Department of Family and Protective Services
Increasing Efficiency and
Effectiveness in Adult Protective
Services:
Implications for the Aging Network
Kez Wold and Karl Urban
June 17, 2013
1
Presentation Objective
The Texas Adult Protective Services (APS)
program is having to do more with less. We
are taking a hard look at who we serve and
how we serve them.
 This presentation describes one critical
change already implemented and one
being developed.
 To have a dialogue with the Aging Network
about these changes.
2
Overview of Presentation
 Brief
overview of APS
 Current trends in APS
 Recent changes in who APS serves
 Upcoming
changes in how we
conduct casework
 Questions
and Answers
3
Mission
The mission of Adult Protective
Services (APS) is to protect the
older adults and people with
disabilities from abuse, neglect,
and exploitation.
4
APS Programs
APS Program has two primary components:

In-Home Investigations and Service
Delivery

Facility Investigations
5
Statutory Authority
Chapter 48 of the Texas Human Resources Code
authorizes APS to investigate reports of abuse, neglect,
and exploitation of:

elderly persons (age 65 and older);

adults with disabilities; and

persons receiving mental health and/or IID services in
a state supported living center, state hospital,
community center, state center, licensed ICF/IDD), or
via Home and Community-based Services (HCS) and
Texas Home Living Medicaid waiver programs.
6
In-Home Investigations
and Services


In-Home investigations are conducted in private residences,
room and board homes not subject to licensure, and/or adult
foster care homes with three or fewer residents.
APS may arrange for or provide the following services:
 emergency financial assistance for rent and utility
restoration
 social services
 emergency shelter
 health services
 referral to or collaborate with other community services,
including guardianship
7
Current In-Home Process
Current APS In-Home Process
Intake
Service Delivery
Investigation
Intake Received
by SWI
Emergency
Services
Case Initiation
Service Plan based
on Outcome Matrix
from CARE Tool
Yes
Client
Assessment:
Risk + CARE
Meets
Criteria
?
ANE
Remediated
?
ANE
Valid?
Yes
Yes
No
No
Closure
No
FY2012 Validated APS In-Home Allegations
Sexual Abuse
0%
Emotional-Verbal Abuse
2%
Exploitation
1%
Suicidal Threat
1%
Medical Neglect
18%
Physical Neglect
66%
Mental Health Neglect
10%
Physical Abuse
2%
9
Current APS In-Home Trends




Target populations are increasing rapidly resulting,
in the long-term, in rising intakes
But durations are shrinking because…
APS has implemented casework practice changes that
have improved efficiency
 Mobile caseworkers
 “As You Go” documentation using tablet-PCs
 Management attention on pending cases and
improved practice
Resulting in, for now, falling caseloads
10
Texas Population Age 65 and over and Population
Age 18 to 64 with a Disability
5
Age 65+
Age 18 to 64 with a Disability
4
Millions
3
2
1
0
2009
2010 Est.
2011 Est.
2012 Est.
2013 Est.
2014 Est.
Population (Millions)
3.97
4.08
4.19
4.23
4.48
4.63
Age 18 to 64 with a Disability
2.45
2.52
2.58
2.69
2.80
2.91
Age 65+
1.52
1.56
1.61
1.54
1.68
1.71
11
APS In-Home Intakes
110,000
105,000
100,000
95,000
90,000
85,000
80,000
75,000
70,000
Intakes
FY 2006
82,029
12
FY 2007
77,223
FY 2008
83,601
FY 2009
89,489
FY 2010
103,401
FY 2011
108,580
FY 2012
107,203
APS In-Home Completed Investigations
90,000
80,000
70,000
60,000
50,000
Investigations
13
FY2006
74,737
FY2007
64,459
FY2008
68,683
FY2009
72,265
FY2010
82,802
FY2011
87,741
FY2012
87,487
APS In-Home Service Delivery Stages
50,000
45,000
40,000
35,000
30,000
FY2006
Service Delivery Stages 35,350
14
FY2007
35,547
FY2008
36,691
FY2009
38,095
FY2010
42,940
FY2011
43,611
FY2012
46,101
APS In-Home Durations
140
Investigation Stage
Service Delivery Stage
120
100
80
60
40
20
0
Total Duration
Service Delivery Stage
Investigation Stage
15
FY2006
124.6
57.8
66.8
FY2007
122.5
51.8
70.7
FY2008
102.9
48.9
54.0
FY2009
99.0
48.0
51.0
FY2010.
95.9
45.0
50.9
FY2011
84.3
41.4
42.9
FY2012
76.9
37.7
39.2
APS In-Home Average Daily Caseloads
60
50
40
30
20
Ave. Daily Caseload
16
FY2006
FY2007
FY2008
FY2009
FY2010
FY2011
FY2012
51.2
36.4
30
30.1
33.1
31
29.6
34
HHSC Forecast of APS In-Home Intakes and Caseloads
FY2011 to FY2015
Caseload
120,000
Intakes
33
32
31
110,000
30
29
28
Caseload
Intakes
FY2011
31
108,580
17
FY2012
29.6
107,203
FY2013 est.
31.2
110,508
FY2014 est.
32.2
112,824
FY2015 est.
33.2
115,284
100,000
Key Casework Challenges

Caseworkers are:







Decreasing (in FY 12-13 biennium)
Leaving (turnover is a problem)
Lacking life experience/skills (new ones, especially)
Practicing defensive casework practice – “fear of the
one bad case”
Managing a mobile workforce
Uniform practice for all types of allegations and levels
of client risk
Limited ability to address needs of some clients
(especially mentally ill, chronically poor) leading to less
than optimal outcomes and frustrated (at best) or
burned-out staff
18
Background on Changing Who
We Serve

SB221 (82nd R) granted HHSC the authority
to define In-Home ANE in APS investigations
by rule in the Texas Administrative Code.

Changes to definitions have allowed APS to:


Focus on providing the most effective protection
possible
Make distinctions in the definitions between paid
and unpaid caretakers
19
Types of Change

Target who we serve as defined in rule and
policy:
Two types of changes definitions of target
populations and definitions of ANE
 For APS to investigate, must be in target
population and then must meet definition of
ANE

Screen more intakes out at Statewide
Intake through better guideline
 Staff training and culture change

20
What Changed?
Generally…



Eliminate cases when the APS investigation
will not alleviate the root cause
Eliminate duplication of cases in which other
entities have clearer responsibility and
resources
Streamline cases in which an expedited
investigation would be more efficient
21
What Changed?
Specifically….







Not investigate “suicidal threat” when there is no ANE
Define “Substantial impairment” in TAC and clarify in
policy (SSDI will no longer be an automatic qualifier)
Must be “emotional harm” or “physical injury” to be
abuse or neglect
For unpaid caretakers, there must “threat” of harm for
emotional/verbal abuse
For paid caretaker, theft and “may have caused”
Self neglect and caretaker neglect are separately
defined
Definition of sexual abuse based on consent; clearly
define when consent cannot22 be given
Definition of Person with a
Disability


A person with a mental, physical, or developmental
disability that substantially impairs the person’s ability to
provide adequately for the person’s care or protection.”
Proposed change is to define “substantial impairment” in
rule:


“grossly and chronically diminishes an adult’s physical or mental
ability to live independently or provide self-care”
Current APS policy defines "substantially impairs" as
"requires assistance" with one or more ADL or qualifies
for SSDI/SSI – Put in place a better way of determining
disability.
23
So What Happened?
24
The Drop in Intakes….
Scared us….
 Caused us to go back and review intakes
and rapidly closed cases to make sure we
were not missing anyone
 So we tweaked

SWI Guidelines
 Policy

26
What’s the Aging Network’s
Experience and Feedback?
27
Changing Casework
Practice


Currently APS treats all cases the same
regardless of the allegation type or the potential
“risk” to the client
Moving forward, APS is:




Implementing new tools to assess safety, risk of
recidivism, and strengths and needs.
Further targeting resources to address the most
“risky” cases.
Providing Caseworkers with tools to support
decisions in the field.
Each tool will help determine our response.
28
Current In-Home Process
Current APS In-Home Process
Intake
Service Delivery
Investigation
Intake Received
by SWI
Emergency
Services
Case Initiation
Service Plan based
on Outcome Matrix
from CARE Tool
Yes
Client
Assessment:
Risk + CARE
Meets
Criteria
?
ANE
Remediated
?
ANE
Valid?
Yes
Yes
No
No
Closure
No
Revised In-Home Process
Proposed Revised In-Home Process
Intake
Investigation
Service Delivery
Intake Received
by SWI
Safety
Assessment
Valid
Findings
?
Yes
Risk
Assmt.
Med/High
Risk
Strengths and Needs
Assessment
Yes
Meets
Criteria
?
No
Service Plan based
on Risk Assessment
and Strengths and
Needs Assessment
Low Risk
Emergency
Services
No
No
Closure
Yes
ANE
Remediated
?
Project Drivers

Review of ANE definitions and
the assessment processes
revealed that new processes are
needed to more effectively
assess client safety and risk

Practice relies on legacy tool –
Client Assessment Risk
Evaluation (CARE) and does not
evaluate safety and risk

Inefficiencies in policy divert APS
resources from clients in most
need
SB 221/New
ANE
Defintions
Increasing
Elderly
Populations
Self-Neglect
comprises
60% of
Investigations
ADM
Project
Deficient
Assessment
Processes
'One Size Fits
All' Practice
Model
National Council on Crime
and Delinquency (NCCD)

Mission: NCCD promotes just and
equitable social systems for individual,
families, and communities through
research, public policy, and practice.
APS Credentials
California
• Riverside County
• San Diego County
• Orange County
• Yolo County

Non-Profit; with focus areas in Adult
Protective Services, Child Welfare, Adult
New Hampshire, National Institute of
Criminal Justice, Juvenile Justice
Justice Grant

Operates 2 Centers:



Children’s Research Center (CRC)
Center for Girls and Young Women
40 State & Local and 10 international
SDM Implementations
Minnesota County Collaborative
National Adult Protective Services
Resource Center partner
Norfolk, VA
Safety Assessment
Components
•
•
•
•
Is there current
threat of serious
harm to the
alleged victim?
Factors influencing vulnerability
Current Danger Factors
Interventions
Safety Decision
What
interventions are
recommended to
address threats to
safety?
Based on client
and CG
acceptance of
interventions,
what is the safety
decision?
Risk Assessment and redefining Risk in APS
What is actuarial research?
•
A simple statistical procedure for estimating the probability that
a “critical” event will occur at some future time.
•
In the auto insurance industry, the critical event is a car
accident involving a driver insured by the agency. Among
breast cancer patients, the critical event is recurrence of
cancer, and risk informs treatment determination.
•
In this case, the critical event is the likelihood of future selfneglect or abuse/neglect by another person.
34
Risk Assessment
Components
•
•
•
•
What is the
likelihood of
future harm?
Self-Neglect Index
Maltreatment by Another Person
Index
Scored Risk Level
Overrides
Should ongoing
intervention
services be
provided?
What intensity of
service is
required?
Strengths and Needs
Assessment
Components
•
•
•
Client domains
Caregiver domains
Prioritization
What are the priority needs
that should be addressed in
service planning?
What existing strengths can
be used to address needs?
What are Implications for
Casework Practice?
Focus on recidivism and root cause.
 Safety vs. Risk, change in
perspectives.
 Actuarial scored risk
 Informed decisions reinforcing
intuition
 “Real” service planning
 Moving beyond bandaid approach

37
What are the Implications for
the Aging Network?
Closure of low risk client cases
 More intensive APS involvement with
high risk client cases
 Community supports as strengths in
service planning

38
Next Steps
Business requirements are completed
and tools are finalizing.
 System requirements for IT and policy
for field is being developed
 In FY 2014, we will

Make IT system changes
 Train on the new policy and practice


In FY 2015, we implement
39
Questions and Answers
40