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7 Evaluating Interventions I n this chapter we discuss policies and programs designed to protect older persons from mistreatment and to ensure their safety. Overall, the panelâs conclusions can be easily summarized: no efforts have yet been made to develop, implement, and evaluate interven- tions based on scientifically grounded hypotheses about the causes of elder mistreatment, and no systematic research has been conducted to measure and evaluate the effects of existing interventions. Mandatory reporting and interventions by adult protective services, the core elements of the current system for preventing and ameliorating elder mistreatment, have never been subjected to a rigorous evaluation. Nor have most other interventions targeted at preventing elder mistreatment or addressing the needs of victims and abusers. While intervention programs are presented at national and regional meetings, these programs have not been subjected to systematic evaluation. Without rigorous evaluation, re- ports of these programs are usually not accepted for publication. More- over, lack of systematic evaluation can result in the duplication of programs in which the benefits of the program, if there are any, are attributable to the characteristics of the agency that carried it out, rather than the effects of the intervention itself. A secondary result of such duplication is the investment of resources, both public and private, for programs that have never been shown to work and that may be ineffective. This inevitably reduces the funding for new innovations. The chapter briefly surveys existing interventions to highlight several important research opportunities. Mandatory reporting requirements are 121
122 ELDER MISTREATMENT discussed first, since they lie at the center of current policy. The chapter then addresses community-based interventionsâfocusing on adult protec- tive services, the health and criminal justice systems, and emerging ex- amples of collaborative programsâbefore turning to mistreatment in insti- tutional settings. REPORTING ELDER MISTREATMENT Reporting of suspected elder mistreatment is the most commonly used and most controversial intervention. The adult protection statutes of all states and the District of Columbia include provisions governing the report- ing of suspected elder mistreatment. All but six of those jurisdictions mandate reporting of suspected mistreatment by specified categories of persons. The other six statesâColorado, New Jersey, New York, North Dakota, South Dakota, and Wisconsinâpermit reporting but do not re- quire it. In general, reports are to be made to the pertinent adult protective services agency; in some jurisdictions, however, reporters may be required to transmit their suspicions to a law enforcement agency or some other type of organization in lieu of or in addition to adult protective services. According to a statutory analysis conducted by the American Bar Asso- ciation Commission on Legal Problems of the Elderly (through December 2001), in eight of the mandatory reporting states (Delaware, Indiana, Ken- tucky, New Mexico, North Carolina, Rhode Island, Texas, and Wyoming), âany personâ who suspects mistreatment is required to report it. In the other jurisdictions, the reporting obligation is directed to various occupa- tional and professional groups. However, nine of those states take a hybrid approach, requiring âany personâ and members of specific occupations to report, depending on the circumstances. In all, 14 states list between 1 and 10 categories, 9 states list between 11 and 20, and 14 states list 21 or more. The occupations and professions commonly mandated to report include: â¢ Health care professionals â¢ Mental health professionals â¢ Caregivers (whether paid or unpaid) â¢ Home care providers â¢ Employees of nonresidential programs for the elderly â¢ Employees of sheltered workshops and similar nonresidential pro- grams â¢ Employees of residential facilities for the elderly â¢ Social workers â¢ Long-term care ombudsman program staff and volunteers â¢ Employees of adult protective services programs
EVALUATING INTERVENTIONS 123 â¢ Employees of area agencies on aging and other aging service pro- viders â¢ Employees of human services, social services, or health depart- ments â¢ Law enforcement and public safety employees â¢ Attorneys â¢ Guardians and conservators â¢ Teachers and educators â¢ Financial profession employees The concept of mandatory reporting of suspected mistreatment was borrowed from the child abuse laws without research demonstrating its applicability to older persons. The ongoing debate concerning mandated reporting raises many empirical questions about the effects of these laws on the behavior of mandated reporters and about the consequences of report- ing on the lives of people affected by them. Yet virtually no research has been conducted on these important issues. For example, to what extent are mandated reporters aware of their legal obligations? To what extent do they comply with them? What factors affect reporting behavior? What are the motivations, concerns, and expectations of those who report and those who decline to do so? Does reporting behavior vary significantly among the professions and occupations required to report under state law? Hawes (this volume) discusses some studies indicating significant underreporting of elder mistreatment by physicians and other health care professionals, long-term care ombudsmen, and residents of long-term care facilities and their family members. The panel is not aware of studies of other profes- sions or occupations. There is much anecdotal evidence of underreporting, but systematic study of reporting behavior is neededânot only to assess compliance but also to provide the necessary foundation for critical evalu- ation of the effects of mandated reporting. Many questions have been raised about the effects of mandated report- ing. What actually happens as a consequence of a report, compared with informal interventions that might otherwise have occurred? What are the consequences (both positive and negative) of being reported on the lives of the victim, the perpetrator, and the family? To what extent does the threat of being reported (and the ensuing intervention) affect the behavior of potential (or previously reported) perpetrators and victims? These impor- tant issues can be addressed in well-designed studies comparing responses to suspected mistreatment in jurisdictions with and without mandatory reporting. The fact that six states do not require reporting affords an unusual opportunity for cross-jurisdictional comparisons. Before-and-after designs may also be possible as some of the six states with voluntary report-
124 ELDER MISTREATMENT ing schemes consider adopting mandatory reporting and other jurisdictions reevaluate their existing reporting requirements. The panel strongly recommends systematic studies of reporting prac- tices and the effects of reporting, taking maximum advantage of the oppor- tunity for comparisons of practices and outcomes in states with and with- out mandated reporting. ADULT PROTECTIVE SERVICES Adult protective services agencies are the backbone of community- based efforts to respond to elder mistreatment. Statutes require every state to respond to reports of abuse of vulnerable adults. The laws generally establish a system for reporting and investigation of alleged abuse or ne- glect and for providing protective services to help the victim and ameliorate the abuse. Most laws pertain to adults who have a disability, vulnerability, or impairment that reduces their capacity to protect themselves. All states include the elderly population that may be eligible by virtue of age or age in combination with disability (see Chapter 2 and Appendix B). The important, and sometimes exclusive, role of adult protective ser- vices in responding to reports of abuse and neglect warrants closer exami- nation. After receiving a report, adult protective services serve three main functions. The first organizational function is to receive, assess, and triage abuse and neglect reports. The initial response includes screening the re- port to evaluate its fit with the applicable abuse and neglect definition. Once a referral is accepted, most states require a response within 24 hours. Many offices have crisis intervention services available through a hotline or on-call system so that an initial determination can be made about the need for emergency services and referrals to other services or providers. A face-to-face visit with the alleged victim is required in most states. This often includes an assessment of risk (of further abuse) along with an assessment of cognitive ability and the ability of a person to function inde- pendently. Although three states (Arizona, Delaware, and Louisiana) use risk assessment tools for which there is some evidence of reliability and validity, the instruments being used in about one-third of the states have not been tested for reliability or validity. The risk assessment instruments in use evaluate client and environmental factors, availability and adequacy of support services, current and historical abuse factors and perpetrator factors. As discussed in Chapter 6, the utility of screening instruments is an important area for research. With regard to adult protective services screen- ing in particular, the panel recommends studies tracking samples of indi- viduals excluded or included for further action. After providing any needed emergency services, the second function of adult protective services is to investigate abuse or neglect reports. Agencies
EVALUATING INTERVENTIONS 125 differ in their approach to finding out whether abuse or neglect occurred. Some are heavily investigative, and others focus on providing social ser- vices. Some rely exclusively on law enforcement to conduct investigations. The balance between investigation and social services may also be influ- enced by other factors, such as federal statutes (e.g., requiring investigation and placement on a registry for nursing assistants and the ombudsman program, which responds to complaints of abuse in nursing homes) or Medicaid rules on abuse (which must be followed in order to receive reim- bursement for services). Several states, including Ohio and Wisconsin, have recently evaluated their entire systems of response to elder mistreatment. Wisconsinâs review concluded that the role of the adult protective services system should be focused exclusively on providing social services and that investigations should be conducted solely by law enforcement agencies (Wisconsin Department of Health and Family Services, 2001). In the context of investigations, a method being increasingly used, modeled on the child protective system, is the state abuse registry. As mentioned above, a federal law requires a registry to be kept for certified nursing assistants who have been substantiated for abuse. Long-term care providers are required to check this registry before hiring an employee. These registries are most often maintained by the state nursing board, but a number of states have developed similar registries for any caregiver sub- stantiated for abuse. Maintaining a registry can be an expensive activity, especially if substantial procedural protections are accorded to people whose names are listed. Florida and Minnesota have well-developed systems but, as is true with other interventions, the effects of maintaining a registry have not been studied. The unanswered questions include whether people are safer and, ultimately, whether these interventions are cost-effective. The third, and often most time-consuming, function of adult protective services is to develop a protective services plan aiming to terminate mis- treatment and ensure safety. Assessments of the individualâs need for help with activities of daily living and of his or her support network are con- ducted as part of the overall plan. Additional services can include attendant care, food, housing, rent or mortgage payments, transportation, money management, changing of locks, cleaning, respite care, and ongoing coun- seling and case management. Adult protective services programs have also tried to adapt the domestic violence model of offender treatment described by Wolfe (this volume) to perpetrators of elder mistreatment. San Fran- cisco and Los Angeles have experimented with small groups targeting per- petrators and using cognitive behavioral techniques to affect the violent behavior. Although reporting is mandatory in most states, a critical principle embodied in most state statutes is client autonomy. Simply put, services cannot be provided to clients without their consent. The policy of least
126 ELDER MISTREATMENT restrictive intervention is generally embraced, along with the goal of maxi- mizing client independence. These principles are laid out in the National Association of Adult Protective Services Administrators statement on ethics (2002). Although the vast majority of services are based on consent of the client, about 10 percent of interventions are provided without client con- sent. Involuntary intervention is legally authorized in most states if the refusing client is exposed to a substantial risk of harm or if the client lacks the capacity to make an informed decision to accept or reject protective services. Available interventions typically include guardianship and conser- vatorship. In addition, emergency protective placements, which are usually limited to 24â72 hours and provided only with judicial approval, may be available. Courts may also issue restraining orders to caregivers and mem- bers of the elderâs family. For difficult cases, adult protective services agencies often convene or participate in multidisciplinary review teams. These teams represent the best effort to offer a coordinated community response to elder mistreat- ment. Many would agree that adult protective services is an underfunded and overworked system, often operating in a crisis management mode (as did childrenâs protective services in its earlier years). However scarce the re- sources, choices are inevitably being made about their allocation. It does not appear that any of the adult protective services activities, including triage, investigation, and service planning and delivery, have ever been evaluated. When surveyed by Rosalie Wolf in 1999, state administrators wanted research to define outcomes and measure them, to identify the best practices for intervention, and to help design effective training for their workers (Wolf, 1999). Research is critically needed on the effectiveness of the interventions that are now being deployed. How well, and at what cost, do interventions improve the safety, security, and independence of older persons who have come to adult protective services attention for mistreat- ment? Research is needed on the effectiveness of adult protective services interventions, ideally in study designs that compare outcomes in cases in which services were provided with those in which eligible recipients de- clined offered services or other cases in which mistreatment of an equiva- lent nature has been identified. It should be noted that a large proportionâin some states, more than halfâof the reports coming into adult protective services concern elderly persons who are neglecting their own care. A typical scenario includes an elderly person with dementia who is losing the ability to cook or take care of a serious medical condition and who has no natural support to call on for assistance. The panel has decided to exclude cases of self-neglect from this report in order to concentrate its attention on the need to develop
EVALUATING INTERVENTIONS 127 knowledge about elder mistreatment. However, the inclusion of self-ne- glect within the jurisdiction of adult protective services can easily confound research on elder mistreatment. Thus it is essential for researchers studying adult protective services interventions (or studying other interventions de- rived from adult protective services activity or using subjects identified in adult protective services databases) to exclude cases of self-neglect or segre- gate them from cases involving harm or neglect by others. HEALTH SYSTEM INTERVENTIONS Wolfe (this volume) describes the progress made in child abuse detec- tion when health care professionals began to routinely screen for child abuse indicators and to report worrisome cases. Family physicians and the emergency room physicians are ideally situated to see mistreated elders and to refer suspected abuse and neglect for appropriate action. The task of designing and implementing an elder mistreatment screening program for health care professionals presents special challenges. It will require educat- ing health care professionals about the normal changes of aging and how these changes may influence the appearance of forensic markers of elder mistreatment, such as bruises, fractures, and pressure sores (see Dyer et al., this volume.) They must be able to distinguish between cases in which an injury is accidental or unpreventable and those in which it is inflicted or otherwise preventable. Research on the effects of training health care professionals in respond- ing to family violence indicates that the best practices are based on adult learning theoryâthat is those in which the curriculum is attached to screen- ing instruments and the ability to practice the skills. The same is likely to be true for neglect cases. Several initiatives are under way to provide special- ized training to health care professionals. For example, the geriatric pro- gram at Baylor University is developing a curriculum on elder mistreatment for medical school use and is involving medical residents in their elder mistreatment assessments. The California Medical Training Center has also developed a program to train health care providers to identify, evalu- ate, and document injuries in collaboration with law enforcement and so- cial services. The increase in home health nursing services has put a number of nurses on the front lines, well situated to see potential abuse or neglect victims. Nursing training typically includes information on family violence but is also limited on its information about elder mistreatment. A promis- ing nursing specialization, developed along with the field of family violence, is forensic nursing. Similar to the development of a national cadre of sexual assault examiners, these and other nurses are expanding their focus to include evaluation of suspicious and serious unexplained injury. These
128 ELDER MISTREATMENT experts are beginning to be used by adult protective services, law enforce- ment agencies, and the rest of the criminal justice system on a small scale, particularly for those elderly persons who are not cognitively able to pro- vide testimony about their abuse- and neglect-related injuries. A few nurs- ing schools offer this type of specialized advance practice training. The first masters level program with this specialty has been established at Johns Hopkins University. Research on the effectiveness of forensic nurses in identifying elder mistreatment (in all settings, including the clinic and the courtroom) would be useful. Another part of the health care system that often provides the first response to elder mistreatment is the emergency medical technician. While some training has been done locally by adult protective services, recently the national organization of emergency medical technicians, in conjunction with the National Center on Elder Abuse, has completed a curriculum for their members on elder mistreatment. Research on emergency medical technicians who are trained and that call in social services (adult protective services) would provide valuable information on this promising new inter- vention. The hospital setting may also offer an opportunity to detect mistreat- ment and to intervene so as to prevent further occurrences. Hospitals and the health care professionals working in hospitals have an obligation to ensure the safest possible discharge for their patients. As methods of detect- ing mistreatment improve, perhaps through the detection of sentinel events associated with mistreatment, it will be possible to target interventions at hospitalized patients who have been mistreated prior to admission. The panel encourages research on hospital-based interventions to prevent fur- ther mistreatment of hospital inpatients after discharge. This research should include hospital emergency departments, where many mistreated elders may be seen but not ultimately admitted to the hospital prior to discharge. Interventions to detect and manage mistreatment in hospital emergency departments should therefore also be evaluated. Other interventions occur at the organization level. The rules of gov- erning organizations like the Joint Commission on Accreditation of Health Care Organizations as well as rules connecting continued Medicaid funding to long-term care and community residential facilities include requirements for recognizing and responding to cases of elder mistreatment. The primary requirements include having a policy to assess possible victims and adher- ing to state legal requirements relating to investigation as well as prevention of further mistreatment. Accreditation policies and practices relating to elder mistreatment should be studied on a systematic and ongoing basis.
EVALUATING INTERVENTIONS 129 CRIMINAL JUSTICE INTERVENTIONS Law enforcement officers respond to and investigate allegations of abuse when they are brought to their attention by some other organization, such as adult protective services, or some other individual. In addition, law enforcement officers are often âfirst respondersâ and are the first agency representatives to be called to an environment in which mistreatment is occurring, either to investigate an allegation that a law has been violated or to make a âwelfare check.â Officers may be the first to realize that an older person is experiencing mistreatment. Officers who recognize the signs of mistreatment and know what community agencies are available to provide assistance can help the victim by bringing in adult protective services, pro- viding referrals to community services, or in other ways. Linking to other agencies is particularly critical when law enforcement officers arrest a caregiver for elder mistreatment and remove him or her from the home; otherwise the victim may be left without needed care. As discussed by Dyer et al. (this volume), medical examiners and coro- ners may be called on to determine whether death resulted from or was related to elder mistreatment. Because of their expertise in assessing un- natural injury and death, they may be asked to make similar determinations about suspected victims who are still alive. They may also be the first to discover that abuse has occurred, during an autopsy conducted for some reason other than suspected mistreatment. Medical examiners and coro- ners can play an important role in fatality review teams that analyze deaths resulting from elder abuse. A key issue is whether and under what circumstances criminal charges should be filed against alleged perpetrators of mistreatment. Reports from law enforcement, adult protective services, and other practitioners indicate that the number of charges filed in such cases has been increasing. The prosecutorial decisions require complex judgments balancing deterrent and punitive considerations (which focus on the seriousness of the offendersâ conduct, including harm and culpability) with protective considerations (which focus on what measures will best ensure the future safety and well- being of the elderly victim). Prosecutorial response to elder mistreatment is an understudied area that should receive heightened attention by the National Institute of Justice and other funders of criminal justice research. Victim/witness professionals (sometimes referred to as victim advo- cates or similar titles) also have a dual role in elder mistreatment interven- tion. Victim/witness professionals may work in law enforcement agencies, prosecutorsâ offices, or community services organizations. The timing of their involvement and their role depends to some extent on the entity for which they work. In general, they assist crime victims by providing sup-
130 ELDER MISTREATMENT port and explaining the criminal justice system, accompanying them to court, arranging transportation for proceedings, coordinating respite care if the victim is a caregiver, and helping the victim file for victim compensa- tion funds. It is possible that victim/witness professionals will be the first to recognize that victims are experiencing elder mistreatment. Accord- ingly, victim/witness professionals need to understand the risk factors for and indicators of mistreatment and to know what services are available for these victims. Elder mistreatment researchers should be aware of the existence of these victim/witness assistance programs, not only as possible targets of research in themselves, but as sources of information in other studies. PROFESSIONAL SPECIALIZATION AND COLLABORATION Many professions, advocacy groups, and other organizations are in- volved in efforts to prevent and respond to elder mistreatment. Although adult protective services is the backbone of the system, community-based interventions draw on the health professions, law enforcement personnel and all participants in the criminal justice system, the bar and other partici- pants in the civil justice system, financial institutions, and many others. Increasingly specialized responses are being developed through targeted training and interdisciplinary collaboration. For example, efforts are under way in many communities to improve the response to elder mistreatment victims by educating criminal justice system participants about the prob- lem, developing specialized investigation and prosecution units, enhancing collaboration, and reforming statutes and policies. Most of these initiatives are of recent origin and have not yet been studied in a systematic way. Professional Specialization Professional specialization is a critical feature of an effective social response to any emerging social problem, once the problem has been recog- nized. In its evolution as a social problem, elder mistreatment is now in this ârecognition and specializationâ stage. Specialized training of health care professionals, mentioned earlier, continues to be an important challenge (Institute of Medicine, 2001). In addition, the increasing numbers of attor- neys specializing in elder law, whether working in private practice or pub- licly funded legal services programs, can be valuable resources in collabora- tive efforts to prevent and respond to all forms of elder mistreatment. Prevention is enhanced through adequate counseling about the potential for abuse of common legal planning tools, such as powers of attorney (particu- larly durable powers of attorney), joint bank accounts, joint property own- ership, trusts, and wills (see Hafemeister, this volume). Collaborative ef-
EVALUATING INTERVENTIONS 131 forts between the specialized bar, health care providers (in counseling and vulnerability assessments), adult protective services and law enforcement, when mistreatment is suspected, could produce new ideas about preven- tion. Depending on the laws of particular jurisdictions, several legal tools can be used to respond to elder mistreatment when it occurs. To stop physical or sexual abuse, a lawyer might need to obtain a civil order of protection to keep the perpetrator away from the victim or pursue an eviction action against an abusive tenant or adult child living with the victim. To combat financial exploitation, a lawyer might need to void a document or transaction because the victim signed it under duress or due to fraud or undue influence. The lawyer might need to help the victim revoke a power of attorney that is being misused or draft a power of attorney or trust in order to wrest control from a perpetrator. It might be necessary to seek to have a guardian or conservator appointed for an abuse victim in order to reduce or terminate the authority of the abuser. It might also be necessary to defend against the appointment of a guardian or conservator or pursue the appointment of an alternative guardian or conservator when the person seeking appointment is mistreating the older person. Civil law- yers also can pursue actions for damages in order to recover money that has been exploited or to make the victim whole for injuries by the perpetrator, and they can pursue actions against companies employing abusive caregivers for negligent hiring and inadequate supervision. Research about the use of civil justice interventions and their effective- ness in preventing exploitation and other harm to elders should be jointly sponsored by the National Institute of Justice and the Administration on Aging. Multidisciplinary Collaboration One of the few federal responses to elder mistreatment has come from the âaging network.â This term refers to a wide array of organizations and services established and funded through the Older Americans Act in part to address elder mistreatment. Title VII of the act supports elder rights pro- grams, including the long-term care ombudsman, legal services, outreach, and elder abuse prevention efforts. The Title VII elder abuse prevention monies fund state units on aging to conduct prevention activities at the state level or to fund area agencies on aging to implement prevention activities at the local level. Community collaborations have played an increasingly important role in recent years by suggesting interventions when serious elder mistreatment occurs. Some jurisdiction have created multidisciplinary teams (sometimes known as MDTs or M-Teams) composed of professionals and practitioners
132 ELDER MISTREATMENT from health, law enforcement, social services, or others as appropriate, to serve one or both of the following purposes: (1) analysis and collaboration on difficult cases that cannot be resolved through the intervention of a single professional or practitioner and (2) recommendations for and devel- opment of systemic improvements in response to problems unearthed through case analysis and experience. Fiduciary abuse specialist teams (sometimes known as financial abuse specialist teams or FASTs) are a distinct type of multidisciplinary team that focuses on fiduciary abuse. As such, they may involve different participants, such as accountants, from a more general team. Fatality review teams (FRTs, also known as death review teams or death investigation review teams) are another specialized form of multidisciplinary team. Their goal is to bring together various disciplines to examine deaths that resulted, or may have resulted, from elder abuse and to determine whether systemic changes in the response to elder abuse victims could prevent similar deaths in the future. Members of fatality review teams may also determine that the circumstances of a death ought to be pursued by a prosecutor; they have been used in the child abuse and domestic violence fields for years, and the elder abuse field is just beginning to establish them. The Administration on Aging and, more recently, the Department of Justice have funded grant projects and conferences and stimulated efforts to identify and share information about best practices in elder mistreatment interventions. For more than 20 years, the Administration on Aging has funded the National Center on Elder Abuse (NCEA) to develop and dis- seminate information on elder mistreatment, including adult protective ser- vices. The Department of Justice has sponsored some focus groups, a roundtable on forensic issues, a national symposium on elder mistreatment and consumer fraud, and several conferences encouraging law enforcement involvement in mistreatment cases, development of training programs for banking personnel, curricula to educate various professionals about the need for and benefit of collaboration, support of fatality review teams, and the development of recommendations related to forensic issues. The Na- tional Center on Elder Abuse recently conducted a national summit, bring- ing together experts from several professions to develop recommendations for a national agenda on elder mistreatment. Recommendations include a nationwide public awareness campaign, coordination of law enforcement efforts, study of adult protective services, and a federal law on elder mis- treatment, among others. All of these efforts are now being pursued in the absence of any evidence regarding the effectiveness of the interventions being proposed and endorsed. The specialized focus and collaboration reflected in these initiatives is an important step forward, because it increases the likelihood that systemic problems will be identified and that targeted interventions will be imple-
EVALUATING INTERVENTIONS 133 mented. Specialization and interdisciplinary linkages also are more likely to lead to collaboration between practitioners and researchers and there- fore to better design and evaluation of new interventions. The panel strongly encourages government agencies and private spon- sors of elder mistreatment programs to give priority to interventions that emphasize specialized professional training and interdisciplinary collabora- tion. Moreover, in the panelâs view, all new initiatives should include sufficient funding for evaluation. INTERVENTIONS IN RESIDENTIAL CARE FACILITIES Throughout this report, the panel has focused attention on general issues concerning the definition, identification, and prevention of mistreat- ment, regardless of setting. Although residential care facilities were not excluded from the panelâs view, family living settings have usually been emphasized. This section briefly addresses several specific research priori- ties pertaining to residential care settings. Current knowledge about mis- treatment in nursing homes and other residential care settings is summa- rized by Hawes (this volume), and a recent report, Improving the Quality of Long-Term Care, by the Institute of Medicine (2001) provides a compre- hensive review of the broader subject of quality improvement, of which patient safety (including avoidance of mistreatment and harm) is a core component. Among the most important priorities identified in Improving the Qual- ity of Long-Term Care concerns the need for uniform definitions and data elements for characterizing the components, processes, and outcomes of long-term care across different jurisdictions, populations, and settings of care (e.g., nursing homes, assisted living facilities, and home health care). The report envisions national systematic and comprehensive data bearing on the staffing and care provided in the various settings of long-term care. This panel endorses the Institute of Medicine committeeâs recommenda- tion, while emphasizing that uniform data elements relating to mistreat- ment (including subjective measures of security) should be included in the outcome measures, and that implementation of this recommendation would facilitate research on the effectiveness of interventions of any kind (whether initiated voluntarily or through regulatory action). Virtually nothing is now known, for example, about the nature and effectiveness of regulatory efforts relating to assisted living facilities and other residential care facilities other than nursing homes (Harrington et al., 2000). Hawes (this volume) discusses the prevalence and demography of mis- treatment among residents of long-term care facilities, as well as discusses the array of government and quasi-government agencies responsible for receiving and investigating complaints of elder mistreatment in nursing
134 ELDER MISTREATMENT homes and other residential care facilities. These agencies include the long- term care ombudsman program, the state agency responsible for licensing nursing homes, the state agency responsible for the operation of the nurse aide registry, Medicaid fraud control units, and professional licensing boards. Adult protective services programs, health care professionals, and participants in the criminal justice and civil justice systems also may be involved in responding to mistreated residents of nursing homes and other long-term care facilities in much the same way that they respond to victims who live in their own homes. The literature on compliance with, and enforcement of, federal regula- tions governing nursing homes has been reviewed by the Institute of Medi- cine (2001) and by Hawes (this volume), and the U.S. General Accounting Office maintains active oversight of regulatory enforcement, calling atten- tion to gaps and weaknesses. For example, a recent report (U.S. General Accounting Office, 2002) called attention to the inconsistent definitions of âabuseâ used in various states, the âhiddenâ nature of many incidents of abuse due to underrecognition and underreporting, and the gaps in em- ployee screening. Despite the widespread perception that institutional residents are at great risk of elder mistreatment, specific interventions to prevent elder mistreatment in long-term care residential settings have been limited. How- ever, current practices in nursing homes and assisted living facilities, as well as more general research on determinants of quality of care in nursing homes, suggest several avenues for intervention. Possible interventions to prevent institutional elder mistreatment fall into three general categories: (1) Hiring and supervision of staff: these are steps that the facility can take, either in terms of practice or policies, to reduce the likelihood of elder mistreatment. (2) Staff training and skill development: staff can be trained in concrete techniques to help make them aware of what elder mistreatment is and when and how to prevent it. (3) Response to and treatment of elder mistreatment: victims of elder mistreat- ment in residential settings may require specialized treatment programs. Because actual interventions are rare, potentially promising interven- tions in this area that require testing and evaluation are briefly reviewed. Hiring and Supervision of Staff The following are examples of managerial initiatives that may reduce the likelihood of elder mistreatment: Address hiring practices: the area that has received most attention in nursing home research is staffing. One of the endemic problems over the past decade has been a shortage of qualified staff. According to the Insti-
EVALUATING INTERVENTIONS 135 tute of Medicine (2001), âresearch evidence suggests that both nursing-to- resident staffing levels and the ratio of professional nurses to other nursing personnel are important predictors of high quality in nursing homes.â The committee accordingly urged the Center for Medicare and Medicaid Ser- vices (CMS) to âgive high priorityâ to research on staffing in nursing homes and the impact of various staffing configurations on outcomes. This panel agrees. The shortage of workers has led in some cases to lax hiring policies and to a lack of serious screening of employees. Some facilities hire a high proportion of individuals at the certified nursing assistant level who have criminal backgrounds or active substance abuse problems. Interventions that improve facilitiesâ ability to screen employees and determine individu- als who are suited for caregiving work would be very useful. State abuse registries may fill some of that need, but research on the problems with state registries and the potential benefits of a federal registry in lieu of, or in addition to, the state registries would be helpful. Tools to assess risk of abusive behavior prior to hiring should be developed. Improve supervision: a persistent problem in long-term care facilities is inconsistent (or absent) supervision. It is clear that supervisory staff must give a consistent message that caring and responsible staff will be rewarded and that elder mistreatment will not be tolerated. Furthermore, a key component of elder mistreatment prevention is the maintenance of a high index of suspicion on the part of supervisors. In reported cases of nursing home mistreatment, supervisors and administrators sometimes ignore signs and symptoms of elder mistreatment because of a false belief that âit canât happen here.â Training and awareness interventions with supervisors in nursing homes, with a focus on detection of elder mistreatment, are likely to be fruitful. Address burnout: one of the strongest research findings is the positive relationship between staff burnout and abusive behavior (Pillemer and Bachman-Prehn, 1991). There is no question that nursing home staff work under stressful conditions. Job stress and burnout can be addressed both at the structural and at the individual levels. A major cause of burnout is chronic short-staffing that is endemic to long-term care facilities (see Hawes, this volume). Although a discussion of solutions to staffing problems in nursing homes is beyond the scope of this report, there is no question that improving the numbers of staff and decreasing turnover rates would con- tribute to elder mistreatment prevention. The effects of different staffing models and staffing patterns could be evaluated to determine the effect on prevalence and severity of elder mistreatment (see Hawes, this volume). On the individual level, stress reduction and management programs should be evaluated to determine whether they have potential for preventing elder mistreatment
136 ELDER MISTREATMENT Staff Training and Skill Development Several factors have been identified as related to elder mistreatment by staff, which can be addressed through training programs. First, a striking finding from several studies (Pillemer and Moore, 1989; Pillemer and Bachman-Prehn, 1991; Hawes, this volume) is the high degree of interper- sonal conflict experienced in nursing home work. For example, the major- ity of staff reported that they had conflicts at least several times a week over residentsâ unwillingness to eat, personal hygiene, unwillingness to dress, toileting, and other issues. Many staff reported such conflicts every day (Pillemer and Moore, 1989). A second area involves problematic behavioral symptoms exhibited by residents, including wandering, yelling, suspiciousness, inability to cooper- ate with care, and particularly anger and verbal and physical aggression. In nursing homes, one of the most important reasons that mistreatment of residents occurs is a lack of training and ability on the part of staff to deal with aggressive behavior by residents (Hawes et al., 2001). Both of these areas point to critical training needs for staff. As a method of elder mistreatment prevention, workers in long-term care set- tings can be shown effective ways of modifying residentsâ behavior that can defuse these difficult situations before aggressive outcomes occur. Noelker and Bass (1995) pointed out that caregivers also need training by staff to make case management more effective. It cannot be assumed that staff will learn how to manage the interpersonal aspects of resident care on the job, as is typically the case. The provision of a tool kit of techniques and methods of handling these problems has elder mistreatment prevention potential. The best-known training program that addresses these issues was de- veloped by the Coalition of Advocates for the Rights and Interests of the Elderly (CARIE), entitled Competence With Compassion: An Abuse Pre- vention Training Program for Long Term Care Staff. This elder mistreat- ment prevention curriculum is designed for nursing assistants in long-term care facilities. The program has three major objectives: to increase staff awareness of actual elder mistreatment and potentially abusive situations; to equip nursing assistants with appropriate conflict intervention strategies; and thereby to reduce staff-resident conflict and abusive behaviors by staff. Although a randomized, controlled evaluation of this program has not been conducted, project data are promising. Individuals undergoing the training showed improved attitudes toward residents between pretest and posttest. Staff also reported less conflict with residents after the training, as well as reductions in resident aggression toward themselves. This is an indication of the success of the training, since the curriculum addressed how to avoid or defuse conflicts with residents before the resident becomes aggressive.
EVALUATING INTERVENTIONS 137 Most important, self-reported abusive actions by staff declined as a result of the training. Response to and Treatment of Elder Mistreatment There is little research or practical guidance regarding effective re- sponse to incidents of elder mistreatment in residential settings or to meth- ods of treating victims to ameliorate the negative outcomes of elder mis- treatment. As Hawes suggests (this volume), studies of the effectiveness of ombudsman programs (which are primarily responsible for coordinating investigation and response to elder mistreatment cases) would be very use- ful. Do such programs have an impact on the incidence of elder mistreat- ment, and do they lead to better outcomes for victims? It is also possible that the range of victim assistance services offered to family violence victims could be applicable to nursing homes. In some cases of sexual assault, rape crisis services have been provided to nursing home residents (Burgess et al., 2000). Thus far, no formal intervention programs have been created to counsel or provide specialized therapy to elder mis- treatment victims in residential settings. Such programs should be devel- oped and evaluated. Unannounced Long-Term Care Facility Inspection Teams At least two states, Florida and California, have developed long-term care facility inspection teams (known as Operation Spot Check and Opera- tion Guardian, respectively) that conduct random, unannounced visits of nursing homes and assisted living facilities. The teams are generally com- posed of representatives from the attorney generalâs office, law enforce- ment, the long-term care ombudsman program, and other government en- forcement agencies, including code enforcement officers and local or state fire marshals. The unannounced visits supplement the existing annual inspections conducted by state government pursuant to federal law. It would be valuable to study whether unannounced long-term care facility inspection teams make any difference in the amount or types of abuse and neglect experienced by residents of these facilities. Another researchable question is the impact on staff and management of these unan- nounced inspections. URGENT NEED FOR OUTCOME RESEARCH The need for careful scientific research on the effects of interventions is underscored by the sobering findings of the only published elder mistreat- ment intervention study using an experimental design. This study, funded
138 ELDER MISTREATMENT by the National Institute of Justice, indicates that households receiving the intervention had an increased risk of subsequent mistreatment (Davis and Medina-Ariza, 2001). The investigators adapted a model they had previ- ously used in a study of the effects of a coordinated team response to family violence (Davis and Taylor, 1997). In the subsequent elder mistreatment study, the target population was persons living in selected public housing units in New York City who reported elder abuse (defined as physical abuse and psychological abuse) incidents to the police. Random assignment for the intervention occurred at two levels. First, 30 of 60 public housing projects were randomly assigned to receive public education about elder abuse (e.g., posters, leaflets, and project staff presentations). Second, in all 60 housing projects, half of the households reporting elder abuse incidents to the police were randomly assigned to receive home visits by a team of a police officer and a domestic violence counselor. The team discussed legal options and police procedures and attempted to link the households to social services. Victims were also encouraged to call the police if repeat incidents occurred. To determine whether abuse continued, police records were checked and victims were interviewed 6 and 12 months after the triggering incident. Six months after the intervention, households receiving the home visit called the police significantly more often than controls, both in housing projects that received public education and those that did not. This is not surprising, since the home visit was designed to invite such reports. But this expectation was based on the assumption that the intervention would change reporting behavior, not that it would increase incidents of abuse. (If anything, one might have expected the number of actual incidents of abuse to be reduced due to deterrence.) The surprising finding was that that the increased number of calls was accompanied by an increased number of incidents of abuse, as reported by the victims to the research interviewers. That is, when households received both home visits and public education, victims of elder abuse reported significantly higher levels of physical abuse than households that received neither intervention or only one of them. During the period between 6 and 12 months after the intervention, the differences in calls to the police disappeared, but households that received the dual intervention continued to report significantly more incidents of physical abuse to the interviewers. The researchers have speculated about the possible explanations for this paradoxical finding, including the possibility that the intervention an- gered the perpetrators. (As they pointed out, however, the perpetrators were not interviewed.) The most pertinent observation from the panelâs perspective is that the study raises more questions than it answers. Even well-intentioned interventions may have unexpected, and even harmful, outcomes.
EVALUATING INTERVENTIONS 139 Research on the effects of elder mistreatment interventions is urgently needed. Existing interventions to prevent or ameliorate elder mistreatment should be evaluated, and agencies funding new intervention programs should require and fund a scientifically adequate evaluation as a compo- nent of each grant. Specifically: â¢ Research is needed on reporting practices and on the effects of reporting, taking maximum advantage of the opportunity for comparisons of practices and outcomes in states with and without mandated reporting. â¢ Research is needed on the effectiveness of adult protective services interventions, ideally in study designs that compare outcomes in cases in which services were provided with those in which eligible recipients de- clined offered services or other cases in which mistreatment of an equiva- lent nature has been identified. â¢ Intervention or prevention research based in existing health care environments that come into contact with mistreated elders, such as hospi- tals, emergency departments, and emergency response services, should be a priority as it takes advantage of the existing expertise and resources of these services. â¢ The development of adult protective services/university research teams should be encouraged in order to evaluate existing data, recommend improvements in the collection of data, analyze incident reports, and design the studies of outcomes urged in this report.