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Program and
Administrative Issues Affecting Adult Protective Services
By Joanne Marlatt Otto, MSW
Executive Director
National Association of Adult Protective Services Administrators
Written for the Public Policy and Aging Report
A publication of the National Academy on an Aging Society
Introduction
Adult Protective Services (APS) are the principal public
source of response to reports and cases of vulnerable adult abuse, neglet
and exploitation. APS programs are empowered by states and local
communities to accept and investigate reports of abuse, neglet and
financial exploitation of the elderly and younger people with
disabilities. Over the decades since 1960, these programs have
proliferated. However, nearly forty years later, there are still no
federal statutes regulating the delivery of Adult Protective Services (APS),
no federal agency charged with responsibility to collect data and issue
reports and no discrete funds provided to states to support and enhance
service delivery.
The only national group devoted to the delivery of APS is the National
Association of Adult Protective Services Administrators (NAAPSA), a
non-profit volunteer organization made up of state and local APS
administrators. The mission of NAAPSA is to improve the quality and
availability of services for disabled adults and elderly persons who are
abused, neglect or exploited, and who are unable to protect their own
interests. Since 1998, NAAPSA has been a partner in the
National
Center
on Elder Abuse which is funded in part by a grant from the U.S.
Administration on Aging.
The lack of national leadership, guidelines and
funding has resulted in a bewildering array of state and local APS
programs. A survey of State Adult Protective Services conducted by NAAPSA
and the National Committee for the Prevention of Elder Abuse for the
National
Center
on Elder Abuse in 2000 showed that APS programs are located in a number of
different government entities at the state level. In eighteen states, APS
are housed in the state human services agency, but are not associated with
aging services. In twenty-six states, APS are located either in the state
unit on aging within the state human services agency or in human services
organization that includes the state unit on aging. Due to the various
locations of state administrative units, APS programs struggle with a lack
of clear identity. Many practitioners complain that APS is an invisible
program, and that the clients it serves suffer as a result.
These various programs locations have resulted in different approaches to
the delivery of adult protective services at the state and local level. A
few states have protective services only for the elderly. In these states,
protective services for younger disabled adults are administered by other
organizations, leading to bifurcation of target groups, practice standards
and data collection.
The majority (90%) of the states provide services to vulnerable adults age
18 and older. Abuse victims with disabilities under the age of 60
represent approximately 30% of the cases nation-wide. Programs lodged in
independent state units on aging focus on protective services for the
elderly. State APS programs that are located in aging services within
human services agencies serve both younger persons with disabilities as
well as the elderly. However their affiliation with aging services tends
to give less emphasis to the protective roles of investigation and
coordination with law enforcement agencies. In those states where the
program is within a state human services agency that does not include the
state unit on aging, APS programs often complete with child welfare for
resources and recognition, and may lack immediate access to support
services for older victims.
The confusion continues. Within a state there may be little program
consistency between one community and another. In some communities, APS
are provided through the local area agencies on aging. While these
agencies may also offer protective services to disabled younger adult,
they are perceived as programs serving only the elderly. This means that
reports of abused younger victims are less likely to be referred to them.
When local departments of human services provide APS, the program is often
overshadowed by the many child welfare services offered by the agency.
Victims and families may be reluctant to make adult abuse referrals to a
“welfare” agency that carries a history of paternalism and family
disruption.
Another factor that affects the
visibility of APS programs is that in many states responsibility for the
investigation of abuse of older persons and/or persons with disabilities
is linked to the victims’ living situations. While APS always conducts
investigations in domestic settings, there are twenty-six states in which
other agencies have responsibility for abuse investigations in
institutions. In some states, APS and other state agencies may share
responsibility for institutional abuse investigations, which further
complicates reporting and program identity. All of these various
administrative options make it often difficult to determine which agency
in a given state is the primary adult protective service agency. This
confusion makes it hard for people who identify cases of possible abuse to
know where to make reports, as well as complicates data collection.
The lack of federal data collection
and reporting means that there is still little understanding as to the
extent of vulnerable adult abuse. A 1997 National Elder Abuse Incidence
Study conducted by the American Public Welfare Association (APWA) on
behalf of the U.S. Department of Health and Human Services concluded that
the number of reports of elder abuse made to local sample APS agencies
represented only “the tip of the iceberg.” This does not included
either cases of elder self-neglect nor abuse of younger persons with
disabilities. A survey of reports to Adult Protective Services in all 50
states, the
District of Columbia
and
Guam
was conducted in 2000 by the National Association of Adult Protective
Services Administrators and the National Committee for the Prevention of
Elder Abuse. In that survey, a total of 472,813 reports of elder and/or
vulnerable adult abuse, exploitation, neglect and self-neglect were made
to the states during that year. However, since there is no federal agency
charged with gathering these data, consistent, comprehensive information
at the national level about the number of reports, as well as the source
of these reports, types of abuse, characteristics of victims and
perpetrators and treatment outcomes is not available.
During the 1980’s, researchers
perceived that elder abuse was an easily identified subject for study, as
well as a dramatic issue to present to legislators and the public. As a
result, research focused exclusively on the problem of elder abuse, which
contributed to the increasing invisibility of adult protective services.
Although estimates of the number of victims continued to increase,
comprehensive and accurate information on actual cases served by local
adult protective services programs is impossible to collect due to lack of
national uniform definitions and reporting requirements as well as
outdated state APS data management systems.
Another complicating issue is the
provision of protective services to self-neglecting disabled and elderly
adults. Researchers have insisted that self-neglect is not a form of
abuse, and as such, should not be included in studies of elder abuse.
Adult protective services practitioners know that self-neglecting adults
make up the majority of their caseloads. A 1989 survey of state APS
programs conducted by NAAPSA found that out of forty-seven states
reporting, NAAPSA issued a position paper that defined self-neglect and
recommended that it be accepted as a valid function of APS, and that all
states recognize and report such cases. Following a national study on
self-neglecting APS clients in 1991, NAAPSA succeeded in convincing the
American Public Welfare Association to adopt a 1995 resolution
acknowledging that self-neglect was a legitimate category of adult abuse.
However the debate between practitioners and researchers continues.
Because self-neglect cases are complex
and time intensive, other community agencies either refuse to get
involved, or do so only briefly, then turn to APS for help. As a result,
the cases most likely to be referred to APS are cases of self-neglect.
These cases are messy and complex. Often they involve a host of community
agencies. Clients have varying degrees of mental incapacity; numerous
physical and emotional ailments and severe health hazards including dozens
of poorly cared for animals. In many cases, as the investigation unfolds
there are indicators of other types of abuse, often financial
exploitation.
APS workers argue with researchers
that to omit these cases from a pure definition of “Elder Abuse” would
reduce the already limited resources for service delivery and marginalize
self-neglecting clients.
While each state created its APS laws
and regulations independently, most have followed similar models of
protective service delivery based on social casework and systems
approaches. The guiding value of the program is that every action taken by
APS must balance the duty to protect the safety of the vulnerable adult
with the adult’s right to self-determination. Areas of abuse covered by
most state statutes include physical, sexual, and emotional abuse,
financial exploitation and caregiver neglect as well as self-neglect.
Definitions vary from state to state, but the core areas of mistreatment
are consistent.
The primary APS activities covered by
most state statutes include receiving reports; conducting investigations;
evaluating client risk and capacity to agree or refuse services;
developing and implementing a case plan; counseling the client; arranging
for a large variety of services and benefits and monitoring ongoing
service delivery. These services protect elderly and/or vulnerable adults
and enable them to live independently.
The majority of APS programs serve younger persons with disabilities
as well as the elderly. Serving younger adults, many of whom have multiple
diagnoses of physical or developmental disabilities, mental illness and/or
substance abuse presents some unique challenges to practitioners. Working
with the developmental disabilities system has often been difficult. These
programs, which offer evaluation, case management, residential care and
vocational services, tend to be closed systems and do not welcome abuse
investigations conducted by outsides agencies. In addition, younger people
with physical disabilities who are abused have resisted intervention
resulting from mandatory reporting requirements. They fear that such
interventions will erode their hard-won right to self-determination.
Working with mental health services also has been due to client
confidentiality constraints as well as limited funding for client
outreach. Many APS clients are socially as geographically isolated. They
do not access community services and usually need extensive outreach
efforts before they are willing to do so. Issues of the victims’ mental
capacity to recognize situations of risk as well as to give informed
consent for intervention and treatment have further complicated
collaboration with both systems.
There are very few programs that serve adults with multiple
diagnoses. While such people are frequently victims of abuse, they are
difficult to maintain safety in the community. When they are referred to
APS, they are almost no residential or ongoing case management services
available for them.
A decade ago, the New York Times ran a front-page article which
called financial abuse on elderly “the crime of the 90’s”. A study
of thirty-nine states conducted by the
National
Center
on elder Abuse in 1994 showed that there were 29,643 reports of
financial/material exploitation in domestic settings made to state APS
programs the previous year. Findings from a 2001 National Survey of States
conducted by NAAPSA on behalf of the National Center on Elder Abuse
indicated that twenty-nine states had received a total of 48,278 reports
of financial exploitation—an increase of 18,630 (61.4%) reports since
1994.
This increase has, in many ways, changed APS practice. In the past,
APS intervention focused primarily on cases of self-neglect, which called
for patience and excellent interpersonal skills as workers struggled to
form bonds of trust with uncooperative clients. These cases are labor and
time intensive, and outcomes are often minimal. The casework goal in these
situations is to develop enough of a trust relationship[ with the
self-neglecting elder to allow some services aimed at reducing a
dangerously unhealthy living situation, while still protecting the
client’s right to make choices about where and how he/she will live.
Often case-worker’s role includes protecting the client from overzealous
intervention by family members or other community agencies. These are
cases that easily may become high profile, and engender a high degree of
community pressure.
Cases of financial exploitation, on the other hand, have very
different dimensions. Often the APS worker is the first to suspect that
the client is being financially exploited. Given this suspicion, the
worker needs to collect and verify large quantities of written
documentation in the form of paid and unpaid bills, check stubs, financial
statements, property deeds, automobile titles, Power of Attorney etc. This
work is also labor intensive, but in a very different way. The focus is on
gathering and making sense of countless documents, as well as eliciting
evidence from reluctant sources.
Often the victim is either confused, due to dementia or illness,
or denies that a possible crime has been committed. The suspected
perpetrator is anxious to hide or destroy the evidence. Financial
institutions are sometimes uncooperative in providing financial records.
Law enforcement officers are reluctant to take on complicated financial
investigations on behalf of victims whose ability to cooperate is limited.
And prosecutors are unwilling to get involved in these cases, as the
victims may be poor witnesses in court, meaning that a great deal of work
must be devoted to developing circumstantial evidence.
In addition, while the amount of actual loss of funds and or assets
to the elderly person may be significant, to a prosecutor who is
accustomed to drug crimes involving millions of dollars, vigorous efforts
to prosecute a crime involving a few thousand dollars is not politically
expedient. For all of these reasons, APS workers need time and specialized
training to develop strong documentation. They also need support from
administration when their advocacy efforts on behalf of their clients
“make waves” with other community agencies.
The past decades has seen increasing cooperation between APS and law
enforcement. While not all elder/adult abuse constitutes criminal
activity, there is increasing recognition from both systems that they need
to work together. What may start out as a simple case of self-neglect may
evolve into a complex criminal investigation of financial fraud. In
addition, in some states, cases of caregiver neglect that formerly were
the responsibility of APS have now been criminalized under state statutes.
This means that law enforcement may conduct a criminal investigation of
negligent patient care while APS supports the victim with counseling and
services designed to provide safe medical and physical care. APS workers
with expertise in aging and disability issues can be of great assistance
to law enforcement and prosecutors in helping to gain victims’
cooperation and assisting in eliciting reliable testimony.
Increasingly APS and law enforcement professionals are engaging in
cross-training at the local and state level. In 2001, on behalf of the
National
Center
on Elder Abuse, NAAPSA conducted a national study of state APS training
programs. The study found that of thirty-six states and one territory
responding, 91% indicated that they were conducting regular cross-training
activities with law enforcement professionals. As a result, APS
caseworkers have become increasingly knowledgeable about criminal and
civil law, and now frequently report suspected crimes to law enforcement.
Another result of this cross-training has been that more and more states
are strengthening their criminal codes to include crimes against
vulnerable adults. In addition, many communities have developed
interagency APS teams in which local law enforcement play an essential
role.
The field of domestic violence is another area in which there is
increasing collaboration and collaboration between professionals. There is
growing recognition that domestic violence continues in later life, and
the physical and emotional affects on disabled and frail victims can be
lethal. Programs serving younger victims of domestic violence are
beginning to look at creative outreach efforts to elderly victims and are
retrofitting their shelters to make them more accessible to people with
disabilities. And APS caseworkers are learning more about the causes of
domestic violence, the importance of holding perpetrators accountable, and
the need to help victims with safety planning.
The issue of lack of training for staff continues to limit APS programs.
The 2001 NAAPSA training study found that almost half of the thirty-six
states and one territory responding to the survey have no annual
identified APS training budgets. For those states reporting that they do
have allocations, the average budget for all APS staff training is
$120,405 annually. Given the vulnerability of the victims and the
complexity of responses required to reduce their risk of abuse,
exploitation and neglect, it is sobering to see how little money is made
available for training APS professionals. Although Elder Abuse Prevention
Funds are available under the Older Americans Act, and can be used to
provide training to APS and other professionals, only 6% of the state
respondents’ APS training allocations came from this limited source.
Almost half of the states’ training funds came from Social Services
Block Grant monies which have been steadily reduced over recent years.
While most states reported using their own staff for training,
many states do not have training specialists with expertise in adult
learning techniques. Thus, state staff, in addition to their other duties,
are called upon to develop training curricula even though they may lack
expertise on curriculum development and adult learning skills. They also
may be called upon to act as trainers on a wide variety of highly
specialized subjects such as indicators of physical and/or mental illness
and complex drug interactions. Only 26% of the states reported using
colleges or universities to help with their training programs.
Given the complexity of the cases, the training components and subject
matter most commonly provided by most states are limited and sporadic, and
educational requirements are minimal. While the majority of the states
require training for new workers, two-thirds of the states allow new
workers into the field before they have completed their training. As a
result, some new workers are independently evaluating clients for
immediate risk without the training required to make such determinations.
This raises very real issues of civil and criminal liability for
caseworkers, employers and the state and local government agencies that
oversee these programs.
There continues to be a need for sound research in the area of
APS. A 1999 research forum conducted for the
National
Center
on Elder Abuse by NAAPSA and the National Committee for the Prevention of
Elder Abuse developed A Research
Agenda on Abuse of Older Persons and Adults with Disabilities. Among
ten priority topics were a number relating directly to APS practice
including:
• The need for national best practice standards for APS
• The need for effective training
for new APS employees
• Outcomes of APS cases in which
clients refused services
• The monetary impact on government
resources of abuse, neglect and exploitation of vulnerable adults
• Outcome definitions and
measurement
• Legal liability of APS workers
• The effectiveness of various
investigation and intervention techniques with different victim
populations
• In December 2001 the
National
Center
on Elder abuse hosted a National Policy Summit on Elder Abuse in
Washington
,
D.C.
A number of recommendations resulted from this meeting. They touched on
the need for public education, federal legislation, funding for training
and supportive services and increased research. It is hoped that many of
these recommendations will be implemented, and that Adult Protective
Services Programs will become more visible and consequently more effective
in helping vulnerable adults who are victims of abuse, exploitation and
neglect.
References
Brandl, Bonnie, MSW, and Raymond, Jane A. MSW.
“Family violence in Later Life”
Victimation of the Elderly and Disabled. Vol.1 No.1. May/June 1998.
Kingston
,
NJ
. 1998.
Duke, Joy. 1990. Position Paper on
Self-Neglect. National Association of Adult Protective Services
Administrators,
San Antonio
, TX.1990.
Duke, Joy. 1991. A National Study of
Self-Neglecting Adult Protective Services Clients. National
Association of Adult Protective Services Administrators. VA. 1991.
National Elder Abuse Incidence Study.
U.S.
Department of Health and Human Services 1997.
Washington
,
D.C.
1997.
Nordheimer, Jon. “A New Abuse of
the Elderly: Theft by Kin and Friends.”
New York Times.
New York
,
NY
12/16/91
.
Otto, Joanne Marlatt, MSW. “The
Role of Adult Protective Services in Addressing Abuse.”
Generations: a Journal of the American Society on Aging. Vol. XXIV
No.112000 San Fransisco, CA. 2000.
Otto, Joanne M, MSW. Survey of State
Adult Protective Services’ Training Programs.
National
Center
on Elder Abuse,
Washington
,
D.C.
2002.
Otto, Joanne M., MSW. Survey of
State Adult Protective Services Responses To Financial Exploitation of
Vulnerable Adults.
National
Center
on Elder Abuse,
Washington
D.C.
2002.
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