Adult Protective Services Research Articles

Adult Protective Services Training: Insights from California Caseworkers

ABSTRACT Adult Protective Services (APS) training is critical to the mission of APS in supporting the workforce, but not much is known from caseworkers’ perspectives. To learn more, 63 caseworkers in five California counties, from urban, suburban, and rural areas, participated in focus groups. Discussion was organized around three open-ended questions regarding implementation of the National Adult Protective Services Association (NAPSA) training content in practice: (1) What trainings have changed your practice and how? (2) How could training be changed to make it easier to implement? (3) What characteristics of your work environment interfere with implementation of learning? Through iterative reading and review of focus group transcripts, four themes emerged: (1) motivations, (2) barriers, (3) facilitators, and (4) impact. Caseworkers also made recommendations to improve training for better implementation of concepts and skills. Caseworkers involved in this study were quick to assert the need for increased access to training, more sophisticated content, and experiential learning. Moreover, expanding and enhancing safety training was recommended, as was aligning training with local needs and policies. Since the NAPSA approved APS core competencies and advanced topics are also offered and used in other counties and states, considering how to improve training could benefit caseworkers nationwide.

Balancing practicality and validity of elder abuse identification measures: using data from adult protective services investigations

ABSTRACT Background and Objectives. In testing a comprehensive decision support system for Adult Protective Services (APS), this study addressed two problems common in APS research and practice: the psychometric quality of the measures and measurement burden. Research Design and Methods. Data were generated on 1,472 APS cases over six months in two California counties using the Identification, Services and Outcomes (ISO) Matrix, a comprehensive decision support system for APS. The ISO Matrix uses Short-Forms developed from the Elder Abuse Decision Support System (EADSS). Mini-Forms were developed from the Short-Forms and tested in order to reduce measurement burden. Mini-Forms were developed on each measure using sensitivity and specificity of the items in predicting the criterion of substantiation (yes/no). Psychometric quality was addressed by estimating predictive validity and Cronbach’s alpha of Short-Forms. Predictive validity and reliability were also estimated on the Mini-Forms as was their correlation with the Short-Forms. Results. On Short-Forms, good predictive validity was found for all measures except those that were very rare. Results for even shorter Mini-Forms were mixed, and some will require further research on their reliability and validity. Discussion and Implications. Short-Forms had good psychometric properties and some Mini-Forms did as well. Ongoing adoption by several California counties and Montana demonstrates the viability and sustainability of using the ISO Matrix for research and practice.

Implementation of financial decision making scales into statewide APS practice: the Michigan experience

ABSTRACT One of the long recognized challenges in Adult Protective Services and other human service works is the implementation of empirically validated tools into regular practice. One area where this is evident is the assessment of financial decision-making abilities in cases investigated for financial exploitation. Using the Promoting Action in Research Implementation in the Health Services (PARIHS) we examined the core aspects of evidence, facilitation and context. Further, the empirical findings of the scale usage were investigated. Over 400 APS workers were trained and certified using an online narrated training system. Over 500 scales were administered across a 12 month period, with 50% demonstrating financial decision-making deficits, and in 88% of the time the APS workers concurred with the risk rating system of the web-based system (https://olderadultnestegg.com).

Piloting the Adult Protective Services’ Identification, Services, and Outcomes Matrix: Focus Group Findings

The historical lack of outcomes-related data in Adult Protective Services (APS) has affected funding coming to the program. Without data quantifying the effectiveness of APS services, policymakers have been unable to justify budget increases to improve wages for workers or professionalize the field. For the first time in APS history, the U.S. Administration for Community Living sponsored a pilot project to implement a novel evidence-based assessment tool into APS electronic systems, called the Identification, Services, and Outcomes (ISO) Matrix. The goal was to improve APS’ ability to reduce harm of abuse and neglect and maintain client’s independence to live in the community. APS workers in San Francisco and Napa Counties were trained and phased into using the ISO Matrix over a six-month implementation period. This poster presents findings from six focus groups conducted between February 13 and March 28, 2019, with 34 San Francisco and Napa County APS workers and supervisors. Utilizing semi-structured, in-depth interviewing techniques, APS workers and supervisors expressed their views and experiences. Facilitators and barriers of implementing the ISO Matrix were assessed and opportunities for improvements were identified. Findings revealed a tension between their hopefulness that the ISO Matrix could modernize APS data-tracking and yield evidence of improved client outcome to bolster the field, and their frustrations about new burdens the ISO Matrix placed on their labor and workflow. Understanding frontline perspectives of APS workers and supervisors has practical and policy implications for adopting the ISO Matrix in other counties and states across the U.S.

Evaluating an Integrated APS–Elder Advocate Intervention Model in the State of Maine

Despite recommendations to include a distinct intervention phase in Adult Protective Services (APS), most APS programs close cases following investigation/substantiation phases without engaging in a defined intervention phase. This study implements and evaluates a novel APS service planning/intervention model in the state of Maine. Using an experimental efficacy trial design with stratified random sampling at the level of Maine APS offices, this study compares standard APS care with an enhanced/integrated APS intervention model involving “elder advocates”. Advocates were trained in motivational interviewing, supported decision-making, teaming, restorative justice, and goal attainment scaling to develop capacity to work with both the older adult victim and perpetrator and to strengthen the family and social systems surrounding the victim-perpetrator dyad. This presentation will present results on the efficacy of this integrated APS/elder advocate model and discuss the challenges and successes in conducting elder abuse intervention research in collaboration with APS and APS clients. Part of a symposium sponsored by Abuse, Neglect and Exploitation of Elderly People Interest Group.

Self-Neglect: One Pathway to Surrogate Decision-Making

Self-neglect, the most frequently reported allegation to Adult Protective Services (APS), involves profoundly harmful behaviors often due to functional or cognitive limitations, health problems, and insufficient resources that result in older adults insufficiently meeting their basic needs. Outcomes include high risk of illness, hospitalization and readmission, hospice and nursing home use, early mortality, and placement under surrogate decision-making authority of either well-intended or opportunistic others. APS staff are charged with assessing self-neglect and intervening to reduce client danger. A nationwide APS survey revealed program policies, procedures, resources, and needs affecting the client welfare. For example, 92% of APS programs have provisions for seeking guardianship for self-neglecting individuals, in 25% of programs staff serve as court-appointed guardians, and a wide variety of tools are used within APS programs to assess clients’ mental capacity. Key study findings, implications, and recommendations will be presented.

Multidisciplinary Healthcare Providers’ Perspectives on Managing Suspected Elder Abuse in the Healthcare Setting

Elder abuse (EA) is common and has devastating health consequences, yet is rarely detected by healthcare professionals. Veterans are at high risk for EA, and the VA has unique resources (e.g., comprehensive social work services) that can help address EA in the healthcare setting. This qualitative study aimed to assess perceived barriers and facilitators to detecting, reporting, intervening on and monitoring EA for VA providers. Providers from two VA facilities were recruited to participate in a one-on-one semi-structured interview. Transcripts of audio-recorded interviews were analyzed using thematic content analysis. Participants (n=22) were 82% female, age 33-64 years, had 4-25 years practicing in VA, and varied in discipline (e.g., nurse, physician, social worker) and practice setting (e.g., emergency department, geriatrics, primary care). For detecting EA, patient and caregiver cognitive impairment were frequently cited barriers, while an interdisciplinary team approach and ability to do home visits were noted facilitators. Common challenges with reporting EA to adult protective services (APS) were perceived lack of APS follow up and discrepancies in VA provider and APS investigator findings. While removing a patient from an unsafe living situation was a frequently cited successful intervention, providers also expressed feeling conflicted when infringing on patient autonomy. Poor communication with APS, patient loss to follow up, and caregiver interference made monitoring EA cases more difficult; intensive case management and in-home services facilitated monitoring. In conclusion, healthcare professionals see interdisciplinary care, in-home care, and better coordination with APS as key facilitators to managing suspected EA in the healthcare setting.

An Orphan Needing a Champion–Barriers to Evaluations of Decision-Making Capacity

Impaired decision making capacity is common in medical and community settings, often coexistent with functional impairment and dementia. Though the legal system determines competence, deciding if guardianship is appropriate often relies on a medical assessment of decision making capacity. Physicians conduct cognitive evaluations but are often unaware of a person’s functional impairments and are unfamiliar with their role in pursuing guardianship. Despite the individual roles of the legal system, medical system, and community agencies (e.g. Adult Protective Services (APS)) in such cases, no agency claims responsibility for ensuring this process’s fidelity. As numbers of older citizens in the US increase along with associated increasing numbers of cases involving impaired decision making capacity, ensuring this processes’ fidelity is essential. We sought to identify the barriers (recognized by each of these parties) in determining decision making capacity of persons for whom guardianship is being considered. Surveys were conducted with professionals in the legal, medical, and APS arenas, to identify barriers to obtaining capacity determinations. Common themes identified amongst these entities included needing to include functional status in this evaluation, and the need for clear communication between the legal system, medical system, and APS. Unique concerns identified in the survey included APS caseworkers challenges in finding physicians willing to complete capacity evaluations, judges’ concerns about evaluations’ failure to address safety issues and need for immediate action , and physician’s concerns about liability and compromising the physician-patient relationship. Continued collaboration between these systems could overcome these barriers.

A Direct Reporting Platform for Financial Exploitation: From Banks to APS

Despite encouraging changes in regulations and practices, opportunities remain to strengthen the collaboration between Financial Services Institutions (FSI) and Financial Exploitation (FE) investigative agencies such as Adult Protective Services (APS). A major barrier to these collaborations is timely and effective information exchange, between the agencies, for maximizing client protection. Often times, the need for more information from the agencies involved delays or mitigates the provision of financial protection to the client/victim. Through the U.S. Office for Victims of Crime, funding has been provided to develop a single reporting platform for enhancing communication and collaboration between FSI and APS. The helpful platform provides an innovative conduit for providing timely and effective information exchange between FSI and APS agencies to better serve and protect older adults against FE. This presentation will discuss the platform development, the lessons learned, preliminary data and future research. Part of a symposium sponsored by Abuse, Neglect and Exploitation of Elderly People Interest Group.

Age Differences in Elder Abuse Harm and Effective Services Offered by Adult Protective Services

In this study, abuse, exploitation, and neglect (ANE) harm was measured by type of abuse using standardized items from the Identification, Services, and Outcomes (ISO) Matrix before Adult Protective Services (APS) interventions (pretest) and after APS interventions (posttest). Change scores from 1,472 older adults (average age 78-year-old; 57% female) and 591 younger adults (average age 53-year-old; 46% female) served by APS during the six months showed reduction of harm using posttest minus pretest. Nonetheless, older adult’s financial abuse harm (pretest=2.2, posttest=1.5) was higher than younger adults’ (pretest=1.5, posttest=1.2), while young adults scored higher in harm on all other types of abuse. Effective interventions differ by age group and by type of abuse, and will be discussed in detail. Results demonstrate the importance to consider vulnerable adult’s age and the etiology of abuse before implementing the services needed to effectively address ANE harm.

Nurses Working in and With Adult Protective Services: Agency Characteristics and Job Responsibilities

The majority of Adult Protective Services (APS) workforce is staffed by social workers, though some agencies have recognized the need to address clients’ medical needs such as wounds, injuries, nutrition issues, hydration issues, premature death and more. Using survey data from the National Adult Protective Services Association (NAPSA), we analyzed 99 nurses’ responses on their role in working in/with APS to help abused, neglect, and exploited adults. Out of the 99 nurses, 65 were direct employees of APS, and 61 did not report directly to a nurse supervisor. Forty-nine nurses carry a caseload like social workers, and 27 carry a caseload in conjunction with social workers. The most common services nurses provide are home visits, evaluations of clients and their medications, and client education. Qualitative data revealed the benefits of having nurses on staff, including assessing medical needs, preventing medical emergencies, providing holistic care, and navigating the healthcare system. Part of a symposium sponsored by Abuse, Neglect and Exploitation of Elderly People Interest Group.

Adult Protective Services’ Intervention on Elder Abuse: Using Standardized Measures for Outcomes

Adult Protective Services (APS) investigates and substantiates vulnerable adult abuse, neglect, and exploitation (ANE) cases. The frontline social service agency also refers or provides needed services to ANE victims. Outcomes of APS has been scarce, with definitions of outcomes varying from study to study. Using a pretest-posttest design, we partnered with San Francisco and Napa APS to measure changes of ANE harm from case investigation (pretest) to case closure (posttest) using standardized measures called the Identification, Services, and Outcomes (ISO) Matrix. Forty-five APS supervisors and caseworkers used the ISO Matrix on 2,063 cases during the six-month pilot demonstration. Dr. Pi-Ju (Marian) Liu will examine findings on changes of ANE harm and APS services that effectively decreased ANE harm. Responding to 2020’s Annual Scientific Meeting theme “Turning 75: Why Age Matters”, ANE harm and APS services will be compared between younger APS clients age 18-64 and older ones above the age of 65. Dr. Zachary Hass will discuss allegation, abuse severity assessment, services provided, and outcomes across racial and language groups. Dr. Kendon Conrad will present reliability and validity of the ISO Matrix and a shorter version useful for APS practice. Ms Sara Stratton will review unusual cases with outlier ISO Matrix scores to inform researchers’ implementation and practitioners’ use of standardized measures. Dr. Kathleen Wilber, our discussant, will reflect on the use of standardized measures in APS and its impact on both practice and research based on the four presentations.

Does the Structure of Aging Services Matter? A Comparative Case Study of California Communities

As the older adult population grows and Federal funding remains stagnant, coordination of services at the local level becomes more critical. Building on the Federal Administration for Community Living model, California’s Master Plan for Aging creates opportunities for innovative restructuring of the way aging services are delivered through the Area Agencies on Aging (AAA). We conducted a comparative case study of California AAAs (N=5) representing different levels of integration, from standalone departments of aging (Los Angeles City, Riverside County), to partial integration (Los Angeles County), to full integration with aging and disability programs (San Diego County, San Francisco County). We examined the impact of departmental organization and integration on the AAAs’ service delivery for older adults. Interviews with leaders of the AAAs were coded by two researchers using constant comparative analysis to identify themes within and between the AAAs. Emerging themes revealed the role that “structure,” “politics,” “funding,” and “visibility” play in service delivery for AAAs with varying levels of integration. Findings suggest that integrating the AAA with other departments (i.e., Health and Human Services) and programs (e.g., Adult Protective Services, In-Home Supportive Services) improves coordination and allows for greater visibility of the AAA. Key stakeholders in standalone AAAs, however, fear that integration would hinder their visibility and “agility” in service provision. Findings shed light on best practices for locally coordinated aging service delivery during a window of opportunity for California AAAs, yet they can also inform how aging services are provided for local governments nationwide.

Allegation Assessment and Outcome Differences Across Racial Groups From Standardized Adult Protective Services Data

Objective assessment is an important tool for Adult Protective Services (APS) in supporting a diverse population. Out of the 1472 APS’ clients, aged 65 and over, assisted during the study period, 39% identified as a non-white race and 30% did not speak English. Providing services to this vulnerable population is made even more difficult by the need to provide culturally appropriate services. In this work, we present on differences in types of abuse alleged, abuse severity assessment, services provided, and preliminary outcomes across racial and language groups. For example, for this population, clients identifying as black race had the highest allegation rates of neglect (16%) and financial abuse (27%), Asians of physical (15%) and emotional abuse (24%), and other races of self-neglect (56%) and isolation (9%). Standardized data collection permits tracking such patterns and objective assessment tools help to avoid systemic bias in aiding this vulnerable population.

Interprofessional Collaboration to Address Elder Abuse, Neglect, and Exploitation With Adult Protective Services

Adult Protective Services (APS) is responsible for investigating reports of abuse, exploitation, and neglect among vulnerable adults. Additionally, APS also refers or provides needed services to victims. Though APS also takes the lead position in investigation and service planning, determining harm and designing person-centered remedies often require other professionals to be prepared to address these elder justice issues with APS. Afterall, adult safeguarding is everybody’s business. This symposium includes four presentations on researchers’ findings working with APS and other professionals. Dr. Burnes will compare outcomes on usual APS care (APS only) versus enhanced APS care (APS plus advocate who are case managers). Dr. Pi-Ju (Marian) Liu will examine nurses’ role in working in and with APS, focusing on how their job responsibilities are different from other nurses and APS social workers. Dr. Jason Burnett will present an innovative referral portal linking banks and other financial firms directly to APS. Lastly, Dr. Zachary Gassoumis will appraise the multidisciplinary teams across the country, including professionals involved, and provide input on what makes a team work well together. Following the four presentations, Dr. Bridget Penhale will open up the discussion regarding protective agencies’ operations and collaboration with other agencies, focusing on the comparison between protective agencies in the United States and European countries. Abuse, Neglect and Exploitation of Elderly People Interest Group Sponsored Symposium.

Inconsistent Capacity Assessment Access for Adult Protective Services: National Survey Results

Throughout the country, access to professional capacity assessments is inconsistent. Capacity assessments are often a critical factor in case management of elder abuse investigations. This unmet need for many Adult Protective Services (APS) programs hampers their ability to protect older adults from mistreatment and preserve self-determination when appropriate. In June 2019, electronic surveys regarding access to capacity assessments were sent to APS leadership in all 58 California counties. A similar survey is planned for each US state in June 2020. In California, with 100% response rate, 53% of counties had no access to assessments and 56.1% had no funding for assessments. Most assessments were completed by physicians or psychologists. Seventy-three percent of counties reported that primary care physicians complete requests for capacity declarations less than half the time. Physicians decline to complete capacity declarations because they don’t know how to do the assessments (22.4%) and are concerned about being called into court (28.5%). Findings from the national survey will be presented along with maps illustrating capacity assessment accessibility. Factors that appear to influence accessibility positively (forensic centers) and negatively (lack of funding and lack of trained evaluators) will be discussed along with policy implications.

Balancing Practicality and Validity of Elder Abuse Measures: Data From Adult Protective Services Investigations

Research in Adult Protective Services suffers from the problems of small sample size, low completion rates, and poor data quality. To address the “small sample size” issue, data were generated on 1,472 elder abuse cases over six months in California using the Identification, Services and Outcomes (ISO) Matrix. The problem of poor data quality was addressed by testing psychometric properties of Short-Forms on each type of abuse. Good reliability and predictive validity were found for all measures except those that were very rare. Finally, even shorter Mini-Forms were developed and tested in order to contribute to improved completion rates. Mini-Form results were mixed, and some will require further research on their reliability and validity, as well as examination of their ability to improve completion rates. Ongoing adoption by two California counties and the State of Montana demonstrate sustainability and increasing sample sizes using the ISO Matrix for research and practice.

Adult Protective Services and Law Enforcement: Does It Add or Subtract to the Precarity of Living Alone With Dementia?

In 2014, more than 12.5 million people age 65+ lived alone in the U.S. Of these, approximately one third had a cognitive impairment. Although protective services may identify risks to such individuals, they may not have a full understanding of the notion of precarity, or the looming uncertainty regarding space and place, that solo dwellers experience. This presentation explores the tension between the intentions of protective services and the experience of precarity for persons living alone. More specifically, persons living alone with dementia participating in online groups and community events report feelings of risk of loss of autonomy and rights if their status becomes known. The presenter will review these impressions against current police and adult protective services policies and standard practices.

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.

Older Adult Fatality Reviews: A Powerful Tool to Improve Policies, Protections, and Services

Older adult maltreatment is a serious problem that can hasten mortality and cause fatality. Child and Domestic Violence Fatality Review teams have made a major impact to improve protections, services, and system responses for victims. There are over 1300 child fatality review teams in 50 US states and 200 domestic violence fatality teams in 45 states. Older adult fatality reviews, in contrast, have not proliferated across the country, missing opportunities to bring interdisciplinary expertise together to resolve policy, protection, and services needed to prevent older adult premature deaths due to violence and abuse. Method: A mini mock review of a fatality of an older adult woman will demonstrate the possibilities of beginning Older Adult Fatality Review Board as recommended by the American Bar Association. Conclusion: Interdisciplinary older adult fatality review teams have been an underutilized tool to make changes in older adult mistreatment protection services and systems.