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MINUTES - 09142004 - C110
PHS#45 Contra TO: BOARD OF SUPERVISORS Ct3sc1 FROM: FAMILY AND HUMAN SERVICES COMMITTEEGoCounty DATE: AUGUST 17, 2004 JIM SUBJECT: ELDER ABUSE PROGRAM UPDATE 41f fa SPECIFIC REQUEST{S}OR RECOMMENDATION(S)&BACKGROUND AND JUSTIFICATION Recommendation: 1. ACCEPT the report presented by the EHSD Aging and Adult Services Bureau providing a status update on the delivery of Elder Abuse and Adult Protective Services. 2. SUPPORT Department efforts to maintain essential Adult Protective Services program components In spite of staffing reductions resulting from funding limitations. Flscal Impact- None BB ,ckaround. On August 9,2004,the Family and Human Services Committee heard the attached report providing an update on the status of the Adult Protective Services(APS)program. Employment and Human Services Department provides elder abuse services under the APS program that offers casework intervention to protect elders and younger dependent adults from abuse,neglect,or exploitation. APS is part of a continuum of programs provided by the Aging and Adult Services Bureau of EHSD which all seek to promote maximum independent functioning for elders and adults with disabilities, assisting clients to avoid unnecessary or Inappropriate institutional care. APS works in close collaboration with these other programs,which Include in home supportive services(IHSS), temporary conservatorship,multipurpose senior services,linkages case management,assistance to caregivers,health insurance counseling and advocacy,and a wide variety of Area Agency on Aging (AAA)programs. APS works closely with co-located Health Services nursing and mental health staff who provide essential consultation and evaluation for APS clients and with Health Services programs including Conservatorship/Guardianship,Mental Health,Public Health,Medical Social Services,CCHP, inpatient and outpatient care. Fiscal challenges that have led to staffing reductions in the APS and other Aging and Adult Services programs,along with the significant cutbacks In many Health Services programs with which APS collaborates,pose serious problems for the APS program. Also,given the aging of the County's population and the increase in the number of elders with physical disabilittesldementia,the number of Individuals who need protection from abuse,neglect or exploitation is steadily increasing. The Inability of funding resources to keep up nth this population growth and to maintain prior levels of service seriously compromise the County's capacity to provide the level of services needed to protect this vulnerable population. 60W*VK*0N ATTACHMENT:--A—YES SI ATURE RECOMMENDATION OF COUNTY ADMINISTRATOR RECOMMENDATIO F BOARD COMMITTEE APPROVE OTHER SIGNATURE{S}: AAROK5SAi NIERJ N 13101A ACTION OF BOARD � a�t�".PPROVE AS RECOMMENDED k OTHER VOTE OF SUPERVISORS I HEREBY CERTIFY THAT THIS IS A TRUE ,. UNANIMOUS {ABSENT_ a�. ) AND CORRECT COPY OF AN ACTION TAKEN AND ENTERED ON THE MINUTES OF THE BOARD AYES: NOES: ABSENT: ABSTAIN: OF SUPERVISORS ON THE DATE SHOWN. ATTESTED C» J0 WEETEN,CLERIC OF THE BOARD OF SUPERVISORS AND COUNTY ADMINISTRATOR Contact Person: Dorothy Sansoe{S-t0o9} CC: CAO HSO EHSD BY; r�,✓JZ. _ DEPUTY EMPLOYMENT & HUMAN SERVICES CON'T'RA COSTA COUNTY Date: August 2, 2004 MEMO TO: FAMILY AND HUMAN SERVICES COMMITTEE FROM: John B. Cullen SUBJECT: Elder Abuse Program Update RECOMMENDATIONS ACCEPT the report presented by the EHSD Director and staff providing a status update on the delivery of Elder Abuse and Adult Protective Services. SUPPORT Department efforts to maintain essential Adult Protective Services program components in spite of staffing reductions resulting from funding limitations. SUMMARY Attached you will find a report providing an update on the status of the Adult Protective Ser- vices (APS) program. EHSD provides elder abuse services under the APS program that offers casework intervention to protect elders and younger dependent adults from abuse, neglect, or exploitation. APS is part of a continuum of programs provided by the Aging and Adult Services Bureau of EHSD which all seek to promote maximum independent functioning for elders and adults with disabilities, assisting clients to avoid unnecessary or inappropriate institutional care: APS works in close collaboration with these other programs, which include In Home Supportive Services (IHSS), Temporary Conservatorhip, Multipurpose Senior Services, Linkages Case Management, Assistance to Caregivers, Health Insurance Counseling and Advocacy, and, a wide variety of Area Agency on Aging(AAA) programs. Moreover, APS works closely with collocated Health Services nursing and mental health staff that provide essential consultation and evaluation for APS clients and with Health Services pro- grams including Conservatorship/Guardianship, Mental Health, Public Health, Medical Social Services, CCHP, inpatient, and outpatient care. The fiscal challenges that have led to staffing reductions in APS and other Aging & Adult Ser- vices programs, along with the significant cutbacks in many Health Services programs with which APS collaborates, pose serious problems for the APS program. The main strategy of the APS program is to make available to the at-risk individual a variety of health and social services programs to remove the risk of abuse, neglect, or exploitation. To the extent that these various services are not readily available or too limited in scope, we are not able to put in place the full ........................................................................................ .......................................................................... ......... .. . . ........................ ................ ......................................... ............... Elder Abuse Program Update August 2, 2004 Page 2 of 2 range of intervention necessary to protect these individuals. This can then result in premature institutional care or repetition of the episodes of abuse or neglect. Furthermore, given the demographic challenge posed by the aging of the county's population, with the attendant increase in elders with physical disabilities and/or dementia, the number of individuals who need protection from abuse, neglect, or exploitation is steadily increasing. The failure of funding resources to keep up with this population growth and our inability to maintain prior levels of service, let alone expand APS and related home and community based services, seriously compromises our capacity to provide the level of services needed to protect this vul- nerable population. To that end, this report also includes recommendations for program devel- opment and enhancement when additional financial resources become available for meeting these critical service needs. 2 LASesslerUlOWover Memo.FHS Elder Abuse.0804 doc ........................................... I�' ; a Si "iii � ti: i•i�' 1•Si l . t E s i ��' ,yiiiiiiisEiia3t3i.•, 1 3 3 39 t t' ja s s !� E�;' 'at lil, � # tt ;as 3stt � � � � � � : 3t :•t+: ' i i3 . i1 EiEals ,•t•• 3 ii i : , c s t s ## 'R E ��'�: E�,�,•,•,iiii 93 � 3 3 33i i i . �,,, ,# i•;;l:, s 93,� � s ,,s,;.:.;.; a ! i i 3 3 ' 3 s.jij.:.:,;,, ! 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Elder Abuse and Adult Protective Services 2004 Status Report This year's report to the Family and Human Services Committee and the Contra Costa County Hoard of Supervisors focuses on"putting a face on APS" as to the types of clients who are at risk,the array of calls received, and the complexity of the issues involved. We also offer some recommendations for future program improvements. Nationally, only 1 in 14 incidences of abuse and/or neglect are actually reported, and with financial abuse it is more likely only 1 in 100 incidences is actually reported. In Contra Costa County,we currently receive an average of 165 APS referrals per month. In March 2004 we received.179 reports of abuse. Following is a sampling of several referrals, and sample responses,from the month of March 2004. Reference numbers at the end of each vignette refer to the attached matrix, entitled"A Day in the Life of APS" (Attachment 1), which accounts for all referrals in the month of March. * Female's mental and physical condition has declined suddenly over last 4-6 months. Bladder incontinence; the apartment and she smell of urine. This is un- characteristic cteristic of her in past. No caregiver. She is now talking to imaginary peo- ple, yells at them. Landlord doesn't want to put other tenants at risk nor does he want to evict her. She is in her 70s. (Line 14) APS made a home visit and determined that she needed medical intervention. APS arranged for hospital admission, where she had a full medical work-up. She was determined to be delirious because of dehydration and malnutrition. She cleared mentally quite a bit, but it became apparent that she had a slight dementia. Although she was suspicious of outside help, she agreed to have APS arrange to clean the apartment. APS also reached an agreement with the landlord not to evict her once he saw that help was being provided. APS helped her apply for IHSS, as she was income-eligible. • Full-time caregiver for wife with Alzheimer's for past 3 years is burning out. He trips over oxygen cords, etc. Feels he is failing and worries he'll die before his wife. Is interested in skilled nursing facility (SNFs) placement for her but cannot follow-through with information.(Line 38) Husband welcomed APS into home. APS arranged for him to talk to Senior Le- gal Services about Medi-Cal for long-term care. Unfortunately, once APS got in- volved he took a turn for the worse, was hospitalized and died in the hospital. APS located a distant relative who agreed to move the wife to a nursing home close to them. * Tax preparer states 90-year old woman is contemplating suicide and that bank has taken her money. Is confused and depressed,but able to use paratransit. Husband is in a nursing home. (Line 71) APS brought their mental health clinical specialist in on the case. Client was de- termined to have a major depression, but was not an imminent suicide risk. APS referred her to Senior Peer Counseling. APS also spent a great deal of time ex- plaining her finances to her. She was still suspicious of the bank, but expressed understanding of her financial situation. It helped to reinforce that her husband's nursing home care was covered under Medi-Cal. • V has wagered and lost $23,000 in Canadian sweepstakes over past eighteen months. Behavior is uncharacteristic and daughter is concerned 77-year old mother may have dementia. APS notified local law enforcement that has been tracking the Canadian lottery scam. They are working with the PBI and Secret Service. The victim liked the phone calls and social contact of these con artists. APS educated the daughter and the mother about the Canadian lottery. APS had her phone number changed. APS worked with her bank, which agreed to notify the police whenever she wanted to make a questionable withdrawal. She did not get any money back. Once the daughter realized that a combination of social isolation and loneliness was a factor in the undue influence the seammers exerted on her mother, she was able to in- volve her mother more in social activities and coached her not to respond to tele- marketers. As a side note one Rossmoor resident, who came to APS' attention has lost $500,000 in this scam. We hope these sample interventions provide a glimpse into the variety of interventions APS workers may employ. A snapshot from March 2004 of our APS calls reveals the following: • 17% of the reports were for dependent adults • 83%were elderly (65+) • 41%of the total reports or 48%of the elderly were for clients 80+ • Self-neglect comprised 37%of the reports received • Financial abuse of some kind presented in 28°x'0 of the reports • Referral sources broke down into the following major categories: 0 31%relatives, friends, neighbors a 23%health professionals 0 8% social workers and case managers in non-health settings 0 8% self-reported 0 7% law enforcement 0 7% building/home related (landlord, apartment/building manager, inspector, mobile home park manager) o 5% IHSS o 4%financial workers (tax preparers,bill payers, financial institution) Program Reductions Past reports to this committee have highlighted the multi-faceted, complex nature of geri- atric interventions. APS has long recognized that elderly and dependent adults face com- plicated, multi-symptom diseases, chronic conditions and diminished mental capacity. Of necessity, effective interventions must be interdisciplinary and coordinated in nature. Over the past two years, APS has experienced major reductions in staff, with the loss of a unit dedicated to investigating self-neglect. Combined with our losses are the losses of other resources APS has relied upon. These other losses will be described in the follow- ing, section. APS has lost a supervisor, a unit clerk, a social service program assistant, and has been reduced from seventeen social casework specialists to eleven. The results of this diminished capacity within APS are evident: Long-term case management is instrumental in tracking and monitoring a vulner- able adult's progression in physical and mental health losses. Long-term case management may keep an individual safe from experiencing a significant, avoid- able loss, such as the improper sale of a home, or a catastrophic medical decline. APS is increasingly oriented towards crisis intervention and cannot monitor a situation over time. Short-term interventions help alleviate the risk for the mo- ment but are not designed to create the environment for long-term lifestyle changes to permanently improve the situation. • People come through the system multiple times as APS is impeded by the crisis intervention modality to make lasting change. • APS used to accept virtually any case within its jurisdiction. Now repeat mental health and substance abuse cases aren't necessarily investigated. In addition, de- mentia is not treated as a mental disorder within mental health and it is difficult to involuntarily evaluate someone on the basis of dementia, since grave disability has to be "due to a mental disorder" as it is defined in Welfare and Institutions Code Section 5150. • In April'2003 APS initiated the option of not trying to have an initial face-to-face investigation (NIFFI) as permitted under the provisions of AB 444 and AB 429. Specifically, AB 429 permits APS to investigate cases without a face-to-face in- vestigation when any of the following may occur: a non-credible reporting source, placement in a permanent facility, protection issue is resolved, or receiving inter- vention from another agency. APS recognizes the immeasurable value of actually seeing a situation in order to assess it properly. Unfortunately, with diminished resources face-to-face 'visits on virtually every report is a luxury our staff cannot afford. Staff attempts to assess a situation based on phone calls and collateral contact when the above criteria are present. Loss of Additional Resources In addition, certain critical Health Services Department resources that APS has utilized in the past no longer exist. Of particular note is the dismantling of Health'Services geropsy- .......... _ .._. .. . .... _. _....... ......_.. ......... ......... .....__............. chiatric unit and the elimination of the focus on geriatrics in the County Health Services outpatient clinics that used to exist in El Cerrito, Concord, and East County. The loss of dedicated mental and physical health practitioners has curtailed the ability of APS to se- cure adequate work-ups. There are no dedicated geriatricians in the outpatient clinics. There are no longer psychiatrists dedicated to the evaluation of geriatric patients. When elderly patients are admitted to Contra Costa Regional Medical Center for involuntary mental health evaluation, they are admitted to a general psychiatric ward where they do not fit in with the patient population. The dismantling of health and mental health resources has occurred at a time when the demographics suggest the opposite and has resulted in APS being increasingly viewed as the first responder for substance abuse and mental health concerns of adults and occa- sionally for homelessness. APS is receiving cases that are not necessarily within the pur- view of APS, however, there are no other places that can take the report. APS's effec- tiveness is greatly diminished when other resources are no longer available. In the cur- rent climate of program elimination and reduction, the APS program faces especially dif- ficult challenges in implementing its mandate to protect elders and dependent adults from abuse,neglect, and exploitation. Successes This year's snapshot of intake reports received in March 2404 highlights a variety of fi- nancial abuse reported by financial workers. Exploiting an eider's finances is the result of exerting undue influence on vulnerable adults whose vulnerability is increased by so- cial isolation,fluctuating or diminished mental capacity, and physical impairment. Some of the different types of financial abuse that the March intake summary illustrates include third parties befriending elders and taking over their finances; literally moving in and confining an elder to a room while exploiting the use of the home and other re- sources; scams, such as the Canadian lottery, that telemarketers exploit, taking over the elder's bank account; improper ATM use. Other types of financial abuse include taking over title to a home or forcing the We of a home and using the liquefied asset. The dam- age done to elders is often irreparable as they may be made homeless, face serious ne- glect, or lose their life savings. In last year's report we discussed protocol development of the Financial Abuse Specialist Team (FAST). There are two aspects to FAST. One is a rapid response team, in which the various public entities agree to essentially be on call to intervene as a case comes to light to help freeze assets before it is too late. The public entities that are essential in this effort include the District Attorney's office, the Public Guardian, APS, and local law en- forcement agencies. The second facet to FAST is a multi-disciplinary meeting that gathers to discuss a case or receive specialized training. In August 2403, APS initiated the first of bi-monthly FAST multi-disciplinary team meetings. This offshoot of the general multi-disciplinary team (MDT)meetings has been highly productive in educating social workers, legal and finan- cial workers, and law enforcement about each other's work and how each of the other disciplines can assist the others. These are the topics that have been presented: • Probate conservatorship process The California Community Partnership for the Prevention of Financial Abuse • Medi-Cal for Long-Term Care: Scams involving selling Living Trusts and Annui- ties How a Case is Prepared and Proceeds through the Legal System • Financial Crimes: Unlawful Sale of Securities and Use of Search Warrants. These FAST topics illustrate the nexus of legal, mental health, and financial systems where APS workers are asked to respond to abuse. APS is glad to be offering these edu- cational MDT's, even though they are only part of the solution. Responding to financial abuse is time-consuming for each of the public entities that play a response role. One of the Concord police officers, who was assigned to Concord's elder abuse unit until re- cently, confided that it was a relief to be back on patrol. She stated investigating the elder financial abuse cases took the most time and proceeded the slowest. We wish the rapid response team were functional to bring the full resources of our community to- gether in a powerful and timely reaction to protect elders and dependent adults. The pub- lic sector agencies involved are all stretched too thin to implement the FAST rapid re- sponse team protocols at this time. The FAST MDT was the venue where a connection was made between the California Community Partnership for the Prevention of Financial Abuse and the Concord Police Department. Concord,through its senior center,hosted a very successful senior forum on financial elder abuse on June 25, 2004. The police officers in Concord's elder abuse in- vestigation unit showed great leadership in arranging for this important public awareness event. Another success is the procurement in June 2004 of a web-based online client tracking system for APS. This system, AACTS, meets state requirements for reporting purposes and is used by seven other counties. Staff are getting used to the new system at this time and working out revisions in internal processes that used to be hard-copy based. Having AACTS will result in far less paper being used, thinner hard copy client files, and greater ease in generating the monthly state report. There may be statistical differences in future reports stemming from this conversion. We will have to wait and see. Program Development The landscape of protective services will change dramatically in the next few years. The elderly population is growing in Contra Costa County and nationally. Baby boomers are poised to retire in record numbers. When Rossmoor is completely built out, it alone is expected to house 10,000 seniors. At a time when this population will need enhanced programs in protective services and across the entire spectrum of health and social ser- vices on a scale never before experienced, Contra Costa County is paring down and eliminating vital services. Between 1990 and 2000 the population age 60+ in the county ................................ . .. .. ........................ _ _..__ ......... ........................ increased by 19.96% from 119,145 to 142,932. By April 1, 2010 that population is pro- jected to be 215,000 and by April 1, 2020 the number will increase to 313,400. Cognitive decline is a unique factor in service provision. As people age they are more likely to experience memory impairment as specified in a 2000 study by the Federal In- teragency Forum on Aging, Related Statistics: Health and Retirement Study. This study found that while the percent of people with moderate impairment is 4.4% in the 65-69 age group, it is 33.27% in the 85+ age group. The percent of people in the study with severe memory impairment was only 1.09% in the 65-69 age group but 12.89% in the 85+age group. As the 85+population is the fastest growing segment of the elderly popu- lation, we need to address dementia care issues in future planning for the adult protective services program. Accordingly, in order to plan for the trends that are clearly emerging, we have identified several expanded program components that will enhance the ability of the APS program to respond to critical service needs of this most vulnerable population. • Re-establish the specialized self-neglect unit. This community care management team of social casework specialists would be able to perform longer-term case management for our most difficult self-neglect cases. • Create the necessary interdepartmental and interagency memoranda of under- standing (MOU's) to have a fully functioning rapid response FAST team. The potential savings that elders could expect to realize is hundreds of thousands of dollars yearly. As mentioned in the case vignettes, one Rossmoor resident lost $500,000 in scams and wasn't even terribly bothered by it because of cognitive decline even though she ran through her life savings. This will happen only when the other County departments and city law enforcement agencies feel they have staff readily available to respond. • Establish a client service team to enhance the protection of the APS population. Prior to staffing reductions in FY 2003-04, the adult case management division had one social service program assistant assigned to client service assistance. That individual was able to purchase and deliver food, medications, health care supplies, household items, etc. to clients' homes; escort clients to medical ap- pointments; and assist in completing application forms for various services. These direct services are critical to support people living at home. With a team of such staff, APS could provide these direct services on a consistent basis. More- over, such a team could perform some bill-paying, money management functions which would be a very effective preventive measure in reducing the incidence of financial abuse and exploitation. • With the elimination of geropsychiatric resources at Health Services, APS needs a specialized geriatric mental health team comprising mental health caseworkers and a psychiatric nurse. These geriatric specialists would be assigned to intervene in risk situations that fall outside the limitations of the existing involuntary mental evaluation process provided under Section 5150 of the Welfare and Institutions Code. Presently, we see mental health clients returning to temporary involuntary conservatorshps multiple times because there are insufficient resources to support them in the community. These individuals end up being hospitalized at great ex- pense to the mental health system rather than continuing to live in a community setting. • As identified in earlier versions of this annual report, the APS program regularly encounters a pool of clients who need conservatorship services but who could re- main living in the community and avoid institutional care with that level of assis- tance. At present the Public Guardian will only conserve people who will be placed in a facility, either a nursing home or a board and care home. There is a need for an APS team of social casework specialists who would work with the Public Guardian to conserve clients who could be managed in their own homes with ongoing case management services rather than be placed into an institution. Conct'usion The elders of Contra Costa County deserve protection and support. The community calls upon the APS program to solve the myriad of problems that put some elders at risk of abuse, neglect, or exploitation. In spite of the reductions of APS staffing over the last three years and in the face of critical Health Services programs being reduced or elimi- nated, the public increasingly turns to,APS to solve problems relating to homelessness, mental health and substance abuse. APS is finding it increasingly difficult to fully ad- dress our clients' needs because of the lack of a comprehensive network of support ser- vices. 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