Payees, Disability Payments and Dual Diagnosis

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DESCRIPTION (provided by applicant): This is an R21 grant application to conduct 3 secondary data analysis studies concerning the need for payee assignment among participants in the ACCESS study (Access to Community Care and Effective Services and Supports). In this unique 100 million dollar study, community agencies in 18 locations in 9 different states provided Assertive Community Treatment (ACT) to homeless persons with severe mental illness. Most of the 7229 participants had concomitant substance abuse disorders. Remarkably for patients who are notoriously difficult to track, 90.5 percent of patients, a total of 7055, completed a follow-up assessment during the subsequent 12 months. In addition, the Social Security Administration has agreed to provide detailed information describing participants' exact month-by-month amount of SSI benefits, SSDI benefits and payee status. STUDY 1: Based upon highly publicized instances of disability payments being spent for drugs of abuse but few empirical examinations of the actual risk, it is widely believed that disability payments to patients without payees contribute to substance abuse. The first study will address the question: What is the association between receipt of disability payments and subsequent substance abuse? The association between disability payments and other clinical outcomes such as psychiatric symptomatology, quality of life, homelessness, incarceration, and hospitalization will also be considered. Multi-level hierarchical linear models will represent the fact that outcomes over time are nested within subjects, and subjects are nested within sites. STUDY 2: In order to curtail misuse of funds, the Social Security Administration and Veterans Benefits Administration may assign a representative payee or fiduciary to manage a beneficiary's payments. The criteria for payee assignment to dually diagnosed recipients are vague, and our group has defined criteria for when patients who use drugs are incapable of managing their own funds, based on a review of legal and policy concerns (Rosen and Rosenheck, 1999). It is unclear whether these criteria for payee assignment or other implicit criteria are used in practice. Study 2 will address the question: What substance use and other characteristics distinguish those recipients of disability payments who were assigned payees from those who were not? STUDY 3: Payee assignment involves considerable curtailment of a recipients' liberty to make spending decisions but little is known about payeeship's efficacy in ameliorating substance abuse and other clinical difficulties. Study 3 addresses the question: Do substance use and other outcomes differ between beneficiaries who were assigned payees to manage their funds and those whose checks were mailed directly to them? Propensity scaling will be used to create matched samples. These studies will address fundamental questions about dispensing of disability payments and assignment of payees to dually diagnosed beneficiaries, questions that cannot be ethically addressed by prospective trials.