This section presents core theoretical components and infrastructure of the prevention interventions developed and implemented by the five grantees, using the Framework as an organizing structure.2
A. Evidence Base/Theoretical Base for the Elder Abuse Prevention Interventions
Among the most immediate needs of the field of elder abuse is a coherent and systematic body of research to inform and guide its efforts, including building an evidence base in effective prevention. While descriptive and observational studies on elder abuse research and practice exist, data on effective methods and practices to prevent or ameliorate mistreatment is significantly lacking and such intervention programs are rarely subject to rigorous evaluation (Daly et al. 2011, 2009; National Research Council 2003; Pillemer et al. 2007; Ploeg et al. 2009).
Crucial to the development of effective and appropriate prevention interventions is an understanding of the potential risk factors for involvement in elder abuse, neglect and exploitation, both as a victim and an abuser. While the following conditions are highly contingent upon the specific category of elder abuse under study, we know from the growing research literature that elder mistreatment in its various forms is associated with health issues and physical impairment, mental health problems, cognitive impairment and dementia, social isolation and inadequate social support, experience of previous traumatic events, shared living arrangements, psychological problems and substance abuse, and abuser dependency on the victim (Acierno et al. 2010; Anetzberger 1987; Beach et al. 2010; Burnett et al. 2006; Dong et al. 2010; Dyer et al. 2000; Fisher & Regan 2006; Lachs et al. 1997; Payne & Gainey 2005; Pillemer & Finkelhor 1988; Wiglesworth et al. 2010). Perpetrators, moreover, are often family members, including adult children and spouses (Acierno et al. 2009).
Elder abuse is a complex and multi-dimensional phenomenon. Given theories of mistreatment differ by category of abuse, moreover, it follows that interventions for particular types of abuse will also differ. While not an exhaustive inventory of programmatic elements, current prevention interventions include screening, mandatory reporting, APS intervention, caregiver support interventions, education of professionals, education of potential victims, home visitation by police/social workers, social support and self-help groups, safe houses and emergency shelters, daily money management programs, case management, multi-service programs, and partnerships with faith communities (Daly et al. 2011; Pillemer et al. 2007; Ploeg et al. 2009).
Reflecting this complexity, each of the elder abuse prevention interventions built upon, or was informed by, a theoretical or clinical foundation aimed at reducing risk or addressing the impact of substantiated abuse, neglect or exploitation for the target population embedded in distinct ecological contexts and relationships. The diversity of conditions and prevention interventions implemented speak to the challenge of defining a unifying conceptual framework in the field of elder abuse (National Research Council 2003). The interventions ranged along a continuum, from detection to prevention to direct intervention. TX/WellMed's project spanned all three, focused on screening for elder abuse using the EASI screening tool, applying preventive measures, and having APS intervene were necessary. USC's Take AIM tested a multi-component model for primary and secondary prevention of abuse of older people with dementia, as they are known to be at high risk for abuse. NYSOFA's E-MDTs intervened in cases of suspected or known financial exploitation. AK DSDS CTI focused on mobilizing supports for at-risk and victimized elders. UTHSC's tested an intervention to increase medication adherence among older adults with a substantiated report of self-neglect, as well decrease social isolation.
To detect elder abuse, neglect, and exploitation among elderly patients in a primary care setting, TX/WellMed administered the EASI in WellMed clinics. The EASI screening tool was developed to improve physicians' identification of elder abuse and to promote referrals of at-risk elders and potential victims for assessment and services (Yaffe, Wolfson, Litwick & Weiss 2008).
|EASI Screening Tool|
The six-item EASI screening tool is administered to cognitively intact elders. Five detection questions are asked as well as one question that must be completed by the physician, as shown at left (the first five may be administered by clinical staff). The impetus for implementing the EASI tool arose from feedback that WellMed Charitable Foundation received when conducting trainings with clinicians. Staff would invariably describe situations that related to elder abuse. There was a clear need to establish protocols on how to identify and report cases of suspected abuse to APS and social services. TX/WellMed's intention for the prevention intervention was to develop a clinical protocol that would screen at least 10,000 patients with the EASI tool and provide patient and caregivers materials and education. The goal was to develop a highly replicable model of screening for elder abuse risk in a primary care environment, along with multiple tools to successfully address elder abuse issues.
Assessment and Prevention
Research in child abuse (Scribano 2010) and domestic violence and intimate partner violence (Murray & Graybeal 2007) has demonstrated: (1) the importance of embedding prevention programs within the social context, targeting family members as well as victims; and (2) tailoring culturally-appropriate prevention strategies to the unique characteristics and needs of the individual situation. Applying this perspective to elder abuse, USC's Take AIM prevention intervention was situated in a social-ecological framework, which stressed the importance of embedding prevention programs within its social context (Doll et al. 2007). As adults with dementia are at higher risk for abuse than other groups of older adults (Anetzberger et al. 2000; Beach et al. 2005; Cooper et al. 2010) and the demands of caregiving may result in caregivers becoming abusers, the goal of Take AIM was to pilot test a multi-component model for early assessment of vulnerability to elder abuse and early preventive intervention, focusing on care recipient/caregiver dyads.
Acting on the findings of the 2011 prevalence study which found that the financial exploitation of elders is a common, serious, and under-reported problem in New York, NYSOFA developed the E-MDTs to address this issue. Findings from the study, Under the Radar: New York State Elder Abuse Prevalence Study Self-Reported Prevalence and Documented Case Surveys (2011) found an elder abuse incidence rate in New York State that was nearly 24 times greater than the number of cases referred to social service, law enforcement or legal authorities. An estimated 260,000 older adults in the state had been victims of at least one form of elder abuse in 2008-2009. Financial exploitation was the most prevalent form of mistreatment reported by respondents, whereas psychological abuse was the most common form of mistreatment reported by agencies providing data on elder abuse victims.
In response, and building on the multi-disciplinary team model involving diverse professionals to address elder abuse (Malks et al. 2003; Teaster & Nerenberg n.d.), NYSOFA's prevention intervention was structured to provide a coordinated approach to investigate and intervene in cases of financial exploitation--where vulnerable elders were subject to undue influence, duress, fraud, or a lack of informed consent--as multi-disciplinary teams have been shown to increase prosecution rates for financial exploitation (Navarro et al. 2012). The E-MDT pilots in Manhattan and the Finger Lakes region were adapted from the Multi-Disciplinary Team model that was successfully implemented in Brooklyn by NYCEAC in 2010 (Ramírez et al. 2012). Enhanced by NYSOFA, the E-MDTs focused on financial exploitation and involved a forensic accountant and geriatric psychiatrist.
AK DSDS's goal in implementing the prevention intervention was to increase community and social support to vulnerable elders and provide services not met by APS. AK DSDS provided case management services over a nine month period to older adults who were at high risk of or who had experienced abuse, neglect, or exploitation. The grantee implemented CTI, a time-limited evidence-based practice that mobilizes support systems and continuity of care during periods of transition.3, 4 The intervention begins with developing a trusting relationship, and then progresses to build and transition supports over three phases: (1) Providing support and connecting the client to services for primary support; (2) Monitoring and strengthening the support network and client's skills; and (3) Transferring services to the support network in place to ensure continuity of care. The model has been used with returning veterans and people with mental illness or those who have been homeless or in prison. AK DSDS's pilot marked the first time that CTI was used with a vulnerable older population.
Elder self-neglect is a serious public health problem and a prevalent concern for APS (Naik et al. 2008). A number of state statutes classify self-neglect as mistreatment that warrants APS involvement (National Research Council 2003). Yet there is considerable debate as to whether self-neglect is a distinct form of elder abuse, along with research underway to better understand its causes and relation to other forms of abuse, neglect, and exploitation. UTHSC's intervention addressed this population, and focused on older adults who had a substantiated report of self-neglect, chronic health conditions, and did not adhere to a medication regimen. The community-based intervention was modelled on an effective home-based treatment protocol using environmental cues and supports to improve medication adherence with a population of adults with severe mental illness (Velligan 2008). Adapted to self-neglecting elders with multiple chronic conditions, the goal of the intervention was to increase medication adherence and reduce adverse outcomes associated with elder self-neglect, including social isolation, dependence, health problems, and likelihood of re-referral to APS.
The five prevention interventions took place in diverse geographic locations nationwide and reached elders in urban, suburban and rural areas, encompassing major metropolitan areas and counties statewide. AK DSDS's ESCM intervention was implemented in the municipality of Anchorage but had a 100-mile service area. USC's Take AIM prevention intervention focused on Orange County and capitalized on pre-existing resources and relationships with the academic and medical community, along with social and legal services.
NYSOFA led two E-MDTs in New York State. One was housed at the NYCEAC in Manhattan and the other at Lifespan of Greater Rochester, which served seven counties in the Finger Lakes region (Monroe, Cayuga, Livingston, Ontario, Seneca, Wayne and Yates counties). UTHSC's medication adherence prevention intervention was located in Houston and covered a 13 county area in southeastern Texas. TX/WellMed's intervention was conducted in WellMed primary care clinics located in four APS regions throughout the State of Texas: San Antonio (Region 8), Austin (Region 7), Rio Grande Valley and Corpus Christi (Region 11), and El Paso (Region 10).
Diverse contextual factors were taken into consideration when planning the prevention interventions. They included: (1) the organizational culture and climate of the primary care setting and clinical hierarchies and routines (TX/WellMed); (2) the social dynamics of small-knit communities (NYSOFA-Lifespan); (3) statewide rural to urban migration and social networks (AK DSDS); (4) the impact of population loss on social isolation of elders and lack of affordable housing (NYSOFA-Lifespan); (5) social diversity and cultural norms (NYSOFA-NYCEAC); and (6) first generation immigrant elders' lack of engagement with the health care system and reliance on traditional healers (UTHSC).
As a condition of the AoA cooperative agreement, each grantee was required to partner in a meaningful way with the state APS agency, a State Unit on Aging, and the justice system. Partnering with APS was essential in order to implement interventions at the local level and also to obtain administrative data to assess outcomes. Coordination with a State Unit on Aging could leverage the resources of aging network service providers and assist with intervention implementation. Connecting with the justice system was essential to ensure that vulnerable elders or their advocates had recourse to law enforcement and/or legal services organizations.
1. Relationship to Adult Protective Services
Grantee partnerships with APS depended on the focus of the prevention intervention and target population. Across the five prevention interventions, APS served as the lead entity, as key implementation partners, and as referral sources. The APS unit at AK DSDS led the CTI and staff served as case managers working directly with elders. APS specialists from Region VIII in Texas were embedded in WellMed's primary care clinics, where they served as liaisons between APS and WellMed, conducted educational trainings, and served as a resource to staff. Local APS units in the Finger Lakes region and Manhattan served on NYSOFA's E-MDTs with the approval of the New York State Office of Children and Family Services. APS Region VI in Texas served as the referral source for self-neglecting elders participating in UTHSC's medication adherence intervention. APS in Orange County, California was one of a number of community-based referral sources for USC's Take AIM intervention. Three APS units--AK DSDS, TX/WellMed, and UTHSC--also provided administrative data to examine program outcomes.
2. Relationship to Aging Networks
The AoA grant program required that each grantee coordinate with a State Unit on Aging in order to leverage the resources of aging network service providers and assist with intervention implementation. The AK DSDS was already an organizational unit within the State Unit on Aging and in a leadership role in the community. Aging services representatives served on the Monthly ESCM Community Partners Meeting convened by AK DSDS that was convened to address challenging cases of elder abuse and coordinate services. For many of the grantees, however, the interventions served local communities and Area Agencies on Aging were enlisted to support the interventions. The California Department of Aging was a key partner with USC's Take AIM prevention intervention, and through its Area Agencies on Aging network in Orange County, facilitated access to community-based services. Area Agency on Aging representatives served as core members of the NYSOFA E-MDTs and on the project advisory committee, along with APS, for UTHSC's prevention intervention.
3. Relationship to the Justice System
The AoA grant program also stipulated that grantees' connect with the justice system to ensure that vulnerable elders or their advocates had access to law enforcement and/or legal services organizations. These alliances were rooted in long-standing organizational affiliations and relationships to address elder abuse in their communities. Three grantees involved the justice system as part of the operating structure of the prevention intervention. For two grantees, the justice system played a more peripheral role in the prevention intervention but was actively involved with elder abuse prevention and APS activities.
Representatives from the District Attorney (DA) offices in Manhattan and Monroe County were core members of the NYSOFA E-MDTs, as well as law enforcement specialists in financial crimes. (However, inclusion of the Manhattan DA on the E-MDT later changed due to constraints on reporting information that might compromise prosecution). Law enforcement in both jurisdictions provided referrals to the E-MDT Coordinators. Partnership with the Orange County Elder Abuse Forensic Center was a key component of USC's prevention intervention, and included representation from the DA's office, Sheriff's Department, and the Public Administrator/Public Guardian. Officers from the Anchorage Police Department served on the Monthly ESCM Community Partners Meeting convened by AK DSDS.
While not directly involved in the implementation of the prevention intervention, Houston area law enforcement is affiliated with the Texas Elder Abuse and Mistreatment Institute which housed UTHSC's medication adherence intervention. To guide the intervention, TX/WellMed initially intended to form an advisory council comprising the San Antonio sheriff's department, the San Antonio police department, and the DA's office. Given that the three agencies were already deeply involved in APS Region VIII daily activities, TX/WellMed ultimately decided to forgo this approach.
D. Evaluability Assessment
At the outset of the evaluation, the evaluation team conducted evaluability assessments. Although this was not a required component of the grantee initiative, we did so to determine whether the grantees were in need of any technical assistance to participate in the evaluation. To this end, we reviewed their logic models, research questions, intended activities, outputs and outcomes, data collection sources and analysis plans, intervention timelines, and resources that would be dedicated to the evaluation. Following this activity, we worked with the grantees to refine some elements of their plans. This activity was instrumental in establishing a degree of comparability across the prevention interventions with respect to intended measures and outcomes. This activity also identified the need to develop a database for one grantee for data collection and extraction. Overall, the evaluability assessments facilitated the development of the evaluation and analytic plan.