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2015 Policy Wrap Up: Screening Public Assistance Clients for Disabilities: A Promising, but Very Frustrating Development

July 22, 2015

Author: Don Friedman

Background

People with disabilities face daunting and sometimes insurmountable barriers in navigating the process for applying for and retaining needed public benefits.  Advocates throughout the state report that too often clients with disabilities have their assistance terminated or their applications denied because they are not able to make it to every mandated appointment or bring in every required document, or because they simply give up under the stress and confusion of the process.  For close to ten years, advocacy groups, including Empire Justice Center, have pressed the Office of Temporary and Disability Assistance (OTDA) to ensure that local departments of social services (LDSSs) properly evaluate clients for disabilities and offer accommodations when needed.  In particular, we urged OTDA to adopt a screening tool to help evaluate clients for mental disabilities, which are often the most challenging to identify and to accommodate. 

After our years of advocacy, OTDA finally chose a screening tool, the Modified Mini Screen (MMS), and engaged the Nathan Kline Institute of the State Department of Mental Health to “validate” it, which they accomplished by testing it with nearly 500 LDSS clients in five counties.  They issued a report in January 2013, finding that the MMS was a valid predictor of a range of mental health conditions.  In late June 2015, OTDA finally issued an Administrative Directive, known as 15-ADM-04, making local districts aware of the availability of this tool.

15-ADM-04: The Modified Mini Screen Mental Health Screening Tool  

15-ADM-04 officially introduces the local social services districts to the Modified Mini Screen.  At the start, the ADM notes that the MMS has been validated as able to accurately and reliably screen for mental health conditions.  The MMS is used to conduct a brief, preliminary screen; then, depending on the client’s score on the screen, the individual may be referred for a more in-depth evaluation, after which accommodations, if indicated, will be offered.

Districts are already required to screen applicants for disability, but only in relation to their ability to engage in work.  And no particular screening tool is required to be used.

The ADM emphasizes that use of the MMS by the districts is optional.  It further provides that if the district decides to adopt the MMS, the decision to be screened must be completely voluntary for the client. However, if a client does agree to be screened and their score results in a referral for further evaluation, then the client must comply with the referral or with a request for medical documentation.  Failure to comply may result in a reduction or termination of assistance.  The client must also sign an Informed Consent form acknowledging, among other things, the possibility of sanctions for failing to follow through with post-screening instructions.  The form also advises clients of their right to tell their DSS worker – at any time – that they believe they have a mental health problem affecting their ability to work.  But if they do so, and DSS instructs them to cooperate with evaluating their employability, their failure to comply may result in sanctions.

The ADM then describes how the MMS will be administered, suggesting that a computer-assisted interview is preferable and that OTDA will provide the necessary software.  The MMS consists of 22 questions designed to briefly assess whether a person may have mood, anxiety, or psychotic disorders.  Each district will designate a “cut point,” that is the score that will trigger a referral for a professionally administered, in-depth evaluation.  In addition, if a client answers “yes” to the question that asks about suicidal thoughts, a crisis intervention must be undertaken. 

All clients taking the MMS must be debriefed, particularly to look for signs of distress or a need for assistance.  After any crises are addressed, the DSS worker will indicate whether the client’s MMS score warrants a referral for an in-depth evaluation.  As noted above, the client’s failure to follow through with the referral may result in a loss of benefits.

The ADM: The Positives and Some Serious Concerns

In some ways, the issuance of this ADM is a positive and somewhat hopeful development:

  • First, it formalizes OTDA’s endorsement of this tool, the Modified Mini Screen, following a rigorous validation process.
  • The ADM provides a thoughtful explanation of the value of mental health screening in general, and the MMS in particular, and of the important ways in which the districts can use it.
  • OTDA offers districts resources to facilitate the use of the MMS, including software, training, and materials in multiple languages.
  • For certain clients, answering some of the MMS questions may be stressful and even disturbing.  The requirement that there be a post-screen debriefing and crisis intervention when needed is a welcome and hopefully adequate step.


Unfortunately, the ADM is flawed in ways that may seriously undermine the benefits and value of introducing the MMS to the districts:

  • The ADM, as noted above, makes a compelling case for adoption of the MMS, but then leaves the decision of whether to use it entirely up to local social services districts.  Given the value of the tool and the importance of identifying and providing accommodations for clients with mental disabilities, not to mention the obligation to do so under the federal Americans with Disabilities Act (ADA), local district use of the tool or a reasonable equivalent should be mandatory.
  • The ADM suggests certain situations in which the screen should be offered and certain types of clients to whom it should be offered.  But, as noted at the beginning of this article, for many clients, failure to identify disabilities very early in their interaction with a LDSS will effectively deny them access to needed services and benefits.  Districts should be instructed to offer the screening process to clients as soon as is feasible once the client has indicated a need for assistance.
  • Perhaps of greatest concern is the punitive and threatening nature of a process that was, in concept, developed to provide assistance and protection to people with mental disabilities.  As mandated by OTDA policy and the ADA, taking the screen must be voluntary.  The ADM calls the process voluntary, but then threatens severe punishment for clients who fail to follow through with actions required as a result of their screening scores.  It must be anticipated that many clients will drop out of the process upon reading the ominous consent form.  Furthermore, the linking of punishments with the client’s failure to follow up with required action after taking the MMS ignores a glaring fact:  That failure to follow up, to attend appointments, to submit to an in-depth evaluation, may well be symptoms of the very disability the screen was designed to detect.  Many of the most fragile, vulnerable clients might thus be worse off than if OTDA had continued its frustrating inaction on mental health screening!  There should be no punishments associated with taking the MMS.


Conclusion

There is no need to restate our support for some features of 15-ADM-04, or our serious misgivings about others.  I will just note that we stand ready to work with OTDA and with local districts to craft a policy that will not be unduly onerous for the districts, and that will optimize their capacity to identify and assist clients with disabilities.  Until appropriate policies are adopted, we fear that too many districts are out of compliance with state and federal law, and, more critically, are failing to properly and adequately serve poor New Yorkers with disabilities.

 





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