Perspectives on elder mistreatment screening and responding in emergency departments: A qualitative study with survivors.

OBJECTIVE: Elder Mistreatment (EM) occurs in approximately 10% of older adults and is associated with trauma-related outcomes including depression, anxiety, posttraumatic stress disorder, and early mortality. Low screening and older adult self-reporting, especially within emergency departments, represent missed opportunities for identify and mitigate future EM occurrences and consequences. To date, no studies have obtained EM survivors' perspectives on EM screening and response practices in emergency departments. METHODS: Semi-structured interviews with 19 EM survivors of those with Adult Protective Services validated EM were completed in older adults' homes. The Elder Mistreatment Emergency Department Screening and Response Tool (EM-SART) was used to guide the interview questions. All interviews were recorded, transcribed, and analyzed using qualitative thematic analyses. RESULTS: The participants were mostly female (63%) and white (58%) with an average age of 74 years. Physical abuse accounted for 67% of the EM incidents. Three themes emerged indicating the survivor preference for (1) building rapport and approaching the older adult with compassion and care, (2) setting the context before asking the EM questions, and (3) allowing mutuality, collaborative work, and shared decision-making during the response. CONCLUSIONS: Older adults are agreeable and willing to self-report and actively engage in the EM screening and response practices in the emergency department if trauma-informed care principles are utilized.

Social connection and self-neglect: A case for broader exploration.

OBJECTIVE: Self-neglect (SN) is the most common report to Adult Protective Services (APS) and is associated with significant morbidity and mortality risks for older adults. Lack of instrumental support is a well-evidenced etiologic factor in the development and continuation of SN, but little is known about other modifiable social connection characteristics. The social connection framework provides evidence-based characteristics across structure, function, and quality missing from SN studies that could be identified if explored. These factors could provide prevention and intervention targets related to poor health. METHODS: A narrative case study is presented using quantitative and qualitative data to explore social connection across structure, function, and quality in the context of SN. RESULTS: The findings highlight the complexity of social connection that may be observed in SN cases reported to APS. Strategic utilization of direct and indirect social interventions to support social connection in this case are presented. CONCLUSION: The results from this case give rise to considerations that may be generalizable to other SN cases. Recommendations for future research on social connection in this population are provided.

Financial decision-making deficits in scam cases: how frequent are they?

Due to the rise in scams perpetrated against older adults, Adult Protective Service workers are more frequently involved in investigating these matters. One significant aspect of scam involvement is the assessment of informed financial decision-making. This study examined 175 consecutive scam cases APS workers investigated using a 10-item financial-decision making tool. Two-thirds of the sample displayed deficits in decision-making. The decision-making tool was effective in differentiating those rated as having deficits from those without deficits. Analysis of each scored item found differences between groups on six of the seven items. A review of the item responses illustrates the types of deficits in understanding and appreciation of the scam and its impact on the older person and their family.

Elder mistreatment experiences, perceptions, and help-seeking behaviors of Asian American older adults.

This study examined the experiences and the perceptions of elder mistreatment (EM), as well as help-seeking knowledge and behaviors, particularly about Adult Protective Services (APS), among community samples of Asian American older adults, including Koreans, Chinese, and others (N = 288). Approximately 27% of the study participants experienced at least one EM incident in the past year. Between 27% and 38% of the participants reported that they were likely to seek help from APS for different types of EM. Significant differences were found across the three Asian groups in their perceptions toward EM and intention to seek help from APS in the event of EM. However, many Asian American older adults in the study did not know about APS prior to participating in the study (75.5%) and other formal sources of help (66.3%). Implications for helping professionals, particularly APS and community-based organizations serving Asian Americans, are discussed.

A collaboration between adult protective services and forensic accounting examiners to investigate complex financial exploitation: formative evaluation findings.

Financial exploitation (FE) is one of the most common reports to Adult Protective Services (APS) and the cases are often complex. Consequently, APS caseworkers report FE investigations to be among the most difficult while simultaneously reporting low confidence in productive outcomes for these investigations. This necessitates finding ways to support APS FE investigations. This paper describes the structure, process, and formative findings of a collaboration between forensic accounting examiners and APS workers to investigate complex cases of FE. Among the 77 FE cases completed, forensic examiners reviewed multiple years of financial records which included over 101,000 transactions, totaling over $213,000,000.00 in finances, and identified over $8,000,000 in questionable activity. Scores on the 8-item Client Satisfaction Questionnaire were high indicating high program satisfaction by APS workers, subject matter experts, and forensic examiners. These findings support the feasibility and acceptability of forensic accounting and APS collaborations to investigate complex cases of FE.

A Qualitative Study of Adult Protective Services Practitioners Responding to Allegations of Elder Abuse and Self-Neglect.

Adult Protective Services (APS) practitioners play an essential role in supporting older adults experiencing elder abuse and self-neglect (EASN), however, very little research has examined their experiences, from their perspectives. The purpose of this study was to examine the experiences of APS practitioners responding to allegations of EASN. Qualitative interviews were conducted with APS practitioners (n = 14) from the state of Maine. A descriptive phenomenological approach involving two independent assessors was used to code transcripts into themes. Two domains, each with various subthemes, were identified: (1) rewarding elements of role and (2) challenging aspects of role. The findings of this study emphasize how APS practitioners are motivated by their capacity to help elicit positive change in the lives of their clients and support the well-being of older adults experiencing EASN. However, APS practitioners must navigate numerous challenges and barriers in their role, including time constraints, high and complex caseloads, limited resources, and broader misconceptions on APS. These findings highlight the importance of addressing these stressors to support the well-being of APS practitioners, which, in turn, can help support the vulnerable older adults they serve.

Racial/Ethnic Group Differences in Older Adults' Involvement with Adult Protective Services.

This paper represents the first study to focus on quantifying racial/ethnic group differences in older adults' involvement with adult protective services (APS).  Across 3 independent county programs, the rate of APS reports was about twice as high for Black older adults compared to White older adults.  These differences were greater for clients who were older and male but remained similar across allegation type.  The percent of reports validated was slightly but consistently lower for Black clients than for White clients, and a lower percentage of Black clients' cases were closed due to investigation or service refusal. Findings for Hispanic clients differed by county, so it was impossible to generalize about their APS experience.  Researchers should distinguish racial/ethnic group differences that persist across multiple programs from those that are program-specific.  Further studies with larger data sets are needed to guide APS practice and ensure equity for all clients served. .

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

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.

Using administrative data from adult protective services: opportunities and considerations.

As federal agencies support the development of data systems for adult protective services (APS), researchers and practitioners are increasingly using administrative data to study types of adult maltreatment, including self-neglect, and the systems that respond to them. To date, however, APS has worked with little guidance about how best to use these data. This situation has contributed to inconsistent findings and uneven quality of research. Based on the authors' experience in multiple states and using examples from research and practice, this paper reviews practical considerations related to organizing and analyzing APS administrative data. We address concerns related to time-limited, erroneous, and missing data, as well as defining metrics and accounting for the multilevel structure of data with repeated observations. Reviewing these methodological details can help APS practitioners strengthen quality assurance processes and improve research in this important area.

Measuring the diverse characteristics of county adult protective services programs.

Adult protective services (APS) programs vary markedly, yet few studies have quantified this diversity. In 2020, a survey of Ohio's 85 county-administered APS programs incorporated subsequent feedback from staff and described the programs in a systematic manner. This process resulted in a 100% response rate and illustrated an efficient approach to measuring organizational characteristics (e.g., whether any staff are mostly dedicated to APS), resources (e.g., access to multidisciplinary teams), and practices (e.g., how often staff create a plan to meet client goals). The prevalence of many factors differed by the number of older adults the program served. For instance, 75% of programs in large counties had regular opportunities to share complex cases with a multidisciplinary team, compared to 28% of programs in small counties. Understanding the diverse characteristics of APS programs - and how to measure them - can help agencies guide quality improvement efforts and the dissemination of innovations.

Examining nurses' role in Adult Protective Services related to safeguarding older people.

AIM: To examine the role of Adult Protective Services' (APS's) nurses in helping abused, neglected and exploited older people, this study investigated how nurses' contribution differs from social workers. Though the majority of APS' workforce is staffed by social workers, some programmes also employ nurses. DESIGN: Secondary data analysis using convergent parallel mixed-method design was conducted. METHODS: Using survey data from the National Adult Protective Services Association, 99 nurses' responses between October 2014 and August 2015 were analysed to examine their agency characteristics, training and qualities, job responsibilities and interprofessional collaboration. RESULTS: The majority of nurses work with social workers or other professionals using a multidisciplinary team (MDT) approach. Among those carrying a caseload, 69% (49 out of 71) of nurses work in conjunction with social workers. Out of all nurses, 64% (63 out of 99) indicated participation in at least one MDT. While the responsibilities nurses provided were similar to social workers, nurses were also able to provide healthcare related services, in their professional competencies, without referral. CONCLUSION: Nurses in APS are in a privileged position to investigate mistreatment and provide/coordinate direct care for victims. IMPACT: Not much was known about nurses who directly investigate elder mistreatment and provide services to victims. This study was the first to highlight the nursing workforce in APS, and described the nurses' unique contribution to the field. Nurses functioned as both social workers and healthcare professionals in APS. Since victims of elder mistreatment often suffer from negative physical, psychological and social consequences, having nurses in APS benefits victims to receive and the programmes in providing better care and services.

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

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).

Adult Protective Services Training: A Brief Report on the State of the Nation.

This brief report summarizes Adult Protective Services training provided to workers across the nation, using survey results from the National Adult Protective Services Association (NAPSA). Although most states delivered training that covered some learning objectives of NAPSA's 23 core competency training modules, there was a wide variation with some states training workers on all 23 topics, while some states did not provide training on any of the core modules. Having a well-trained APS workforce possessing core competencies to perform the job should be federal and state agencies' goal, because the quality and level of services for older people and people with disabilities should not differ based on the states they live in.

Which Items of the Financial Decision Tracker Differentiate Those with Decision-making Deficits from Those with No Deficits? Data from the Michigan APS Implementation Project.

Objectives: Lichtenberg et al. reported on the implementation of a 10-item financial decision-making screening scale (Financial Decision Tracker-FDT) in a state-wide Adult Protective Services (APS) project. This study examined which of the seven scored items, reflecting the Appelbaum & Grisso decisional abilities model, were most sensitive to decision-making deficits.Methods: The Financial Decision Tracker was administered to 445 adults aged 60 years of older during APS investigations of financial exploitation. APS workers administered the FDT as part of their financial exploitation investigation. Overall, seven scored FDT items were compared using T tests.Results: Six of the seven risk-scored items were significantly different between those with and without decision-making deficits. Two of the items had small effect sizes, and four items had moderate effect sizes. The larger, moderate effect sizes were related to risk to financial well-being (appreciation), impact on finances (understanding), and who benefits most from the decision (understanding).Conclusions: The main findings of the study supported the Appelbaum and Grisso's decision-making model and the ability of specific items related to understanding and appreciation to differentiate between individuals with and without financial decision-making deficits.Clinical Implications: The FDT is a clinically reliable and validated tool for older adults.

Adult Protective Services Training: Insights from California Caseworkers.

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.

Using diffusion of innovations framework to examine the dissemination and implementation of the adult protective services national voluntary consensus guidelines.

The National Voluntary Consensus Guidelines for Adult Protective Services (APS) were released in 2016 by the Administration for Community Living. These Guidelines help standardize systems to ensure the protection of older adults and adults with disabilities against abuse, neglect, and financial exploitation. Since their release, the extent to which state APS programs are aware of and using the Guidelines is unknown. This study examined the dissemination and implementation of the Guidelines across APS programs in the US. Researchers used the Diffusion of Innovations Theory to develop a survey sent to APS directors in all states. Forty-two states responded, and results were used to select a subset of states in which to conduct in-depth interviews. Awareness of the Guidelines was widespread but varied. Reported use of the Guidelines indicates that states are working to incorporate them into their practices. Respondents identified the need for more research and training in evidence-based practices.

Who is in the revolving door? Policy and practice implications of recurrent reports to adult protective services.

Repeat referral to adult protective services APS (recurrence) is a much-discussed topic among APS agencies as it may indicate ongoing harm, yet there is limited research examining prevalence or causes. This paper provides a foundational investigation of recurrence within a California APS county program. Drawing from thirty-three months of de-identified reports, we used logistic regression to examine the impact of intake report characteristics on repeat referral within one year after baseline case closure. One-fifth of the sample was recurrent (19.9%, n=987/4,958), with self-neglect being the most common type of report to recur (14.3%, n=307/2,141). Overall recurrence was predicted by female gender, older age, living alone, and multiple elder abuse, neglect, and exploitation (ANE) types reported at baseline, and report placed by social service provider, friends, family, landlords, and victim self-reports. Reporters personally related to the victim and social service providers are potential partners in identifying ANE, and alternate intervention approaches may be necessary.

Capacity evaluations for adult protective services: videoconference or in-person interviews.

The Geriatrician clinicians of the Texas Elder Abuse and Mistreatment Institute - Forensic Assessment Center Network (TEAM-FACN) in Houston, have many years of experience providing capacity assessment services for Adult Protective Services (APS) and Texas courts. A process has developed which is efficient, consistent, and evidence-informed. In the last two years, telecommunication has been added to this process to conduct assessments of APS clients in areas of Texas remote from the Houston area. Of the 545 capacity assessments TEAM-FACN has completed across the state of Texas over the first two years of adding telecommunication, 211 (39%) were conducted with in-person interviews and 334 (61%) were conducted using videoconference interviews. APS and the courts in remote areas of Texas have embraced the use of the videoconference assisted capacity assessments. This article describes this evidence-informed process and how telecommunication technology is incorporated to expand the reach of the service.

Can standardized measures provide helpful feedback about adult protective services substantiation? Pilot data from a short self-neglect assessment.

Can standardized assessment contribute to improving Adult Protective Services (APS) practice? In this exploratory study, San Francisco and Napa APS utilized a newly developed short self-neglect assessment to test how standardized measures provide information for substantiation decision making. Findings demonstrated satisfactory reliability and validity for the short self-neglect assessment, and analyses revealed important issues that could improve practice. Review of outliers revealed: (1) problems using the assessment tool, (2) misunderstandings of APS procedures, and (3) struggles navigating the case management system. These revelations could all be easily addressed in training. Caseworker's clinical judgment and experience also continue to have a place in complementing the use of the standardized assessment.

"Opening the door": developing and pilot testing an adult protective services worker engagement training in New York city.

About 10% of Americans over the age of 60 experience elder abuse (EA), but EA is frequently under detected. As the primary responders for alleged EA cases, Adult Protective Service (APS) caseworkers are ideally positioned to improve detection and intervention. The Opening the Door (OTD) training was developed in a multidisciplinary setting and designed in collaboration with APS workers to enhance their engagement skills in potential EA cases and thus maximize the possibility of disclosure. Rooted in a relational approach and utilizing adult learning theory, it is divided into three main topics: Preparing for Engagement, Engagement Practice, and Processing Engagement. The eight-hour training was piloted with three groups of urban APS caseworkers with a wide range of work experience. Pre- and post-tests and case reflections indicate a positive impact on caseworkers' sense of self-efficacy, while focus groups indicate the necessity for ongoing provision of trainings and development of additional supports for APS caseworkers. Future work could further explore the efficacy of the training and expand its reach.