TEXAS ELDER ABUSE
PREVENTION AND
INTERVENTION GRANTS
AGING IN TEXAS CONFERENCE
JUNE 17, 2013
Texas Department of Family and Protective Services
WellMed Charitable Foundation
University of Texas Health Science Center at Houston
• Organization overview
WORKSHOP
OVERVIEW
• ACL Grant Overview
• Grant Projects
– DFPS/WellMed
– TEAM Institute
• Outcome Measures
ORGANIZATION
OVERVIEW
ADULT
PROTECTIVE
SERVICES
• The mission of Adult
Protective Services is to
protect older adults and
people with disabilities from
abuse, neglect and
exploitation
• In Texas, elderly is defined as
65 and older and a disabled
adult is aged 18-64
ORGANIZATION
OVERVIEW
ADULT
PROTECTIVE
SERVICES
• Investigative Authority: Texas
Human Resources Code, Chapter 48
– Mandates investigations of
abuse, neglect and exploitation
– Requires mandatory reporting
– Provides immunity for
cooperating with the
investigation
– Provides confidentiality
protection for the reporter
– Provides APS with access to all
records (banking, medical, etc.)
HOW TO MAKE A REPORT:
ORGANIZATION
OVERVIEW
ADULT
PROTECTIVE
SERVICES
Statewide Intake (24/7):
1-800-252-5400
(APS/CPS/CCL)
Online reporting:
www.txabusehotline.org
(not anonymous/checked infrequently)
If an emergency, dial 9-1-1
ORGANIZATION
OVERVIEW
ADULT
PROTECTIVE
SERVICES
• In-home investigations:
– Private residences
– Room and board homes not
subject to licensure by DADS
– Adult foster care homes with
three or fewer residents
• Facility investigations:
– State supported living centers
– State hospitals
– Community centers
– Facility and community center
contractors (HCS homes)
– Privately operated ICF-IDD’s
2012 STATISTICS
ORGANIZATION
OVERVIEW
ADULT
PROTECTIVE
SERVICES
• Completed In-Home Investigations:
– 87,487
• Validated In-Home Investigations:
– 59,595
• Most common person reporting A/N/E:
– Medical personnel (20.8%)
• Most common allegation validated:
– Physical neglect (66.5%)
• Most common validated perpetrator:
– Relationship: Adult children (40.8%)
– Gender: Male (51.1%)
– Age: Over 45 (50.7%)
• Most common client characteristic:
– Gender: Female (60.5%)
– Age: Over 65 (50.2%)
http://www.dfps.state.tx.us
WellMed – Organization Overview
50 primary care clinics (in-house lab, x-ray,
pharmacy) with more than 100 physicians in Texas
and Florida.
WELLMED - ORGANIZATION OVERVIEW
Primary Care Centric Medical Group (Family Practice, Internal Medicine
+ added Podiatry, Dermatology, Cardiology, Oncology, Pain Medicine)
Manages Full-Risk Capitated Insurance Contracts
Specializes in Medicare-eligible Seniors – responsible for 87,000 lives
Contracts for all Medical Services (Specialty, Hospital, Ancillary, Hospice)
•Fully functional primary care centric, patient centered medical home
(PCMH) functioning as an accountable care organization (ACO)
Shared incentives with physicians measured by annual quality metrics
The WellMed Care Model
One Team, One Goal
Community
Resources
“Stoplight” Stratification Process
10% of
Panel:
Elevated
Risk
Patients
Green
5 % of
Panel:
Highest
Risk
Patients
Yellow
Red
Approach for identifying the acuity level or
hospitalization risk of a patient
85% of
Panel:
Average
Risk
Patients
11
HEALTHY LIFESTYLE PLAN
Healthy Lifestyle Plan
EATING BETTER
WEIGHT
MANAGEMENT
COPING WITH
STRESS
EXERCISE
TAKE MY
MEDICINE
REDUCING
UNHEALTHY HABITS
My Goal: (What I want to do – example: start exercising)
________________________________________________________
My Healthy Lifestyle Plan: (How I will do this – example: walking)
________________________________________________________
My Commitment to a healthy lifestyle:
I, ___________________________, agree to begin to
________________________________________________________
(activity, how often, length of time – example: walk 4x/week for 30 minutes)
by ______________________(set a start date).
I will discuss my progress at my next clinic visit.
Patient signature ____________________ Date _________________
WELLMED
OVERVIEW
• The Robert Graham Center: Policy Studies in Family
Medicine and Primary Care, the research arm of the
American Academy of Family Physicians studies 10 years
of WellMed patient data
ROBERT
GRAHAM
CENTER STUDY • Found that the “mortality rate was consistently and
considerably” lower than the Texas senior population as a
whole according to the article published in the Journal of
Ambulatory Care
• Aggressive chronic disease management decreases
hospitalizations, decreases morbidity, decreases mortality
and yields high quality outcomes
GRANT OVERVIEW
GRANT PERIOD:
SEPTEMBER 2012OCTOBER 2015
• Funds were awarded by the
Administration on Community
Living/ Administration on Aging
• Funds will be used to implement,
test and measure performance of
new approaches to identify,
intervene and prevent elder abuse,
neglect, and exploitation
• Review risk factors related to elder
abuse, neglect or exploitation to
enhance future prevention efforts
GRANT
OVERVIEW
• Alaska – Department of Health and
Social Services
FIVE STATES
RECEIVED
AWARDS
• California – University of California,
Irvine
TEXAS RECEIVED
TWO
• New York – New York State Office
for the Aging
• Texas – Department of Family and
Protective Services/WellMed AND
University of Texas Health Science
Center, Houston
DFPS/WELLMED
GRANT OVERVIEW
• Validate a short 6-item screening tool to
identify and prevent elder abuse and
neglect in a primary care setting (EASI)
PROJECT GOALS
• Develop and test protocols for
screening seniors at risk of elder abuse
in a primary care setting including:
– Embedding two APS staff into the
WellMed system
– Referrals to APS for “high-risk”
patients and follow-up
– Monitor patients at “low-risk” of
abuse
– Referrals to community resources
DFPS/WELLMED
GRANT OVERVIEW
PROJECT GOALS
• Delivery of training to WellMed clinical
staff on:
– Elder abuse risk factors
– APS referrals mechanisms
– APS reporting requirements
– Identification of risk factors
• Delivery of education materials to
patients and caregivers on:
– Targeted information to patients
at risk of abuse based on EASI tool
– General patient population
EASI TOOL
• Elder Abuse Suspicion Index
OVERVIEW
• Developed in Montreal, Canada at McGill
University and CSSS Cavendish to raise
suspicion about elder abuse
• Validated in ambulatory clinical settings
in Canada with cognitively intact seniors
• 6 question survey administered by a
clinician
• Adopted by the World Health
Organization
EASI TOOL
QUESTIONS 1-3
• Have you relied on people for any of
the following: bathing, dressing,
shopping, banking, or meals?
• Has anyone prevented you from
getting food, clothes, medication,
glasses, hearing aides or medical
care, or from being with people you
wanted to be with?
• Have you been upset because
someone talked to you in a way that
made you feel shamed or
threatened?
EASI TOOL
• Has anyone tried to force you to
sign papers or to use your money
against your will?
QUESTIONS 4-6
• Has anyone made you afraid,
touched you in ways that you did
not want, or hurt your physically?
• Doctor: Elder abuse may be
associated with findings such as:
poor eye contact, withdrawn
nature, malnourishment, hygiene
issues, cuts, bruises, inappropriate
clothing, or medication compliance
issues. Did you notice any of these
today or in the last 12 months?
DFPS/WELLMED
GRANT
•
•
•
•
PARTNERS
•
•
•
•
•
•
•
DFPS/Adult Protective Services
WellMed Charitable Foundation
WellMed Medical Management, Inc.
Margret Blenkner Research Institute,
Benjamin Rose Institute on Aging
Elder Justice Coalition
Department of Aging and Disability
Services
Area Agencies on Aging in Austin and El
Paso
Lucy Barylak, MSW
San Antonio Police Department
Bexar County Sheriff’s Department
Bexar County District Attorney’s Office
TEAM INSTITUTE
AWARD
The main objective is to pilot a tailored
MAIN OBJECTIVE
health promotion intervention to
reduce medication non-adherence
among (n=100) frail older adults in
Harris County who self neglect.
TEAM INSTITUTE
AWARD
SECONDARY
OBJECTIVES
• Change personal and environmental
determinants of medication nonadherence
• Increase active participation in the
self-management of chronic
diseases
• Reduce social isolation
• Implement environmental supports
TEAM INSTITUTE
AWARD
INTERVENTION
BACKGROUND
• Elder Self Neglect
– Most common referral in APS
Region VI
– Myriad chronic and acute diseases
– High mortality rates
• High prevalence of medication non
adherence in a sample of community
dwelling older adults with Adult
Protective Services – validated self
neglect
TEAM INSTITUTE
AWARD
TEAM MEMBERS
• Carmel Dyer, MD – UT Health Houston
• Jason Burnett, PhD – UT Health Houston
• Pamela Diamond, PhD – UT Health
Houston
• Dawn Velligan, PhD – UT Health Houston
• Beini Zhu, MPH – UH Health Houston
• Sarah Schwaller, MPH – UT Health
Houston
• Leslie Clark, RN – UT Health Houston
• James Booker, MA – TX DFPS/APS
• Deborah Moore, MBA – Harris County
Agency on Aging
• Lynne Parsons, JD – Harris County
District Attorney’s Office
TEAM INSTITUTE
AWARD
TARGET
POPULATION
• 65 years of age and older
• English and/or Spanish speaking
• Community dweller in Harris County
• 2 or more referrals to APS Region VI
for self neglect
TEAM INSTITUTE
AWARD
ACTIVITIES,
METHODS AND
STRATEGIES
• Home visits
– Weekly visits to elders’ homes
– In-home education sessions –
medications, health conditions,
use of environmental supports
– In depth assessments
• Evidence based intervention
mapping approach
– Increase knowledge, selfefficacy, outcome expectations,
perceived control, skills
WELCOME TO THE MATRIX
Performance
Objectives
Knowledge
Self-efficacy and
Skills
Outcome
Expectations
PO1. Decide to become
an active participant in
managing medications.
PO1. K1. Explain the role
of an active participant
in managing
medications.
PO1. SE1. State high
confidence in becoming
an active participant.
PO1. OE1. State positive
outcomes of becoming
an active participant.
PO2. Set specific goals to
achieve medication
adherence.
PO2. K2. Identify
important health
management behaviors,
e.g. medication
adherence, routine
physician visits.
PO2. SE2. Express selfconfidence in
performing specific selfmanagement goals.
PO2. OE2. State positive
outcomes of achieving
these goals.
PO3. Develop a
personalized medication
management action plan
with RN/CHW.
PO3.K3. Explain the
purpose of a medication
management action
plan.
PO4. Perform specific
self-management tasks.
PO4. K4. List steps for
managing medications,
e.g. taking meds on time,
not missing doses.
Perceived
Control
PO1. PC1. State control
over specific aspects of
managing medications.
PO3. PC3. Explain how
this action plan
facilitates control.
PO4. SE4. Demonstrate
specific and accurate
medication management
behaviors, e.g. opening
pill bottles.
PO5. OE5. Believe that
performing medication
management tasks will
increase health status.
EVALUATION
AND OUTCOMES
• National Evaluator for the grant
project – NORC at the University of
Chicago
• Conduct evaluation of grantee
prevention interventions
• Move the field of elder abuse
prevention forward
• Data analysis, data collection,
infrastructure, implementation,
data sharing and reporting
DFPS/WELLMED
OUTCOMES
PERFORMANCE
OBJECTIVES
• 10,000 Patients screened over the
grant period
• 10,000 Patients provided with
education materials (approximately
10% of WellMed’s annual patient
population)
• 600 Clinical staff trained over the
grant period
• Improved knowledge by clinicians’
of identification of abuse, neglect
and exploitation and referral
sources based on pre and post
training surveys
• Validation of the EASI tool for use in
a clinical setting
DFPS/WELLMED
OUTCOMES
• Validated screening tool that can be
replicated in the United States
(EASI)
• Establish protocols for screening
seniors at risk of abuse, neglect and
exploitation in a clinical care setting
• Increased collaborative
relationships between team
members and agencies
• Decrease in elder abuse
TEAM INSTITUTE
PERFORMANCE
OBJECTIVES
• Decide to become an active
participant in managing
medications
• Set specific goals to achieve
medication adherence
• Develop a personalized medication
management action plan with a
RN/CHW
• Perform specific self-management
tasks
TEAM INSTITUTE
• Increased medication adherence
OUTCOMES
• Decreased social isolation
• Decreased dependence
• Decreased health problems
• Reduced likelihood of re-referral to
APS
CONTACT
INFORMATION
Rachel Duer, MA
Adult Protective Services
210-871-3036
Rachel.Duer@dfps.state.tx.us
Carol Zernial
WellMed Charitable Foundation
210-877-7719
CZernial@wellmed.net
Jason Burnett, Ph.D.
TEAM Institute
713-873-4685
Jason.Burnett@uth.tmc.edu