Development of the Clinician Assessment of Financial Incapability (CAFI)

Abstract

The Social Security Administration (SSA) provides financial support to adults disabled by psychiatric conditions to provide for their basic needs. For beneficiaries identified as incapable of managing their funds, representative payee assignment is mandated. However, studies indicate that the current SSA method of determining capability leads to idiosyncratic payee assignment, with a tendency to under-identify beneficiaries needing payees. Over two phases with data from 78 mental health clinicians treating 134 patient-beneficiaries, we describe the development of a new assessment, the Clinician Assessment of Financial Incapability (CAFI). Item generation, subscale construction, and preliminary assessments of validity are described. We also describe the simultaneous development of a criterion measure of capability, a comprehensive review of all data. Experts identified four subscales mapping to four criteria of incapability; factor analysis provided support for this item structure. Close to one-half of patients were determined to be incapable by review of all data. CAFI and SSA methods correctly classified 73% of cases, but errors with CAFI were more evenly distributed between false negatives and false positives. The implications of classification error are considered, and advantages of CAFI over the SSA method are enumerated. Plans for future instrument revision are briefly described.

Ambiguity in Determining Financial Capability of SSI and SSDI Beneficiaries With Psychiatric Disabilities

“…Although applying standardized criteria can clearly identify the majority of beneficiaries as capable or incapable of managing finances (18, 19), in the absence of more precise guidance, capability determinations are left to clinicians’ best judgment. In addition to considering whether a beneficiary is capable, clinicians should also consider whether assignment of a representative payee would be helpful (15) and whether payee assignment is feasible.…”

“…Assessors used all available data from a comprehensive set of participant assessments conducted as part of a money management assessment study (19), clinical records, and a questionnaire about recent functioning and money management completed by a treating clinician (18). Assessors also conducted a semi-structured clinical interview with each participant, inquiring about the participant’s expenditures, living situation, times when the participant did not have enough money for basic needs in the previous six months, how much money had been spent on harmful things, and plans for the future.…”

“…Financial capability was assessed in 119 adults with severe mental illness and histories of substance abuse who received and managed their own SSI or SSDI payments (17, 18). In order to better understand challenges involved in making capability determinations, this paper describes ten beneficiaries for whom capability determinations were not clear cut, despite a comprehensive assessment of financial capability having been conducted.…”

Financial Capability: Clinicians' Assessment of Beneficiaries With Dual Diagnoses

“…Beneficiaries and clinicians enrolled in a study to develop and validate a new clinician-rated instrument to determine beneficiaries' capability to manage SSA payments (Black et al, 2014;Claycomb et al, 2013;Lazar et al, 2015;Lazar et al, 2016;Serowik et al, 2013). This study was approved and monitored by the Yale University Institutional Review Board and was conducted in accordance with relevant ethical standards (American Psychological Association, 2017).…”

“…A reason for clinicians' use of non-financial information to decide capability is that, notwithstanding the Recovery Movement emphasis on treating people and not diagnoses, clinicians treating people with severe mental illnesses may know about clinical history and symptoms but less about day-to-day financial management. In a study by our research group enrolling 78 clinicians for 134 beneficiaries, clinicians often endorsed "don't know" when asked Likert-scaled questions about how often, in the last six months, the beneficiary had borrowed money to meet living expenses (47% don't know), had problems related to failing to pay a bill (53%), and impulsively spent an SSA check as soon as they got it (43%) (Black et al, 2014).…”