AACP POSITION
STATEMENT:
REPRESENTATIVE
PAYEESHIPS
I. INTRODUCTION
AND PURPOSE:
Many people with
psychiatric disorders receive federal and other financial support. There is a range of ability among these
individuals to manage these funds adaptively.
Federal regulations require that in order for a representative payeeship
to be conferred to a third party, an individual receiving disability payments
must be shown to be unable to manage them.
People eligible for payeeships are routinely without means to
functionally survive, unable to provide themselves even the basic needs of food
and housing.
There are various models
for administering representative payeeships.
When available and working in the person's best interest, and if the
person prefers it, family are the often the best choice to fill this role, but
community religious groups and other non-clinical organizations, like local
Mental Health Associations, are also excellent resources. In some cases, mental health providers
initiate representative payeeships and may consequently also disburse payments
to consumers. This arrangement is best
viewed as an early rehabilitative step toward independent money
management. However, as mental health
providers work with consumers, payeeship also presents issues concerning
clinical practice, administrative procedures, and ethics.
This AACP position
statement outlines these issues and makes practical recommendations to clinical
and rehabilitation services whose workers act in a function of representative
payee.
II. ISSUES:
A.) CLINICAL:
The most compelling published clinical support for
payeeships are a decrease in hospitalization days. There is also some evidence that it does increase housing
stability, thus reducing homelessness among people with psychiatric
disorders. The effect of representative
payeeship on substance abuse is equivocal, although when linked to contingency
management techniques, it may offer a constructive role.
Day to day clinical issues are also salient. The technique's effect on the alliance
between patients and their clinicians is important. Representative payeeship lies on a continuum of clinical
leverage, and if used insensitively, it has potential to negatively affect
rehabilitative goals of reducing alienation toward treatment and of enhancing
personal independence. Clinical
transference responses noted in the literature are passive dependence, in which
patients cease clinical engagement when representative payeeship ends, and
outright displays of rage, with harassment and threats to clinical staff.
In turn, clinical countertransference responses occur in
which clinicians become fearful of their patients or become hostile, feeling
that their patients are ungrateful for efforts made on their behalf. The representative payeeship can become a
source of clinician grandiosity, in which the predominant instrument of
behavioral management is the payeeship itself.
B) ADMINISTRATIVE:
There are two essential models for management of the
payeeship within a clinical relationship.
The first is when an individual clinician, usually a primary therapist
or case manager, acts as a legally identified payee. Issues concerning this paradigm arise from the payee receiving
relatively less supervision. Moreover,
the payee can face legal action from the consumer, even in the absence of
impropriety or error.
The second model
involves a corporate entity assuming payeeship. This model creates greater accountability. Clinicians may act as payee agents or the
entity may create a separate role of "payee manager," who directs
accounts and disburses payments to the consumer.
A primary
advantage in having the casemanager be the payee agent is that coordination of
money management within the treatment or service plan is relatively
uncomplicated, obviating a necessarily close communication between casemanager
and payee manager. This model does
require rigorous accounting and bookkeeping on the part of the
casemanager. Some clinicians also
report greater tension within the alliance with their patients under this
arrangement
Alternatively, the role of payee manager may be embraced in a separate job description: a worker who keeps all payee accounts and routinely disburses funds. In some cases, a clinical program director or deputy fulfills that role. In either case, there is centralized accounting and bookkeeping, diminishing the chance of administrative error, or even fraud. However, under these circumstances, there are challenges in building efficient and client-friendly mechanisms to disburse funds. The experience of a person waiting on line for more than a very few minutes to receive his or her own funds is a dehumanizing one. Similarly, it is crucial for payee managers to acquire a clinical role and be in close contact with the rest of the clinical team so there is full coordination concerning changes in money management and other clinical variables that affect the patient's relationship with the program.
Regardless of whether a clinician or designated payee
manager is used, there is a necessity to have accountability to the
consumer. Representative payeeships
demand procedures of accounting, managing, and documenting fund disbursement
that are accessible to the person whose funds are being managed.
C)
ETHICAL AND LEGAL:
Concerns about legal exposure frequently arise among
providers who are contemplating representative payeeships. These fall into two categories.
The most obvious risk for any entity to acquire a
representative payee role is that of criminal liability. If an individual or program embezzles
disability funds, there are fairly clear cut consequences, and risk arises when
consumers believe they have not been paid.
On the other hand, civil malpractice liability appears to be virtually
unknown regarding responsibility for consumers who engage in self-destructive
activities with their allocated funds.
There are related ethical issues. Growing out of controversy concerning the
correctness of any person using federal benefits in pursuit of self-destructive
or illegal activities, like drinking heavily or buying street drugs, some opine
that representative payees ought to withhold benefits in these
circumstances. Others note the coercive
nature of this position and assert that a harm-reduction approach and
contingency management techniques may better advance eventual recovery.
The coercion implicit in representative payeeships is
even more ethically questionable without incentives for increasing financial
autonomy and higher adaptation, like the optimal learning of money management
skills, or establishing objectives around housing or vocational rehabilitation.
III SUMMARY AND RECOMMENDATIONS:
A) GENERAL: If an entity
elects to enter into a payee arrangement, it must establish and clearly
articulate its rep payee policy. This requires:
·
Understanding its own position on coercion and
leverage and its ramifications on patient care.
·
Being able to articulate its payee policy
clearly and responsibly to consumers, with transparent accountability
mechanisms.
·
Having an administrative structure that can
fiscally manage the representative payee arrangement.
·
Having clinical and rehabilitation staff that is
trained in and comfortable with working within the administrative structure.
B)
CLINICAL:
The AACP recommends the following best practice:
1) Selection for representative payeeship:
a)
Clear indication that the person cannot manage
his or her own funds, finding basic functioning routinely, directly, and
significantly affected by this problem.
·
This is evidenced by inability to pay bills,
frequent borrowing, and lacking money for basic needs, particularly when
associated with impulsive or inappropriate expenditures (e.g alcohol, drugs,
lottery tickets).
·
Indication that the person would welcome, or be
willing to accept, assistance with money management in the form of a payeeship.
·
Voluntary requests for assistance are so much
more respectful of autonomy than coercive payeeship that we recommend extended
ongoing negotiation with the patient in order to obtain this result. Such negotiation might include progressive
contracts: "if you are unable to pay money for rent for the third month in
a row, would you then consider a payeeship?"
·
If, after extended negotiation, a person's
difficulty with money management continues to create severe problems (homelessness,
lack of food), then guardianship may be required.
·
Consultation with family, especially, or other
collaterals is highly desirable throughout this process, and may involve a
collective "intervention" with the patient, as well as discussion of
the best candidate for being the payee.
In the event of guardianship, the patient must be given measurable
indicators of what demonstrable skills would be required in order for the
payeeship to end, and how those skills would be demonstrated.
b) There are some patients with whom the
clinical relationship will be significantly complicated or compromised if his
or her service provider becomes a representative payee. These situations are better managed by using
other models of representative payeeships (e.g. through Mental Health
Associations or consumer advocacy organizations).
2)
Implementation:
Clinical policy must
balance the need for appropriate supervision of money management by the payee
with the provision of opportunities to help the patient use the payeeship to
develop new skills through both learning opportunities and contingency
management arrangements within the payeeship structure.
a) Programs must use available evidence-based
factors (e.g. reductions in hospitalizations and homelessness) to help plan
clinical objectives and measure the effect of representative payeeship.
·
Prioritizing essential bill payments (e.g. rent,
utilities) is therefore critical and other matters like amounts for emergency
savings and the frequency of disbursements should be individually negotiated.
a)
Programs must consider how representative
payeeship influences ongoing rehabilitation planning, highlighting the
therapeutic alliance. There must be
maximum opportunity for choice and patient involvement in decision-making
should always be a primary objective. A
critical rehabilitative goal in this regard is either a short or long-term plan
for the eventual termination of the payeeship.
·
To this end, there should be a mechanism by
which the patient earns increased financial responsibility in small yet
frequent increments by demonstrating successful accomplishment of certain
skills.
·
This necessarily includes money management
education, simultaneously introducing specific time frames for reevaluating the
patient's representative payeeship. This
minimizes exaggerated transference and countertransference responses,
establishes accountability, and optimizes consumer satisfaction and autonomy.
c)
Payee managers and clinical workers must receive
education and training about the issues in institutional representative
payeeships. Important areas are:
·
Transference and countertransference issues,
including techniques in preventing volatile situations with patients.
·
Budgeting principles and techniques in
negotiating with patients.
·
Ongoing individual supervision concerning the challenges of
this role. Individual supervision may
be augmented by group supervision for creative problem solving
C)
ADMINISTRATIVE:
AACP recommends the following best practice:
1) A corporate model of administration of
representative payeeship.
a) If a payee manager is used it is important to adopt a team approach to guarantee communication.
·
Payee managers must participate in regular
clinical meetings, actively working with the consumer and
clinician/casemanager, first helping a person cover necessary basic expenses,
then forging a plan for stepwise disbursement of discretionary money, with
graduations toward financial autonomy.
b) Appropriate human and technological resources to manage the accounting responsibilities inherent in managing representative payeeships include:
· Centralized records, with computer software capabilities.
· Professional fiscal staffing who are adequately trained and supervised
c)
Accounting procedures must be transparent,
assuring the consumer that funds are managed appropriately. Toward this, there must be:
·
Foolproof documentation of disbursement of funds, including
receipts for the consumer.
· Formal grievance procedures, both concerning the elements of a treatment plan as it pertains to money management and concerning disbursement itself.
· Legal consultation available to anticipate areas of liability and audit.
2) To enhance consumer satisfaction, the program
must routinely survey patients on the representative payee program, making
ongoing program modifications.
3) If provider safety is of concern, a formal
mechanism must be in place to manage it.
Administrative management focuses on how to recruit legal supports, like
restraining orders, in the relatively rare instances that they are needed.
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