ELDER ABUSE, SELF-NEGLECT AND MANDATED REPORTS

Sandy Hovey, Director of Elder Protective Services for the city of Boston (housed at Ethos), spoke at a special staff meeting in October 2006 on elder abuse and self-neglect awareness, reporting, and the investigation process. The following is a summation of his presentation and additional information from materials provided.

Background

Two years ago the state’s Elder-at-Risk statute was re-written so that social workers and other care providers are mandated reporters for Elders at Risk, and the program was subsumed under Elder Protective service. Notably though, no additional funding was appropriated to serve the increase in referrals (a 40% increase in referrals at Ethos).

Elder Protective Services Regulatory Requirements

Elder Protective Services (EPS) has jurisdiction over protective services for the state’s elders 60 and over. Younger adults (18-59) only have such state protections if disabled or receiving care in a facility (those reports would go to the Disabled Person’s Protection Commission and the Department of Public Health respectively).

Massachusetts’ Elder Protective Services programs investigate reports of suspected abuse or neglect, sexual abuse, emotional abuse, financial exploitation, and self-neglect when the elder is sixty years of age or older and the suspected perpetrator is in a care-giving or personal relationship with the victim (except in self-neglect cases).

Staff at EPS can be used for case consultation when it is not clear whether a report is appropriate. Call EPS and ask for the Screening Supervisor and discuss the case without identifying the elder. If you use the elder’s name, by law, they must open an investigation.

Philosophy

One of the main responsibilities of EPS is to balance the elder’s rights of self-determination versus their need for protection. Keep in mind that elders are assumed to be competent unless adjudicated otherwise or there is sufficient information to warrant a formal capacity evaluation. They have the right, like any other adult, to make their own decisions such as to refuse services, and make decisions that others might disagree with or consider unwise. “In the ideal case, protection of adults seeks to achieve simultaneously and in order of importance: freedom, safety, least disruption of life-style and least restrictive care alternative.” There are two exceptions to an elder’s right to refuse an investigation.

EPS staff’s preferred approach to families is to ally with and engage the elder and family in a problem-solving process, and where appropriate, to put in place supportive services to alleviate the problem. To this end, EPS can waive the regular eligibility criteria (income and functional need) for state elder services offered through the ASAPs. One key way that hospital/community staff can help is to avoid setting EPS staff up as the “bad guys” in an investigation. In cases where staff have used the threat of calling EPS as a stick to make elders/caregivers change, it sets up a negative dynamic that increases resistance and impedes trust and cooperation when EPS does join the case.

Forms of Abuse

Physical Abuse - the non-accidental infliction of serious physical injury or the threat of serious physical injury in which there is reasonable cause to believe that an individual may have the intent and capacity to carry out the threats.

Neglec t- The failure or refusal by a caretaker to provide one or more of the necessities essential for physical well-being; such as food, clothing, shelter, personal care, and medical care; which has resulted in, or where there is substantial reason to believe that this will immediately result in, serious physical harm.

Financial Exploitation- Defined for EPS purposes as the non-accidental, unauthorized use of an elder’s funds or resources which results in a substantial loss to the elder or gain to another person which would otherwise benefit the elder. Elders who own their homes outright are a prime target for elder financial exploitation, especially in these times of still record home-values. Often, due to physical or mental limitations, elders rely on others to manage their finances and even sign-over rights via a Power of Attorney. Legally even if the individual has a POA, there is some recourse if the POA willfully mismanage the elder’s funds. The POA’s management of the elder’s finances is required by law to be in the best interest of the elder.

Sexual Abuse- Is defined as any form of sexual contact or activity without the elder’s consent or where the elder is incapable of providing adequate consent, and includes threats of sexual abuse where the individual has the intent and capacity to carry out the threats. Sexual abuse is the least reported form of abuse due to the stigma attached to it. Mandated reporters are encouraged to be aware of and look for indicators of this type of abuse (see below).

Emotional Abuse- Emotional abuse is the non-accidental infliction of serious emotional injury. There must be a relationship between the abusive actions, behaviors or language and a resulting effect on the emotional state or functioning of the elder.

Serious Emotional Injury includes:

Family styles and cultural differences sometimes make it difficult to assess emotional abuse. Mr. Hovey shared a case example in which the elder and family had always shared a communication style that involved shouting and swearing. Suddenly the elder voiced concerns with day program staff that she was afraid to return home. Investigation determined that her worsening dementia made her misinterpret her loving family’s rough talk. EPS was able to educate the family and help them modify their communication style with the elder so that she would feel safe.

Self-Neglect - Self-neglect is defined as the failure, inability or resistance of an elder to provide for him/herself essential necessities without which the elder would be unable to safely remain in the community. A guideline for referring these cases is if the elder is refusing help and the consequence of that refusal is high.

Some of the most difficult cases involve mental illness. EPS has been working with BEST team (Boston Emergency Services Team), a twenty-four hour psychiatric crisis team, to coordinate services, share expertise and even make joint visits to asses individuals. Again, elders are presumed competent unless adjudicated otherwise or there is sufficient information to warrant a formal capacity evaluation. Therefore, they have the right to refuse services. There are a few legal interventions EPS can pursue to ensure an elder at least temporarily receives needed services.

Some Indicators of Abuse

Physical Abuse: bruises, welts, lacerations, black eyes, bone fractures, sprains, medication overdose or under utilization of medication, sudden changes in behavior, refusal of a care-giver to allow visitation, bruising whose shape is similar to an object.

Sexual Abuse: torn, stained, or bloody underclothing, bruises around the breasts and/or genital area, unexplained STD’s, unexplained vaginal or anal bleeding.

Emotional Abuse: Hyper-vigilance of abuser’s actions, movements, etc.; change in eating or sleeping habits, depression, withdrawal, agitation, crying, shaking, trembling, exaggerated fear response.

Neglect: dehydration, malnutrition, untreated bedsores, poor personal hygiene, unattended health problems, hazardous or unsanitary living conditions, inadequate or inappropriate clothing.

Financial Exploitation: Reports of missing valuables, elder lack of access to checkbook or cash, disparity between income/assets and lifestyle, questionable transfer of assets or property.

Filing a Report

The report of suspected abuse should be called in to the local EPS agency. For the City of Boston, this is Ethos- (617) 522-6700 Monday through Friday between 9 and 5. After hours call the Elder Abuse hotline at 800-922-2275. Other area offices can be found in IRis (keyword: Inhomecare/StateFunded) or use the map at www.800ageinfo.com/map.

A written report must follow within 48 hours of the verbal report. When filing a report, reporters are asked to provide as much first-hand information as possible. If the information is second hand, it is imperative that this is noted. It is also equally important that a reporter list all people involved in the situation including family (both involved and uninvolved), service providers, doctors, etc. EPS staff also appreciate reporters sharing their understanding of the level of risk to the individual and to investigators. Upon receiving this information, the EPS will sort the report in one of three risk levels and their corresponding action timeline:

EPS programs have seen a dramatic increase in referrals since the implementation of the Elder at Risk reporting mandate. During times when they exceed capacity they may institute a “triage” response model in which only those situations posing immediate danger or uncertain risk will be investigated.

Approach to Investigations

EPS utilizes phone calls, unannounced visits and generic letters to initiate contact with the elder. After an initial evaluation of the person’s capacity, EPS works with the elder to first develop a rapport and then discuss services and options for the elder, maintaining the person’s self-determination as a top concern. Where there is not imminent danger, investigators try to proceed at the elder’s pace and follow the elder’s priorities. Investigations typically last thirty days, in which an EPS staff member will meet with the individual at least twice. The time period and number of visits are flexible at the staff’s option to extend them.

District Attorney Referrals

Cases of serious physical abuse, death due to abuse, financial abuse and sexual abuse are referred to the DA’s office. Cases that were closed in the past due to lack of evidence or cooperation can be introduced as evidence of a history of abuse. So it may be important to file even if the elder will not cooperate.

State Guardianship Program

Individuals who are legally incapacitated may be appointed a guardian to make decisions about all aspects of their lives including housing, medication, health care, and money management. But it can be nearly impossible to find a guardian for those who have no appropriate family or friends to serve as guardians and have inadequate financial resources. The State of Massachusetts currently has limited slots (60 for the entire state) that fund guardians, and they are generally full. Currently the Boston-area contract to manage these cases is held by Jewish Family & Children’s Services. Due to the new mandate, guardian slots are accessible to self-neglect cases, if a slot is available. Legislation to create a Public Guardianship Commission that would provide additional guardianship slots and oversight is being considered in the legislature, but is not expected to pass.

Handouts and supporting documents are available on the Staff Access area of our website (www.mghsocialwork.org) Professional Resources > Forms & Policies > Elder Abuse.

-Special thanks to Sandy Hovey for his presentation.

10/06