Adult Protective Services Cases Research Articles

INTEGRATING PRACTITIONER KNOWLEDGE INTO AN ALGORITHM TO IDENTIFY CASES FOR REVIEW BY AN ADULT MALTREATMENT MDT

Abstract Case review multidisciplinary teams (MDTs) bring together professionals from health, social service, and justice systems to address complex cases of elder abuse, neglect, self-neglect, and maltreatment of younger adults with disability or vulnerability. MDTs are a promising intervention, but MDTs nationwide face challenges identifying cases for review. In partnership with San Francisco Adult Protective Services (APS), we developed an algorithm-driven process to systematically identify APS cases that appear appropriate for MDT review. To construct the algorithm, a retrospective analysis of APS case data was augmented by insights received during six listening sessions held with 48 study partners (MDT members and APS staff). These sessions gauged perspectives on cases’ suitability for MDT review. Listening session transcripts were coded using constant comparative analysis, revealing themes of Client, Case Details, and Service Utilization Patterns. Client included physical or cognitive impairment, high-risk of abuse or other harms, need for assistance from multiple service systems, and limited motivation to make changes. Case Details referred to aspects of the abuse such as concurrent self-neglect, client protectiveness of the suspected abuser, client denial of the abuse, and limited evidence of criminal conduct. Service Utilization Patterns were recurrence within APS, attempting multiple solutions, inability to provide services, and referral by medical professionals, fire departments, or paramedics. These topics guided the inclusion of variables in the project’s algorithms. This mixed-methods approach provides an example of community-engaged research being applied to develop knowledge and guide the practice of service delivery for vulnerable older adults and other victims of adult maltreatment.

A QUALITATIVE EVALUATION OF RISE FROM THE PERSPECTIVE OF ADULT PROTECTIVE SERVICES CASEWORKERS

Abstract Our understanding of effective elder abuse and self-neglect (EASN) response interventions is limited. Adult Protective Services (APS), the primary agency responsible for responding to EASN, lacks a coherent, conceptually driven, prolonged intervention phase. Informed by ecological-systems, client-centered, and relational perspectives and adapting evidence-based modalities from other fields, the RISE intervention addresses this systems gap and compliments and augments APS services. Based on a three-year pilot project involving a partnership between RISE and Maine APS, the current study conducted a qualitative evaluation of RISE, from the perspective of APS caseworkers (n=14) who worked with RISE. The purpose of this evaluation was to understand RISE strengths, areas for improvement, and qualities of the RISE/APS partnership. Findings suggest APS workers perceive that RISE benefits clients, complements the scope and nature of APS, enhances APS caseworker well-being, and reduces repeat APS cases. Further APS/RISE collaboration and clarification on RISE role responsibilities and referral eligibilities represent areas of growth. This study provides preliminary evidence for RISE as a community-based EASN intervention in partnership with APS

A qualitative evaluation of the “RISE” elder abuse intervention from the perspective of adult protective services caseworkers: addressing a service system gap

ABSTRACT Our understanding of effective elder abuse (EA) response interventions is limited. Adult Protective Services (APS), the primary agency responsible for responding to EA, lacks a coherent, conceptually driven, prolonged intervention phase. Informed by an ecological-systems perspective and adapting evidence-based modalities from other fields, the RISE EA intervention addresses this APS systems gap. Based on a three-year pilot project involving a partnership between RISE and Maine APS, the current study conducted a qualitative evaluation of RISE, from the perspective of APS caseworkers (n = 14) who worked with RISE, to understand RISE strengths and areas for improvement. Findings suggest APS workers perceive that RISE complements the scope and nature of APS, enhances APS caseworker well-being, and reduces repeat APS cases, while further APS/RISE collaboration and clarification on RISE role responsibilities and referral eligibilities are areas of growth. This study provides preliminary evidence for RISE as a community-based EA intervention in partnership with APS.

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.

Pathways to and Consequences of Surrogate Decision-Making for Older Adults

With a burgeoning aging population, there is a growing need for surrogate decision makers, yet oversight of and guidance for them remains inadequate. People needing surrogate decision makers are an especially vulnerable population because they rely on others for care and/or are unable to advocate for themselves. Their vulnerability leaves them susceptible to elder abuse (e.g., physical, sexual, psychological abuse; active and passive neglect; financial exploitation), which affects approximately five million older Americans each year. Personal, financial, and societal impacts can be devastating and are estimated to cost billions annually. The issue of abuse, neglect and exploitation by surrogates has been highly visible nationally, evidence indicates that some surrogate decision makers perpetrate abuse. One purpose of this symposium is to discuss ways in which surrogates do and do not make decisions for older adults. Ramsey-Klawsnik and Burnett present data at the systemic level to illustrate how self-neglect sequelae can result in placement under surrogate decision-making authority of either well-intended or opportunistic others. Bolkan, Teaster, Ramsey-Klawsnik, and Gerow present findings from a six-state study on surrogate decision maker victims and perpetrators who were substantiated in Adult Protective Services cases. Zhao, Katz, and Teaster show, using a survey of M-Turk participants, how a general population makes and is comfortable with surrogate decisions. Discussant Shawn Meyers will pull together the findings by exploring their translation to judicial best practices for making determinations regarding surrogate decision makers and the effects of their decisions on the surrogate as well as collaterals.

Pent-up demand for care among dual-eligible victims of elder financial exploitation in Maine

ABSTRACT Elder financial exploitation (EFE), the misuse of a vulnerable adult’s property or resources for personal gain, is a form of elder abuse. This study addresses whether dual-eligible EFE victims were experiencing pent-up demand for health services alleviated through investigation by Adult Protective Services (APS). A quasi-experimental design addressed health service utilization and costs for 131 dual-eligible Maine APS clients over age 60 with substantiated allegations of EFE relative to comparable non-APS controls. APS case files spanning 2007–2012 were linked to 2006–2014 Medicare and Medicaid claims data. Service utilization and costs were analyzed 1 year prior, during, and 2 years after the initial APS investigation. Difference in differences logistic regression and generalized linear models addressed the likelihood of incurring costs and expenditure levels relative to matched controls, respectively. Victims of EFE had higher overall odds of using inpatient and long-term services and supports (LTSS) and higher odds of using LTSS post-investigation than controls. Higher overall levels of outpatient and prescriptions expenditures and higher inpatient expenditures during the APS event year contributed toward APS clients incurring $1,142 higher PMPM total costs than controls. Victims of EFE were experiencing significant pent-up demand for health services post-APS involvement.

Older adults neglected by their caregivers: vulnerabilities and risks identified in an adult protective services sample

PurposeUsing a risk and vulnerability framework, the purpose of this paper is to describe the characteristics of older adults that Adult Protective Services (APS) substantiated for neglect by caregivers, their caregivers and the interrelationships between them.Design/methodology/approachThe paper uses a qualitative study of 21 APS case record narratives using a template analysis.FindingsNeglect related to withholding or refusing medical care was the most common. The older adults had multiple health conditions and geriatric syndromes. Caregivers had difficulties in carrying out caregiving role due to health and mental health issues, work responsibilities and lack of insight into older adults’ needs. The refusal to access or accept services by both the older adults and the caregivers was a predominant theme.Research limitations/implicationsThe sample size was small, limited to one geographical area, and non-representative of all neglect cases. The data were extracted from written case narratives and not directly from the older adults and their family members. Case records varied in the case detail provided.Practical implicationsTo protect vulnerable older adults and improve quality of life, APS involvement in cases of caregiver neglect needs strategies to get people to accept help and access services to address multiple health and psychosocial problems for both older adult victims and their caregivers.Originality/valueThis study provides in-depth information on APS cases involving caregiver neglect that add to understanding of this complex problem and points to areas for further study.

C-69The Role of Cognition in Self-Advocacy in Adult Protective Services Cases

C-69The Role of Cognition in Self-Advocacy in Adult Protective Services Cases

Developing an undue influence screening tool for Adult Protective Services

ABSTRACTThe study purpose was to develop and pilot an undue influence screening tool for California’s Adult Protective Services (APS) personnel based on the definition of undue influence enacted into California law January 1, 2014. Methods included four focus groups with APS providers (n = 33), piloting the preliminary tool by APS personnel (n = 15), and interviews with four elder abuse experts and two APS administrators. Social service literature—including existing undue influence models—was reviewed, as were existing screening and assessment tools. Using the information from these various sources, the California Undue Influence Screening Tool (CUIST) was developed. It can be applied to APS cases and potentially adapted for use by other professionals and for use in other states. Implementation of the tool into APS practice, policy, procedures, and training of personnel will depend on the initiative of APS management. Future work will need to address the reliability and validity of CUIST.

Perceived Stress and Elder Abuse: A Population-Based Study of Adult Protective Services Cases in Chicago.

To characterize the relationship between perceived stress and Adult Protective Services (APS) elder abuse cases in a population-based sample. Cross-sectional. Chicago. community-dwelling, older adults (N = 8,558; mean age 74 ± 7, 62% female, 64% African American). Perceived Stress Scale (PSS), APS database linkage. Bivariate and adjusted analyses showed that perceived stress was significantly higher in APS clients than in participants without any APS interaction for various subtypes of abuse (e.g., abuse from a perpetrator and self-neglect). This relationship was strongest for those with a confirmed history of abuse from a perpetrator, with a medium-large effect size (t = -5.8, P < .001, Cohen D = -0.6). Those in the highest stress tertile had a likelihood of having confirmed history of abuse from a perpetrator that was nearly three times as great as that of those in lower stress tertiles (odds ratio = 2.7, 95% confidence interval = 1.2-6.2). Analyses of individual PSS items revealed a robust relationship between distress items and APS involvement. Items reflecting coping were inconsistently associated with elder abuse. Clients of APS have higher levels of perceived stress, and abuse from a perpetrator strengthens this relationship. Therefore, victims of abuse from a perpetrator may be at the highest risk of stress-related consequences and should be targeted for intervention efforts that enhance empowerment and effective coping strategies.

Informing Evidence-Based Practice: A Review of Research Analyzing Adult Protective Services Data

The mission of Adult Protective Services (APS) is to protect older and vulnerable adults from abuse, neglect, and exploitation. The complexity of APS cases and the potential for life-changing interventions point to the need for research that examines and evaluates APS practices. A literature review identified 50 studies published during a 16-year period that used APS agencies, clients, data, or resources to test hypotheses regarding elder abuse. The analysis revealed promising efforts toward knowledge development about elder mistreatment and self-neglect. This article provides an overview of salient findings, notes the scarcity of studies that analyze the effectiveness of APS, and highlights the need for additional research. Lessons learned are described, and APS practitioners and researchers are urged to work collaboratively to develop key practice-related questions about APS processes and outcomes that can be tested with appropriate research methodologies.

Forensic Markers Associated with a History of Elder Mistreatment and Self-Neglect: A Case-Control Study

Elder mistreatment (EM) and elder self-neglect (SN) are risk factors for mortality. Medical examiners (ME) seldom investigate EM and SN as potential influences of death in older adults. Recognizing forensic markers associated with EM and/or SN may lead to further investigation into EM and SN as potential contributors and thus, may impact the cause and manner of death.MethodsOne-hundred and ninety-two Adult Protective Services (APS)-substantiated EM and SN cases 65 years of age and older, residing in Houston, Texas in Harris County with ME records were matched on age, race, gender and socio-economic status to individuals with ME records and no APS history. A conditional logistic regression was conducted to identify variables that reliably predict ME cases with an APS history.ResultsAPS cases had significantly higher odds of having a history of pressure sores (OR: 2.4; 95% CI = 1.2 – 4.9), but had significantly lower odds of presenting with abnormally high body mass indexes (OR: 0.5; 95% CI = 0.3 – 0.9).ConclusionThese data suggest that forensic case information such as a decedent history of pressure sores may indicate a past history of elder mistreatment or self-neglect. In contrast, having an abnormally high body mass index may indicate a lack of APS history. More studies are needed to better define these predictors and to identify other predictors that may assist forensic pathologists in identifying deaths in older adults that may have been impacted by EM and/or SN.

Adult Protective Services Clients Confirmed for Self-Neglect: Characteristics and Service Use

Self-neglect is a complex and inadequately understood phenomenon that accounts for the majority of Adult Protective Services cases. This retrospective, record-based study of the characteristics of 210 older adults who were reported to Adult Protective Services and confirmed for self-neglect revealed that common health problems included nutritional frailty, arthritis, and incontinence. Comparisons based upon length of service showed differences in worker-rated social environment risk, client capacity, and activities of daily living performance. Comparisons of findings with those of other studies of self-neglect underscore the need for systematic research on this population.

Comparing Routes of Reporting in Elder Sexual Abuse Cases

ABSTRACT An exploratory study of 284 cases of alleged elder sexual abuse revealed fairly equal numbers of reports to the criminal justice system (CJS) and to Adult Protective Services (APS). Comparison of these two routes of reporting indicated the following: Suspected victims reported to APS were more likely to reside in their own homes, not receive rape exams, and have cognitive disabilities. Their alleged offenders were typically spouse/partners or family members age 40 or older. Victims reported to CJS were more frequently abused in institutions, received rape exams, and were victimized by offenders under age 40 who also committed nonsexual crimes. In cases reported to the CJS, alleged offenders were less likely than those in the APS cases to be identified, but once identified, were more likely to be arrested, referred for prosecution, and convicted, or to plea bargain their case.

Sexual Abuse of Vulnerable Young and Old Men

During a 4-year period, aggregated data from Adult Protective Services case files in Virginia revealed 17 cases of sexually abused young, middle-age, and old men. The most common types of sexual abuse across age groups involved instances of sexualized kissing and fondling and unwelcome sexual interest in the individual men's bodies. The majority of alleged perpetrators were male; they typically were similar in age to the men and resided in the same residential facility. In none of the cases was the alleged perpetrator prosecuted. Only two of the men continued to be at risk of further sexual abuse by the alleged perpetrator. Implications of these data for future research and practice include a need for studies that focus on differences between male and female victims, especially concerning investigations and interventions, and for training on reporting and intervention for facilities and agencies and organizations working with victims and alleged perpetrators.

Sexual Abuse of Vulnerable Young and Old Women

Aggregated data from 125 substantiated Adult Protective Services cases of sexually abused women were collected during a 5-year period. Women older than 59 years represented 63% of the cases. Regardless of age, the most common types of abuse involved sexualized kissing and fondling and unwelcome sexual interest in the women's body. Most identified perpetrators were older males. Family members were most likely to abuse women living in the community, whereas women living in facilities usually experienced abuse by another resident. Perpetrators were prosecuted and convicted in six cases. About 12% of the women continued to be at risk of further sexual abuse.

Experiences and Needs of Adult Protective Services Case Managers When Assisting Clients Who Have Companion Animals

ABSTRACTEnhancing the safety and quality of life of adults who require protective services must frequently include consideration of their companion animals. Six Adult Protective Services case managers reported on their experiences with clients who had pets. Issues discussed included clients' neglect of themselves and their pets, attachment to and loss of pets, abuse and threats to harm a pet, collecting or hoarding of animals, and staff encounters with aggressive animals. The case managers made recommendations concerning agency procedures, staff training and useful support services to offer staff and clients when companion animals are present.