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<h1 itemprop="headline">Homeless People Whose Self-Reported <abbr class="spell">SSI</abbr>/<abbr class="spell">DI</abbr> Status Is Inconsistent with Social Security Administration Records</h1>
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<div id="hByline">by <span itemprop="author">Marc I. Rosen, Thomas J. McMahon, and Robert A. Rosenheck</span><br>Social Security Bulletin, <abbr title="Volume">Vol.</abbr> 67, <abbr title="Number">No.</abbr> 1, 2007 (released August 2007)</div>
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<p id="synopsis" itemprop="description">Clinicians routinely ask indigent new clients whether they receive Supplemental Security Income (<abbr class="spell">SSI</abbr>) payments or Social Security Disability Insurance (<abbr class="spell">DI</abbr>) benefits, and this information is incorporated into treatment planning. Using questionnaire responses by 7,220 homeless people with mental illness, we first determined what demographic and clinical factors were associated with reporting receipt of <abbr class="spell">SSI</abbr> or <abbr class="spell">DI</abbr> benefits and not being in the <abbr class="spell">SSA</abbr> database and, second, what factors were associated with reporting not receiving benefits but have <abbr class="spell">SSA</abbr> records indicating otherwise. The low agreement between client reports and administrative records suggests that clinicians should verify the information provided by clients, especially those who are psychotic or medically ill, because that information is often inaccurate.</p>
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<p>Marc I. Rosen, <abbr class="spell">MD</abbr>, is an Associate Professor of Psychiatry at the Yale University School of Medicine, <abbr class="spell">VA</abbr> Connecticut Healthcare System, Department of Psychiatry. Thomas J. McMahon, <abbr class="spell">PhD</abbr>, is an Associate Professor of Psychiatry at the West Haven Mental Health Center, West Haven, <abbr title="Connecticut">CT</abbr>. Robert Rosenheck, <abbr class="spell">MD</abbr>, is a Professor of Psychiatry and Public Health at the Yale Medical School, Director of the Division of Mental Health Services and Treatment Outcomes Research in the Yale Department of Psychiatry, and Director of the Department of Veterans Affairs Northeast Program Evaluation Center, West Haven, <abbr title="Connecticut">CT</abbr>.</p>
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<p><i>Acknowledgments</i>: We would like to acknowledge the Social Security Administration for providing beneficiary data and explaining their database to us. This work was supported in part by the following grants: R21-DA17311, R01-DA012952, MHI 02-001, K02-DA017277 (MIR), the VISN 1 MIRECC, and P50-DA09241.</p>
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<p>Contents of this publication are <a href="/policy/accessibility.html">not copyrighted</a>; any items may be reprinted, but citation of the <i>Social Security Bulletin</i> as the source is requested. The findings and conclusions presented in the <i>Bulletin</i> are those of the authors and do not necessarily represent the views of the Social Security Administration.</p>
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<h2>Summary</h2>
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<p>Clinicians routinely ask people with disabling psychiatric illnesses whether they receive Supplemental Security Income (<abbr class="spell">SSI</abbr>) or Social Security Disability Insurance (<abbr class="spell">DI</abbr>) benefits. We looked at self-reported receipt of <abbr class="spell">SSI</abbr> or <abbr class="spell">DI</abbr> by 7,220 homeless people with mental illness and compared those self-reports with information in Social Security Administration (<abbr class="spell">SSA</abbr>) databases. Overall agreement between the two sources was only fair (kappa = 0.60), and 41.3 percent (934/2,257) of clients reporting receipt of <abbr class="spell">SSI</abbr> or <abbr class="spell">DI</abbr> were not in <abbr class="spell">SSA</abbr>'s databases. In multivariate analyses, people reporting receipt of <abbr class="spell">SSI</abbr> or <abbr class="spell">DI</abbr> that is unconfirmed by <abbr class="spell">SSA</abbr> administrative records had disproportionately more severe psychotic and medical illnesses than confirmed nonrecipients. Among recipients identified by <abbr class="spell">SSA</abbr>, those who did not report receiving <abbr class="spell">SSI</abbr> or <abbr class="spell">DI</abbr> were more likely to claim, apparently incorrectly, that they instead received Social Security <i>retirement</i> benefits. Clinicians should verify basic demographic information provided by clients, especially those who are psychotic or medically ill, because that information is often inaccurate.</p>
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<h2>Introduction</h2>
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<p>People disabled by psychiatric illness depend on Supplemental Security Income (<abbr class="spell">SSI</abbr>) and Social Security Disability Insurance (<abbr class="spell">DI</abbr>) benefits to meet their basic needs. Disability payments provide critical financial support in preventing homelessness among the indigent (Sosin and Grossman 1991) and contribute to improved outcomes when homeless mentally ill people receive treatment (Rosenheck, Frisman, and Gallup 1995). Clinicians routinely ask indigent new clients if they receive <abbr class="spell">SSI</abbr> or <abbr class="spell">DI</abbr>, and this information is incorporated into treatment planning.</p>
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<p>Given the importance of disability payments to people disabled by psychiatric illnesses, it is ironic that no prior studies have been done on the validity of self-reported <abbr class="spell">SSI</abbr>/<abbr class="spell">DI</abbr> status among the mentally ill. Some studies have described the low reliability (Jenkins and others 2005) and accuracy (Pedace and Bates 2001; Card, Hildreth, and Shore-Sheppard 2004; Jackle and others 2004) of self-reported income among poor people, but there are no studies to inform clinicians by describing specific psychiatric and medical characteristics of people whose self-reported <abbr class="spell">SSI</abbr>/<abbr class="spell">DI</abbr> status is inaccurate. The underreporting of symptoms and the inconsistency of information provided are considerable when people with substance abuse (Stephens 1972; Rounsaville and others 1981) or psychiatric disorders (Strauss, Carpenter, and Nasrallah 1978) are asked to describe their psychiatric history and symptoms. However, there is little data concerning whether homeless people with mental illness inaccurately report basic demographic information and, specifically, whether they accurately report receipt of <abbr class="spell">SSI</abbr> and <abbr class="spell">DI</abbr>.</p>
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<p>There are several potential explanations for why clients might report <abbr class="spell">SSI</abbr>/<abbr class="spell">DI</abbr> receipt inaccurately. The misreporting of <abbr class="spell">SSI</abbr>/<abbr class="spell">DI</abbr> benefits may reflect neuropsychological deficits. Inaccurate self-reports might track related constructs like the degree of knowledge about one's medical care, which is lower in people with cognitive deficits and reading difficulties (Baker and others 1995; Kalichman and others 2000; Baker and others 2002). Another possibility is that inaccurate self-reported income is influenced by subtle social pressures to underestimate income. Evidence for the underreporting of income by poor people is that families reporting low income in the Labor Department's Consumer Expenditure Survey reported much higher expenditures, and low income and high expenses are difficult to reconcile (Jencks 1997).</p>
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<p>The first goal of this study, conducted in 2004, was to document the degree of agreement between a client's self-report that he or she received <abbr class="spell">SSI</abbr> or <abbr class="spell">DI</abbr> benefits and <abbr class="spell">SSA</abbr> administrative records of whether the person was receiving benefits. We then characterized those clients whose self-reported <abbr class="spell">SSI</abbr>/<abbr class="spell">DI</abbr> status was not consistent with <abbr class="spell">SSA</abbr> administrative records using comprehensive clinical data, self-reported <abbr class="spell">SSI</abbr>/<abbr class="spell">DI</abbr> status, and <abbr class="spell">SSA</abbr> administrative data from participants in a large study of individuals who were homeless and mentally ill. This study first determined what demographic and clinical factors were associated with self-reports of <abbr class="spell">SSI</abbr>/<abbr class="spell">DI</abbr> receipt and not being in the <abbr class="spell">SSA</abbr> database; it then identified what factors were associated with reporting <i>not</i> receiving benefits but having <abbr class="spell">SSA</abbr> records that indicate otherwise.</p>
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<h2>Methods</h2>
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<h3>Participants and Sampling</h3>
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<p>Participants were enrolled in the <abbr>ACCESS</abbr> (Access to Community Care and Effective Services and Supports) demonstration study, a study of service delivery strategies for homeless people with mental illness (Randolph and others 2002). In <abbr>ACCESS</abbr>, agencies in 18 cities offered Assertive Community Treatment (Stein and Test 1980) to 100 participants per year for 4 years. Participants were eligible if they were homeless, had a severe mental illness, and were not engaged in psychiatric treatment at the time of enrollment. Eligible participants were identified and offered case management services. After providing informed consent, a comprehensive set of assessments was completed.</p>
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<h3>Data Collection</h3>
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<p>Research assistants using structured interviews collected data. Basic demographic data included age, sex, children in residence, race and ethnicity, years of education, longest full-time job, and veteran status. Homelessness was characterized by age at the first episode of homelessness, number of times homeless, lifetime number of years homeless, and years living in the current city of residence. Legal status questions included questions about having ever been convicted or incarcerated. History of arrests (McClellan and others 1980) and victimization (Lehman 1988) within the last 60 days were also documented. Self-reported data concerning the presence or absence of 17 medical disorders and whether the client was taking prescribed medication were also recorded. Other self-reported symptoms quantified social support (Vaux and Athanassopulou 1987; Lam and Rosenheck 1999), service utilization (Rosenheck and others 2002), a history of conduct disorder (Helzer 1981), and stability of family of origin (Kadushin, Boulanger, and Martin 1981). Participants reported the number of days in the last 60 that they had been housed and the number of days in the last 30 that they had been employed. Overall quality of life was also assessed by the question "Overall, how do you feel about your life right now?" on a scale ranging from 1 (terrible) to 7 (delighted) (Lehman 1988).</p>
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<p>Psychiatric diagnoses were those of the admitting clinicians on the case management teams. Psychiatric measures were derived from the Addiction Severity Index (<abbr class="spell">ASI</abbr>) psychiatric composite problem index, a depression scale derived from the Diagnostic Interview Schedule (Robins, Helzer, and Croughan 1981), and a psychotic symptoms scale derived from the Psychiatric Epidemiology Research Interview (Dohrenwend 1982). Depression was quantified as the number of symptoms of depression out of 5 endorsed by the client, and interviewer ratings of psychosis were derived from 13 items ranked on a <span class="nobr">0–4</span> Likert scale.</p>
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<p>Substance abuse was assessed by questions drawn from the Addiction Severity Index (McClellan and others 1980), and a referring clinician rated the patient's substance use on <span class="nobr">5-point</span> clinical rating scales anchored by 1 (abstinence) and 5 (severe dependence) (Mueser and others 1995).</p>
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<p>Service utilization was measured by questions concerning receipt of six types of services: assistance from a public housing agency, mental health services, general health care, substance abuse services, public income support, and vocational rehabilitation. The number of services received was calculated. Finally, the research assistant rated the reliability of the participant's data on a <span class="nobr">5-point</span> scale.</p>
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<h3>Income Data</h3>
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<p>Participants were asked to record how much income they had received during the past month from a list of possible sources. Participants were also asked to record earnings for the current month, even if the money had not yet been received. The sources listed included earned income, Social Security retirement benefits, Supplemental Security Income, Social Security Disability Insurance, social welfare benefits from state or county governments such as general welfare and Aid to Families with Dependent Children (<abbr class="spell">AFDC</abbr>), and nine other potential sources of income. Participants were asked if there was anyone who "handles your money for you (like a payee or guardian)" and, if so, whether the client's checks were mailed directly to this person.</p>
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<p><abbr class="spell">SSA</abbr>'s Office of Research, Evaluation, and Statistics provided client-level data on beneficiary status by cross-matching Social Security numbers of <abbr>ACCESS</abbr> participants with those in <abbr class="spell">SSA</abbr>'s Master Beneficiary Record and Payment History Update System, which record payments from the <abbr class="spell">DI</abbr> program, and the Supplemental Security Record, which records payments from the <abbr class="spell">SSI</abbr> program. <abbr class="spell">SSA</abbr> provided data only when its files contained a corresponding Social Security number verified by date of birth. <abbr class="spell">SSA</abbr>'s algorithm for determining whether there is a cross-match—the Enumeration Verification System—did not require the supplied dates of birth to exactly match those in <abbr class="spell">SSA</abbr>'s databases. A Social Security number match was verified when the years of birth agreed or when the months agreed and the years differed by one year.</p>
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<h3>Data Analysis</h3>
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<p>The purpose of the study was to determine whether participants could distinguish <abbr class="spell">SSI</abbr> from <abbr class="spell">DI</abbr> from other sources of income. We were not concerned with whether participants could distinguish <abbr class="spell">SSI</abbr> from <abbr class="spell">DI</abbr>, so receipt of <abbr class="spell">SSI</abbr> or <abbr class="spell">DI</abbr> was considered a single measure (<abbr class="spell">SSI</abbr>/<abbr class="spell">DI</abbr>). Kappa was calculated to characterize the overall agreement between self-reported and <abbr class="spell">SSA</abbr> verification of receipt of <abbr class="spell">SSI</abbr>/<abbr class="spell">DI</abbr>. The kappa statistic describes the agreement between two dichotomous variables with a range of zero (no agreement) to 1 (perfect agreement). Then, two similar analyses were conducted. The first analysis determined demographic and clinical factors that differentiated people who reported receiving <abbr class="spell">SSI</abbr>/<abbr class="spell">DI</abbr> but were not in the <abbr class="spell">SSA</abbr> database from those who did not report receiving <abbr class="spell">SSI</abbr>/<abbr class="spell">DI</abbr> and were also not in the <abbr class="spell">SSA</abbr> database. Chi-square and <span class="nobr">t-test</span> comparisons between the two groups were conducted on a broad range of measures. Measures that differentiated the two groups at p<.05 were entered into a logistic regression, and backward elimination was used to identify the most salient correlates at p<.01. A similar approach was employed to compare two other groups: those reporting that they did not receive <abbr class="spell">SSI</abbr>/<abbr class="spell">DI</abbr> but in fact were in the <abbr class="spell">SSA</abbr> databases as receiving benefits and those who reported receiving <abbr class="spell">SSI</abbr>/<abbr class="spell">DI</abbr> and were confirmed by <abbr class="spell">SSA</abbr> records.</p>
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<h2>Results</h2>
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<h3>Sampling and Overall Agreement Between Self-Report and <abbr class="spell">SSA</abbr> Databases</h3>
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<p>Altogether, 16 percent of participants ([934 + 193]/7,220) reported <abbr class="spell">SSI</abbr>/<abbr class="spell">DI</abbr> status that was not verified by the <abbr class="spell">SSA</abbr> database (Table 1). The majority of the discordant reports were from participants who reported having received <abbr class="spell">SSI</abbr>/<abbr class="spell">DI</abbr> but were not in the <abbr class="spell">SSA</abbr> database (13 percent of the total sample) and 3 percent who reported not having received <abbr class="spell">SSI</abbr>/<abbr class="spell">DI</abbr> but in fact were in the <abbr class="spell">SSA</abbr> database. Kappa was 0.60, indicating moderate agreement between self-reports and <abbr class="spell">SSA</abbr> records (Cicchetti and Sparrow 1981).</p>
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<div class="table" id="table1">
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<table>
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<caption><span class="tableNumber">Table 1. </span>Agreement on <abbr class="spell">SSI</abbr>/<abbr class="spell">DI</abbr> receipt between self-reports and <abbr class="spell">SSA</abbr> records</caption>
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<th class="stubHeading" rowspan="2" scope="colgroup">Receipt of <abbr class="spell">SSI</abbr>/<abbr class="spell">DI</abbr> benefits verified by <abbr class="spell">SSA</abbr> records?</th>
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<th class="spanner" colspan="2" scope="colgroup">Self-reported receipt of <abbr class="spell">SSI</abbr>/<abbr class="spell">DI</abbr> benefits?</th>
|
|
</tr>
|
|
<tr>
|
|
<th scope="col">No</th>
|
|
<th scope="col">Yes</th>
|
|
</tr>
|
|
</thead>
|
|
<tbody>
|
|
<tr>
|
|
<th class="stub0" scope="row">No</th>
|
|
<td>4,770</td>
|
|
<td>934</td>
|
|
</tr>
|
|
<tr>
|
|
<th class="stub0" scope="row">Yes</th>
|
|
<td>193</td>
|
|
<td>1,323</td>
|
|
</tr>
|
|
</tbody>
|
|
<tfoot>
|
|
<tr>
|
|
<td class="firstNote" colspan="3">SOURCE: Self-report data were collected in the <abbr>ACCESS</abbr> demonstration and were cross-matched with the Social Security Administration's Master Beneficiary Record, Payment History Update System, and the Supplemental Security Record.</td>
|
|
</tr>
|
|
<tr>
|
|
<td class="lastNote" colspan="3">NOTES: The data include 7,220 observations.
|
|
<div class="newNote">Kappa = 0.60</div>
|
|
</td>
|
|
</tr>
|
|
</tfoot>
|
|
</table>
|
|
</div>
|
|
<h3>Sample Characteristics by Self-Reported and <abbr class="spell">SSA</abbr>-Verified <abbr class="spell">SSI</abbr>/<abbr class="spell">DI</abbr> Status</h3>
|
|
<p>The sample characteristics shown in Table 2 indicate, as expected, relatively long durations of homelessness and high rates of psychiatric comorbidity and substance abuse. All the measures in Table 2, within the groups of those who had and had not received <abbr class="spell">SSI</abbr> or <abbr class="spell">DI</abbr> according to <abbr class="spell">SSA</abbr>, significantly differentiated the participant group whose self-report was concordant with <abbr class="spell">SSA</abbr> from participants whose self-report was discordant with <abbr class="spell">SSA</abbr>'s administrative records.</p>
|
|
<div class="table" id="table2">
|
|
<table>
|
|
<caption><span class="tableNumber">Table 2. </span>Baseline characteristics, by <abbr class="spell">SSI</abbr>/<abbr class="spell">DI</abbr> status according to <abbr class="spell">SSA</abbr> records and self-reports</caption>
|
|
<colgroup span="1" style="width:22em"></colgroup>
|
|
<colgroup span="4" style="width:8em"></colgroup>
|
|
<thead>
|
|
<tr>
|
|
<th class="stubHeading" rowspan="2" id="c1">Characteristic</th>
|
|
<th class="spanner" colspan="2" id="c2">Mean or percentage (standard deviation) of those <b>with</b> <abbr class="spell">SSI</abbr>/<abbr class="spell">DI</abbr> according to <abbr class="spell">SSA</abbr></th>
|
|
<th class="spanner" colspan="2" id="c3">Mean or percentage (standard deviation) of those <b>without</b> <abbr class="spell">SSI</abbr>/<abbr class="spell">DI</abbr> according to <abbr class="spell">SSA</abbr></th>
|
|
</tr>
|
|
<tr>
|
|
<th id="c4" headers="c2">Self-report concordant with <abbr class="spell">SSA</abbr> (n = 1,323)</th>
|
|
<th id="c5" headers="c2">Self-report discordant with <abbr class="spell">SSA</abbr> (n = 193)</th>
|
|
<th id="c6" headers="c3">Self-report concordant with <abbr class="spell">SSA</abbr> (n = 4,770)</th>
|
|
<th id="c7" headers="c3">Self-report discordant with <abbr class="spell">SSA</abbr> (n = 934)</th>
|
|
</tr>
|
|
</thead>
|
|
<tbody>
|
|
<tr>
|
|
<th class="stub0" id="r1" headers="c1">Demographic</th>
|
|
<td colspan="4"></td>
|
|
</tr>
|
|
<tr>
|
|
<th class="stub1" id="r2" headers="r1 c1">Age (years)</th>
|
|
<td class="nobr" headers="r1 r2 c2 c4">40.4(9.5)</td>
|
|
<td class="nobr" headers="r1 r2 c2 c5">43.6(13.7) ***</td>
|
|
<td class="nobr" headers="r1 r2 c3 c6">37.5(9.4)</td>
|
|
<td class="nobr" headers="r1 r2 c3 c7">40.3(9.2) ***</td>
|
|
</tr>
|
|
<tr>
|
|
<th class="stub1" id="r3" headers="r1 c1">Sex (male)</th>
|
|
<td class="nobr" headers="r1 r3 c2 c4">67.0%</td>
|
|
<td class="nobr" headers="r1 r3 c2 c5">67.7%</td>
|
|
<td class="nobr" headers="r1 r3 c3 c6">61.9%</td>
|
|
<td class="nobr" headers="r1 r3 c3 c7">56.5% **</td>
|
|
</tr>
|
|
<tr>
|
|
<th class="stub1" id="r4" headers="r1 c1">African American</th>
|
|
<td class="nobr" headers="r1 r4 c2 c4">51.2%</td>
|
|
<td class="nobr" headers="r1 r4 c2 c5">37.4% ***</td>
|
|
<td class="nobr" headers="r1 r4 c3 c6">44.9%</td>
|
|
<td class="nobr" headers="r1 r4 c3 c7">53.2% ***</td>
|
|
</tr>
|
|
<tr>
|
|
<th class="stub1" id="r5" headers="r1 c1">Hispanic</th>
|
|
<td class="nobr" headers="r1 r5 c2 c4">3.1%</td>
|
|
<td class="nobr" headers="r1 r5 c2 c5">5.1%</td>
|
|
<td class="nobr" headers="r1 r5 c3 c6">6.3%</td>
|
|
<td class="nobr" headers="r1 r5 c3 c7">3.2% ***</td>
|
|
</tr>
|
|
<tr>
|
|
<th class="stub1" id="r6" headers="r1 c1">English first language</th>
|
|
<td class="nobr" headers="r1 r6 c2 c4">3.9%</td>
|
|
<td class="nobr" headers="r1 r6 c2 c5">7.2% *</td>
|
|
<td class="nobr" headers="r1 r6 c3 c6">6.5%</td>
|
|
<td class="nobr" headers="r1 r6 c3 c7">4.2% **</td>
|
|
</tr>
|
|
<tr>
|
|
<th class="stub1" id="r7" headers="r1 c1">Years of education</th>
|
|
<td class="nobr" headers="r1 r7 c2 c4">11.7(2.6)</td>
|
|
<td class="nobr" headers="r1 r7 c2 c5">11.5(3.0)</td>
|
|
<td class="nobr" headers="r1 r7 c3 c6">11.7(2.5)</td>
|
|
<td class="nobr" headers="r1 r7 c3 c7">11.1(2.6) ***</td>
|
|
</tr>
|
|
<tr class="topPad1">
|
|
<th class="stub0" id="r8" headers="c1">Vocational</th>
|
|
<td colspan="4"></td>
|
|
</tr>
|
|
<tr>
|
|
<th class="stub1" id="r9" headers="r8 c1">Veteran</th>
|
|
<td class="nobr" headers="r8 r9 c2 c4">22.8%</td>
|
|
<td class="nobr" headers="r8 r9 c2 c5">26.8%</td>
|
|
<td class="nobr" headers="r8 r9 c3 c6">18.7%</td>
|
|
<td class="nobr" headers="r8 r9 c3 c7">13.2% ***</td>
|
|
</tr>
|
|
<tr>
|
|
<th class="stub1" id="r10" headers="r8 c1">Years at longest full-time job</th>
|
|
<td class="nobr" headers="r8 r10 c2 c4">3.5(4.7)</td>
|
|
<td class="nobr" headers="r8 r10 c2 c5">4.7(7.6) **</td>
|
|
<td class="nobr" headers="r8 r10 c3 c6">3.6(4.7)</td>
|
|
<td class="nobr" headers="r8 r10 c3 c7">2.4(4.4) ***</td>
|
|
</tr>
|
|
<tr>
|
|
<th class="stub1" id="r11" headers="r8 c1">Days working in last 30</th>
|
|
<td class="nobr" headers="r8 r11 c2 c4">0.9(3.5)</td>
|
|
<td class="nobr" headers="r8 r11 c2 c5">1.2(4.3)</td>
|
|
<td class="nobr" headers="r8 r11 c3 c6">2.4(5.7)</td>
|
|
<td class="nobr" headers="r8 r11 c3 c7">0.7(3.2) ***</td>
|
|
</tr>
|
|
<tr>
|
|
<th class="stub1" id="r12" headers="r8 c1">Years homeless</th>
|
|
<td class="nobr" headers="r8 r12 c2 c4">3.5(5.3)</td>
|
|
<td class="nobr" headers="r8 r12 c2 c5">3.3(5.9)</td>
|
|
<td class="nobr" headers="r8 r12 c3 c6">3.0(4.8)</td>
|
|
<td class="nobr" headers="r8 r12 c3 c7">3.9(6.0) ***</td>
|
|
</tr>
|
|
<tr>
|
|
<th class="stub1" id="r13" headers="r8 c1">Days housed in last 60</th>
|
|
<td class="nobr" headers="r8 r13 c2 c4">12.8(18.3)</td>
|
|
<td class="nobr" headers="r8 r13 c2 c5">9.9(16.5) *</td>
|
|
<td class="nobr" headers="r8 r13 c3 c6">11.3(17.1)</td>
|
|
<td class="nobr" headers="r8 r13 c3 c7">12.6(18.0) **</td>
|
|
</tr>
|
|
<tr>
|
|
<th class="stub1" id="r14" headers="r8 c1">Days incarcerated in last 60</th>
|
|
<td class="nobr" headers="r8 r14 c2 c4">1.3(5.9)</td>
|
|
<td class="nobr" headers="r8 r14 c2 c5">2.6(10.0) **</td>
|
|
<td class="nobr" headers="r8 r14 c3 c6">2.2(8.3)</td>
|
|
<td class="nobr" headers="r8 r14 c3 c7">1.4(6.9) **</td>
|
|
</tr>
|
|
<tr class="topPad1">
|
|
<th class="stub0" id="r15" headers="c1">Income</th>
|
|
<td colspan="4"></td>
|
|
</tr>
|
|
<tr>
|
|
<th class="stub1" id="r16" headers="r15 c1">Percentage reporting receipt of—</th>
|
|
<td colspan="4"></td>
|
|
</tr>
|
|
<tr>
|
|
<th class="stub2" id="r17" headers="r15 r16 c1">Social Security retirement income</th>
|
|
<td class="nobr" headers="r15 r16 r17 c2 c4">3.7%</td>
|
|
<td class="nobr" headers="r15 r16 r17 c2 c5">29.2% ***</td>
|
|
<td class="nobr" headers="r15 r16 r17 c3 c6">0.6%</td>
|
|
<td class="nobr" headers="r15 r16 r17 c3 c7">1.0%</td>
|
|
</tr>
|
|
<tr>
|
|
<th class="stub2" id="r18" headers="r15 r16 c1">Food stamps</th>
|
|
<td class="nobr" headers="r15 r16 r18 c2 c4">35.2%</td>
|
|
<td class="nobr" headers="r15 r16 r18 c2 c5">22.1% ***</td>
|
|
<td class="nobr" headers="r15 r16 r18 c3 c6">48.9%</td>
|
|
<td class="nobr" headers="r15 r16 r18 c3 c7">41.7% ***</td>
|
|
</tr>
|
|
<tr>
|
|
<th class="stub2" id="r19" headers="r15 r16 c1">Other social welfare benefit</th>
|
|
<td class="nobr" headers="r15 r16 r19 c2 c4">4.5%</td>
|
|
<td class="nobr" headers="r15 r16 r19 c2 c5">9.2% **</td>
|
|
<td class="nobr" headers="r15 r16 r19 c3 c6">23.7%</td>
|
|
<td class="nobr" headers="r15 r16 r19 c3 c7">7.6% ***</td>
|
|
</tr>
|
|
<tr>
|
|
<th class="stub1" id="r20" headers="r15 c1">Number of types of benefits received</th>
|
|
<td class="nobr" headers="r15 r20 c2 c4">0.5(0.6)</td>
|
|
<td class="nobr" headers="r15 r20 c2 c5">0.7(0.7) ***</td>
|
|
<td class="nobr" headers="r15 r20 c3 c6">0.8(0.8)</td>
|
|
<td class="nobr" headers="r15 r20 c3 c7">0.6(0.7) ***</td>
|
|
</tr>
|
|
<tr>
|
|
<th class="stub1" id="r21" headers="r15 c1">Percentage reporting someone else receives and manages check</th>
|
|
<td class="nobr" headers="r15 r21 c2 c4">29.3%</td>
|
|
<td class="nobr" headers="r15 r21 c2 c5">21.2% *</td>
|
|
<td class="nobr" headers="r15 r21 c3 c6">4.4%</td>
|
|
<td class="nobr" headers="r15 r21 c3 c7">27.6% ***</td>
|
|
</tr>
|
|
<tr class="topPad1">
|
|
<th class="stub0" id="r22" headers="c1">Psychiatric</th>
|
|
<td colspan="4"></td>
|
|
</tr>
|
|
<tr>
|
|
<th class="stub1" id="r23" headers="r22 c1">Schizophrenia</th>
|
|
<td class="nobr" headers="r22 r23 c2 c4">51.5%</td>
|
|
<td class="nobr" headers="r22 r23 c2 c5">52.8%</td>
|
|
<td class="nobr" headers="r22 r23 c3 c6">27.9%</td>
|
|
<td class="nobr" headers="r22 r23 c3 c7">53.9% ***</td>
|
|
</tr>
|
|
<tr>
|
|
<th class="stub1" id="r24" headers="r22 c1">Bipolar</th>
|
|
<td class="nobr" headers="r22 r24 c2 c4">22.1%</td>
|
|
<td class="nobr" headers="r22 r24 c2 c5">19.5%</td>
|
|
<td class="nobr" headers="r22 r24 c3 c6">20.4%</td>
|
|
<td class="nobr" headers="r22 r24 c3 c7">17.2% *</td>
|
|
</tr>
|
|
<tr>
|
|
<th class="stub1" id="r25" headers="r22 c1">Major depression</th>
|
|
<td class="nobr" headers="r22 r25 c2 c4">33.9%</td>
|
|
<td class="nobr" headers="r22 r25 c2 c5">31.8%</td>
|
|
<td class="nobr" headers="r22 r25 c3 c6">56.7%</td>
|
|
<td class="nobr" headers="r22 r25 c3 c7">32.6% ***</td>
|
|
</tr>
|
|
<tr>
|
|
<th class="stub1" id="r26" headers="r22 c1">Lifetime psychiatric hospitalizations</th>
|
|
<td class="nobr" headers="r22 r26 c2 c4">8.5(12.3)</td>
|
|
<td class="nobr" headers="r22 r26 c2 c5">6.4(12.2) **</td>
|
|
<td class="nobr" headers="r22 r26 c3 c6">3.0(6.2)</td>
|
|
<td class="nobr" headers="r22 r26 c3 c7">7.8(11.4) ***</td>
|
|
</tr>
|
|
<tr>
|
|
<th class="stub1" id="r27" headers="r22 c1">Observer-rated psychosis</th>
|
|
<td class="nobr" headers="r22 r27 c2 c4">11.6(7.9)%</td>
|
|
<td class="nobr" headers="r22 r27 c2 c5">12.3(8.8)%</td>
|
|
<td class="nobr" headers="r22 r27 c3 c6">10.0(7.8)%</td>
|
|
<td class="nobr" headers="r22 r27 c3 c7">12.8(8.3)% ***</td>
|
|
</tr>
|
|
<tr>
|
|
<th class="stub1" id="r28" headers="r22 c1">Depression symptoms (number out of 5)</th>
|
|
<td class="nobr" headers="r22 r28 c2 c4">2.7(2.1)</td>
|
|
<td class="nobr" headers="r22 r28 c2 c5">2.5(2.1)</td>
|
|
<td class="nobr" headers="r22 r28 c3 c6">3.5(1.9)</td>
|
|
<td class="nobr" headers="r22 r28 c3 c7">2.7(2.1) ***</td>
|
|
</tr>
|
|
<tr class="topPad1">
|
|
<th class="stub0" id="r29" headers="c1">Substance use</th>
|
|
<td colspan="4"></td>
|
|
</tr>
|
|
<tr>
|
|
<th class="stub1" id="r30" headers="r29 c1">Clinician-rated alcohol use</th>
|
|
<td class="nobr" headers="r29 r30 c2 c4">2.2(1.3)</td>
|
|
<td class="nobr" headers="r29 r30 c2 c5">2.0(1.2) *</td>
|
|
<td class="nobr" headers="r29 r30 c3 c6">2.2(1.3)</td>
|
|
<td class="nobr" headers="r29 r30 c3 c7">2.2(1.3)</td>
|
|
</tr>
|
|
<tr>
|
|
<th class="stub1" id="r31" headers="r29 c1">Clinician-rated drug use</th>
|
|
<td class="nobr" headers="r29 r31 c2 c4">2.1(1.4)</td>
|
|
<td class="nobr" headers="r29 r31 c2 c5">1.8(1.2) **</td>
|
|
<td class="nobr" headers="r29 r31 c3 c6">2.0(1.3)</td>
|
|
<td class="nobr" headers="r29 r31 c3 c7">1.9(1.3)</td>
|
|
</tr>
|
|
<tr>
|
|
<th class="stub1" id="r32" headers="r29 c1">Years of alcohol use</th>
|
|
<td class="nobr" headers="r29 r32 c2 c4">5.7(8.7)</td>
|
|
<td class="nobr" headers="r29 r32 c2 c5">4.9(9.0)</td>
|
|
<td class="nobr" headers="r29 r32 c3 c6">5.9(8.4)</td>
|
|
<td class="nobr" headers="r29 r32 c3 c7">4.6(7.8) ***</td>
|
|
</tr>
|
|
<tr>
|
|
<th class="stub1" id="r33" headers="r29 c1">Years of cannabis use</th>
|
|
<td class="nobr" headers="r29 r33 c2 c4">5.9(8.6)</td>
|
|
<td class="nobr" headers="r29 r33 c2 c5">4.0(8.0) **</td>
|
|
<td class="nobr" headers="r29 r33 c3 c6">6.0(8.2)</td>
|
|
<td class="nobr" headers="r29 r33 c3 c7">5.3(8.4) *</td>
|
|
</tr>
|
|
<tr>
|
|
<th class="stub1" id="r34" headers="r29 c1">Years of cocaine use</th>
|
|
<td class="nobr" headers="r29 r34 c2 c4">1.8(4.5)</td>
|
|
<td class="nobr" headers="r29 r34 c2 c5">1.2(3.8)</td>
|
|
<td class="nobr" headers="r29 r34 c3 c6">2.0(4.5)</td>
|
|
<td class="nobr" headers="r29 r34 c3 c7">1.3(3.7) ***</td>
|
|
</tr>
|
|
<tr class="topPad1">
|
|
<th class="stub0" id="r35" headers="c1">Medical</th>
|
|
<td colspan="4"></td>
|
|
</tr>
|
|
<tr>
|
|
<th class="stub1" id="r36" headers="r35 c1"><abbr class="spell">HIV</abbr> seropositive</th>
|
|
<td class="nobr" headers="r35 r36 c2 c4">4.8%</td>
|
|
<td class="nobr" headers="r35 r36 c2 c5">3.1%</td>
|
|
<td class="nobr" headers="r35 r36 c3 c6">2.5%</td>
|
|
<td class="nobr" headers="r35 r36 c3 c7">5.2% ***</td>
|
|
</tr>
|
|
<tr>
|
|
<th class="stub1" id="r37" headers="r35 c1">Percentage diagnosed with seizure disorder</th>
|
|
<td class="nobr" headers="r35 r37 c2 c4">10.1%</td>
|
|
<td class="nobr" headers="r35 r37 c2 c5">10.3%</td>
|
|
<td class="nobr" headers="r35 r37 c3 c6">7.2%</td>
|
|
<td class="nobr" headers="r35 r37 c3 c7">11.6% ***</td>
|
|
</tr>
|
|
<tr class="topPad1">
|
|
<th class="stub0" id="r38" headers="c1">Baseline treatment in last 60 days</th>
|
|
<td colspan="4"></td>
|
|
</tr>
|
|
<tr>
|
|
<th class="stub1" id="r39" headers="r38 c1">Percentage receiving psychiatric Rx</th>
|
|
<td class="nobr" headers="r38 r39 c2 c4">70.8%</td>
|
|
<td class="nobr" headers="r38 r39 c2 c5">60.8% **</td>
|
|
<td class="nobr" headers="r38 r39 c3 c6">62.4%</td>
|
|
<td class="nobr" headers="r38 r39 c3 c7">71.4% ***</td>
|
|
</tr>
|
|
<tr>
|
|
<th class="stub1" id="r40" headers="r38 c1">Percentage receiving substance abuse Rx</th>
|
|
<td class="nobr" headers="r38 r40 c2 c4">30.3%</td>
|
|
<td class="nobr" headers="r38 r40 c2 c5">23.6%</td>
|
|
<td class="nobr" headers="r38 r40 c3 c6">33.8%</td>
|
|
<td class="nobr" headers="r38 r40 c3 c7">28.5% **</td>
|
|
</tr>
|
|
<tr>
|
|
<th class="stub1" id="r41" headers="r38 c1">Number of services accessed</th>
|
|
<td class="nobr" headers="r38 r41 c2 c4">2.4(1.0)</td>
|
|
<td class="nobr" headers="r38 r41 c2 c5">1.6(1.1) ***</td>
|
|
<td class="nobr" headers="r38 r41 c3 c6">1.6(1.1)</td>
|
|
<td class="nobr" headers="r38 r41 c3 c7">2.3(0.9) ***</td>
|
|
</tr>
|
|
</tbody>
|
|
<tfoot>
|
|
<tr>
|
|
<td class="firstNote" colspan="5">SOURCE: Self-report data were collected in the <abbr>ACCESS</abbr> demonstration and were cross-matched with the Social Security Administration's Master Beneficiary Record, Payment History Update System, and the Supplemental Security Record.</td>
|
|
</tr>
|
|
<tr>
|
|
<td class="note" colspan="5">* Significant difference from corresponding <abbr class="spell">SSA</abbr> concordant group at p<.05.</td>
|
|
</tr>
|
|
<tr>
|
|
<td class="note" colspan="5">** Significant difference from corresponding <abbr class="spell">SSA</abbr> concordant group at p<.01.</td>
|
|
</tr>
|
|
<tr>
|
|
<td class="lastNote" colspan="5">*** Significant difference from corresponding <abbr class="spell">SSA</abbr> concordant group at p<.001.</td>
|
|
</tr>
|
|
</tfoot>
|
|
</table>
|
|
</div>
|
|
<p class="noindent"><span class="h4">Comparison Among Clients not Receiving <abbr class="spell">SSI</abbr>/<abbr class="spell">DI</abbr> According to <abbr class="spell">SSA</abbr>: Participants Self-reporting Receipt of <abbr class="spell">SSI</abbr>/<abbr class="spell">DI</abbr> versus Those not Self-reporting Receipt.</span> In multivariate analyses, the measures that significantly (p<.01) distinguished the 934 individuals reporting receipt of <abbr class="spell">SSI</abbr>/<abbr class="spell">DI</abbr> (without <abbr class="spell">SSA</abbr> verification) from the 4,770 not reporting receipt (in concordance with <abbr class="spell">SSA</abbr> records) are listed in Table 3. The 934 participants with unverified reports of receiving <abbr class="spell">SSI</abbr>/<abbr class="spell">DI</abbr> were more impaired in several realms. They had disproportionately less education and employment and were disproportionately more likely to have been diagnosed with schizophrenia, human immunodeficiency virus (<abbr class="spell">HIV</abbr>), and seizure disorders.</p>
|
|
<div class="table" id="table3">
|
|
<table>
|
|
<caption><span class="tableNumber">Table 3. </span>Logistic regression analysis of group who reported receiving <abbr class="spell">SSI</abbr>/<abbr class="spell">DI</abbr> among the sample of those without benefits per <abbr class="spell">SSA</abbr> records</caption>
|
|
<colgroup span="1" style="width:22em"></colgroup>
|
|
<colgroup span="2" style="width:8em"></colgroup>
|
|
<thead>
|
|
<tr>
|
|
<th class="stubHeading" scope="col">Measure</th>
|
|
<th scope="col">Odds ratio</th>
|
|
<th scope="col">99 percent confidence limits</th>
|
|
</tr>
|
|
</thead>
|
|
<tbody>
|
|
<tr>
|
|
<th class="stub0" scope="rowgroup">Demographic, vocational, and housing</th>
|
|
<td colspan="2"></td>
|
|
</tr>
|
|
<tr>
|
|
<th class="stub1" scope="row">Age</th>
|
|
<td>1.05</td>
|
|
<td class="nobr">1.03–1.06 ***</td>
|
|
</tr>
|
|
<tr>
|
|
<th class="stub1" scope="row">English first language</th>
|
|
<td>0.55</td>
|
|
<td class="nobr">0.32–0.96 *</td>
|
|
</tr>
|
|
<tr>
|
|
<th class="stub1" scope="row">Years of education</th>
|
|
<td>0.92</td>
|
|
<td class="nobr">0.88–0.97 ***</td>
|
|
</tr>
|
|
<tr>
|
|
<th class="stub1" scope="row">Veteran</th>
|
|
<td>0.6</td>
|
|
<td class="nobr">0.42–0.84 ***</td>
|
|
</tr>
|
|
<tr>
|
|
<th class="stub1" scope="row">Years at longest full-time job</th>
|
|
<td>0.91</td>
|
|
<td class="nobr">0.88–0.94 ***</td>
|
|
</tr>
|
|
<tr>
|
|
<th class="stub1" scope="row">Days working in last 30</th>
|
|
<td>1.01</td>
|
|
<td class="nobr">1.01–1.02 ***</td>
|
|
</tr>
|
|
<tr>
|
|
<th class="stub1" scope="row">Days housed in last 60</th>
|
|
<td>0.92</td>
|
|
<td class="nobr">0.89–0.95 ***</td>
|
|
</tr>
|
|
<tr>
|
|
<th class="stub1" scope="row">Days incarcerated in last 60</th>
|
|
<td>0.98</td>
|
|
<td class="nobr">0.96–0.99 **</td>
|
|
</tr>
|
|
<tr class="topPad1">
|
|
<th class="stub0" scope="rowgroup">Psychiatric</th>
|
|
<td colspan="2"></td>
|
|
</tr>
|
|
<tr>
|
|
<th class="stub1" scope="row">Schizophrenia</th>
|
|
<td>1.54</td>
|
|
<td class="nobr">1.19–2.01 ***</td>
|
|
</tr>
|
|
<tr>
|
|
<th class="stub1" scope="row">Major depression</th>
|
|
<td>0.66</td>
|
|
<td class="nobr">0.51–0.86 ***</td>
|
|
</tr>
|
|
<tr>
|
|
<th class="stub1" scope="row">Number of psychiatric hospitalizations</th>
|
|
<td>1.05</td>
|
|
<td class="nobr">1.04–1.07 ***</td>
|
|
</tr>
|
|
<tr>
|
|
<th class="stub1" scope="row">Observer-rated psychosis</th>
|
|
<td>1.03</td>
|
|
<td class="nobr">1.02–1.05 ***</td>
|
|
</tr>
|
|
<tr>
|
|
<th class="stub1" scope="row">Depression symptoms (number out of 5)</th>
|
|
<td>0.88</td>
|
|
<td class="nobr">0.83–0.94 ***</td>
|
|
</tr>
|
|
<tr class="topPad1">
|
|
<th class="stub0" scope="rowgroup">Substance Use</th>
|
|
<td colspan="2"></td>
|
|
</tr>
|
|
<tr>
|
|
<th class="stub1" scope="row">Years of alcohol use</th>
|
|
<td>0.98</td>
|
|
<td class="nobr">0.96–0.99 ***</td>
|
|
</tr>
|
|
<tr>
|
|
<th class="stub1" scope="row">Years of cocaine use</th>
|
|
<td>0.96</td>
|
|
<td class="nobr">0.93–1.0 *</td>
|
|
</tr>
|
|
<tr class="topPad1">
|
|
<th class="stub0" scope="rowgroup">Medical</th>
|
|
<td colspan="2"></td>
|
|
</tr>
|
|
<tr>
|
|
<th class="stub1" scope="row"><abbr class="spell">HIV</abbr> status</th>
|
|
<td>1.85</td>
|
|
<td class="nobr">1.02–3.34 *</td>
|
|
</tr>
|
|
<tr>
|
|
<th class="stub1" scope="row">Seizure</th>
|
|
<td>1.58</td>
|
|
<td class="nobr">1.06–2.36 *</td>
|
|
</tr>
|
|
<tr class="topPad1">
|
|
<th class="stub0" scope="rowgroup">Other</th>
|
|
<td colspan="2"></td>
|
|
</tr>
|
|
<tr>
|
|
<th class="stub1" scope="row">Other social welfare benefit (yes or no)</th>
|
|
<td>0.12</td>
|
|
<td class="nobr">0.07–0.20 ***</td>
|
|
</tr>
|
|
<tr>
|
|
<th class="stub1" scope="row">Number of types of benefits received</th>
|
|
<td>0.77</td>
|
|
<td class="nobr">0.62–0.96 *</td>
|
|
</tr>
|
|
<tr>
|
|
<th class="stub1" scope="row">Self-report that someone else receives and manages check</th>
|
|
<td>7.3</td>
|
|
<td class="nobr">5.2–10.3 ***</td>
|
|
</tr>
|
|
<tr>
|
|
<th class="stub1" scope="row">Number of services accessed in last 60 days</th>
|
|
<td>2.62</td>
|
|
<td class="nobr">2.32–2.96 ***</td>
|
|
</tr>
|
|
</tbody>
|
|
<tfoot>
|
|
<tr>
|
|
<td class="firstNote" colspan="3">SOURCE: Self-report data were collected in the <abbr>ACCESS</abbr> demonstration and were cross-matched with the Social Security Administration's Master Beneficiary Record, Payment History Update System, and the Supplemental Security Record.</td>
|
|
</tr>
|
|
<tr>
|
|
<td class="note" colspan="3">NOTES: Total sample size is 5,407; 934 reported receiving <abbr class="spell">SSI</abbr>/<abbr class="spell">DI</abbr> but were shown as not receiving benefits in the Social Security Administration's records.
|
|
<div class="newNote">Somers' D = 0.91.</div>
|
|
</td>
|
|
</tr>
|
|
<tr>
|
|
<td class="note" colspan="3">* Significant difference from group who reported receiving <abbr class="spell">SSI</abbr>/<abbr class="spell">DI</abbr> at p<.01 by pairwise comparison.</td>
|
|
</tr>
|
|
<tr>
|
|
<td class="note" colspan="3">** Significant difference from group who reported receiving <abbr class="spell">SSI</abbr>/<abbr class="spell">DI</abbr> at p<.001 by pairwise comparison.</td>
|
|
</tr>
|
|
<tr>
|
|
<td class="lastNote" colspan="3">*** Significant difference from group who reported receiving <abbr class="spell">SSI</abbr>/<abbr class="spell">DI</abbr> at p<.0001 by pairwise comparison.</td>
|
|
</tr>
|
|
</tfoot>
|
|
</table>
|
|
</div>
|
|
<p>Not all functional indices were worse among those with unverified claims. Within this population of homeless people, those who had unverified claims were likely to have used alcohol and cocaine for fewer years and to have been incarcerated for fewer days in the preceding 60 than were those who did not claim receipt of <abbr class="spell">SSI</abbr>/<abbr class="spell">DI</abbr>. Self-reported depressive symptoms and a diagnosis of major depression were associated with a lower likelihood of making an unconfirmed claim of receiving <abbr class="spell">SSI</abbr>/<abbr class="spell">DI</abbr>.</p>
|
|
<p>Benefit status differed between the two groups. Participants with unverified claims of receiving <abbr class="spell">SSI</abbr>/<abbr class="spell">DI</abbr> were more likely to report having a payee than were those who did not claim benefit receipt. Those with unverified claims also had received fewer benefits overall.</p>
|
|
<p class="noindent"><span class="h4">Comparison Among Clients Receiving <abbr class="spell">SSI</abbr>/<abbr class="spell">DI</abbr> According to <abbr class="spell">SSA</abbr>: Participants not Self-reporting Receipt of <abbr class="spell">SSI</abbr>/<abbr class="spell">DI</abbr> versus Those Self-reporting Receipt.</span> Participants who did not report receiving <abbr class="spell">SSI</abbr>/<abbr class="spell">DI</abbr> in contradiction to <abbr class="spell">SSA</abbr>'s records that they actually had received benefits were more likely to have reported receipt of Social Security retirement benefits and other social welfare benefits (Table 4). In a post hoc analysis, we considered the possibility that clients who thought they received Social Security retirement benefits were disproportionately aged 62 or older, and they were. Altogether, 17.4 percent (34/195) of participants who inaccurately reported nonreceipt of <abbr class="spell">SSI</abbr>/<abbr class="spell">DI</abbr> were aged 62 or older, but only 3 percent (39/1,322) of those with concordant reports of receiving <abbr class="spell">SSI</abbr>/<abbr class="spell">DI</abbr> were aged 62 or older (chi-square 77.8, p<.0001).</p>
|
|
<div class="table" id="table4">
|
|
<table>
|
|
<caption><span class="tableNumber">Table 4. </span>Logistic regression analysis of group who denied receiving <abbr class="spell">SSI</abbr>/<abbr class="spell">DI</abbr> among the sample of those with benefits per <abbr class="spell">SSA</abbr> records</caption>
|
|
<colgroup span="1" style="width:22em"></colgroup>
|
|
<colgroup span="1" style="width:8em"></colgroup>
|
|
<colgroup span="1" style="width:8em"></colgroup>
|
|
<thead>
|
|
<tr>
|
|
<th class="stubHeading" scope="col">Measure</th>
|
|
<th scope="col">Odds ratio</th>
|
|
<th scope="col">99 percent confidence limits</th>
|
|
</tr>
|
|
</thead>
|
|
<tbody>
|
|
<tr>
|
|
<th class="stub0" scope="row">Days incarcerated in last 60</th>
|
|
<td>1.03</td>
|
|
<td class="nobr">1.00–1.06 *</td>
|
|
</tr>
|
|
<tr>
|
|
<th class="stub0" scope="row">Clinician-rated alcohol use</th>
|
|
<td>0.82</td>
|
|
<td class="nobr">0.68–1.0 *</td>
|
|
</tr>
|
|
<tr>
|
|
<th class="stub0" scope="row">Social Security retirement income</th>
|
|
<td>17.45</td>
|
|
<td class="nobr">9.10–33.43 ***</td>
|
|
</tr>
|
|
<tr>
|
|
<th class="stub0" scope="row">Food stamps</th>
|
|
<td>0.53</td>
|
|
<td class="nobr">0.30–0.91 *</td>
|
|
</tr>
|
|
<tr>
|
|
<th class="stub0" scope="row">Other social welfare benefit (yes or no)</th>
|
|
<td>5.54</td>
|
|
<td class="nobr">2.31–13.29 ***</td>
|
|
</tr>
|
|
<tr>
|
|
<th class="stub0" scope="row">Number of services accessed in last 60 days</th>
|
|
<td>0.34</td>
|
|
<td class="nobr">0.26–0.45 ***</td>
|
|
</tr>
|
|
</tbody>
|
|
<tfoot>
|
|
<tr>
|
|
<td class="firstNote" colspan="3">SOURCE: Self-report data were collected in the <abbr>ACCESS</abbr> demonstration and were cross-matched with the Social Security Administration's Master Beneficiary Record, Payment History Update System, and the Supplemental Security Record.</td>
|
|
</tr>
|
|
<tr>
|
|
<td class="note" colspan="3">NOTES: Total sample size is 1,516; 193 reported not receiving <abbr class="spell">SSI</abbr>/<abbr class="spell">DI</abbr> but were shown as receiving benefits in the Social Security Administration's records.
|
|
<div class="newNote">Somers' D = 0.87.</div>
|
|
</td>
|
|
</tr>
|
|
<tr>
|
|
<td class="note" colspan="3">* Significant difference from group who denied receiving <abbr class="spell">SSI</abbr>/<abbr class="spell">DI</abbr> at p<.01 by pairwise comparison.</td>
|
|
</tr>
|
|
<tr>
|
|
<td class="note" colspan="3">** Significant difference from group who denied receiving <abbr class="spell">SSI</abbr>/<abbr class="spell">DI</abbr> at p<.001 by pairwise comparison.</td>
|
|
</tr>
|
|
<tr>
|
|
<td class="lastNote" colspan="3">*** Significant difference from group who denied receiving <abbr class="spell">SSI</abbr>/<abbr class="spell">DI</abbr> at p<.0001 by pairwise comparison.</td>
|
|
</tr>
|
|
</tfoot>
|
|
</table>
|
|
</div>
|
|
<h2>Discussion</h2>
|
|
<p>Fully 41 percent (934/2,257) of clients who reported receiving <abbr class="spell">SSI</abbr>/<abbr class="spell">DI</abbr> benefits did not receive them according to <abbr class="spell">SSA</abbr>. Clients whose report of receiving <abbr class="spell">SSI</abbr>/<abbr class="spell">DI</abbr> was unconfirmed were more likely to have conditions associated with neurocognitive impairment: they were disproportionately psychotic, <abbr class="spell">HIV</abbr>-positive, diagnosed with a seizure disorder, and occupationally impaired. Clients who misreported basic demographic information may also not have understood the benefits they receive, the question asked, or how to translate their knowledge into a correct response. The clients whose report of receiving <abbr class="spell">SSI</abbr>/<abbr class="spell">DI</abbr> was not confirmed used cocaine and alcohol for disproportionately fewer years, but this finding is not inconsistent with a cognitive explanation for anomalous self-reports—some studies indicate that within populations of people with mental illness, those who use drugs may actually be higher functioning (Ries and others 2000).</p>
|
|
<p>Cognitive problems also may have been a factor when participants who had received <abbr class="spell">SSI</abbr>/<abbr class="spell">DI</abbr> according to <abbr class="spell">SSA</abbr> did not report receiving those benefits. These clients appear to have been confused by different types of "social" benefits and apparently indicated receipt of Social Security retirement benefits and social welfare benefits instead of the actual <abbr class="spell">SSI</abbr>/<abbr class="spell">DI</abbr> they were receiving.</p>
|
|
<p>The overreporting of <abbr class="spell">SSI</abbr>/<abbr class="spell">DI</abbr> receipt relative to administrative databases in this homeless, mentally ill population is in contrast to the underreporting of income among poor people generally (Hotz and Scholz 2002). For example, validation of data from the Survey of Income and Program Participation suggested that self-report responses underestimated <abbr class="spell">SSI</abbr> receipt by as much as 23 percent (Marquis and Moore 1990). The responses of homeless people with mental illness may be affected by neurocognitive difficulties that are less salient in poor people who are not defined by homelessness and mental illness.</p>
|
|
<p>One clinical implication of the problematic self-reports is that when a client reports receiving <abbr class="spell">SSI</abbr> or <abbr class="spell">DI</abbr>, the assertion should be verified. The client can be asked the amount of the check or how the check came to be awarded. Clients should also be questioned to make sure the check referred to is an <abbr class="spell">SSI</abbr> or <abbr class="spell">DI</abbr> check and not another kind of payment. Information about benefit receipt can be obtained when another person receives the benefit check or by examining the clients' Medicare card. Primary Medicare beneficiaries who are too young to qualify for retirement benefits presumably receive <abbr class="spell">DI</abbr>.</p>
|
|
<p>The low agreement between self-report and <abbr class="spell">SSA</abbr> databases among the homeless, mentally ill population has other far-reaching implications. Data concerning sources of income are collected in the <abbr>U.S.</abbr> Census and several surveys specifically targeting poor people (Hotz and Scholz 2002). Accurate data about use of public support payments is crucial to assessing the impact of policies such as welfare reform (Primus and others 1999) and changes in eligibility for <abbr class="spell">SSI</abbr> and <abbr class="spell">DI</abbr> (Watkins, Wells, and McLellan 1999). In health services research, self-reported Social Security numbers and dates of birth are frequently used to cross-match data from people with known clinical characteristics with another database of interest (Friedman and others 1996; Bach and others 2002). A systematic bias is unwittingly introduced to data when a failure to cross-match is not random.</p>
|
|
<p>Some clients who reported receiving <abbr class="spell">SSI</abbr>/<abbr class="spell">DI</abbr> but did not appear in <abbr class="spell">SSA</abbr> databases probably did not cross-match with <abbr class="spell">SSA</abbr> databases because they provided inaccurate Social Security numbers (<abbr class="spell">SSN</abbr>s) or inaccurate dates of birth. In the 1996 Survey of Income and Program Participation, a full 16 percent of the <abbr class="spell">SSN</abbr>s provided by survey participants appeared to be inaccurate because they did not match <abbr class="spell">SSN</abbr>s in the Summary Earnings Record (Huynh, Rupp, and Sears 2002). One reason to suspect that inaccurate <abbr class="spell">SSN</abbr>s were provided is that the 1,323 participants whose reported receipt of <abbr class="spell">SSI</abbr>/<abbr class="spell">DI</abbr> was validated by <abbr class="spell">SSA</abbr> administrative records were similar to the 934 whose self-reported receipt was not validated (Table 2). For instance, both groups included high proportions of clients who reported that someone else received their check and managed it for them (29.3 percent and 27.6 percent, respectively). The clients who are discordant with <abbr class="spell">SSA</abbr> records could have some sort of non-<abbr class="spell">SSA</abbr> fiduciary arrangement, but the 27.6 percent reporting that someone else receives their check is consistent with other estimates that approximately a third of adults under the age of 65 who receive <abbr class="spell">SSA</abbr> payments based on a psychiatric disability have been assigned a payee to manage their funds (Social Security Administration 2001a, Table 7; and 2001b, Table 32).</p>
|
|
<p>Social Security numbers have high sensitivity and specificity in validating death against the National Death Index (Williams, Demitrack, and Fries 1992), and <abbr class="spell">SSA</abbr> databases are highly regarded (Waldron 2001). Yet underreporting of deaths to <abbr class="spell">SSA</abbr> does occur and is not random—underreporting of death information provided to <abbr class="spell">SSA</abbr> by third parties (such as state vital record systems) is less likely when the deceased was a woman, black, younger, unmarried, or from the South (Curb and others 1985; Wentworth, Neaton, and Rasmussen 1983; Boyle and Decoufle 1990).</p>
|
|
<p>Benefits for the Supplemental Security Income and Disability Insurance programs provide a vital safety net for clients disabled by psychiatric disorders. It is important that each individual's benefit status be accurately determined for that client's clinical care and that studies dependent on demographic information provided by impaired clients be independently verified so that use of the Social Security safety net is accurately described.</p>
|
|
<div id="references">
|
|
<h2>References</h2>
|
|
<p>Bach, P.B., E. Guadagnoli, D. Schrag, N. Schussler, and J.L. Warren. 2002. Patient demographic and socioeconomic characteristics in the <abbr>SEER</abbr>-Medicare database: Applications and limitations. <i>Medical Care</i> 40(8 Suppl): <span class="nobr">19–25</span>.</p>
|
|
<p>Baker, D.W., J.A. Gazmararian, J. Sudano, M. Patterson, R.M. Parker, and M.V. Williams. 2002. Health literacy and performance on the Mini-Mental State Examination. <i>Aging and Mental Health</i> <span class="nobr">6(1)</span>: <span class="nobr">22–29</span>.</p>
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|
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