article Key Questions to Ask for the SOAR FAST MSR

When writing the SOAR Functional Assessment Statement (FAST) Medical Summary Report (MSR) there are key questions to ask for gathering information pertinent to the disability determination process. The following sections provide sample questions that you can use to respectfully gather a thorough and relevant history. 

Gathering Information

How questions are asked can be critical to obtaining the appropriate information. It is important to be sensitive to influences that affect a person’s ability and willingness to provide information (past experiences with the mental health system, etc.).

• The interviewing process can also uncover sensitive topics like past and current trauma that need to be approached with care
• When asking about trauma, it is critical that the person does not become overwhelmed
• It is equally important that the person will be safe and secure after leaving the interview
• Gathering such personal information requires sensitivity and skill

Interviewers who feel uncomfortable or ill-equipped to explore certain topics should not do so. Instead, they should seek assistance from someone who is more clinically skilled, more able to assess responses, and more confident in ensuring that the person feels safe from self-harm and/or emotional distress when the interview ends.

How Do I Ask?

• Your challenge is to gather the greatest amount of information while remaining respectful and compassionate.
• Remember to talk with the person about their strengths and their struggles
• Keep your questions simple and direct without being judgmental
• Consider using the sample questions throughout the MSR Interview Guide
• Make note of the person’s non-verbal as well as verbal responses

Open-ended Questions

• Open-ended questions encourage responses that are descriptive and rich with information.
• Avoid yes/no questions, such as “Can you _____?” Most people answer “yes” because they want to be seen in the best light
• Examples: “Why did you leave the last job you had?” “When you do _____, how do you feel?”

Ability or Access?

It is important to distinguish between ability and access. DDS evaluates the extent to which the applicant’s illness impairs their ability to function, rather than impairments in functioning due to lack of access to facilities.

• This is especially important for people who are experiencing homelessness
• Does someone not cook because they can’t manage cooking or because they don’t have a stove?
• How you ask the question can help clarify this issue
• Examples “What do you like to cook?” “When was the last time you did?” “If you had a kitchen would you cook? Why or why not?”

Support and Lack of Support

Someone may appear to function well but have a robust support system making this possible.

• Ask questions that help you assess how the person functions without supports
• Describe the supports
  • Who assists?
  • How do they help?
  • What do they help the person do?
• Examples
  • Family
  • Job coach at work
  • Sheltered work environment
  • Companion who accompanies the person on outings or provides frequent reminders
  • Case manager or other clinical team member who visits or calls daily

Observations versus Self Report

• Applicants often want to present themselves in the best light possible
• Sometimes the applicant's answers and the case manager's observations are different
• In these cases, it is important to document any discrepancies and link them to the impairment

Occupational History

Ask these questions for each job, including any supported employment.

• When did you work there? What did you do?
• How long did you work there?
• What did you like or dislike about working there?
• What were your relationships like with your co-workers? Supervisors?
• Did you have any difficulties completing tasks or working with others?
• What made you leave the position? 

Substance Use History

All substance use or history should be documented, regardless of whether the applicant has a formal diagnosis of substance use disorder. As a case manager it is important for you to try to understand the role(s) that alcohol and other drugs play in a person's life. Questions about why a person uses and how the use helps (or doesn't) are crucial to this understanding.

What You Need to Know

It is important to understand the role of alcohol and other drugs in the person’s life and its meaning to that individual’s unique life experience.

• Why does the person use?
• How does it help?
• How does it interact with symptoms?
• How does it impact the person’s impairments?
• How is it relevant to disability?

Common Challenges

Case managers must go beyond asking “do you use?” or “have you ever used?”

• This type of question often yields only a “yes” or “no” answer
• Simply asking what, when, and how much may not be helpful
• It is not your role to make a diagnosis of substance use disorder

Denial

Phrasing questions in a judgmental way can put you at odds with the person.

• The individual may not consider the alcohol or drug use as “abuse” – and perhaps it is not
• Denial is a common element of substance abuse and addiction
• The individual may fear that admitting to substance use will lead to denial or loss of benefits
• Possession of drugs or paraphernalia is often illegal, so the person may fear arrest
• The person may fear that sobriety is required to receive benefits; however, they may not be able to stop using right now (this is an issue for treatment)

Phrasing Questions About Alcohol and Drug Use

Questions should lead to developing a comprehensive sense of what substance use means to the person. Rather than ask “do you use,” ask questions around “when you use.”

• What was going on in your life when you started using/drinking?
• When you use (or drink), how do you feel?
• When you use, how does it affect your (mental illness symptoms)? Does it make them better or worse?
• Have you ever stopped or tried to limit your use? Why? What happened?

Documentation or Further Evaluation

• Gather documentation of treatment for substance use disorders or documentation indicating periods of sobriety when symptoms of mental illness were present.
• Look for records of hospital emergency room visits, stays in detox units, and participation in substance abuse or alcoholism treatment programs or co-occurring disorders treatment in mental health settings
• Inquire about involvement in self-help programs such as Alcoholics Anonymous, Narcotics Anonymous, or other programs that do not keep records; document in case notes
• If the person has been involved with the criminal justice system, they may have received treatment in jail or while on probation
• If there are few or no medical records, it may be useful to have the person evaluated for co-occurring substance use disorders, preferably by a current or past treatment provider
• It is important to be able to illustrate to the DDS examiner that the person would still be disabled even if they were clean and sober. We often have to do this while the person is still drinking or using drugs.

Do not try to “hide” current or past substance use

• DDS will find evidence in the medical records and need to make a materiality determination
• Be sure that it is fully explained in your Medical Summary Report

Look for periods of time when the person was sober

• Hospitalized
• In jail or prison
• Participating in treatment programs

Were they experiencing symptoms of their mental illness and struggling with their functioning despite their sobriety?

Describe the context of their use

• Does he drink to quiet the voices so he can sleep?
• Does she smoke crack to escape the pain of trauma?
• When she stops drinking/drugging, does she become more depressed and have thoughts of hurting herself?

Functional Information

Key Questions to Ask

Daily routine:

• What time do you get up in the morning?
• How do you spend your days?
• How many meals do you usually have in a day? What times? What do you eat? If you don’t eat regularly, how come?
• How do you spend your evenings?
• What time do you usually go to bed? How do you sleep?
• Does your routine change on the weekend? If so, how does it change?

Activities of Daily Living:

• What do you know how to cook? When was the last time you were able to cook? What are your favorite foods to prepare?
• If you needed to shop for food to last a few days, would you need assistance or is that something you can tackle yourself? Do you usually have someone go with you to shop? Who? What assistance does he or she provide?
• Are you able to use the telephone? When was the last time you were able to make a call?
• If you needed a phone number and didn’t have it, how would you get it? (Question relates to the use of a phone book or information, i.e., 411)
• When you have your own place to live, what kind of housekeeping things do you do on a regular basis? What kind of chores do you find difficult to do? If the person lives with someone else: How are the chores split up? Do you need reminders to do chores?
• About how often are you able to bathe or shower? Is this what’s been your usual routine? Do you need any assistance doing this? If the person doesn’t bathe regularly: What keeps you from bathing or showering? (You want to distinguish between access and ability)
• Are you able to do your own laundry? How often do you usually do it? If not: How come? Who does your laundry?
• Have you ever been to the post office? What services did you use there?
• Budgeting is something we all struggle with. How are you at budgeting? Are you able to set up a budget and stick with it — or might that be something you could use assistance with? If this applies: When you have income, what usually happens to your money? Do you spend it right away or are you able to make it last?
• How do you usually get to places? Walk? Drive? Use public transportation? How does that work for you?
• If this applies: When were you able to have your own place to live? What happened that you don’t live there anymore? How did things go when you were there?

Areas of Mental Functioning

Understand, Remember, or Apply Information

Your Observations Are Important!

• Do you frequently have to remind the applicant of upcoming appointments, or does the applicant miss scheduled SOAR appointments?
• Does the applicant exhibit frustration or anxiety when unable to remember information related to your questions? Does the applicant have trouble remembering dates and details of treatment or work history?
• Does the applicant get distracted and have trouble organizing their thoughts or questions for you during appointments? If you give them multiple steps to complete a task (e.g. fill out this document, find John at the shelter to sign it, then return it to the front desk) are they able to successfully follow all instructions?

Key Questions to Ask

Remember Information

• Do you notice any changes in your memory? Do you find it easier to remember things from the past or things that happened recently? What do you notice that is different about your memory? When do you notice this? Can you give me a specific example?
• When someone gives you directions or instructions, are you able to remember them? Do you use any techniques to help remember things?
• How often do you have difficulty remembering something, such as a person’s name, an appointment time, or instructions?
• Was there ever a time that you forgot something that was really important? If so, what happened?
• When you are having difficulty, how much effort do you have to put into remembering?
• Are there any activities that you cannot do because of a problem with your memory or because you have trouble understanding the instructions?
• Do you take your medicine at the time that you are supposed to? Do you forget to take your medicine? How do you respond when you don't take your medicine?

Understand and Apply Information

• Do you have difficulty learning a new task, for example, learning how to get to a new place? Can you tell me about a time that happened?
• If you aren’t sure of how to do something, what do you do?
• When someone gives you more than three instructions on how to do a task, do you experience any difficulty in remembering the order of steps?
• When you begin to work on a task and something goes wrong, how do you correct it?
• Have you ever followed a recipe? Tell me about your experience with that.
• If the applicant has a work history: When you start a new job and are learning what to do, how quickly do you catch on?
• When someone asks you a question and you don’t know the answer, what do you do?

Interact with Others

Your Observations Are Important!

• Do you observe the applicant appearing fearful of or displaying anxiety about being around others? Does the applicant have difficulty maintaining eye contact?
• Has the applicant canceled appointments with providers due to being fearful or avoidant of leaving where he or she stays?
• Does the applicant frequently repeat phrases, comments, or questions? During conversations, does the applicant continuously return to one or two specific subjects and require redirection?
• Don’t forget to gather information and observations from other people who interact frequently with the applicant. Overnight shelter staff, program staff, family members and former coworkers can be invaluable sources of observed behavior. 

Key Questions to Ask

Interacting with others in the community:

• If applicable: Do you maintain contact with your family? If not, why?
• How often do you go somewhere outside? Do you usually go by yourself or with other people? Do you prefer to be alone or with other people? Why?
• How often do you visit other people? Who do you usually visit? How often do other people come to see you?
• Describe any difficulties you have with traveling outside the house.
• Do you notice that you had friendships before that you don’t have now? Do you have thoughts about that?
• Who do you see on a regular basis? How do you and ________ get along?
• What do you do if someone makes you really angry? How do you respond? What do you do?
• What do you do when you have general disagreements with others?
• Do you feel like you avoid being around other people? If yes, why?
• Are you in any groups? Do you like being in groups?
• What kind of person would you say you get along with best? Who gives you the most difficulty?

Interacting with others in work settings:

• When you worked before, how did you get along with your supervisor? Your coworkers? If the applicant has never worked before, continue to ask the following questions related to the applicant’s experience in the community or at school (if the applicant is a young adult)
• When someone corrects you, or tells you that you could have done something better, how do you respond?
• If you don’t know how to do a task, at work or in general, what do you do?
• Have you ever disagreed with a rule at work or in the community? How did you handle that?
• Do you work better with a group of people or by yourself?

Concentrate, Persist, or Maintain Pace

Your Observations Are Important!

• Do you frequently need to redirect the applicant back to the conversation or question during interviews? Does the applicant appear to be responding to internal stimuli?
• Does the applicant speak too slowly or take a long time to answer questions? Or, does the applicant have rapid speech or tangential thought patterns?
• Former employers can be great sources of information about the applicant’s ability to complete tasks and stay focused

Key Questions to Ask

• Have you noticed any changes in your ability to concentrate? If so, what have you noticed?
• Would you describe yourself as someone who is easily distracted or do you find you can stay focused on a task if you need to?
• When you work around others, do you find it difficult to complete your tasks or block out the noise and other distractions?
• Have you had any times in the past when you got into trouble at work due to talking too much with others or not staying on task?
• What do you enjoy doing? What do you have an opportunity to do? When did you last do this? Are there any changes in what you enjoy now and what you used to enjoy?
• Do you like to watch TV? If yes, what do you watch? Would you be able to watch an hour-long show and tell me about it shortly after you saw it?
• Do not ask this if you know the person is unable to read. What do you usually read? Do you do this often? Could you tell me what you just read if I asked you soon after?
• Ask the person to complete serial 7s (i.e., Subtract 7 from 100, then subtract 7 from that total ... until the person reaches 65). If the person can’t do 7s, ask him or her to try serial 3s. Note what happens.
• Ask the person to follow a three-step instruction: Take this paper, fold it in half, and please return it to me.

Adapt or Manage Oneself

Your Observations Are Important!

• How does the applicant react when an appointment time is changed? Does the applicant act aggressively or do you observe challenging behavior?
• Do any of the applicant’s goals or plans appear to be unrealistic or grandiose?
• Do you observe that the applicant has difficulty in maintaining personal hygiene, or wears clothing that isn’t appropriate for the weather (e.g. wearing heavy coats in summer)?

Key Questions to Ask

Managing daily activities

• How do you spend your days? What time do you get up in the morning and go to sleep? How do you sleep?
• How many meals do you usually have in a day? What times? What do you eat? If you don’t eat regularly, how come?
• If you needed to shop for food to last a few days, would you need assistance or is that something you can tackle yourself? Do you usually have someone go with you to shop? Who? What assistance does he or she provide?
• What do you know how to cook? When was the last time you were able to cook? What are your favorite foods to prepare?
• About how often are you able to bathe or shower? Is this what’s been your usual routine? Do you need any assistance doing this? If the person doesn’t bathe regularly: What keeps you from bathing or showering? (You want to distinguish between access and ability)
• When you have your own place to live, what kind of housekeeping things do you do on a regular basis? What kind of chores do you find difficult to do? If the person lives with someone else: How are the chores split up? Do you need reminders to do chores?
• Are you able to do your own laundry? How often do you usually do it? If not: How come? Who does your laundry?
• How do you usually get to places? Walk? Drive? Use public transportation? How does that work for you?
• Budgeting is something we all struggle with. How are you at budgeting? Are you able to set up a budget and stick with it — or might that be something you could use assistance with? If this applies: When you have income, what usually happens to your money? Do you spend it right away or are you able to make it last?

Adapting to change/challenges

• When a major change or event happens in your life, how do you respond?
• When a supervisor changes your tasks or expectations, how do you handle it?
• If this applies: How do you handle times when you have physical pain while at work?
• If this applies: You mentioned times when you feel [insert symptoms the applicant has discussed such as depressed or anxious] . Does that ever happen at work? How do you handle it?
• Tell me about some short term goals you have for yourself, then some long term goals.