A. Implementation Strategies
1. Prevention Intervention Characteristics
The target populations for four prevention interventions were elders at risk of abuse, neglect or exploitation (USC, AK DSDS, NYSOFA, TX/WellMed). One prevention intervention focused exclusively on substantiated victims of self-neglect (UTHSC). The minimum age for eligibility in the intervention was 60 years for two prevention interventions (UTHSC, NYSOFA) and 65 for the other three (AK DSDS, TX/WellMed, USC). The majority of elders was community-dwelling and resided in private homes, although some resided in assisted living or group homes. The prevention interventions served elders living in diverse urban, suburban, and rural areas.
Frail elders and those with cognitive impairment or dementia were targeted by the prevention interventions. A few of the prevention interventions identified similar risk factors with respect to elders' mental and physical health, which then served as eligibility criteria. Three prevention interventions targeted elders with cognitive impairment or dementia (AK DSDS, NYSOFA, USC) and four targeted elders with a physical impairment or health problem(s) (AK DSDS, NYSOFA, UTHSC, TX/WellMed). One prevention intervention targeted elders with detectable signs of possible financial exploitation present (NYSOFA).
Certain prevention interventions emphasized the connection between a vulnerable elder and a trusted person in his/her social network and the potential for abuse (i.e., the focal subject and responsible actor). This focus on relationships varied across the prevention interventions, as did the clinical or service delivery effort. USC explicitly focused on older adults with dementia at risk for abuse and their primary caregivers. In cases served by AK DSDS, there was a known abuser who was dependent on the victim. NYSOFA identified social isolation and inadequate social support as risk factors (and eligibility criteria), along with identification of perpetrators of financial exploitation, for cases served by the E-MDTs in the Finger Lakes region and Manhattan.
The prevention interventions varied in the number of elders served over the course of the three-year grant period. Original expectations were tempered by the ebb and flow of referrals from partners or the willingness of elders to participate. Changes in the anticipated number of elders to be served were approved by AoA through the grant modification process.
Three of the prevention interventions had rolling enrollment but with defined periods for participation and completion, therefore the numbers reported herein are stable. AK DSDS received 170 referrals and had 87 elders participate in ESCM. UTHSC recruited and enrolled 34 elders in the medication adherence prevention intervention. USC recruited a cohort of 76 dyads. Two prevention interventions had a more fluid referral stream. The NYSOFA E-MDTs served more than 220 elders (over the 18 month period covered by the DUA). At any given time, this included new cases and follow-up cases. TX/WellMed screened 11,426 elders using the EASI tool. Of these, 35 elders were referred to APS. Additionally, 588 WellMed patients were served through the APS specialists and 474 were referred to APS. APS had 310 victims in their records. The difference in number is in part due to the longer period of data collection by the APS Specialists.
Collectively, the prevention interventions targeted and addressed multiple forms of abuse, neglect, and exploitation and its co-occurrence. While the eligibility criteria focused on defined risks, co-morbid problems were addressed through the intervention. Those that emerged through assessments or during the intervention were addressed through referrals to service partners. UTHSC's intervention focused on medication adherence for self-neglecting elders, yet also by design addressed social isolation, dependence, health problems, and the likelihood of re-referral to APS. Along with cognitive impairment, case managers implementing the CTI with AK DSDS found that their clients had health problems, mental health issues, depression, substance abuse issues, and were homeless or had no family or support system in place. While targeting financial exploitation, NYSOFA's E-MDTs addressed the presenting and immediate safety issues of a case but also elders' basic needs, such as legal guardianship, medical assistance, food security, and housing. TX/WellMed's intervention benefitted from the complementary services that APS and WellMed provided, which often expedited patient services. For example, whereas APS could not make specific recommendations on nursing homes to families, WMMI social workers had a network of nursing homes that they could recommend. Alternatively, if WellMed patients were out of their medication, APS had access to and could use purchase client funds to address client needs. APS could provide a diverse array of services to clients, including counseling, money management, pest removal, housecleaning, building ramps, and boarding pets, among others. Focused on dyadic relationships and elder abuse risk factors, USC addressed care recipients' aggressive behavior, resistance to care, and activities of daily living (ADLs) dependency due to dementia and caregivers' anxiety, depression, and burden.
Essential Intervention Components
Building upon a theory of change, the core components of a program or intervention are the essential functions or principles and activities that are necessary to achieve the intended outcomes (Blase & Fixsen 2013). Identification of these core components is necessary to determine if a program or intervention had been "successfully implemented, effectively evaluated, improved over time, and subsequently scaled up if results are promising" (Blase & Fixsen 2013:10). The core components of each grantee's prevention intervention are briefly described below.5
AK DSDS: The ESCM prevention intervention was an adaptation of the CTI for homeless populations, which uses a client-centered approach. The ESCM included multiple components: referral and intake; informed consent; a nine-month case management intervention; and monthly community partner meetings. Support was provided over three phases. During the first three months (Transition Phase), case managers provided specialized intense support and set goals with the client to address critical needs (e.g., obtaining food, housing, transportation, or medical attention). Client contact was very high and involved frequent home visits and phone calls. Months 4-7 (Try-Out Phase) involved identifying informal and formal supports to meet client needs, with greater responsibility transferred to the client, identified caregiver, or service providers. Regular contact continued. During the last two months (Transfer Phase), case managers transferred care to the long-term support system created for the client. Contact with the client was reduced to monthly conference meetings. A case manager generated a report of harm report if the client was in need of APS.
NYSOFA: E-MDT meetings convened by Lifespan and NYCEAC were typically held twice per month for 1.5-2 hours, and were facilitated by the E-MDT coordinator. Each E-MDT was composed of professionals from multiple agencies and organizations, including APS, aging services and resource centers, law enforcement, DA's office, legal services, community-based organizations, the banking industry, shelter services, geriatric medicine, and forensic accounting and financial investigations. Participation was required for core members. Case presentations were held which addressed the reason for referral, presenting issue(s), alleged perpetrator(s), the nature of abuse, and interventions provided to date. Comprehensive assessments were conducted to identify service needs (e.g., safety plan, order of protection, health care needs, mental health treatment referrals, guardianship, caregiver supports or respite, temporary housing or shelter, or APS home visits). Participants discussed each case of financial exploitation and identified barriers, resources, and action steps. The E-MDT Coordinator prepared an action plan for referrals and services. The E-MDTs used a coordinated, person-centered care approach. All E-MDT members were held accountable to follow through with assigned action items to ensure the cases moved forward in a timely manner. Depending on the fact pattern of the case and forensic accountant review, criminal prosecution of the suspected perpetrator was pursued. Plans and supports were revisited at subsequent E-MDT meetings until case resolution.
TX/WellMed: The prevention intervention had four components.6 First, APS specialists were embedded at WellMed and served as a resource by providing educational training to clinicians on elder abuse, neglect and exploitation, instruction on how to use the EASI screening tool, and the clinical protocols for reporting flagged cases to APS and WellMed's Complex Care workers. They also provided consultation to clinical staff through individual inquiries or PCC meetings for high-risk patients (i.e., due to hospitalization, discharge, etc.). Second, clinicians were trained on screening and identification of elder abuse. Third, medical staff and physicians administered the EASI screening tool to cognitively intact patients without the presence of their caregiver at least once a year. The risk-level was assessed (high, elevated, or low) and the corresponding protocol followed: High-risk patients were reported to APS and referred to WellMed's Complex Care worker; Elevated risk patients were referred to complex care for follow-up; and Low-risk patients did not receive intervention. All patients, regardless of rating, were offered educational materials on elder abuse, neglect and exploitation; families received information on caregiver stress. The EASI tool was incorporated into the electronic medical record. Fourth, caregivers of WellMed patients with dementia or Alzheimer's disease were referred to their Stress Busting program.
USC: Focusing on care recipient and caregiver dyads in which the care recipient had dementia, the multi-component Take AIM intervention included baseline and follow-up risk assessments, linkages to existing services in the community to address identified needs and risks, and home visits over the course of three months. During the first home visit and assessment, the care recipient and caregiver (the dyad) were interviewed separately. The USC interviewer assessed decision-making capacity, obtained informed consent, and administered the risk assessment. For the care recipient, the domains assessed were aggression, resistance to care, and ADLs dependency. Risk domains assessed for the caregiver were anxiety, depression, and perceived burden. Contextual factors, such as limited social support, financial strain, and relationship quality, were assessed. A risk assessment profile was developed and appropriate community-based resources for assistance were identified (i.e., treatment, training, or concrete service). USC developed a Toolkit of Existing Interventions to address each need identified. For care recipients with dementia this included: Geropsychiatry to address aggression; the Savvy Caregiver Plus course to address resistance to care; and in-home caregiver agency for ADL dependency. For the caregiver, options included: Problem-Solving Therapy to address anxiety; Individual counseling to deal with depression; and the Friendly Visitor Program to address burden. A caregiver support group was recommended for limited social support, Legal Aid to help with financial strain, and family counseling to address concerns with relationship quality. The profile was reviewed during the second home visit. During the third and final home visit, the USC interviewer assessed decision-making capacity, administered the follow-up risk assessment, and assessed service use, based on the interventions suggested in the Toolkit.
UTHSC: The medication adherence prevention intervention for self-neglecting elders included multiple components: referral and intake; informed consent; a six-month medication adherence intervention; and a six-month follow-up phase. The three step enrollment process involved both APS and the UTHSC team. The APS caseworker conducted a home visit with a substantiated self-neglecting elder and asked if s/he was interested in the medication adherence intervention. If interested, the UTHSC research staff called the elder to verify eligibility, and then research staff led elders through the informed consent process. The six- month intervention focused on social support and medication management through monthly, one-hour home visits, premised on communication and engagement. In Months 1 and 2, activities focused on the baseline assessment, the medication safety assessment (conducted by a geriatrician), and education. The education component was tailored to each elder's knowledge and personal efficacy skills. During months 2-6, the registered nurse and research assistant made joint home visits to provide further education and troubleshoot medication management concerns. In the post-intervention phase, UTHSC conducted home visits to monitor adherence and provide educational reinforcement.
Delivery Method and Duration
As to be expected given the heterogeneity of the five prevention interventions, their delivery methods and service duration varied, and depended on the population targeted and the nature of abuse or risk.
One common delivery element across all of the prevention interventions was the use of home visits as a primary method to reach at-risk elders, although the degree of contact varied. AK DSDS case managers conducted multiple home visits and had telephone contact with elders while implementing the CTI model. UTHSC's research nurse and staff conducted monthly home visits and had weekly telephone contact with elders to monitor medication adherence. The program coordinator and interviewer for USC's Take AIM intervention focused on monthly home visits with care recipient and caregiver dyads over the three month intervention period. Although the NYSOFA's E-MDTs did not engage directly with elders, service professionals recommended increasing the number of home visits by APS to monitor and mitigate risk.
As noted above regarding the core components, the intensity or dose of services varied with each prevention intervention, depending on the identified needs, the treatment protocol or case plan, the resource capacity of providers, and uptake by the elder. The duration of the prevention interventions varied, as well. Three were time-limited, with the duration ranging from three-months (USC), six-months (UTHSC), or nine-months (AK DSDS). Two were open-ended and depended on case resolution by the E-MDT (NYSOFA) or APS intervention as a result of screening or care coordination efforts (TX/WellMed).
Manual and Training Information
To varying degrees, each of the prevention interventions were standardized (or manualized) by creating manuals and protocols for staff implementation. As noted in the research literature, manualization provides structure to an intervention, improves implementation fidelity, and fosters well-designed research (Goldstein et al. 2012). While time-consuming, it yields multiple benefits, helping to identify key intervention components and processes; ensure quality service delivery and supervision; ensure consistency and fidelity of service delivery; and replicate practices (Fraser et al. 2009). In human service delivery environments were turnover is high, such as APS, manualization of an intervention helps to orient and train new staff, build and maintain organizational capacity, and transfer and share knowledge. Manualization also assists with documenting adaptations to a protocol and decision rules over time, as well as increasing team accountability to the protocol.
UTHSC's team used Intervention Mapping (Bartholomew et al. 2006) to develop theory-based protocols and to map core components to desired behavioral outcomes for the medication adherence prevention intervention. The team was actively involved in the development of the study instruments, procedures manual, and protocols. Training to implement the intervention included 1-2 observations with the geriatrician interacting with the participant, a review of the assessments, a clinical training session on the informed consent process, in-home observations of the protocol, and a review of safety procedures. Working closely with the Lifespan and NYCEAC teams, NYSOFA developed a Decision Document that guided the eligibility, intake, service utilization tracking, and financial exploitation outcomes for the elders served, taking into consideration policy and operational distinctions of the Finger Lakes' and Manhattan jurisdictions. USC's Take AIM prevention intervention developed and implemented an assessment tool that generated a risk profile and a Toolkit of Existing Interventions that specifically addressed the identified risk factors.
AK DSDS case managers received in-person training on CTI from the program developer (Center for the Advancement of Critical Time Intervention) to implement the prevention intervention. Case managers were also trained in Motivational Interviewing. TX/Well conducted a Training the Trainer for the APS Specialists to train WellMed clinical staff on APS reporting requirements and procedures, how to administer the EASI tool in the clinics with WellMed patients, and the protocols for how and when to report a case to APS for follow-up.
|TABLE 2. Intended Outcomes of Prevention Interventions|
|Target Populations||Prevention Intervention||Intended Outcomes Over Time -->|
|Care Recipient and Caregiver Dyads||USC||
|At-risk Elders and Victims||AK DSDS||
Service Provider Involvement
The role and scope of service providers' involvement varied--from limited to extensive--across the prevention interventions. UTHSC had limited contact with external service providers in the community, but could turn to APS or a primary care physician in the event a problem or urgent need was identified. AK DSDS's case management model required coordination for referrals and service linkage with a range of community service providers within a 100-mile radius of Anchorage. Operating on a smaller scale in Orange County, USC had pre-existing relationships with service providers in the community and they jointly established a protocol to fast-track access to services by the care recipient/caregiver dyads. Operating within the primary care settings, APS Specialists engaged WellMed social workers to help identify and better coordinate services for clients. Through the APS Specialist, information was shared about available services provided by both agencies. By virtue of their purpose and structure, the Lifespan and NYCEAC E-MDTs had representation of diverse professionals drawn from multiple systems including: APS, social services, medical, law enforcement, legal, and financial. The E-MDT coordinator received referrals, consulted with referral sources, and obtained information. Following each E-MDT meeting, members were committed to fulfilling a key action item of the agreed-upon case plan for an elder.
Intended outcomes were targeted to the population of interest and intervention-specific. As shown in Table 2, they are organized to present outcomes associated with three target populations: care recipients and caregiver dyads; at-risk elders and victims; and substantiated victims. Despite the heterogeneity of the prevention interventions, common outcomes exist: (1) Reduced risk for abuse; and (2) Reduced likelihood of referral to APS.
Other risk and protective factors were shared by some but not all prevention interventions. Examples of these included improved increased social support, improved sense of safety, increased awareness, and strengthened partnerships.
B. Adaptation to Fit Local Context
The core components of each prevention interventions (as identified above) were implemented as intended, as revealed through on-site interviews with key stakeholders and observations of the prevention intervention. Yet, a few adjustments to the intended models were made in response to local conditions and constraints. Key informants reported that the intervention benefitted from the change. In two cases, the changes strengthened APS involvement in the intervention and by extension with the wider community of services professionals. TX/WellMed's APS Specialists were included in the weekly PCC meetings where cases involving high-risk were discussed. USC's Take AIM team members modified their approach in response to participants' reception to and uptake with services referrals, taking a more patient-centered approach.7 Realizing that the care recipient/caregiver dyads were overwhelmed by the choices of recommended services, the USC team found that they were not following up on the referrals. USC revised the protocol for delivering recommendations on referrals so that dyads could select one or two options that seemed most relevant. Additionally, this gave the care recipient and the caregiver the opportunity to voice why these referrals seemed most relevant and how they would obtain the services.
NYSOFA made a change to the model in each jurisdiction where it was implemented. These changes involved structure and key partners. Rather than creating a hub E-MDT at the Lifespan office in Rochester and using technology for "satellite" locations in the adjoining jurisdictions, early on NYSOFA opted for having in-person meetings in each of the seven counties in the Finger Lakes region. While logistically challenging to organize, the in-person meetings fostered greater coordination and collaboration across the service professionals. A later modification to the E-MDT concerned the use of forensic accountants based in the New York DA's office. Constraints on their ability to report activities to the E-MDT, owing to their role in the DA's office and pursuit of criminal cases, required that the Manhattan team use community services for forensic accountants.
Three of the five prevention interventions identified areas that may be important to change in future, based on their implementation experience and their interim findings. In attempting to replicate an evidence-based intervention developed for homeless adults with a population of vulnerable elders, AK DSDS found that greater flexibility was needed in the intervention's case management timeframe. Short-term cases where client goal and needs could easily be met within the first three months could be closed out by APS, thus reducing the duration of the intervention from nine months to three. Having implemented the EASI screening tool in 73 primary care settings throughout its service region, TX/WellMed identified some modifications to their prevention intervention that would aid in future, statewide replication. These included providing scripts and language to clinics for dealing with family members about mandatory reporting of suspected elder abuse and adapting the screening intervention to better fit within an organization's existing protocols. With cost-effectiveness and optimal service delivery in mind, UTHSC considered that, in the future, it may be beneficial to use a less intensive staffing model or a more triaged assessment and tiered intervention. Another consideration would be to align the home-based intervention with a primary care provider or coordinate information gathering with an electronic health record. Other elements of the intervention that may need to be modified were the number of assessments administered and home visits conducted. UTHSC also thought it would be preferable to use 1-2 measures that predict adherence to medications or the intended outcomes.
Staff that implemented the prevention interventions also focused on how they might, in the future, work in closer collaboration with project partners. Examples included forming an advisory board (TX/WellMed) or using monthly meetings with community partners to focus on vulnerable elders and not just those that were the focus of the intervention or known to APS (AK DSDS).
C. Facilitators and Challenges to Implementation
A number of common factors aided with the implementation of the five prevention interventions. To various degrees, all were grounded in strong partnerships with APS and community partners that assisted with intervention planning and/or implementation (AK DSDS, NYSOFA, TX/WellMed, UTHSC, USC). Some partnerships, such as UTHSC's partnership with APS Region VI in Texas, preceded the intervention, as did the partnering of Lifespan and NYCEAC for the NYSOFA E-MDTs and the community partners working with USC.
Although there was some turnover, continuity in staffing and leadership across the prevention interventions was critical in providing consistency in implementation and maintaining relationships developed between case managers and clients (AK DSDS), research staff and elders (UTHSC, USC), APS specialists and clinic staff (TX/WellMed), and E-MDT coordinators and community partners (NYSOFA).
Four of the prevention interventions had established referral partners that contributed resources in various capacities: to recruit and enroll elders in the intervention protocol (UTHSC, USC); take up a case with the E-MDT (NYSOFA); or provide community-based services once needs were assessed (AK DSDS, NYSOFA, UTHSC, USC). TX/WellMed's APS Specialists had to build relationships across all clinical staff in WellMed, including Complex Care provider services to facilitate referrals.
Use of a client-driven or patient-driven approach in social service or clinical settings was extended by involving partners, community agencies, advocacy organizations, and other entities in monthly standing meetings to address elder's needs stemming from abuse or risk of harm. Such forums helped expedite service delivery to specialists (NYSOFA, USC), provide complimentary services and reduce fragmentation (TX/WellMed), and build awareness of available resources for referrals (AK DSDS, UTHSC).
Most challenges tended to be site-specific; a few were common across the prevention interventions, such as recruitment, referrals, retention, appointment cancellations, and service access. All experienced some early issues, and two had start-up delays and turnover with APS or project staff that affected early implementation (AK DSDS, NYSOFA).
The AK DSDS, USC, and UTHSC prevention interventions involved direct engagement of elders with interactions taking place in client homes. Few challenges were experienced in these settings and there were protocols in place to address concerns. In contrast, TX/WellMed's prevention intervention relied on the use of intermediaries in a clinical setting. Introducing an elder abuse screening protocol into an existing workflow that was already time-constrained was initially challenging, resulting in some staff and physician reluctance to complete the EASI forms (some of which were integrated into the electronic medical record) or include APS Specialists in PCC meetings. These concerns were resolved by cross-training caseworkers and physicians, which helped dispel misperceptions about APS and elder abuse, improve working relationships, and garner support for the intervention. TX/WellMed also introduced a communications protocol where a lead medical doctor was designated to communicate and consult with other physicians using the EASI tool to facilitate implementation of the intervention.
Challenges with recruitment and referral varied across the prevention interventions. For AK DSDS, generating regular referrals to the intervention was an unexpected challenge. This was understood to be partially due to the newness of the program and the perception on the part of some APS investigators that clients may not need continued case management because they were no longer facing imminent risk. For UTHSC, referrals and enrollment in the intervention depended on coordination with APS caseworkers. Although UTHSC provided education and materials for them to solicit referrals, it was up to the caseworkers to make referrals. This required sending friendly reminders and reaching out to APS to increase the referral rate. Some elders were initially hesitant to participate which affected initial recruitment and enrollment.
As noted earlier, after finding that referral to and uptake of services were limited, USC adopted a different approach. They gave care recipient and caregiver dyads greater voice and choice in service selection (e.g., adult day care, caregiver support groups, family counseling, legal aid), with USC then facilitating the referral linkage. To protect client confidentiality, the service agencies did not provide USC with information on whether the dyad had contacted the agency or used their services, thus limiting the extent to which important outputs and outcomes could be tracked. TX/WellMed experienced a similar issue. Because there was no formal data tracking system in place to capture all of the WellMed referrals, it was difficult to systematically track referrals made to APS outside of the EASI screening. Lack of a feedback loop to communicate about patient activities also created data gaps and limited the ability to track intervention outcomes.
Limited services and access to services affected two of the prevention interventions. Even if client needs had been identified, AK DSDS's intervention relied on existing services which were sometimes difficult for elders to access. Transportation and affordable housing were identified as service gaps in the Anchorage area. For UTHSC, elders lived across a 13 county service area served by APS. Some counties were resource-rich while others were not. Harris County offered an array of health services for elders while some rural counties lacked basic health facilities and pharmacies, had wait lists for services, and had few geriatric specialists. Limited public transportation across the service area was a barrier to service access.
Evaluation-related challenges concerned efforts to obtain secondary data that resided in grantee or APS systems. In some cases this required the development of new systems for data collection and tracking. Within APS, data may reside in different internal systems, thus requiring permission to access data from multiple sources. In cases where there was internal staff turnover at APS, some grant directors or project coordinators had to create new relationships and educate colleagues about the evaluation and data collection plans. In one circumstance, the prevention intervention staff provided support to APS to access data for the evaluation. This created an unanticipated burden and increased the amount of time needed to obtain relevant data. Development of a data collection system to track client information and service outcomes was needed for one prevention intervention that operated across service sectors. Prevention interventions' ability to track service utilization across their provider network was also restricted due to confidentiality concerns, thus limiting the availability of these data for outcome analysis.