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Makaroun LK, Halaszynski JJ, Smith KA, Drake R, Amelio-Hering V, Atchison K, Dichter ME, Rosland AM, Thorpe CT, Rosen T. Screening for Elder Abuse in the Veterans Health Administration: Varied Approaches Across a National Health System. J Gen Intern Med 2024; 39:2225-2232. [PMID: 38191973 PMCID: PMC11347547 DOI: 10.1007/s11606-023-08560-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 12/01/2023] [Indexed: 01/10/2024]
Abstract
BACKGROUND Elder abuse (EA) is common and has devastating health consequences yet is rarely detected by healthcare professionals. While EA screening tools exist, little is known about if and how these tools are implemented in real-world clinical settings. The Veterans Health Administration (VHA) has experience screening for, and resources to respond to, other forms of interpersonal violence and may provide valuable insights into approaches for EA screening. OBJECTIVE Describe EA screening practices across a national integrated healthcare system serving a large population of older adults at risk for EA. DESIGN Survey of all 139 VHA medical centers from January to August 2021. PARTICIPANTS Surveys were completed by the Social Work Chief, or delegate, at each site. MAIN MEASURES The survey assessed the presence and characteristics of EA-specific screening practices as well as general abuse/neglect screening conducted with patients of all ages, including older adults. Follow-up emails were sent to sites that reported screening requesting additional details not included in the initial survey. KEY RESULTS Overall, 130 sites (94%) responded. Among respondents, 5 (4%) reported screening older adults for EA using a previously published tool, while 6 (5%) reported screening for EA with an unstudied or locally developed tool. Forty-eight percent reported screening patients of all ages for general abuse/neglect using unstudied questions/tools, and 44% reported no EA screening at their site. Characteristics of screening programs (e.g., frequency, clinical setting, provider type) varied widely between sites, as did respondents' understanding of the definition of screening. CONCLUSIONS High variability in screening practices for abuse/neglect and lack of EA-specific screening in a system that has successfully deployed other standardized screening approaches present an important opportunity to standardize and improve EA detection practices. Lessons learned in VHA could help advance the evidence base for EA screening more broadly to increase overall detection rates for EA nationally.
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Affiliation(s)
- Lena K Makaroun
- VA Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA.
- Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA.
- VA Geriatric Research, Education and Clinical Center, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA.
| | | | | | - Ruth Drake
- G.V. (Sonny) Montgomery VA Medical Center, Jackson, MS, USA
| | | | - Karley Atchison
- VA Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Melissa E Dichter
- VA Center for Health Equity Research and Promotion, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA
- School of Social Work, Temple University Philadelphia, Philadelphia, PA, USA
| | - Ann-Marie Rosland
- VA Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Carolyn T Thorpe
- VA Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Division of Pharmaceutical Outcomes and Policy, University of North Carolina at Chapel Hill Eshelman School of Pharmacy, Chapel Hill, NC, USA
| | - Tony Rosen
- Department of Emergency Medicine, Weill Cornell Medical College/New-York Presbyterian Hospital, New York, NY, USA
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Makaroun LK, Rosland AM, Mor MK, Zhang H, Lovelace E, Rosen T, Dichter ME, Thorpe CT. Frailty predicts referral for elder abuse evaluation in a nationwide healthcare system-Results from a case-control study. J Am Geriatr Soc 2023; 71:1724-1734. [PMID: 36695515 PMCID: PMC10258119 DOI: 10.1111/jgs.18245] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Revised: 12/14/2022] [Accepted: 12/23/2022] [Indexed: 01/26/2023]
Abstract
BACKGROUND Elder abuse (EA) is common and has devastating health impacts. Frailty may increase susceptibility to and consequences of EA for older adults, making healthcare system detection more likely, but this relationship has been difficult to study. We examined the association between a recently validated frailty index and referral to social work (SW) for EA evaluation in the Veterans Administration (VA) healthcare system. METHODS We conducted a case-control study of veterans aged ≥60 years evaluated by SW for suspected EA between 2010 and 2018 (n = 14,723) and controls receiving VA primary care services in the same 60-day window (n = 58,369). We used VA and Medicare claims data to measure frailty (VA Frailty Index) and comorbidity burden (the Elixhauser Comorbidity Index) in the 2 years prior to the index. We used adjusted logistic regression models to examine the association of frailty or comorbidity burden with referral to SW for EA evaluation. We used Akaike Information Criterion (AIC) values to evaluate model fit and likelihood ratio (LR) tests to assess the statistical significance of including frailty and comorbidity in the same model. RESULTS The sample (n = 73,092) had a mean age 72 years; 14% were Black, and 6% were Hispanic. More cases (67%) than controls (36%) were frail. LR tests comparing the nested models were highly significant (p < 0.001), and AIC values indicated superior model fit when including both frailty and comorbidity in the same model. In a model adjusting for comorbidity and all covariates, pre-frailty (aOR vs. robust 1.7; 95% CI 1.5-1.8) and frailty (aOR vs. robust 3.6; 95% CI 3.3-3.9) were independently associated with referral for EA evaluation. CONCLUSIONS A claims-based measure of frailty predicted referral to SW for EA evaluation in a national healthcare system, independent of comorbidity burden. Electronic health record measures of frailty may facilitate EA risk assessment and detection for this important but under-recognized phenomenon.
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Affiliation(s)
- Lena K. Makaroun
- VA Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
- VA Geriatric Research, Education and Clinical Center, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
- Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Ann-Marie Rosland
- VA Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
- Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Maria K. Mor
- VA Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
- Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Hongwei Zhang
- VA Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
| | - Elijah Lovelace
- VA Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
| | - Tony Rosen
- Department of Emergency Medicine, Weill Cornell Medical College/New-York Presbyterian Hospital, New York, New York, USA
| | - Melissa E. Dichter
- VA Center for Health Equity Research and Promotion, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA
- School of Social Work, Temple University Philadelphia, PA
| | - Carolyn T. Thorpe
- VA Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
- Division of Pharmaceutical Outcomes and Policy, University of North Carolina at Chapel Hill Eshelman School of Pharmacy, Chapel Hill, North Carolina, USA
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Makaroun LK, Halaszynski JJ, Rosen T, Haggerty KL, Blatnik JK, Froberg R, Elman A, Geary CA, Hagy DM, Rodriguez C, McQuown CM. Leveraging VA geriatric emergency department accreditation to improve elder abuse detection in older Veterans using a standardized tool. Acad Emerg Med 2023; 30:428-436. [PMID: 36575600 PMCID: PMC10192131 DOI: 10.1111/acem.14646] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Revised: 12/09/2022] [Accepted: 12/15/2022] [Indexed: 12/29/2022]
Abstract
Elder abuse (EA) is common and has devastating health impacts, yet most cases go undetected limiting opportunities to intervene. Older Veterans receiving care in the Veterans Health Administration (VHA) represent a high-risk population for EA. VHA emergency department (ED) visits provide a unique opportunity to identify EA, as assessment for acute injury or illness may be the only time isolated older Veterans leave their home, but most VHA EDs do not have standardized EA assessment protocols. To address this, we assembled an interdisciplinary team of VHA social workers, physicians, nurses, intermediate care technicians (ICTs; former military medics and corpsmen who often conduct screenings in VHA EDs) and both VHA and non-VHA EA subject matter experts to adapt the Elder Mistreatment Screening and Response Tool (EM-SART) to pilot in the Louis Stokes Cleveland VA Medical Center geriatric ED (GED) program. The cornerstone of their approach is an interdisciplinary GED consultation led by ICTs and nurses who screen high-risk older Veterans for geriatric syndromes and unmet needs. The adapted EM-SART was integrated into the electronic health record and GED workflow in December 2020. By July 2022, a total of 251 Veterans were screened with nine (3.6%) positive on the prescreen and five (2%) positive on the comprehensive screen. Based on the first-year pilot experience, the interdisciplinary team was expanded and convened regularly to further adapt the EM-SART for wider use in VHA, including embedding flexibility for both licensed and nonlicensed clinicians to complete the screening tool and tailoring response options to be specific to VHA policy and resources. The national momentum for VHA EDs to improve care for older Veterans and secure GED accreditation offers unique opportunities to embed this evidence-based approach to EA assessment in the largest integrated health system in the United States.
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Affiliation(s)
- Lena K. Makaroun
- VA Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
- VA Geriatric Research, Education and Clinical Center, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
- Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | | | - Tony Rosen
- Department of Emergency Medicine, Weill Cornell Medical College/New-York Presbyterian Hospital, New York, New York, USA
| | | | | | | | - Alyssa Elman
- Department of Emergency Medicine, Weill Cornell Medical College/New-York Presbyterian Hospital, New York, New York, USA
| | | | - Dyan M. Hagy
- Louis Stokes Cleveland VA Medical Center, Cleveland, Ohio, USA
| | | | - Colleen M. McQuown
- VA Geriatric Research, Education and Clinical Center, Louis Stokes Cleveland VA Medical Center, Cleveland, Ohio, USA
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Makaroun LK, Thorpe CT, Mor MK, Zhang H, Lovelace E, Rosen T, Dichter ME, Rosland AM. Medical and Social Factors Associated with Referral for Elder Abuse Services in a National Healthcare System. J Gerontol A Biol Sci Med Sci 2021; 77:1706-1714. [PMID: 34849854 PMCID: PMC9373957 DOI: 10.1093/gerona/glab354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Elder abuse (EA) is common and has devastating health consequences yet is not systematically assessed or documented in most health systems, limiting efforts to target healthcare-based interventions. Our objective was to examine sociodemographic and medical characteristics associated with documented referrals for EA assessment or services in a national US healthcare system. METHODS We conducted a national case-control study in US Veterans Health Administration facilities of primary care (PC)-engaged Veterans age ≥60 years who were evaluated by social work (SW) for EA-related concerns between 2010-18. Cases were matched 1:5 to controls with a PC visit within 60 days of the matched case SW encounter. We examined the association of patient sociodemographic and health factors with receipt of EA services in unadjusted and adjusted models. RESULTS Of 5,567,664 Veterans meeting eligibility criteria during the study period, 15,752 (0.3%) received services for EA (cases). Cases were mean age 74, and 54% unmarried. In adjusted logistic regression models (aOR; 95%CI), age ≥85 (3.56 v. age 60-64; 3.24-3.91), female sex (1.96; 1.76-2.21), child as next-of-kin (1.70 v. spouse; 1.57-1.85), lower neighborhood socioeconomic status (1.18 per higher quartile; 1.15-1.21), dementia diagnosis (3.01; 2.77-3.28) and receiving a VA pension (1.34; 1.23-1.46) were associated with receiving EA services. CONCLUSION In the largest cohort of patients receiving EA-related healthcare services studied to date, this study identified novel factors associated with clinical suspicion of EA that can be used to inform improvements in healthcare-based EA surveillance and detection.
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Affiliation(s)
- Lena K Makaroun
- VA Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA.,VA Geriatric Research, Education and Clinical Center, VA Pittsburgh Healthcare System, Pittsburgh PA.,Department of Medicine, School of Medicine, University of Pittsburgh
| | - Carolyn T Thorpe
- VA Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA.,University of North Carolina at Chapel Hill Eshelman School of Pharmacy, Chapel Hill, NC
| | - Maria K Mor
- VA Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA.,Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh
| | - Hongwei Zhang
- VA Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA
| | - Elijah Lovelace
- VA Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA
| | - Tony Rosen
- New-York Presbyterian Hospital Weill Cornell Medical College, New York, NY
| | - Melissa E Dichter
- VA Center for Health Equity Research and Promotion, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA.,School of Social Work, Temple University Philadelphia, PA
| | - Ann-Marie Rosland
- VA Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA.,Department of Medicine, School of Medicine, University of Pittsburgh
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Rosen T, Makaroun LK, Conwell Y, Betz M. Violence In Older Adults: Scope, Impact, Challenges, And Strategies For Prevention. Health Aff (Millwood) 2019; 38:1630-1637. [PMID: 31589527 PMCID: PMC7327526 DOI: 10.1377/hlthaff.2019.00577] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Although often perceived to be a problem of the young, violence commonly affects older adults, a rapidly growing segment of the population. Violence can be directed toward older adults (elder abuse and intimate partner violence), self-directed (suicide), or perpetrated by older adults against others (intimate partner violence and violence in dementia). Across forms of violence, firearm access increases lethality, and veterans may be a particularly high-risk population. The forms of violence in older adults have some common risk factors (such as medical or psychiatric illness) and common challenges for prevention (such as balancing autonomy and well-being in vulnerable adults). The integration of prevention strategies across the life span, disciplines, and forms of violence offers promise for promoting older adult health and well-being. Looking forward, key areas for attention will include raising awareness about these topics and prioritizing funding for the implementation and evaluation of violence prevention interventions in health care settings and the community.
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Affiliation(s)
- Tony Rosen
- Tony Rosen is an assistant professor of emergency medicine at Weill Cornell Medical College, in New York City
| | - Lena K Makaroun
- Lena K. Makaroun is a research fellow in the Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, in Pennsylvania
| | - Yeates Conwell
- Yeates Conwell is a professor in the Department of Psychiatry, University of Rochester Medical Center, in New York
| | - Marian Betz
- Marian Betz ( Marian. Betz@ucdenver. edu ) is an associate professor of emergency medicine at the University of Colorado School of Medicine and a research physician at the Eastern Colorado VA Geriatric Research Education and Clinical Center, both in Aurora
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Abstract
Purpose
The purpose of this paper is to provide an overview of rural older veterans in the US and discuss how the US Department of Veterans Affairs (VA) is increasing access to health care for older veterans in rural areas.
Design/methodology/approach
This is a descriptive paper summarizing population and program data about rural veterans.
Findings
VA provides a variety of health care services and benefits for older veterans to support health, independence, and quality of life. With the creation of the Veterans Health Administration Office of Rural Health (ORH) in 2006, the needs of rural veterans, who are on average older than urban veterans, are receiving greater attention and support. ORH and VA have implemented several programs to specifically improve access to health care for rural veterans and to improve quality of care for older veterans in rural areas.
Originality/value
This paper is one of the first to describe how VA is addressing the health care needs of older, rural veterans.
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Rosen T, Stern ME, Elman A, Mulcare MR. Identifying and Initiating Intervention for Elder Abuse and Neglect in the Emergency Department. Clin Geriatr Med 2018; 34:435-451. [PMID: 30031426 PMCID: PMC6057151 DOI: 10.1016/j.cger.2018.04.007] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Elder abuse and neglect are common and may have serious medical and social consequences but are infrequently identified. An emergency department (ED) visit represents a unique but usually missed opportunity to identify potential abuse and initiate intervention. ED assessment should include observation of patient-caregiver interaction, comprehensive medical history, and head-to-toe physical examination. Formal screening protocols may also be useful. ED providers concerned about elder abuse or neglect should document their findings in detail. ED interventions for suspected or confirmed elder abuse or neglect include treatment of acute medical, traumatic, and psychological issues; ensuring patient safety; and reporting to the authorities.
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Affiliation(s)
- Tony Rosen
- Division of Emergency Medicine, Emergency Department, Weill Cornell Medical College, NewYork-Presbyterian/Weill Cornell Medical Center, 525 East 68th Street, Room M130, New York, NY 10065, USA.
| | - Michael E Stern
- Division of Emergency Medicine, Emergency Department, Weill Cornell Medical College, NewYork-Presbyterian/Weill Cornell Medical Center, 525 East 68th Street, Room M130, New York, NY 10065, USA
| | - Alyssa Elman
- Division of Emergency Medicine, Emergency Department, Weill Cornell Medical College, NewYork-Presbyterian/Weill Cornell Medical Center, 525 East 68th Street, Room M130, New York, NY 10065, USA
| | - Mary R Mulcare
- Division of Emergency Medicine, Emergency Department, Weill Cornell Medical College, NewYork-Presbyterian/Weill Cornell Medical Center, 525 East 68th Street, Room M130, New York, NY 10065, USA
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