—including representatives from SSA, the Department of Health and Human Services, the Department of Education, the Department of Labor, and the Office of Management and Budget—about the design and parameters of the demonstration funded by our FY 2015 Appropriation.^[1] This demonstration project will help the agencies develop an evidentiary base for future potential DI and SSI program reforms. Responses to the RFI will also inform how SSA and its interagency partners could deploy additional resources for early interventions that were requested in the FY 2016 President's Budget.

Background

SSA and other Federal agencies have begun to outline the basic parameters of an early intervention demonstration project for individuals with mental impairments. This discussion provides background on those broad parameters and potential models under consideration, and the next section requests information on a series of program design issues.

Early interventions may be warranted in light of research indicating that health problems begin in advance of complete disability onset and data showing that earnings begin to decline well before DI benefits are awarded. Some evidence suggests that intervening before an individual fully detaches from the labor market may be more effective than providing services after disability benefit receipt. For example, the Centers for Medicare and Medicaid Services Demonstration to Maintain Independence and Employment (DMIE) found that health and employment supports for working adults with potentially disabling conditions lowered the likelihood of receiving payments from our disability programs. The National Institute of Mental Health's Recovery After an Initial Schizophrenia Episode (RAISE) project is testing whether intervening at the point of first diagnosis and using early and aggressive treatment will reduce the symptoms and prevent the gradual deterioration of functioning that is characteristic of chronic schizophrenia. However, a broader, more extensive research base would help policymakers design programs and policies that improve outcomes for individuals and reduce program costs.

A key challenge for early interventions is to identify individuals at risk of becoming long-term DI beneficiaries or SSI recipients who would also have the potential to benefit from the intervention methods. For an initial demonstration, we are considering targeting intervention services towards prime-working-age people with disabilities to keep them in the labor market. Specifically, we are interested in developing an intervention model for workers with mental impairments between the ages of 18 and 50 which would allow them to remain in the labor force. By providing medical and/or vocational services prior to benefit receipt in a demonstration, we will be able to test whether such services help individuals with these impairments remain and succeed in the workforce.

We are considering a design in which individuals will be identified as early as possible after a first episode of mental illness. Our initial focus for target populations is potentially on two groups: (1) Individuals receiving services from a State Vocational Rehabilitation (VR) agency who are not DI or SSI disability beneficiaries; and (2) individuals who have recently applied for SSI or DI disability benefits and whose claims were denied. Both of these groups include individuals who are on the margin between employment and receiving disability benefits. Prior research estimates that 40 percent of DI claimants denied at the appeals level become DI beneficiaries within 10 years.^[2] One goal of the demonstration is to determine whether some of those individuals would be able to remain in the labor market if they are provided appropriate health care and employment supports. People who seek VR services may hold an interest in employment despite a documented impairment. We are considering focusing on applicants whose claims have been denied as well as VR participants because they are a population that can be easily identified, and the intervention, if successful, could be scaled up. The ideal target population has both a likelihood of receiving SSA disability benefits in the future and yet maintains a recent or strong enough connection to the labor market that they are likely to respond to the offer of employment services.

We are considering an approach that includes some of the features of the successfully implemented Mental Health Treatment Study (MHTS). The MHTS demonstration found that employment supports, along with medical support and coordinated care, were successful in improving health, lowering hospitalizations, and increasing employment for DI beneficiaries with schizophrenia and affective disorders. The MHTS followed the evidence-based Individual Placement and Support (IPS) model, a supported employment model designed for rapid placement of individuals into competitive employment. In the new early intervention demonstration being developed, we are considering providing participants with a team of mental health providers and employment specialists who would coordinate and provide services that would optimize that individual's ability to obtain and retain employment.

The demonstration could provide participants with an intensive set of behavioral health and related services beyond what is available through the individual's existing health plan and long-term employment services, to help them remain in or return to the labor market rather than seek SSA disability benefits. For example, IPS services are delivered by supported employment teams that operate within community mental health agencies and other medical providers, with a key differentiator from other interventions being the linkage between employment and medical services.

The MHTS is one of several studies using the IPS model to show increases in employment rates for persons with severe mental impairments.^[3] The health-related treatment could include behavioral health and related services, medication, and disease management services.^[4] The employment-related services could include job training, job placement, and pre- and post-placement support services. We would likely require service providers to have strong employer contacts and demonstrate the ability to place participants in sustainable, paid, competitive employment. Support services could include: Help with incidentals necessary to secure and maintain employment (for example, work clothes or transportation) and with navigating other available supports, such as systematic medication management and nurse-care coordinator services; and low intensity, long-term services that would focus on employment retention once a job is secured (for example, providing an employment retention coach).

We intend to issue a contract solicitation for demonstration implementation later in FY 2015 with an award in early calendar year 2016. SSA and collaborating agencies are considering a multi-site demonstration, an approach on which we solicit feedback in this RFI. A multi-site demonstration would likely include a 1-year design refinement phase, during which one or two sites would begin enrollment to inform implementation of any additional sites during calendar year 2016. The demonstration would then transition to a five-year implementation phase. Over that period, we would evaluate impacts on outcomes such as employment, earnings, health, and DI and SSI applications and benefit receipt.

Request for Information

Through this RFI, we are soliciting feedback from a broad range of stakeholders on the initial design of an early intervention demonstration focused on improving outcomes related to employment and earnings for individuals with mental impairments, including services that could optimize an individual's ability to obtain and retain employment. Responses to this RFI will inform the work of SSA and its interagency partners in designing a new demonstration project and potentially future projects.

This RFI is for planning purposes only and should not be construed as a solicitation or as an obligation on our part or on the part of participating Federal agencies.

We ask respondents to address the following questions, where possible, in the context of the discussion in this document. You do not need to address every question and should focus on those where you have relevant expertise or perspectives. To the extent possible, please clearly indicate which question(s) you address in your response.

Key Questions

1. What early intervention programs or practices have shown promise at the State or local level to assist workers with mental health impairments to remain in the workforce?

2. In the context of this demonstration project, what programs and practices might be especially applicable to individuals who might qualify for DI or SSI benefits in the absence of interventions?

3. What are the outcomes of interest that an evaluation should capture?

Detailed Questions

I. Population and Sites

1. Should we focus on specific types of mental impairments in establishing the parameters for this demonstration? If so, which ones, and why those?

2. Would individuals with non-mental impairments benefit from similar services? If so, would the intervention look different and how?

3. We are considering focusing on individuals who are ages 18 to 50 for services in this demonstration. How appropriate is this age range?

4. We are considering focusing on individuals who are receiving services from a State VR agency but who are not SSA disability beneficiaries. Is this an appropriate population from which to draw a sample? If so, how can we identify those VR clients who are likely to apply for DI or SSI benefits in the future without inducing an application?

5. We are considering focusing on individuals who have applied for DI or SSI benefits and whose claims were denied. Is this an appropriate population from which to draw a sample?

6. Are there other populations on which we should consider focusing? How can we identify these populations?

7. What types of sites would be the most beneficial for us to consider including?

8. Are there sites we could look to as exemplars based on current practices? What evidence suggests these sites effectively address early intervention services for workers with mental impairments?

9. At how many sites should we consider implementing this demonstration?

10. How might we best consider structuring the demonstration to investigate the potential for screening workers for both their likelihood of receiving disability benefits and their likelihood of responding to employment supports?

II. Mental Health Services

11. What types of mental health services should we consider as an early intervention for workers with mental impairments?

12. What variations in timing should we consider for early interventions?

13. To what extent should certain mental health services be prioritized, whether behavioral health and related services, medication, or disease management services?

14. What are the best ways to involve workers with disabilities in planning and implementation in order to ensure that demonstration services will be effective in meeting their needs?

15. What mental health service program designs and interventions demonstrate promise for improving long-term employment outcomes for workers with disabilities? What evidence supports these interventions?

III. Employment and Job-Related Services

16. What specific employment-related interventions related to skill development, job training, job placement, or pre- and post-placement services should we consider?

17. What employment program designs and interventions demonstrate promise for improving long-term employment outcomes for workers with disabilities? What evidence supports these interventions?

Guidance for Submitting Documents

We ask that each respondent include the name and address of his or her institution or affiliation, and the name, title, mailing and email addresses, and telephone number of a contact person for his or her institution or affiliation, if any.

Rights to Materials Submitted

By submitting material in response to this RFI, you agree to grant us a worldwide, royalty-free, perpetual, irrevocable, nonexclusive license to use the material, and to post it publicly. Further, you agree that you own, have a valid license, or are otherwise authorized to provide the material to us. You should not provide any material you consider confidential or proprietary in response to this RFI. We will not provide any compensation for material submitted in response to this RFI.

Dated: April 29, 2015.

Carolyn W. Colvin,

Acting Commissioner of Social Security.

Footnotes

1.  FY 2016 President's Budget, Appendix Volume—Supplemental Security Income Program, p. 1206 (see http://www.whitehouse.gov/​sites/​default/​files/​omb/​budget/​fy2016/​assets/​ssa.pdf#Page=​2.

2.  French, Eric, and Jae Song. 2014. “The Effect of Disability Insurance Receipt on Labor Supply.” American Economic Journal: Economic Policy, 6(2): 291-337. https://www.aeaweb.org/​articles.php?​doi=​10.1257/​pol.6.2.291.

3.  See MHTS Final Report at http://socialsecurity.gov/​disabilityresearch/​documents/​MHTS_​Final_​Report_​508.pdf.

4.  See Nuechterlein, et al. for example of an adaptation of the IPS model at http://www.ncbi.nlm.nih.gov/​pubmed/​18407884. The Demonstration to Maintain Independence and Employment provided enhanced medical care and employment services. See http://www.sciencedirect.com/​science/​article/​pii/​S1936657413001179.