Informing evidence-based practice: a review of research analyzing adult protective services data

Use of Motivational Interviewing by Advocates in the Context of an Elder Abuse Response Intervention: The RISE Project

Purpose

Despite the increasing number of elder abuse and self-neglect (EASN) cases, many older adults are reluctant to engage with formal support services, such as Adult Protective Services (APS). This study examined the use of motivational interviewing (MI) by advocates, as a component of a larger EASN intervention, RISE (Repair Harm, Inspire Change, Support Connection, Empower Choice), implemented in partnership with APS. Advocates applied MI as part of RISE to help clients explore and resolve ambivalence around pursuing change and ultimately enhance service engagement.

Methods

This study conducted qualitative interviews and a focus group with all RISE advocates (n = 4) to understand how MI is applied in the context of an EASN intervention with older adult clients. A descriptive phenomenological approach involving two independent assessors was used to code verbatim transcripts into themes.

Results

Three domains were identified: (1) therapeutic relationship, which describes the importance of foundational relationship building in MI to support older adults who have experienced EASN; (2) techniques, which refers to MI strategies advocates apply and adapt in the context of EASN intervention; and (3) implementation challenges, which reflects the difficulties advocates encounter when using MI in cases of EASN.

Conclusions

The experiences of advocates suggest MI is a beneficial and amenable approach to help older adults who have experienced EASN navigate issues of ambivalence and explore their motivation for change. This study represents the first in-depth exploration of MI in the context of EASN intervention.

Implementing a Financial Decision-Making Scale in APS Financial Exploitation Investigations: Use of the PARIHS Conceptual Framework

BACKGROUND AND OBJECTIVES

Adult protective services (APS) agencies investigate cases of financial exploitation, and a critical aspect of such investigations is often the assessment of decision-making abilities. This study examined APS workers' implementation of a 10-item financial decision-making screening tool, the Financial Decision Tracker (FDT), across a 34-month period: pre-COVID-19, throughout COVID-19 restrictions, and for 1 year following the restrictions.

RESEARCH DESIGN AND METHODS

Using the Promoting Action in Research Implementation in the Health Services implementation science conceptual framework, we examined aspects of context, facilitation, and evidence to determine how well APS workers were trained, certified, and skilled in using the FDT. Using individual and group interviews, we assessed factors often related to successful implementation (context and facilitation) and measured the number of scales used, the types of decisions under investigation, and how the tool's scoring system aligned with the APS workers' final ratings (evidence).

RESULTS

Overall, implementation was sustained throughout the 34-month period. However, during COVID-19 restrictions, usage dropped to a rate 58% below that prior to and following the restrictions. A total of 839 scales were administered. Individuals with no decision-making deficits were slightly older (78.7 vs 77.1 years; t(837) = 2.54, p = .01) and had completed high school at a significantly higher rate (69% vs 59%, χ 2(1) = 5.20, p = .023) than those who had decision-making deficits.

DISCUSSION AND IMPLICATIONS

Overall, the implementation trial can be considered a success. The FDT was used so often and effectively that it is now an APS best practices tool, meaning that in audits, the correct use of the FDT will be assessed.

A qualitative evaluation of the "RISE" elder abuse intervention from the perspective of adult protective services caseworkers: addressing a service system gap

Our understanding of effective elder abuse (EA) response interventions is limited. Adult Protective Services (APS), the primary agency responsible for responding to EA, lacks a coherent, conceptually driven, prolonged intervention phase. Informed by an ecological-systems perspective and adapting evidence-based modalities from other fields, the RISE EA intervention addresses this APS systems gap. Based on a three-year pilot project involving a partnership between RISE and Maine APS, the current study conducted a qualitative evaluation of RISE, from the perspective of APS caseworkers (n = 14) who worked with RISE, to understand RISE strengths and areas for improvement. Findings suggest APS workers perceive that RISE complements the scope and nature of APS, enhances APS caseworker well-being, and reduces repeat APS cases, while further APS/RISE collaboration and clarification on RISE role responsibilities and referral eligibilities are areas of growth. This study provides preliminary evidence for RISE as a community-based EA intervention in partnership with APS.

RISE: A Conceptual Model of Integrated and Restorative Elder Abuse Intervention

Despite a growing number of elder abuse cases nationwide, response programs such as Adult Protective Services (APS) lack a defined, prolonged intervention phase to address these complex situations. This paper presents RISE, a model of elder abuse intervention that works alongside APS or other systems that interact with at-risk older adults. Informed by an ecological-systems perspective and adapting evidence-based modalities from other fields (including motivational interviewing, teaming, restorative justice, goal attainment scaling), the RISE model intervenes at levels of the individual older adult victim, individual harmer, their relationship, and community to address elder abuse risk and strengthen systems of support surrounding the victim-harmer dyad. The RISE model addresses an intervention gap in existing systems to better meet the needs of elder abuse victims and others in their lives, leading to more sustainable outcomes.

Measuring the diverse characteristics of county adult protective services programs

Adult protective services (APS) programs vary markedly, yet few studies have quantified this diversity. In 2020, a survey of Ohio's 85 county-administered APS programs incorporated subsequent feedback from staff and described the programs in a systematic manner. This process resulted in a 100% response rate and illustrated an efficient approach to measuring organizational characteristics (e.g., whether any staff are mostly dedicated to APS), resources (e.g., access to multidisciplinary teams), and practices (e.g., how often staff create a plan to meet client goals). The prevalence of many factors differed by the number of older adults the program served. For instance, 75% of programs in large counties had regular opportunities to share complex cases with a multidisciplinary team, compared to 28% of programs in small counties. Understanding the diverse characteristics of APS programs - and how to measure them - can help agencies guide quality improvement efforts and the dissemination of innovations.

Pragmatic Randomized Control Trial of a Coordinated Community Response: Increasing Access to Services for At-Risk Older Adults

BACKGROUND

Elder abuse, neglect, and financial exploitation (EANF) impacts over five million community-dwelling older adults. Yet, no evidence-based intervention models exist that prevent EANF.

OBJECTIVES

In this article, we describe the assessment of process outcomes for a Community Complex Care Response Team (C3RT) model developed, via a practitioner-researcher partnership, to reduce instances of EANF victimization among higher risk community-dwelling older adults by identifying and coordinating their service needs. Specifically, we evaluated whether this C3RT approach produced more service coordination among providers (measured as documented interagency communications), more referrals for services, and more enrollment in services.

METHODS

A pragmatic randomized control trial using a 1:1 randomization scheme allocated participants to either the C3RT intervention (N = 74) or standard practice (N = 72) group offered by a local Area Agency on Aging. Outcome data were extracted from the participants' administrative service records.

RESULTS

The participants assigned to C3RT had significantly more interagency communications and services provided (p < 0.05) than those in standard practice.

CONCLUSIONS

Communications and services increased across a broad range of multidisciplinary services, which attend to the social determinants of health. This study is the first to use objective outcome measures to evaluate the processes of a coordinated community response approach systematically.

Using administrative data from adult protective services: opportunities and considerations

As federal agencies support the development of data systems for adult protective services (APS), researchers and practitioners are increasingly using administrative data to study types of adult maltreatment, including self-neglect, and the systems that respond to them. To date, however, APS has worked with little guidance about how best to use these data. This situation has contributed to inconsistent findings and uneven quality of research. Based on the authors' experience in multiple states and using examples from research and practice, this paper reviews practical considerations related to organizing and analyzing APS administrative data. We address concerns related to time-limited, erroneous, and missing data, as well as defining metrics and accounting for the multilevel structure of data with repeated observations. Reviewing these methodological details can help APS practitioners strengthen quality assurance processes and improve research in this important area.

OUP accepted manuscript

Background and Objectives

Adult Protective Services (APS) are the frontline agencies investigating elder mistreatment and providing/coordinating postinvestigation services. Yet, their effectiveness in reducing different types of mistreatment in relation to services is unknown. This study aimed to address the knowledge gap by identifying services provided by mistreatment type, and examining the associations of services with mistreatment reduction.

Research Design and Methods

A pretest–post-test design was implemented using the Identification, Services, and Outcomes (ISO) Matrix to assess mistreatment levels during case investigation and at case closure after services were provided. San Francisco and Napa APS participated in a 6-month data collection.

Results

The 4 most prevalent types of mistreatment were examined: emotional, physical, financial abuse, and neglect by others. On average, level of mistreatment decreased across mistreatment types after APS intervention. Care/case management, mental health, and other services were most common, while specific services differed depending on type of mistreatment. Care/case management services were associated with physical and emotional abuse reduction, legal services further correlated with emotional abuse reduction; financial planning services were associated with financial abuse reduction; care/case management and other services were associated with neglect reduction.

Discussion and Implications

This is the first study to address APS services by mistreatment type and the outcomes of services. Adoption of the ISO Matrix by APS programs opens the possibility of research and practice collaboration in APS outcomes research using a standardized approach.

Service providers' use of harm reduction approaches in working with older adults experiencing abuse: a qualitative study

BACKGROUND

Although abuse experienced by older adults is common and expected to increase, disclosure, reporting and interventions to prevent or mitigate abuse remain sub-optimal. Incorporating principles of harm reduction into service provision has been advocated as a strategy that may improve outcomes for this population. This paper explores whether and how these principles of harm reduction were employed by professionals who provide services to older adults experiencing abuse.

METHODS

Thematic analysis of qualitative interviews with 23 professionals providing services to older adults experiencing abuse across three Western provinces of Canada was conducted. Key principles of harm reduction (humanism, incrementalism, individualism, pragmatism, autonomy, and accountability without termination) were used as a framework for organizing the themes.

RESULTS

Our analysis illustrated a clear congruence between each of the six harm reduction principles and the approaches reflected in the narratives of professionals who provided services to this population, although these were not explicitly articulated as harm reduction by participants. Each of the harm reduction principles was evident in service providers' description of their professional practice with abused older adults, although some principles were emphasized differentially at different phases of the disclosure and intervention process. Enactment of a humanistic approach formed the basis of the therapeutic client-provider relationships with abused older adults, with incremental, individual, and pragmatic principles also apparent in the discourse of participants. While respect for the older adult's autonomy figured prominently in the data, concerns about the welfare of the older adults with questionable capacity were expressed when they did not engage with services or chose to return to a high-risk environment. Accountability without termination of the client-provider relationship was reflected in continuation of support regardless of the decisions made by the older adult experiencing abuse.

CONCLUSIONS

Harm reduction approaches are evident in service providers' accounts of working with older adults experiencing abuse. While further refinement of the operational definitions of harm reduction principles specific to their application with older adults is still required, this harm reduction framework aligns well with both the ethical imperatives and the practical realities of supporting older adults experiencing abuse.

Who is in the revolving door? Policy and practice implications of recurrent reports to adult protective services

Repeat referral to adult protective services APS (recurrence) is a much-discussed topic among APS agencies as it may indicate ongoing harm, yet there is limited research examining prevalence or causes. This paper provides a foundational investigation of recurrence within a California APS county program. Drawing from thirty-three months of de-identified reports, we used logistic regression to examine the impact of intake report characteristics on repeat referral within one year after baseline case closure. One-fifth of the sample was recurrent (19.9%, n=987/4,958), with self-neglect being the most common type of report to recur (14.3%, n=307/2,141). Overall recurrence was predicted by female gender, older age, living alone, and multiple elder abuse, neglect, and exploitation (ANE) types reported at baseline, and report placed by social service provider, friends, family, landlords, and victim self-reports. Reporters personally related to the victim and social service providers are potential partners in identifying ANE, and alternate intervention approaches may be necessary.

Developing a comprehensive understanding of elder abuse prevention in immigrant communities: a comparative mixed methods study protocol

INTRODUCTION

Older adults are the fastest growing age group in Canada. Elder abuse has significant individual and societal implications, so it is critical to address. While interest in this topic is increasing, little is known about the risk factors for elder abuse in immigrant communities in Canada, or about culturally relevant strategies to address these risk factors.

METHODS AND ANALYSIS

This mixed-methods study is guided by the intersectionality and ecological frameworks. We will include two long-term (ie, established) and two recent immigrant communities from East Asian and South Asian communities in the Greater Toronto Area: Chinese, Korean, Punjabi and Tamil. Through structured group interviews, we will first identify factors that contribute to elder abuse within and across each of the immigrant communities and then explore culturally relevant strategies to address those risk factors. Group interviews will be conducted separately with five stakeholder groups in each of the four languages: older women, older men, family members, community leaders and service providers. Quantitative and qualitative data will be analysed at the level of the particular interview groups, subgroups and communities, and will be integrated across communities to identify common and unique risk factors and strategies to address elder abuse.

ETHICS AND DISSEMINATION

The study protocol has received ethics approval from the two universities associated with the research team. Given the comprehensive approach to incorporate local knowledge and expert contributions from multi-level stakeholders, the empirical and theoretical findings will facilitate practice change and improve the well-being of older men and women in immigrant communities.

Development and Spanish translation of the Weinberg Center Risk and Abuse Prevention Screen (WC-RAPS)

Barriers for enhanced detection, identification, and reporting of elder abuse include the paucity of appropriate, valid, easily administered screening tools. This article describes the qualitative methods used in the development of the Weinberg Center Risk and Abuse Prevention Screen (WC-RAPS), and of its Spanish version. Focus groups and cognitive interviews were instrumental in identifying problematic items, underscoring potential response errors, and informing about putative causes for divergent interpretations of item-intent. Seven of the 11 original items were modified, a double-barreled item was segregated into two, one item deleted, and three additional items included to create the final 13 WC-RAPS items. The multi-step approach implemented for the Spanish conversion evidenced deviation from the original intended meaning for one item. The readability for English and Spanish versions was also assessed. Screening for elder abuse, if implemented systematically can be instrumental in identifying unrecognized abuse and preventing reoccurrence.

Addressing the measurement challenge in elder abuse interventions: need for a severity framework

The field of elder abuse is evolving toward an emphasis on intervention research. However, researchers currently rely on binary approaches to measure elder abuse phenomena, which fail to capture changes in problem status over the course of intervention. This commentary develops a case for severity as a framework to operationalize and measure elder abuse in intervention research and practice. A severity framework provides enhanced elder abuse measurement responsiveness and aligns with the dominant client-centered, harm-reduction clinical approach to intervening with elder abuse cases.

Moving forward: recommendations for advancing late-life polyvictimization practice, policy, and research

This article synthesizes what has been learned from the entire polyvictimization in later-life project and offers five categories of recommendations for addressing polyvictimization and its elderly victims through practice, policy, and research. These five recommendations relate to definitions and frameworks, practice, training and education, research and evidence-based interventions, and prevention. Specifically, this article focuses on changes to improve identification, development of policies and practices, and research priorities.

Item response theory analysis of the Lichtenberg Financial Decision Screening Scale

The focus of these analyses was to examine the psychometric properties of the Lichtenberg Financial Decision Screening Scale (LFDSS). The purpose of the screen was to evaluate the decisional abilities and vulnerability to exploitation of older adults. Adults aged 60 and over were interviewed by social, legal, financial, or health services professionals who underwent in-person training on the administration and scoring of the scale. Professionals provided a rating of the decision-making abilities of the older adult. The analytic sample included 213 individuals with an average age of 76.9 (SD = 10.1). The majority (57%) were female. Data were analyzed using item response theory (IRT) methodology. The results supported the unidimensionality of the item set. Several IRT models were tested. Ten ordinal and binary items evidenced a slightly higher reliability estimate (0.85) than other versions and better coverage in terms of the range of reliable measurement across the continuum of financial incapacity.

Evidence-Based Practice: Attitude and Knowledge of Social Workers across Geographic Regions

The objective of the author in this article was to examine possible differences in knowledge and attitudes toward evidence-based practice (EBP) among social workers across geographic regions. A random national sample of 180 NASW members was obtained from mail and Internet groups. MANOVA analysis was performed to determine possible differences in knowledge and attitudes toward EBP among these social workers. Findings suggest that knowledge and attitude toward EBP did not differ among these practitioners. Despite increasing efficacy and widespread knowledge of EBPs, there is little or no empirical evidence to support any differences in attitudes and knowledge of EBP among social workers across geographic regions.

State of the science on prevention of elder abuse and lessons learned from child abuse and domestic violence prevention: Toward a conceptual framework for research

The goal of this review is to discuss the state of the science in elder abuse prevention. Findings from evidence-based programs to reduce elder abuse are discussed, drawing from findings and insights from evidence-based programs for child maltreatment and domestic/intimate partner violence. A conceptual measurement model for the study of elder abuse is presented and linked to possible measures of risk factors and outcomes. Advances in neuroscience in child maltreatment and novel measurement strategies for outcome assessment are presented.

Community Elder Mistreatment Intervention With Capable Older Adults: Toward a Conceptual Practice Model

Community-based elder mistreatment response programs (EMRP), such as adult protective services, that are responsible for directly addressing elder abuse and neglect are under increasing pressure with greater reporting/referrals nationwide. Our knowledge and understanding of effective response interventions represents a major gap in the EM literature. At the center of this gap is a lack of theory or conceptual models to help guide EMRP research and practice. This article develops a conceptual practice model for community-based EMRPs that work directly with cognitively intact EM victims. Anchored by core EMRP values of voluntariness, self-determination, and least restrictive path, the practice model is guided by an overarching postmodern, constructivist, eco-systemic practice paradigm that accepts multiple, individually constructed mistreatment realities and solutions. Harm-reduction, client-centered, and multidisciplinary practice models are described toward a common EMRP goal to reduce the risk of continued mistreatment. Finally, the model focuses on client-practitioner relationship-oriented practice skills such as engagement and therapeutic alliance to elicit individual mistreatment realities and client-centered solutions. The practice model helps fill a conceptual gap in the EM intervention literature and carries implications for EMRP training, research, and practice.

All Elder Abuse Perpetrators Are Not Alike: The Heterogeneity of Elder Abuse Perpetrators and Implications for Intervention

The tendency to label all elder abuse perpetrators as the "bad guys" has diminished our ability to respond effectively. A review of the literature demonstrates that elder abuse perpetrators are in fact heterogeneous with important differences across types of abuse. A reformulation of perpetrator interventions away from a singular emphasis on prosecution to meaningful alternatives that utilize criminal justice and/or therapeutic approaches tailored to the needs of the case is needed. These interventions must incorporate the needs of both victims and perpetrators, take into consideration the type of abuse involved, acknowledge the variations in perpetrator culpability, and recognize the continuum of complexity among these cases. Without addressing these nuances, intervention and prevention efforts will be futile if not harmful.

The Sexual Victimization of Older Women Living in Nursing Homes

This study examined 64 cases of sexual victimization of women ages 65+ (mean = 81) living in facilities that were investigated by APS and regulatory agencies in five states over a six-month period. Typically, abuse involved molestation (53%) and unwelcome sexual interest in the body (20%). Abilities and needs of women in substantiated and unsubstantiated cases were comparable. Resident perpetrators were more likely to be substantiated than staff or any other perpetrator (p = 0.008). Our results underscore the need to evaluate differences associated with gender, age, and residence, and to train on reporting and intervention by disciplines serving victims.

The Case for Individualized Goal Attainment Scaling Measurement in Elder Abuse Interventions

Research available to inform the development of effective community-based elder abuse protective response interventions is severely limited. Elder abuse intervention research is constrained by a lack of research capacity, including sensitive and responsive outcome measures that can assess change in case status over the course of intervention. Given the heterogeneous nature of elder abuse, standard scales can lack the flexibility necessary to capture the diverse range of individually relevant issues across cases. In this paper, we seek to address this gap by proposing the adaptation and use of an innovative measurement strategy-goal attainment scaling-in the context of elder protection. Goal attainment scaling is an individualized, client-centered outcome measurement approach that has the potential to address existing measurement challenges constraining progress in elder abuse intervention research.