Generations_National_Collaboratory

Taking Action Against Elder Mistreatment

The National Collaboratory on Elder Mistreatment By Rebecca Jackson Stoeckle and Scott Bane

An initiative in which the whole is greater than the sum of its parts

E ven as we enter into an era of increasing “age- friendliness,” the estimated one in ten older adults who experience elder mistreatment (EM) (Rosen et al., 2019) (physical, fnancial, psycho­ logical, or sexual abuse or neglect) remain large­ ly unrecognized and uncared for. A confluence of factors drives this disparity. Unlike older adults with other high-risk conditions, persons experi- encing elder mistreatment are much less likely to seek help, due to their impairments, shame, iso- lation, or dependency upon a caregiver who may be the abuse perpetrator. Pervasive ageismmeans that even clinicians may not reflexively respond to elder mistreatment with the urgency, for example, of a response to suspected child abuse. Given this backdrop, the creation of the National Collaboratory to Address Elder Mistreatment (The Collaboratory) has been a long time in com- ing. The most signifcant benchmarks in the feld have included the following: framing elder mis- treatment in a medical paradigm; aligning part- The National Collaboratory to Address Elder Mistreatment

ners at the state level; raising the profle of the issue generally with the public and with policy makers; and working to identify elder mistreat- ment in public hospitals. In 2016, several leaders in the feld came together with the assistance of The John A. Hartford Foundation, the Gordon and Betty Moore Foundation, and the Education Develop- ment Center to form The Collaboratory and to raise the awareness of elder abuse. Their abiding engagement with elder mistreatment, described below, serves as a critical backdrop to The Col- laboratory’s work. Framing EM within the medical model One of the frst methods for ensuring that elder mistreatment is taken more seriously by policy makers and the public has been to frame the issue within a medical model. Elder mistreat- ment had long been known to social scientists and social service organizations, but it had escaped clinicians’ radar. Two leaders of this work have been Laura Mosqueda, a geriatrician, family medicine phy-

abstract This article describes the development of The National Collaboratory on Elder Mistreatment, a joint initiative of the Education Development Center, The John A. Hartford Foundation, and the Gordon and Betty Moore Foundation. The Collaboratory’s model uses the hospital emergency room as the point of entry. The article details benchmarks in the field of elder mistreatment prior to the creation of the Elder Mistreatment Emergency Department Care Model, which is undergoing feasibility testing at six sites nationwide, with results expected by early 2021. | key words : National Collaboratory on Elder Mistreatment, Elder Mistreatment Emergency Department Care Model, TEAM Institute

Copyright © 2020 American Society on Aging; all rights reserved. This article may not be duplicated, reprinted or distributed in any formwithout written permission from the publisher: American Society on Aging, 575Market St., Suite 2100, San Francisco, CA 94105-2869; e-mail: info@asaging.org . For information about ASA’s publications visit www.asaging.org/publications . For information about ASA membership visit www.asaging.org/join.

Volume 44 . Number 1 | 33

GENERATIONS – Journal of the American Society on Aging

‘Unlike older adults with other high- risk conditions, persons experiencing elder mistreatment are much less likely to seek help.’ of elder mistreatment that “an estimated overall prevalence of approximately 10 percent appears reasonable” (Lachs and Pillemer, 2015). The feld also has developed practical mod- els of intervention, such as the Abuse Interven- tionModel, which assesses the older adult, his or her “trusted other” (who is the potential or known perpetrator of mistreatment), and the context in whichmistreatment could be or is taking place (Mosqueda and Sivers-Teixeira, 2017). Placing elder sician, and dean of the Keck School of Medicine at the University of Southern California, in Los Angeles, and Mark Lachs, a geriatrician, inter- nist, and the Irene F. and I. Roy Psaty Distin- guished Professor of Clinical Medicine at Weill Cornell Medical College, in New York City. Drs. Mosqueda and Lachs and several colleagues helped to bring the language of medicine to elder mistreatment. They achieved this by using quantifable measurement and forensics, so that professionals in the feld can collectively say with confdence mistreatment within a medical model also has had the important additional beneft of creating a steady flow of clinicians interested in the issue. Another important development in the feld has been to encourage states to take a leadership role on the issue. Alice Bonner, former secretary of the Executive Office of Elder Affairs for the Commonwealth of Massachusetts, had long been concerned with elder mistreatment. A nurse practitioner with more than twenty-fve years of experience, Bonner oversaw a state budget of nearly $30 million per year devoted to elder abuse (Singer, 2018). In overseeing statewide efforts on States’ leadership in elder mistreatment raises awareness

elder mistreatment, Bonner took a one-size-does- not -ft-all approach. States must develop train- ings, protocols, and materials that can be used everywhere, from small towns to larger cities. State leadership in elder mistreatment has been critical to raising the issue’s profle. The elder mistreatment feld also has been able to demonstrate that identifying elder mistreat- ment is not the luxury of well-resourced commu- nities. This has been a reality in Texas with the creation of the Texas Elder Abuse and Mistreat- ment (TEAM) Institute (see Dyer et al. article on page 91 for more on this Institute), the frst collaboration in the country among Adult Pro- tective Services (APS), a medical school, and a public hospital (Texas Department of Family and Protective Services, 2019a). Carmel Dyer, a professor of Geriatric and Collaborative models can work in under-resourced communities Palliative Medicine at the McGovern Medical School at the UT Health Science Center at Hous- ton, was instrumental in creating the TEAM Institute. The Institute’s process includes an APS investigation, a targeted geriatric assess- ment, medical and capacity evaluations, joint APS and medical team care planning, and court- related services. The Institute’s model begins its work when it is called in by APS. Established in 1997 in Har- ris County, which includes the City of Houston, the Institute in 2017 expanded statewide and has provided services in more than 2,500 cases of elder mistreatment, including self-neglect. Importantly, the TEAM Institute demonstrates that elder mistreatment can be identifed and treated in a large public institution, where pub- lic dollars are stretched thin, and not only in resource-rich environments affiliated with academic medicine. But for all of the promise and accomplish- ments of the TEAM Institute model, the Texas Department of Family and Protective Services said the program was limited by constrained

Copyright © 2020 American Society on Aging; all rights reserved. This article may not be duplicated, reprinted or distributed in any formwithout written permission from the publisher: American Society on Aging, 575Market St., Suite 2100, San Francisco, CA 94105-2869; e-mail: info@asaging.org . For information about ASA’s publications visit www.asaging.org/publications . For information about ASA membership visit www.asaging.org/join.

34 | Spring 2020

Taking Action Against Elder Mistreatment

resources and training to adequately address the needs of a growing popu- lation of older adults (Texas Depart- ment of Family and Protective Services, 2019b). As much as the Institute needs to grow, it can grow only so much if it primarily relies upon limited state fnancial resources. The Collaboratory’s ED Care Model Emergency departments (ED), which disproportionately care for older persons

Figure 1. Emergency Mistreatment Care Model Core Elements

with known risk factors for elder mistreatment, are underused when it comes to identifying and appropriately referring elder mistreatment cases. Here, though, systems gaps, including staff over- load, absence of elder mistreatment expertise, and a dearth of validated tools, have prevented widespread adoption of best practices that would improve rates of screening, intervention, and appropriate follow up for older adults experienc- ing or at risk for elder mistreatment (Wilber, 2019). To address this gap, using the planning grant from The John A. Hartford Foundation in part- nership with the Gordon and Betty Moore Foun- dation, the group, which is composed of the four national experts in elder mistreatment cited above along with the Education Development Center (EDC) serving as Collaboratory convener, has designed and prototyped an integrated Elder Mistreatment Emergency Department Care Model with four core elements: the Emergency Department Assessment Profle (a brief staff sur- vey that assesses challenges and opportunities and drives practice change); staff training mod- ules; brief screening and response tools adapted Department Care Model is ready for use by a broad range of ER departments. The feasibility study will determine if the Elder Mistreatment Emergency

from a validated measure; and a roadmap for leveraging community resources to support referral and follow-up. Each core element has been designed with signifcant input and feedback from clinical part- ner sites in each state, and with a clear focus on the feasibility of implementation in under- resourced settings (i.e., settings with little or no access to expertise in elder mistreatment). The development and testing of this model represent a signifcant step forward in addressing the all- too-common observation by emergency depart- ment clinicians that they are intuitively aware that many older adults who are experiencing mis- treatment are passing through their care without being identifed as victims of mistreatment. Introducing change into complex and over- burdened systems of care requires a deep understanding of how staff work and priori- tize decisions, skillful identifcation of opportu- nities to introduce and sustain practice change, committed local champions, easy-to-use tools that support the targeted evidence-based best practices, and technical assistance to ensure implementation that puts the model’s critical components into action. The Collaboratory has addressed each of these elements in the development and initial testing of the Elder Mistreatment Emergency Depart- ment Care Model, and is conducting a feasibility trial with a cohort of six hospitals representing a range of characteristics: public and private, large and small, rural and urban, and fee-for-service or

Copyright © 2020 American Society on Aging; all rights reserved. This article may not be duplicated, reprinted or distributed in any formwithout written permission from the publisher: American Society on Aging, 575Market St., Suite 2100, San Francisco, CA 94105-2869; e-mail: info@asaging.org . For information about ASA’s publications visit www.asaging.org/publications . For information about ASA membership visit www.asaging.org/join.

Volume 44 . Number 1 | 35

GENERATIONS – Journal of the American Society on Aging

new care model feasible to implement in hospital EDs? Are EDs better able to identify and manage cases of elder mis- treatment when they implement the new protocol? How does implementa- tion of the new protocol affect ED func- tioning? These last data, looking at

Figure 2. Map of Elder Mistreatment Feasibility Trial Participant Sites

systems-level impacts, will be important to capture to facilitate a planned later phase of national dissemination begin- ning in early 2021. Data also will be used during the trial to iteratively improve the model so that it meets essential requirements for widespread adoption: evidence of effectiveness, acceptability, relevance in a range of contexts, and sustainability. Concurrently, The Collaboratory is developing and deepening relationships with parallel initia- tives, such as the Geriatric Emergency Depart- ment Collaborative (tinyurl.com/yykvgaym), and the Geriatric Emergency Department Accredita- tion Program (tinyurl.com/y3wufpws), which can serve as amplifers and dissemination channels for the fnal care model. The feld of elder mistreatment may have been slow to coalesce around pragmatic, sustain- able interventions, but the pace of change is rap- idly accelerating, and the Elder Mistreatment Emergency Department Care Model will be a critical driver of that change. Rebecca Jackson Stoeckle, B.A., is a vice president at the Education Development Center in Waltham, Massachusetts. She can be contacted at rstoeckle@ edc.org . Scott Bane, J.D., M.P.A., is a program officer at The John A. Hartford Foundation, in New York City. He can be contacted at scott.bane@ johnahartford.org .

accountable care organizations. Results from the feasibility trial are expected in early 2021. The Importance of Feasibility The National Institutes of Health and others have noted the importance of feasibility trials to ensure evidence-based interventions are a reasonable ft with and likely to be used under real-world condi- tions (Bowen, et al., 2009). The key objective of the The Collaboratory feasibility study is to deter- mine whether the Elder Mistreatment Emergen­ cy Department Care Model is ready for use by a broad range of hospital emergency departments. In the frst six months of implementation, The Collaboratory’s evaluation teamwill collect quantitative and qualitative data from key infor- mant interviews and focus groups, the Elder Mis- treatment Emergency Department Assessment Profle, and hospital indicator data. The evalu- ation design is structured to reduce burden on hospital EDs and providers, making use of exist- ing records whenever possible and minimizing provider time spent on evaluation activities. Data collection has been designed to answer three overarching research questions: Is the

References Bowen, D. J., et al. 2009. “HowWe Design Feasibility Studies.” Ameri- can Journal of Preventive Medicine 36(5): 452–7.

Mosqueda, L., and Sivers-Teixeira, T. 2017. “Taking AIM at Elder Mis- treatment.” Aging Today . tinyurl. com/y6m9fj2s. Retrieved July 26, 2019.

Lachs, M., and Pillemer, K. 2015. “Elder Abuse.” The New Eng- land Journal of Medicine 373(20): 1947−56.

Copyright © 2020 American Society on Aging; all rights reserved. This article may not be duplicated, reprinted or distributed in any formwithout written permission from the publisher: American Society on Aging, 575Market St., Suite 2100, San Francisco, CA 94105-2869; e-mail: info@asaging.org . For information about ASA’s publications visit www.asaging.org/publications . For information about ASA membership visit www.asaging.org/join.

36 | Spring 2020

Taking Action Against Elder Mistreatment

Rosen, T., et al. 2019. “Review of Programs to Combat Elder Mis- treatment: Focus on Hospitals and Level of Resources Needed.” Jour- nal of the American Geriatrics Soci- ety 67(6): 1286–94. Singer, P. 2018. “New National Data Show ‘Crisis’ of Elder Abuse.” New England Center for Investigative Reporting. tinyurl.com/y4py7s5v. Retrieved July 23, 2019.

Texas Department of Family and Protective Services. 2019a. “APS and the TEAM Institute.” tinyurl. com/y3odbnm5. Retrieved July 23, 2019. Texas Department of Family and Protective Services. 2019b. Adult Protective Services Protecting with Purpose, Passion and Persistence Strategic Plan FY19–23. tinyurl. com/y6b5qh4w. Retrieved July 23, 2019.

Wilber, K. H. 2019. “Combating Elder Mistreatment: Still Mud- dling—Not Yet Transformed.” Journal of the American Geriatrics Society 67(6): 1117–9.

Copyright © 2020 American Society on Aging; all rights reserved. This article may not be duplicated, reprinted or distributed in any formwithout written permission from the publisher: American Society on Aging, 575Market St., Suite 2100, San Francisco, CA 94105-2869; e-mail: info@asaging.org . For information about ASA’s publications visit www.asaging.org/publications . For information about ASA membership visit www.asaging.org/join.

Volume 44 . Number 1 | 37

Page 1 Page 2 Page 3 Page 4 Page 5

Made with FlippingBook - professional solution for displaying marketing and sales documents online