Representative Payee Research Articles

Recipients of Representative Payeeship with Mental Illness: Financial Leverage, Conflict, and Satisfaction.

This study aimed to examine self-report of financial leverage, conflict, and satisfaction pertaining to representative payeeship for persons with mental illness, which research has not examined in the past decade. Sixty representative payee recipients with mental illness residing across the U.S. completed an online survey, with most (n = 50) receiving representative payeeship by family members/friends. Wilcoxon-Mann-Whitney tests and Spearman correlations were computed. One-third of participants reported experiencing financial leverage and conflict "sometimes" or more often and were dissatisfied with their representative payee arrangement. With the exception of use of alcohol and/or drugs, no participant characteristic was associated with financial leverage, conflict, or satisfaction. Financial leverage was reported to be greater when representative payees were family members/friends. Financial leverage and conflict were positively associated with each other and negatively associated with satisfaction. It is advisable that satisfaction with representative payeeship be increased and conflict resulting from representative payeeship be minimized.

Systematic Review of Financial Interventions for Adults Experiencing Behavioral Health Conditions.

The authors reviewed the literature on finance-based interventions used to improve clinical and psychosocial outcomes among adults experiencing mental disorders, substance use disorders, or both. A systematic review of the peer-reviewed literature, published from 1900 to 2022, was conducted. Only studies with participants with a mental disorder or a substance use disorder, a structured finance-based intervention or program, a quantitative dependent variable in a behavioral health outcomes domain, and a defined research design were included. Studies were rated with a quality assessment tool, and overall evidence (levels I-VII) for the outcomes was rated. In total, 544 articles were identified, screened for eligibility, and reduced to 55 articles. These articles were rated by two independent raters, and 18 articles were ultimately included. Of these 18 articles, four reported findings of randomized controlled trials (RCTs), one conducted a secondary analysis of an RCT, and the remaining articles were observational studies. The most studied intervention was representative payeeship, which reduced substance use and enhanced money management, showing the strongest evidence for improving outcomes among adults with behavioral health conditions. Weaker evidence suggested that financial education and assistance interventions could improve health care utilization and other psychosocial outcomes among individuals with mental or substance use disorders. Level II-V evidence indicates that finance-based interventions can improve outcomes among adults experiencing behavioral health conditions. Further research is needed to assess the impact of interventions beyond representative payee programs on objectively measured outcomes.

Elucidating Harm Reduction Principles in a Client-Centered Representative Payee Program.

Harm Reduction seeks to mitigate harms associated with health behaviors without the expectation that these behaviors be extinguished completely. Client-Centered Representative Payee (CCRP) is an intervention that modifies the US Social Security Administration's (SSA) Representative Payee policy by incorporating relational harm reduction. We used Human-Centered Design (HCD) methods to elucidate ways that harm reduction principles are present in and integral to CCRP and to create a blueprint for replication. Thirteen individuals familiar with CCRP brainstormed 88 statements, which were parsed, consolidated, and then independently assigned by a subgroup of participants to six principles of harm reduction. After refining the data, 29 statements aligning with harm reduction principles remained. Delineating harm reduction within CCRP, which can empower and establish trust with clients, may help other providers identify how to offer representative payee services that are respectful, compassionate, rooted in harm reduction, and ultimately improve client outcomes.

More Than a Means to an End: Alignment of Social Service Organizations' Missions with Representative Payee Program Goals.

Although nearly 5 million Social Security Income and Social Security Disability Insurance beneficiaries receive entitlements through representative payee programs and approximately 5% of these receive representative payee services from social service agencies, few studies have assessed ways that these services align with their organizations' missions. We conducted nine qualitative interviews with 15 staff members of organizations in Pennsylvania that provide representative payee services in addition to other social or supportive services, with some interviews conducted with multiple representatives within an organization. The purpose of the interviews was to explore the goals of representative payee services for these organizations, whether these providers incorporated representative payee services into their organizational missions, and the extent to which organizations incorporate client-centered approaches in their representative payee services. We identified three main goals of the representative payee programs, which were in alignment with the organizations' missions: financial and housing stability, financial literacy, and improving health outcomes. In addition, participants discussed challenges related to representative payee services that were encountered within their organizations and with clients. Findings indicate that organizations view representative payee services as not just financial management but also a means to improve clients' knowledge and skills and assist them with achieving their goals. Client-centered practices were emphasized as a means of reducing paternalism and to support clients' goals. Given that participants discussed the importance of incorporating client-centeredness into the provision of representative payee services and there are currently no published guidelines or best practices on how this can be achieved, we suggest that guidance on how to effectively provide client-centered representative payee services to improve client outcomes is essential.

Abuse of Vulnerable Older Adults by Designated Surrogate Decision Makers

Abuse perpetrated by designated surrogates has become highly visible nationally, yet no reliable data exist on its nature or extent. Because vulnerable older adults needing surrogate decision makers typically rely upon others for care, they may be unable to advocate for themselves and are susceptible to abuse. We prospectively gathered Adult Protective Services (APS) data from six geographically diverse counties on over 400 substantiated cases of abuse by perpetrators (53% non-surrogates; 47% documented or claimed surrogate) of vulnerable adults 65+ living in community settings. Most perpetrators (85%) were designated power of attorney, while approximately 8% were guardians, and 7% were representative payees; most perpetrators were family members. Polyabuse occurred frequently. Almost 25% of cases involved a prior substantiated APS report. This presentation highlights how surrogates perpetuate abuse and outcomes on older adult victims. Our findings inform practice and policy for better prevention, detection, investigation, and intervention in these challenging cases.

“Support People the Way in Which They Want to Be Supported”: Best Practices for Incorporating Client-Centeredness in Representative Payee Programs

Nearly 1 million Social Security beneficiaries have representative payees to manage their funds. Although coercion and paternalism are historically associated with payee services, a recent study showed high satisfaction in a payee program incorporating client-centered practices. Separately we reported ways organizations align payee services with their missions to empower clients and improve outcomes. Here we share results from nine provider qualitative interviews describing client-centered best practices and exploring beliefs regarding their value. We identified four best practices: Shared Decision-Making on Bills and Spending, Non-Paternalistic Substance Use Policies, Client Advocacy, and Additional Service Policies, (changing fee structures, termination policies, incorporating opting in or out, and "graduation"). Results indicate prioritizing clients' goals and agency may improve the quality of life of beneficiaries and reduce the paternalism and coercion historically associated with payee. Creating a client-centered payee toolkit and a payee collaborative may empower organizations to refine their services and provide opportunities for shared learning and support.

Protocol of a randomized controlled trial to test the effects of client-centered Representative Payee Services on antiretroviral therapy adherence among marginalized people living with HIV

BackgroundClient-Centered Representative Payee (CCRP) is an intervention modifying implementation of a current policy of the US Social Security Administration, which appoints organizations to serve as financial payees on behalf of vulnerable individuals receiving Social Security benefits. By ensuring beneficiaries’ bills are paid while supporting their self-determination, this structural intervention may mitigate the effects of economic disadvantage to improve housing and financial stability, enabling self-efficacy for health outcomes and improved antiretroviral therapy adherence. This randomized controlled trial will test the impact of CCRP on marginalized people living with HIV (PLWH). We hypothesize that helping participants to pay their rent and other bills on time will improve housing stability and decrease financial stress.MethodsPLWH (n = 160) receiving services at community-based organizations will be randomly assigned to the CCRP intervention or the standard of care for 12 months. Fifty additional participants will be enrolled into a non-randomized (“choice”) study allowing participant selection of the CCRP intervention or control. The primary outcome is HIV medication adherence, assessed via the CASE adherence index, viral load, and CD4 counts. Self-assessment data for ART adherence, housing instability, self-efficacy for health behaviors, financial stress, and retention in care will be collected at baseline, 3, 6, and 12 months. Viral load, CD4, and appointment adherence data will be collected at baseline, 6, 12, 18, and 24 months from medical records. Outcomes will be compared by treatment group in the randomized trial, in the non-randomized cohort, and in the combined cohort. Qualitative data will be collected from study participants, eligible non-participants, and providers to explore underlying mechanisms of adherence, subjective responses to the intervention, and implementation barriers and facilitators.DiscussionThe aim of this study is to determine if CCRP improves health outcomes for vulnerable PLWH. Study outcomes may provide information about supports needed to help economically fragile PLWH improve health outcomes and ultimately improve HIV health disparities. In addition, findings may help to refine service delivery including the provision of representative payee to this often-marginalized population. This protocol was prospectively registered on May 22, 2018 with ClinicalTrials.gov (NCT03561103).

PRELIMINARY FINDINGS ON FAMILY PERPETRATORS AS DESIGNATED SURROGATE DECISION MAKERS

Vulnerable older adults needing surrogate decision makers typically rely upon others for care and are unable to advocate for themselves. The issue of EFFE perpetrated by family members designated as surrogates has become highly visible nationally, yet no reliable, empirical documentation exists on the nature or extent of exploitation by surrogate perpetrators. In collaboration with the National Adult Protective Services Association (NAPSA), we prospectively gathered APS data from six geographically diverse counties on 450 substantiated cases of abuse by POAs, representative payees, and guardians of vulnerable adults 65+ living in community settings. This presentation will highlight how family member surrogates perpetuated abuse and the outcomes on elder victims. These findings elucidate person and process-level factors (e.g., characteristics of victims, perpetrators, and their relationships) within the context of the APS system and can inform practice and policy recommendations for better prevention, detection, investigation, and intervention in these challenging cases.

A Systematic Review of Health Outcomes Associated With Provision of Representative Payee Services.

The Social Security Administration's Representative Payment Program appoints payees as financial managers for individuals determined incapable of managing their funds. The aim is to afford stability and increase clients' ability to meet health and behavioral priorities. This systematic review examined literature on the effect of representative payee services on identified outcomes. A search of academic databases and gray literature was conducted in November 2015 and repeated in December 2017. Included studies had a comparison group; excluded studies examined services other than representative payee. Primary outcomes included substance use, symptoms of mental illness, housing stability, quality of life, and other health-specific outcomes. Secondary outcomes included the client-payee relationship and client satisfaction with services. Eighteen articles met inclusion criteria. Studies assessing primary outcomes found several positive and few negative effects of representative payee services. Studies examining secondary outcomes indicated that receipt of such services may affect the client-provider relationship, increase conflict and violence, and increase clients' perceptions of financial leverage (i.e., a payee's use of control over funds to encourage, incentivize, or otherwise coerce certain behaviors). Most studies were of poor or moderate quality. Studies spanned nearly two decades, and results may have been confounded by the evolution of service delivery modalities. Representative payee services are largely beneficial or neutral in terms of health and behavior outcomes. Negative findings mainly involved the client-payee relationship. Given that more than five million individuals have a representative payee, assessing the impact of these services with more rigorous research designs is worthwhile.

Financial Management Support for SSA Beneficiaries: Looking Beyond the Payee

People with mental illness who are on Social Security Administration (SSA) disability benefits have few options for support with their finances beyond handing control over to a representative payee. This helps some, but many others’ needs remain unmet. This research presents findings that examined the support options for people in the gray area between those who are clearly incapable and must have another person control their finances and those who are clearly capable of managing their finances without assistance. The research focused on understanding how the broader financial services environment impacts financial management. We gathered qualitative data from people with personal experience using a representative payee and explored innovative financial tools and products that could be helpful, as well as potential shared control/legal arrangements outside the payee mechanism.

Cognitive Impairment and Social Security’s Representative Payee Program

ABSTRACTSocial Security’s Representative Payee Program faces a difficult balance with respect to dementia: Many people living with dementia can conduct their finances without a payee if they have help from informal caregivers, but those without help are at risk. To date, it has been unclear what share of retirees with dementia use a payee, what share has help potentially available from another source, and what share has no observed means of assistance. This study finds that while fewer than 10% of retirees with dementia use a payee, only about 8% have no observed means of help.

Financial Capability: Clinicians' Assessment of Beneficiaries With Dual Diagnoses

Objective: Adults with mental health disorders whose ability to work is sufficiently impeded are entitled to financial supports from the Social Security Administration. Beneficiaries determined to be incapable of managing these funds are supposed to be assigned a representative payee to assist beneficiaries in meeting their needs. However, patterns of payee assignment suggest that payee assignment is impacted by factors other than those the Social Security Administration instructs clinicians to consider. In this study, we tested the association between clinicians' judgments of their clients' financial capability and hypothesized predictors (demographic characteristics, psychiatric diagnosis, recent alcohol and other substance use, self-rated money mismanagement, recent homelessness, and provider characteristics). We posited that predictors might act indirectly on capability judgment via their impact on beneficiaries' money management. Methods: Altogether, 261 people receiving intensive mental health care who did not have payees or fiduciaries were enrolled after providing written informed consent. These beneficiaries completed in-person assessment interviews, reporting demographic characteristics, treatment history, substance use, and homelessness. Mental health clinicians identified by the beneficiaries were enrolled in the study and asked to judge their clients' financial capability with standard Social Security instructions for determining capability. Bivariate associations between hypothesized predictors and clinicians' determinations of incapability were tested. In multivariate probit regression models, incapability determination was modeled as a function of all beneficiary and clinician characteristics that had significant bivariate associations with the outcome. Results: Providers identified 24% of their clients as financially incapable. Determinations of financial incapability were unrelated to any beneficiary or provider demographic characteristics but were positively associated with money mismanagement, homelessness, and having a psychotic disorder. Alcohol use and other substance use were only significantly associated with capability determinations indirectly through their effects on money mismanagement. Conclusions: Providers' judgments of beneficiaries' capability to manage their funds were associated with factors that were consistent with Social Security Administration guidelines and were, importantly, not associated with personal characteristics. This finding suggests that guidelines can be fairly applied by clinicians and that reported inconsistencies in payee assignment are accounted for by other factors. The Social Security Administration is currently considering other approaches to standardize capability determinations.

Because the clients told us so

Purpose Eliciting client narratives and creating community-informed interventions have been effective methods of engaging those who are unstably housed in care. Previous studies have shown that these approaches foster client empowerment and provide insight as to the importance of creating community-driven solutions. However, few studies report the impact of these methods on homeless people living with HIV. The purpose of this paper is to describe methods used to engage consumers in sharing their stories, including formative focus groups, qualitative interviews, and feedback from peer staff. Design/methodology/approach Data for the case study were derived from program notes, board minutes, and feedback from founding board members of The Open Door. Two researchers who were involved with the program from its inception reviewed these data and then developed a schematic of the methods used to develop and inform the program itself. The authors determined that three methods were used to elicit client and community narratives to inform program decisions. These include a formative focus group that helped to structure and implement the program in its earliest stages; qualitative interviews, which helped to pinpoint effective program components and enabled the rapid expansion of the service delivery model; and feedback from peer staff, which has consistently allowed for the refinement and prioritization of services. Data were collected for the purposes of program development and improvement but since qualitative interviews were conducted by faculty affiliated with an academic institution, the institutional review board of that institution was consulted and the qualitative interviews were determined to be exempt from review. Findings The focus group informed the authors that they wanted to live in their own apartments but have on-site supports. They also indicated that traditional housing program rules such as abstinence were too restrictive for them to navigate. In the qualitative interviews, the clients reported an increased sense of community with peers and peer staff members, which helped to reduce stigma. Second, residents reported that supportive services helped them to connect to and maintain in HIV clinical care. Third, residents reported that the representative payee services were a key factor in helping them improve housing and financial stability. Research limitations/implications There are a number of limitations to this case study that demand the need for caution in interpreting results. Although the authors used several different methods to elicit client narratives and community feedback, sample sizes were small, control groups were not utilized, and data were specific to individuals receiving services through one housing program. Thus, results are not generalizable. In addition, the methods reported herein mix those conducted for the purposes of research (in-depth qualitative interviews) with others conducted specifically to inform program delivery and improvement (focus group and peer staff feedback). Thus, rigor is not equally applied across all methods. In addition, the individuals conducting research and authoring this paper were directly involved with the creation of the program and ongoing service delivery. Therefore, interviewer and reporting bias also present threats to validity. Practical implications There are many strengths involved in utilizing the narrative feedback of the residents and peer staff to inform the practice. One is that this method is an incredibly cost-efficient way to assess client and program needs to inform intervention development and improvement. The results are also very transparent and easily translatable to the agency’s everyday work. These methods are practical in both their approach to clients and their ability to be easily incorporated into the daily work of clients and staff. These methods allow for rapid application as results are immediate and feedback can be implemented quickly. Social implications When seeking client and staff feedback, it is important to be cognizant of believing the client and recognizing that all people have their own personal perspectives, including their own version of the “truth.” Eliciting this type of feedback puts individuals in a vulnerable place, so it is critical to guarantee their safety. All information solicited must be regarded in a positive light to inform improved service delivery and not as a means to receive information that “tells on” clients or peer staff. Feedback should be reviewed as an opportunity for learning and not as a mechanism for retaliation. Originality/value The clients and staff have been significantly marginalized in the society. It is possible that having providers be kind and respectful to them and asking for their opinions is a very new experience which might make them feel grateful and more likely to be favorable in their responses. Clients may feel loyal to the program and be much more likely to speak of it positively. Regardless of these potential biases, the quantitative results of improved health outcomes published elsewhere indicate that the clients may not just be being nice, but may in fact be receiving interventions that are working.

Guardianship and the Representative Payee Program

Research suggests that 0.3 percent of all adults have been appointed a legal guardian. While the requirements for being placed into guardianship can vary from state to state, a lack of decision-making capacity is a precondition. As a result, one would expect Social Security beneficiaries who have a guardian to also have their guardian act as a representative payee. Yet little is known about the relationship between guardianship and the Representative Payee Program. In response to a request from the Social Security Administration, this report uses the Survey of Income and Program Participation (SIPP) linked to the Social Security Master Beneficiary File and the Supplemental Security Record to investigate three questions: 1) how many beneficiaries with representative payees have guardians?; 2) how many beneficiaries have their guardian as their payee?; and 3) what are the characteristics of those with both a payee and a guardian. Because the SIPP does not include individuals residing in nursing homes, the project also examines data from the Health and Retirement Study, which does include these individuals. This paper found that: - Guardianship is more common among those in the Representative Payee Program than in the population writ large, with between 5 percent to 11 percent of those with a representative payee also having a guardian, depending on the program and dataset considered. - For those with both a representative payee and a guardian, the guardian serves as the payee the vast majority of the time. - Individuals with a representative payee are more likely to have a guardian if they are older, white, and are not living with their representative payee. The policy implications of this paper are: - While guardianship could lessen the need for representative payees since it provides a protective legal arrangement, few individuals with a representative payee have one. - As more representative payees are needed with the aging of the Baby Boomers, pre-existing guardians seem unlikely to fill a large portion of the need.

Dementia, Help with Financial Management, and Well-Being

Earlier research indicated that the vast majority of retirees with dementia do not use the U.S. Social Security Administration’s Representative Payee Program, despite the fact that many have lost the capacity to manage their own finances. However, that research also indicated that most retirees with dementia do have access to informal caregivers who could assist them (e.g., a resident adult child or non-impaired spouse), but the research did not examine whether those individuals provided assistance specifically with financial management. This paper uses the National Health and Aging Trends Study to determine whether beneficiaries with dementia receive help from their informal caregivers in managing their finances. The paper also examines the financial well-being of those with assistance compared to those without assistance.

Cognitive Impairment and Social Security's Representative Payee Program

Social Security’s Representative Payee Program allows one individual to receive benefits on behalf of a retiree or disabled person who is incapable of managing them. In the case of retirees with cognitive impairment, the program could help prevent fraud by ensuring that Social Security benefits are immediately turned over to a capable individual. This paper seeks to answer three questions about the Representative Payee Program and its relationship to cognitive impairment. First, what share of individuals with cognitive impairment use a representative payee? Second, if individuals with cognitive impairment are not using a payee, what are they doing instead? Finally, is it possible to identify recipients with cognitive impairment who have no help managing their finances (through a representative payee or otherwise), a situation that makes them especially vulnerable to fraud? This paper found that: • Just over 9 percent of retirees with dementia, the most severe form of cognitive impairment, have a payee, while only 2 percent of those with mild cognitive impairment have one. • Over 95 percent of retirees with dementia have some form of assistance with their financial management, whether it is a payee, a non-impaired spouse or child, a power of attorney, or through their residence in a nursing home. The comparable number for those with mild cognitive impairment is 85 percent. • Retirees with spouses or kids living nearby are less likely to use a payee, indicating they may view family as substitutes for a payee. • Less educated, non-white, and relatively isolated retirees are most likely to lack formal or informal means of assistance with their financial management. The policy implications of this paper are: • Most individuals with cognitive impairment seem to have an institution or individual available who could serve as a representative payee should an expansion of the program become desirable. • Educating family and other caregivers about a primary benefit of the program – that the vulnerable person does not have access to his or her money – may help expand coverage.

Environment-Level Strategies to Support Independent Control of Finances: A Response to the SSA Review of Financial Capability Determination Review.

The Social Security Administration (SSA) recently completed an evaluation of the process by which representative payees are assigned. The SSA report is welcome, particularly for its focus on developing more accurate, real-world assessments of a person's financial capability and its recognition of the need for more flexible options for people with disabilities. Crucially, the report discusses the impact of the broader environment-specifically, conditions related to living in poverty. However, it provides no guidance about environmental interventions that could enable more beneficiaries to manage their funds without a payee. Innovative financial products could be offered to beneficiaries, and the retail industry could develop processes to support responsible financial management by people with mental illness. Changes to SSA benefits systems, including raising benefits levels and asset limits, could enable more beneficiaries to manage their funds independently.

Improving Social Security's Financial Capability Assessments.

When Social Security beneficiaries are incapable of managing their benefits, the agency can appoint a representative payee to administer benefits on their behalf. A committee of the Institute of Medicine was asked by the Social Security Administration to review the process by which financial capability determinations are made and to recommend improvements. The committee's conclusions and recommendations include the following: giving priority to real-world financial performance in assessing capability, providing clearer instructions to informants, developing systematic approaches to identifying beneficiaries at risk of incapability, exploring the use of a supervised direct payment option, and instituting regular data collection to assist in improving operations.

All-data approach to assessing financial capability in people with psychiatric disabilities.

The goal of this project was to develop an evidence-based method to assess the ability of disabled persons to manage federal disability payments. This article describes the development of the Financial Incapability Structured Clinical Assessment done Longitudinally (FISCAL) measure of financial capability. The FISCAL was developed by an iterative process of literature review, pilot testing, and expert consultation. Independent assessors used the FISCAL to rate the financial capability of 118 participants (57% female, 58% Caucasian) who received Social Security disability payments, had recently been treated in acute care facilities for psychiatric disorders, and who did not have representative payees or conservators. Altogether, 48% of participants were determined financially incapable by the FISCAL, of whom 60% were incapable because of unmet basic needs, 91% were incapable because of spending that harmed them (e.g., on illicit drugs or alcohol), 56% were incapable because of both unmet needs and harmful spending, and 5% were incapable because of contextual factors. As expected, incapable individuals scored higher on a measure of money mismanagement (p < .001) compared with capable individuals. Interrater reliability for FISCAL capability determinations was very good (κ = .77) and interrater agreement was 89%. In this population, the FISCAL had construct validity; ratings demonstrated good reliability and correlated with a related measure. Potentially, the FISCAL can be used to validate other measures of capability and to help understand how people on limited incomes manage their funds.

The impact of representative payee services on medication adherence among unstably housed people living with HIV/AIDS

ABSTRACTRates of viral suppression among people living with HIV/AIDS remain low, especially within marginalized populations such as people who are unstably housed. Representative payee is a service in which the US Social Security Administration appoints an individual or an organization to provide financial management for vulnerable individuals who are unable to manage their finances including housing payments. Little or no published research examines the association between financial management services such as representative payee and HIV clinical adherence. We conducted a pilot study with 18 unstably housed participants living with HIV/AIDS to examine the impact of representative payee services on viral suppression. Of the 11 participants who were not virally suppressed at baseline, 9 (81.8%) of them had achieved viral suppression at six-month follow-up (p = .004). Our findings suggest that providing unstably housed people living with HIV/AIDS with representative payee services may help them to improve their housing stability and clinical adherence. Additional research is needed to fully explore correlations between representative payee services and viral suppression.