A. Elder Abuse Prevention Interventions Background
Elder Justice Act and AoA's Prevention Interventions Demonstration Program
The Elder Abuse Prevention Interventions demonstration, authorized by the Elder Justice Act and funded by the Administration on Aging (AoA), U.S. Department of Health and Human Services (HHS) in FY 2013, provided funding to test interventions designed to prevent elder abuse, neglect, and exploitation. The Elder Abuse Prevention Interventions program provided $5.5 million to five states and three Tribes.
The HHS Office of the Assistant Secretary for Planning and Evaluation (ASPE) contracted with NORC at the University of Chicago to design and conduct an evaluation of the interventions being tested through this demonstration. The purpose of the evaluation was to study the development and implementation of the state grantees' elder abuse interventions and report findings on the characteristics of victims and perpetrators of elder abuse or those at-risk, the use of prevention services, and outcomes. Awards for the five states ranged from $625,000 to $1,020,000 for a three-year period. The five grantees funded by AoA are:
Alaska Division of Senior and Disabilities Services (AK DSDS)--Using a Critical Time Intervention Approach for Elder Services Case Management
New York State Office for the Aging (NYSOFA)--Using Enhanced Multi-Disciplinary Teams to address Financial Exploitation
Texas Department of Family and Protective Services and the WellMed Charitable Foundation (TX/WellMed)--Implementing Elder Abuse Screening and Embedding APS Specialists in Clinical Settings
University of Southern California (USC)--Take AIM against Elder Abuse: The Abuse Intervention Model
University of Texas Health Science Center (UTHSC)--The Self-management of Medication of Independent Living Elders who Self-Neglect (SMILES) Study
Grantees were expected to finalize partnerships with Adult Protective Services (APS) and related institutions, develop and implement the proposed intervention, collect and deliver program data to AoA/ASPE and the evaluation (for a minimum of 18 months), and report semi-annually on achievements, barriers, and strategies to overcome those barriers.
All pilot projects shared common goals and requirements, including: (1) the design of a selective and/or indicated preventive intervention; (2) targeting of 1-3 categories of people at high risk of elder abuse; (3) the establishment of key stakeholder partnerships; (4) provision of local and state-level APS administrative data; and (5) agreement to collect a core set of data elements. Beyond these five objectives, grantees were afforded broad discretion in developing prevention interventions tailored to their specific communities and contexts.
Collectively, the interventions included the development and/or use of various screening and assessment tools, time-limited case management, tailored health promotion, enhanced multi-disciplinary teams (E-MDTs), improved coordination of referral and care, projects supported by multiple and diverse partnerships, and provision of education and training to a variety of target audiences (e.g., clients, clinicians, professionals, communities of interest). All projects were directly responsible for developing and customizing care plans. However, some projects directly administered those services to clients, whereas others either coordinated existing services or provided a combination of the two. Pilot projects were also characterized by their heterogeneity, including a focus on one type of abuse or potentially all forms, implementation in a variety of settings (primary care, APS, multi-disciplinary teams, etc.) and geographic areas (urban and rural), as well as assorted recruitment strategies or points of entry.
Given the complex and multi-dimensional nature of elder abuse, as well as different underlying theories guiding elder abuse subtypes, each of the five grantees developed a variety of multi-component and/or multi-disciplinary prevention interventions for elder abuse victims and/or perpetrators. Below is a brief description of each grantee's prevention intervention.
AK DSDS through the APS Unit and in partnership with the Anchorage Police Department and other key partners implemented, tested and measured the performance of the Critical Time Intervention (CTI) case management model to prevent elder abuse, neglect and exploitation. CTI is an evidence-based model shown to be successful in preventing homelessness among individuals with mental illness following institutional discharge. Alaska's pilot represented the first time CTI was applied to vulnerable adults. The project targeted services to both victims and where possible, caregivers.1
NYSOFA, in conjunction with multiple partners, implemented an E-MDT incorporating forensic accountants and geriatric psychiatrists to investigate and intervene in complex cases of elder financial exploitation and elder abuse. The intervention was aimed at improving protecting victim safety and assets through systems collaboration and awareness of signs of financial exploitation among both the public and private sectors (i.e., financial industry) and was implemented in Manhattan by the New York City Elder Abuse Center (NYCEAC) and the Finger Lakes region by Lifespan of Greater Rochester.
The USC Keck School of Medicine in partnership with the California Department of Aging, California Department of Social Services, Legal Aid Society of Orange County, and the Orange County Elder Abuse Forensic Center piloted a multi-dimensional intervention called Abuse Intervention Model (AIM) that targeted elder abuse prevention among adults with dementia. The project designed and piloted a multi-component model for primary and secondary prevention of abuse of elders with dementia. This involved early assessment of vulnerability and targeted interventions for the person with dementia and/or the caregiver.
The UTHSC at Houston, in partnership with APS, the Texas Department of Aging and Disability Services (DADS), and the Houston area justice system piloted an intervention to increase medication adherence in older adults who have chronic health conditions and who neglect themselves. The tailored health promotion intervention implemented by UTHSC was aimed at increasing the active participation of elder self-neglecters in managing their chronic disease medications, reducing their level of social isolation, and implementing environmental supports to increase medication adherence.
TX/WellMed developed and tested clinical screening protocols within WellMed Clinics, including use of the Elder Abuse Suspicion Index© (EASI) screening tool to identify at-risk elders and prevent elder abuse. The screening protocols were implemented in WellMed clinics in five areas of Texas: San Antonio, Austin, Corpus Christi, the Lower Rio Grande Valley, and El Paso. TX/WellMed also embedded two APS Specialists within WellMed Medical Management Inc. (WMMI), a primary care physician group, to provide technical assistance, communication facilitation, and education supporting increased screening to prevent elder abuse.
Description of the grantees' prevention interventions are noted in Table 1 below. They are arrayed based on whether they served victims, at-risk elders and victims, and care recipients and caregivers.
|TABLE 1. Description of Grantee Prevention Interventions|
|Intervention Strategy||Tailored medication adherence intervention involving home visits and social calls||ESCM Prevention Intervention||E-MDT including forensic accountant and geriatric psychiatrist||Use of EASI screening tool and embedding of APS specialists within WellMed clinics||Multi-component intervention focusing on care recipient/ caregiver dyad|
|Intervention model||2 previous feasibility studies||CTI for homeless population||Brooklyn MDT||EASI tool tested previously in primary care setting||REACH* (caregiver component)|
|Type of prevention**||Indicated||Selective and Indicated||Indicated||Universal and Selective||Universal and Selective|
|Type of abuse addressed||Self-neglect||All forms||Financial neglect and co-occurring forms of abuse||All forms||All forms|
|Setting||Community||Community||Community||Primary care setting||Primary care setting|
|Location of intervention||Houston area||Municipality of Anchorage||Manhattan and Finger Lakes region||San Antonio Corpus Christi Austin Lower Rio Grande Valley El Paso||Orange County|
|Intervention duration||6 months||9 months||Open-ended||Open-ended||3 months|
|Implementation Staff||Registered Nurse, Research staff (2), Geriatrician||Case Managers (3)||E-MDT Coordinators (2); Multi-disciplinary teams (8)||APS Specialists (2)||Clinical Interviewer|
|Participants||Victims||At-risk elders/Victims||At-risk elders/Victims||At-risk elders/Victims||Care recipients Caregivers|
|Participant criteria for elders||Frailty||Physical and cognitive impairment||Physical and cognitive impairment, social isolation||Frailty||Dementia|
|Age minimum||65 years||60 years||60 years||65 years||65 years|
|* REACH refers to Resources for Enhancing Alzheimer's Caregiver Health project.
** Prevention interventions are generally designed to target those at risk for being involved in elder abuse, neglect or exploitation. A commonly used classification system was developed by the Institute of Medicine in 1994, and incorporates the concepts of universal, selective, and indicated preventive interventions. A description of each concept and their corresponding primary, secondary, and tertiary designations (which is not part of the IOM classification) are: (1) Universal Preventive Interventions (primary), targeted to the general public or communities of interest and not based on individual risk factors; (2) Selective Preventive Interventions (secondary), which are targeted to a subgroup of the population determined to be at higher risk for experiencing a phenomena; and (3) Indicated Preventive Interventions (tertiary), targeted to individuals displaying detectable signs of a phenomena.
B. Organization of the Report
Chapter II of the report presents an overview of the purpose of the evaluation and the key research questions, followed by the guiding framework for the presentation of findings. We then describe the data sources and data collection procedures, followed by the analytic approach and limitations of the study. Chapter III focuses on elements of grantees' planning for implementation of the prevention interventions, addressing the evidence base or theoretical/clinical basis of the interventions, setting characteristics, partnerships, and scale. It also describes the use of evaluability assessment by the research team to explore the feasibility of evaluating each prevention intervention. Chapter IV describes key components of the prevention interventions. This includes: the target population; problems addressed; essential intervention components; delivery method; duration of the intervention; manual and training information; service provider roles; and intended outcomes. Adaptations to fit the local context are discussed, as are facilitators and challenges to implementation. Although an examination of the implementation costs and resources expended was not in scope of the evaluation, the value to address costs in future is noted. Chapter V presents the findings related to the risk factor of the elders served by the prevention interventions, service utilization patterns, and outcomes.