Fiduciary Services for Veterans With Psychiatric Disabilities

In contrast, VBA requires regular assessment by a field examiner for continuation of the fiduciary arrangement.¹¹ It is possible to rescind this arrangement if the veteran is found to be competent to handle his/her own funds, understands his/her financial situation, is applying funds to his/her needs appropriately, and would not benefit from further VBA supervision. Additionally, a trial period of limited fund disbursement for 3 to 5 months can be recommended in order to determine how well the veteran manages his/her money. This is commonly done when there are substantial amounts of money being held in trust for the veteran.¹¹

Trustee Effectiveness

Considerable research has examined the effectiveness of the SSA representative payee program as well as potential benefits and risks to the payee. For example, in beneficiaries with psychiatric disabilities, payees can be instrumental in promoting residential stability, basic health care, and psychiatric treatment engagement.⁶ In addition, representative payeeship has been shown to be associated with reduced hospitalization, victimization, and homelessness.^34,35 Finally, research has found better treatment adherence among consumers with payees compared with those without.⁵

On the other hand, risks noted in some studies suggest payeeship may be used coercively, thwart self-determination, and increase conflict.²⁵ Additionally, payeeship was not associated with a differential reduction in substance use compared with SSA beneficiaries without a payee, nor did it have any effect on clinical outcomes.^36-38 These studies may or may not be applicable to the veteran population: Few studies of SSA payeeship include veterans, and there are no studies examining the effectiveness of the VBA fiduciary program exclusively.

Conrad and colleagues reported on a randomized trial of a community trustee and case management program integrated with psychiatric care provided by the VHA.⁴ Twelve-month outcomes favored the use of the more integrated program, which showed a reduction in substance use, money mismanagement, and days homeless, along with an increased quality of life. However, the study did not distinguish between funding source (VBA, SSA, or both) and trustee status (SSA representative payee or VBA fiduciary). A voluntary program in which veterans worked with money managers who helped them manage funds and held their check books/bank cards also resulted in some improvement in substance use and money management, but this program did not involve either the formal SSA payee or VBA fiduciary systems.³⁹

Although there is a perception that fiduciaries are unwanted impositions on individuals with mental illness, many veterans who have difficulty managing their money seem to want assistance. In one study, nearly 75% of the veterans interviewed agreed with the statement, “Someone who would give me advice around my funds would be helpful to me.” Thirty-four percent agreed with the statement, “Someone who would receive my check and control my funds would be helpful to me,” and 22% reported that they thought a money manager would have helped prevent their hospitalization.⁴⁰ Additionally, veterans who had payees reported generally high levels of satisfaction and trust with their payee, as well as low feelings of coercion.¹⁵ Although similarities with the SSA system may allow some generalizing of findings across SSA and VBA, significant differences in how the programs are administered and the amount of money at stake justify independent evaluation of the VBA fiduciary program.

Conclusion

Veterans with psychiatric disabilities who are deemed incompetent to manage their finances are typically assigned a trustee to disperse disability funds. Both the VBA and SSA provide disability compensation and have a process for providing formal money management services for those determined to be financially incapacitated. However, these 2 federal programs are complex and have many differences.

Clinicians may come into contact with these programs when referring a veteran for services or when a veteran complains about their existing services. The decision of when to refer a veteran for evaluation for a fiduciary is challenging. Once a veteran is referred to the VBA rating agency, the VBA completes a more formalized evaluation to determine whether the beneficiary meets the criteria for a fiduciary. The VBA also has outlined more rigorous ongoing assessment requirements than has the SSA and has designated field examiners to complete these; however, in practice, field examiner heavy case-loads may make it more challenging for the VBA to achieve this rigor.

The VBA provides a formal means of evaluating a veteran’s ability to manage his or her funds through Supervised Direct Payment, which can allow a veteran to demonstrate the ability to manage money and thus end a fiduciary relationship that is no longer needed. In contrast, SSA has no formal evaluation program. Additionally, requesting an end to a payeeship for SSA funds can potentially trigger the loss of benefits, discouraging recipients from ever managing their money independently again.