Generations_Connecting

Taking Action Against Elder Mistreatment

Connecting Community-Based Resources and Health Systems to Keep Older Adults Safe By Kristin Lees Haggerty, Alice Bonner, and Debi Lang

Healthcare systems, including emergency departments, offer an untapped way to identify and respond to elder mistreatment.

E lder mistreatment (EM) affects an estimated 10 percent of adults ages 60 and older in the United States (Acierno et al., 2010), and is associ- ated with an increased risk of death (Dong, 2005), poorer physical health (Lachs et al., 1998; Scho- feld, Powers, and Loxton, 2013), and negative psychological health outcomes (Dyer et al., 2000), as well as increased time spent in healthcare facilities (Dong and Simon, 2013a, 2013b, 2013c). Despite evidence of the prevalence of elder mistreatment, the existence of Adult Protective Services (APS) in all states, and laws mandating the reporting of suspected mistreatment in most states, many instances of EM go unreported (Lachs and Berman, 2011) and unaddressed. Healthcare professionals, while seemingly well- positioned to identify mistreatment, are among the least likely to report it (Rosenblatt, Cho, and Durance, 1996).

Barriers to identifying and reporting include difficulty distinguishing elder abuse, lack of awareness about EM and the reporting process (Rodríguez et al., 2006; Schmeidel et al., 2012), a dearth of tools to address the problem, time constraints, and challenges in communicating with other healthcare providers (Rosen et al., 2017, 2018). Recognizing that the hospital emergency department (ED) provides a unique opportu- nity to identify EM that may otherwise go unno- ticed, The National Collaboratory to Address Elder Mistreatment (The Collaboratory), a group of EM experts, innovators, and researchers, was convened via support from The John A. Hartford Foundation and the Gordon and Betty Moore Foundation, and developed the Elder Mis- treatment Emergency Department Care Model (EMED). The approach to building this model

abstract Healthcare systems, particularly hospital emergency departments (ED), offer an opportu- nity to identify and respond to elder mistreatment (EM), but often are uninvolved in coordinated com- munity responses. This article describes how key informant interviews with health systems, Adult Protective Services, and other stakeholders led to the Community Connections Toolkit, a core element of The National Collaboratory to Address Elder Mistreatment’s Elder Mistreatment Emergency Department Care Model. The toolkit is designed to help hospitals engage with key community organizations to keep older adults safe from EM once discharged. | key words : emergency departments, elder mistreatment, key informant interviews, the Community Connections Toolkit

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.

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started with a research phase, including a lit- erature review of programs and interventions to address EM (Rosen et al., 2019), key infor- mant interviews and focus groups, and in-person meetings to discuss results and reach consensus on the model’s core aspects. The EMED was designed for a variety of set- tings—urban and rural, large and small, and those with and without EM expertise. It consists of the following four elements: 1. A brief survey for ED clinical staff to help identify opportunities and barriers and drive practice change; 2. Training modules for clinical staff and internal champions; 3. Streamlined screening and response tools to identify, document, and report suspected EM and to inform discharge plans to help keep patients safe once they leave the ED; and 4. The Community Connections Toolkit to help hospital emergency departments develop and maintain relationships with community organizations and initiate or join community efforts to mitigate EM. This article focuses on the fourth element, presenting methods and results from key infor- mant interviews, which were instrumental in developing the Community Connections Toolkit. Also, it discusses lessons learned and strategies healthcare systems can apply to build a more coordinated community response to EM. Key Informant Interviews Methods : The interview goals were to document whether or not hospital staff perceived EM to be an urgent issue in the ED; to identify factors that help or hinder staff ability to address EM in the ED; to identify types of training, screening, and response protocols currently in use; and to determine if there was a coordinated community response to EM. The co-authors of this article worked as a team to identify hospitals in Massachusetts that represented a diverse set of potential end-users of the care model, including those that had var-

ied access to EM experts, were and were not affiliated with an academic medical center and- or a large health system, and those that served patients in rural and urban areas. They also identifed APS agencies within these hospitals’ service areas. Key informants included a purpo- sive sample of hospital clinicians, administra- tors, and APS staff. Semi-structured interviews, “I imagine that [elder mistreatment] is probably more prevalent than what we identify,” said an ED medical director. with twenty-two participants, were conducted by phone or in person between April and Sep- tember 2017. At least two article co-authors attended each interview; one facilitated the con- versation and one took notes, which were later supplemented by review of audio recordings to which informants had given consent. Co-authors reviewed and coded the notes, and developed themes based on discussion of key fndings. Key Themes : What follows are three key interview themes and how they informed the Community Connections toolkit development: EM as a priority; gaps and opportunities in cur- rent ED practice; and practicality of a coordi- nated response to EM. Elder mistreatment as a priority Hospital informants felt there was a sense of urgency to better address EM in the setting in which they worked and-or in the community, and that their ability to do so was dependent upon available resources (i.e., access to internal or external EM experts). They reported a lack of protocols to screen for EM beyond a generic question related to feeling safe at home, and sev- eral hospitals suspected that they were missing EM cases. “I think it is one of those things that probably flies under the radar . . . I imagine that it is prob-

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ably more prevalent than what we identify,” said one ED medical director. When asked how they address mistreat- ment once suspected, informants said they usu- ally turn to case management or social work staff because they seem to have the most contact with APS. Some informants mentioned holding patients in the ED, or admitting them as hospital inpatients if there was not an immediate safe dis- charge option outside the hospital. Throughout these informant interviews, participants reported that the ED’s focus is on patients’ immediate medical concerns. While clinical leaders and frontline staff recognize many patients have ongoing needs, the ED gener- ally does not have the resources to follow up with individual patients in the ED, or after discharge. “The ED is a primary source for identifca- tion, not for necessarily for treatment so . . . [to become] the mecca for elder mistreatment, that’s going to overburden already overburdened EDs with patients who are better served elsewhere,” said a community hospital’s director of Emer- gency Services. Gaps and Opportunities in Current Prac- tice : Participants shared factors that might help or hinder ED efforts to implement a new EM care model. Regardless of hospital size, setting, or location, article co-authors consistently heard that due to the nature of EDs, it is a challenge to institute new protocols when staff have lit- tle time beyond providing acute care, and espe- cially in community hospitals where specialized resources are limited. Downsizing and turnover also can slow down or derail new initiatives, whether due to loss of external grant funding or mergers. Many of the key informants experi- enced either or both. “. . . if you know the resources here, it is very, very limited . . . we are just left with one social worker at this point,” said one medical direc- tor of a community hospital geriatric psychiat- ric unit. Several informants suggested that leverag- ing electronic health records or leveraging the

‘At one of the APS agencies, medical residents go on home visits as part of their geriatric rotation.’ expertise of sexual assault nurse examiners could increase the ED’s capacity to identify and respond to EM. In addition, it is crucial to receive support from executives, which requires evi- dence that new services or approaches to bene- ft patients will generate cost-savings. Finally, an internal champion can help effect a new project. Practicality of a Coordinated Response to EM : The Collaboratory’s literature review indi- cated that multidisciplinary teams (MDT) are a promising best practice to address EM (Rosen et al., 2019). Informants were asked about their experience with MDTs or other types of commu- nity collaborations. The response was that some EDs in both urban and rural areas were involved in community collaborations to address critical public health issues such as falls, domestic vio- lence, substance abuse, and suicide. The Collaboratory also learned about expe- riences with initiatives such as Nurses Improv- ing Care for Health system Elders (NICHE), or grants used to help connect patients to commu- nity resources. However, such initiatives and grants did not impact hospitals’ approaches to EM and, in some cases, were neither sustainable nor required systems change. Nonetheless, all key informants thought an MDT, or something similar, could strengthen their response to EM. The sidebar (on page 62) showcases exam- ples of initiatives that connect hospitals to com- munity resources and highlights the importance of ongoing funding for promising practices that demonstrate a positive impact on patients and are feasible on a systems level. Key informants from one hospital noted that while staff training related to EM and mandated reporting occur as part of onboarding and annu- ally for all healthcare personnel in their organiza- tion, they suggested training could be improved

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Initiatives Connecting Hospital Patients with Community-Based Services Senior Support Team : An MDT started by an ED physician, which included APS, police, fire, EMTs, and the city elder services agency. The group reviews 911 call logs to identify elders who were frequent callers, in order to meet their needs and reduce ED visits. Limitations: The ED doctor relocated out of the area, which meant that the group lost its leadership. It contin- ues to meet sporadically. Community Hospital Acceleration, Revitalization, and Transformation (CHART) : Massachusetts state funds were awarded to community hospitals for two years to improve healthcare delivery. The Collaboratory learned from hospital informants about the following CHART-funded projects: • Connected frequent ED users to a primary care provider and-or social worker to receive services such as medication management; • A “Patient-Centered Medical Neighborhood” connected patients to a care manager, who helped set up a care plan for discharge and connected patients to community supports; • High-risk care teams integrated technology to manage complex patients and reduce acute care utilization; and • MDTs addressed behavioral health with efforts that included a behavioral health team within the ED. Limitations: Hospitals often could not sustain these projects once the funding ended. PatientPing : A software platform that provides real-time hospital admission and discharge notifications. In central Massachusetts it is used by a hospital to contact case management and APS staff at an Aging Services Access Point agency (ASAP) when one of their clients is admitted. This tool not only flags high ED users, but also helps to strengthen care transitions and post-discharge follow-up, to reduce hospital readmissions. Limitations: Requires participation by each hospital. If a patient presents to an ED that is not participating in PatientPing, APS will not be notified. RIGHT Project : ASAP case managers are onsite at several hospitals to assess older high-risk ED patients and to provide a rapid response for post-discharge services. Limitations: ASAP staff must meet credentials for working in hospitals. Telehealth, Telemedicine : Described as a promising practice, especially for small community hospitals that do not have the patient volume to justify hiring staff for specialized services, or in large rural health systems where it could take an expert a long time to travel between sites. Limitations: A barrier to leveraging telehealth is that in Massachusetts, consulting telehealth-telemedicine doctors cannot bill for their time. Training with APS Home Visitors : At one of the APS agencies, medical residents go on home visits as part of their geriatric rotation, and medical–nurse practitioner students visit and learn about APS. The residents said they find the experience “extremely valuable and eye-opening.” Limitations: The APS informant said that 95 percent of residents in the rotation, who are near the end of their graduate medical education, do not know about APS. Grand Rounds/Schwartz Rounds : The article co-authors presented on EM at Grand Rounds at two hospitals and on the EMED at Schwartz Rounds at another. Limitations: None. The HUB : The Hub is a community-based collaboration that brings together service providers from a variety of disciplines and organizations to identify client risks that cannot be addressed by a single agency alone. Through focused discussion, The Hub determines an intervention plan, then the relevant agencies take over (Nilson, 2016). Limitations: Two cities in Massachusetts have HUB initiatives, but there is no data yet regarding their effectiveness. Community-Based Care Transitions Program (CCTP) (tinyurl.com/yhpe6jlf): The CCTP, created by the Affordable Care Act, tested models for improving care transitions from the hospital to other settings and reduc- ing readmissions for high-risk Medicare beneficiaries. A total of eighteen CCTP programs were funded. One of the ASAP agencies the co-authors spoke with was among seven ASAPs and two hospitals that participated. Limitations: The program, administered by the Centers for Medicare & Medicaid Services, ran from 2012–17.

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.

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to raise awareness that EM is an important issue, to help staff identify subtle cases of mistreatment, and to better understand APS’ role. “To be comprehensive [and] raise awareness of everyone in the organization, it may be bene- fcial to educate everybody, even those that have limited patient contact,” said a leader at an urban academic health center. APS programs are critical partners in any ED’s effort to address EM. There is, however, wide variation in how APS operates by state and sometimes within states, and in reality, hospi- tal staff and APS do not always effectively com- municate with one another (Susman, Lees, and Fulmer, 2015). Informants from APS in Mas- sachusetts gave their perspective on how they interact with hospitals and healthcare systems: They agreed that hospital staff are most likely missing EM cases, and mentioned that when they do report such cases, APS staff often are not readily available or able to provide addi- tional information upon request. One APS super- visor noted that when mandated reporters in the community (e.g., healthcare, municipal, law enforcement, and criminal justice personnel) are educated about APS and the reporting system, the number of reports to APS increase, and the quality of reporting improves. “If [healthcare professionals] understand [APS] better, it will prompt them to be more pro- active. All the pieces need to work together,” said one APS supervisor. To supplement what was learned from clin- ical and community partners, The Collabora- tory reached out to leaders at the federal level to gain a national perspective on elder mistreat- ment, and MDTs’ and APS’ relationship with healthcare. They corroborated that there are few examples of elder mistreatment MDTs that involve healthcare or hospitals, and were inter- ested to learn about which best practices are emerging to strengthen communication between APS and healthcare systems. The Collaboratory also learned about Age- Friendly Health Systems, a new initiative that

is testing an evidence-based framework to meet older adults’ goals and preferences across health- care settings (Institute for Health Care Improve- ment, 2019) to determine if and how their efforts align with The Collaboratory’s. The Community Connections Toolkit Acknowledging the success of the MDT model and recognizing the potential benefts that including healthcare systems on these teams could have for older adults, hospitals, and com- munities, The Collaboratory agreed that the EMED care model would ideally include the development of an MDT. A gap exists between health systems’ identification of elder mistreatment in the ED and communication with APS agencies. However, feedback from clinical partners in the ED made it clear that they would not be able to commit the staffing or operational capac- ity required to develop and maintain an MDT. Thus, The Collaboratory prototyped the Com- munity Connections Toolkit. The toolkit offers a staged approach to guiding EDs in needs assess- ment and resources, and in prioritizing the most important community-based organizations with which to connect, with the ultimate goal of developing a collaborative to address EM in manageable and sustainable ways. The toolkit suggests that hospitals frst assess community and older patients’ needs as well as the internal and external opportunities to deepen their EM response, as identifed by reviewing results of the EMED model’s frst core element, the Elder Mistreatment Emergency Department Assessment Profle. This helps hos- pitals or health systems to choose the best start- ing point to establish meaningful community connections that beneft older patients, espe- cially people who screen positive for, or are at risk for, elder mistreatment.

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The steps described in the toolkit frst sug- gest that hospitals identify and contact local APS agencies in order to improve EM reporting, to optimize referrals, and to discuss ongoing com- munication strategies. Hospitals can continue to connect with community-based organizations to establish procedures for referral and follow-up for patients identifed in the ED as being at risk for EM. Through these connections, hospitals can join an existing MDT that currently focuses on EM or one that is willing to expand its focus to include protecting elders. If an MDT does not exist in the community, the toolkit points to the U.S. Department of Justice’s MDT Tool- kit and technical assistance center (tinyurl.com/ m4wctgc). Finally, The Collaboratory’s toolkit helps hos- pitals to evaluate progress, barriers, and oppor- tunities, and recommends improvements for addressing EM. This information can be used to determine if users have reached their goals and, if not, what next steps are needed. Key Lessons and Strategies This section presents key lessons and strategies that can be employed in communities to better address EM, while emphasizing the importance of including healthcare systems in these conversa- tions and efforts. Importantly, organizations and communities can learn fromThe Collaboratory’s formative research, as well as from the Commu- nity Connections Toolkit, to immediately begin developing a more coordinated EM response. The informant interviews often revealed how healthcare systems were isolated from commu- nity social services networks. While healthcare and social services are distinct entities, each with specifc missions, informants from both services acknowledged the need and desire to learn from one another and to work more collaboratively going forward. In several cases, leadership teams from the hospital or health system convened meet- Healthcare, Adult Protective Services, and social service silos

ings or conference calls with local political leaders, educators, social service agency senior staff, and others in their city, town, or region. To eliminate silos between healthcare and social or community services, including APS, key stakeholders must engage in discussions to establish the shared purpose of keeping older adults safe. Thus, the Community Connections Toolkit’s foundation is to “engage with adult pro- tection,” and outlines how hospitals and health systems can purposefully and meaningfully par- ticipate as cities, towns, and-or regions convene those parties committed to addressing EM as a serious public health threat. Including EM in a region’s overall strategic plan Safe, cost-effective care of older adults may save community resources that can be leveraged to fund other priority projects, such as improving transportation, or building a new school or fre station. Local leaders should include work on EM as part of a city, town, or region’s compre- hensive plan for older adults and their families. The Collaboratory recommends that interested municipal, town, or regional leaders consider the following strategies for improving communica- tion among health systems, social service organi- zations, and APS: • Describe efforts to address EM to com- munity and municipal leaders (e.g., participa- tion in The Collaboratory’s EMED care model) and interest in improving EM screening and response; • Invite APS to participate in grand rounds and to deliver trainings; • Visit the ED; and • Brainstorm ways that hospitals may help APS to do their jobs more easily, and vice versa. Multidisciplinary teams As noted above, MDTs can be a dynamic and effective approach to a serious health issue. While many MDTs look somewhat similar across communities, they form in different ways and there is no “right way” to convene an MDT. Each

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community has its own strengths and opportuni- ties and MDTs should build upon those charac- teristics. Whether a team is started by a hospital nurse or a social worker, an older adult volunteer, a mayor or a city council member, a high school superintendent, or other leaders, the results often are similar in terms of collaboration and coopera- tion across sectors, over time. Data collection and reporting to APS A common theme in The Collaboratory’s work is recognition of the gap between heath systems’ identifcation of EM in the ED and reporting or communication with APS agencies. Laws and regulations vary state to state, and influence whether reports to APS may be made at any time or only during certain business hours. It is known that under-reporting of EM is a signifcant issue, thus each state should develop standardized APS regulations to optimize or maximize EM report- ing to APS; this would improve communication between health systems and APS professionals. Better tracking of ED cases of elder mistreat- ment and quality assurance programs that seek to identify missed cases that should have been reported to APS will help hospitals and health systems to improve the quality of their EM screening and reporting. Getting set up to report effectively is a big part of this work and requires dedicated people and other resources to achieve desired results. Thinking through these steps should be part of the process from the beginning. Use of community volunteers, interns Using community volunteers to assist more frail, vulnerable individuals may help municipalities to reduce the incidence of EM. Volunteers may help with giving older adults rides to the grocery store and-or to medical appointments, or provid- ing companionship, Learning from communities where volunteerism has been successful could be helpful to cities and towns that would like to promote similar opportunities. Many communities have one or more edu- cational venues, (e.g., community colleges, uni-

versities, trade schools, middle schools, and high schools) looking for clinical placements or internship opportunities for students and fac- ulty. These placements can encompass research or data collection projects (which are ways to spend time with and learn from older adults), needs assessment projects, and-or the creation of more comprehensive community support pro- grams for older adults. The co-authors recommend that any city or town working to become age friendly and to eliminate EM develop a list of local institutes of higher learning and fnd one helpful champion or contact at each institution. Meeting with this “champion” could lead to an ongoing collabora- tion and opportunities for students and faculty to gain valuable experience working with vulnera- ble older adults. It also is an opportunity for stu- dents and faculty to become knowledgeable about EM and to provide presentations or to run sem- inars or webinars on mistreatment and related topics for the public. Conclusion Given its work to date, The Collaboratory believes that communities can come together and work cooperatively to enhance programs and support for older adults and their families, and that health systems are critical partners in this effort. Local community leaders can lever- age volunteerism and a commitment to older adults’ well-being via the community’s public school systems and academic institutions, and ensure that plans to reduce and eliminate EM are part of a municipality’s strategic plan. Work- ing to end elder mistreatment can be part of any city, town, or region’s Age-Friendly Health System approach, which should always include a requirement to address such mistreatment. It is The Collaboratory’s hope that communities will consider these recommendations to combat elder mistreatment.

Kristin Lees Haggerty, Ph.D., M.A., is a project director at the Education Development Center, in Waltham,

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Massachusetts. She may be contacted at Klees@edc. org . Alice Bonner, Ph.D., R.N., is the senior advisor for Aging at the Institute for Healthcare Improvement, in Boston. Debi Lang, M.A., is the training and evalua- tion manager at Commonwealth Medicine, and an instructor of Family Medicine & Community Health at UMass Medical School, in Worcester.

Acknowledgment The authors would like to thank Bree Cunning- ham, director of Protective Services, Massachu- setts Executive Office of Elder Affairs, for her ongoing support and feedback on this project, as well as hospital leadership and staff and APS lead- ership and staff who participated in this research.

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Institute for Healthcare Improve- ment. 2019. “Age-Friendly Health Systems: Guide to Using the 4Ms in the Care of Older Adults.” tinyurl. com/y2oxwxsf. Retrieved Novem- ber 11, 2019. Lachs, M., and Berman, J. 2011. Under the Radar: New York State Elder Abuse Prevalence Study Self- Reported Prevalence and Docu- mented Case Surveys Final Report . New York: Lifespan of Greater Rochester, Inc., Weill Cornell Med- ical Center of Cornell University, and New York City Department for the Aging. tinyurl.com/y6kdko8a. Retrieved November 11, 2019. Lachs, M. S., et al. 1998. “The Mor- tality of Elder Mistreatment.” JAMA 280(5): 428–32. Nilson, C. 2016. Technology- Enabled Hubs in Remote Commu- nities PROJECT UPDATE. Report prepared for the Centre for Foren- sic Behavioural Science and Jus- tice Studies, Saskatoon, Canada. tinyurl.com/. Retrieved November 11, 2019. Rodríguez, M. A., et al. 2006. “Mandatory Reporting of Elder Abuse: Between a Rock and a Hard Place.” Annals of Family Medicine 4(5): 403–9. Rosen, T., et al. 2017. “Emergency Medical Services Perspectives on Identifying and Reporting Vic- tims of Elder Abuse, Neglect, and Self-neglect.” Journal of Emergency Medicine 53(4): 573–82.

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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.

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