CO-ORDINATED CARE &
QUESTIONABLE CAPACITY
Introductions
Joan Braun - Lawyer and Social
Worker
Maria Denholme – Social Worker
Objectives

To examine issues of care coordination in situations where
clients have diminished capacity or mental health challenges,
with a focus on abuse, neglect, and self-neglect..

To present a practice based perspective on what some of the
challenges can be in day to day practice, and consider one
model from BC

To explore these issues from a practitioners perspective with a
particular focus on the intersection of legal and psycho-social
services.

To provide tools to help responders be prepared for issues
which will increase as society faces the upcoming
demographic wave).
Outline
 Why this is important and some definitions
 VANGUARD Project
 Re:act a model for assessment and intervention from BC
 Journey of Care (three perspectives legal, mental health
practitioner, mediator)
 Discussion
 Questions
Introduction
 Coordination of elder care is always a complex issue
 When abuse or neglect is part of the picture further
complexity is introduced, including legal complexities
 When the adult’s capacity is in question still further
complexities enter the picture.
 Providing best practice care in these situations involves
bringing all of the caregivers and players into one
integrated process and plan.
Why is This Important
Elder Rights Issue
Well meaning or concerned friends or family members (or those who motives are
personal gain) may allege incapability and on that basis may push for services or
decisions against the older adults wishes.
Family members or service providers may also try to prevent the adult from making
decisions he or she is entitled make without the legal authority to do so in situations
where the adult’s decisions is putting him or her at risk of abuse or harm.
This may result in an unnecessary loss of autonomy – especially with society’s ageist
beliefs that older adult’s are always forgetful, frail and in need of care. However, this
is not always the case.
For example: Dementia – there is an assumption among many that older adults
are always forgetful. However, dementia is a disease process. Although there is a
higher prevalence rate among older adults (especially with greatly increased age)
it is not a part of normal aging
Vulnerability and Capability
People commonly confuse vulnerability and capability.
 From a legal perspective, adults have the right to make
their own decisions unless incapable. However, this is a
very complex area of law with many “grey” issues arising
at a practitioner level.
 In situations where abuse is occurring or the adult is
being neglected or self neglecting how should autonomy
and protection of the vulnerable be balanced?
Autonomy and Protection
How do professionals who provide care to older adults with mental
health or cognitive challenges balance autonomy and protection?
They have to do with this balancing act within the framework of the
law. Laws are different from jurisdiction to jurisdiction.
To be able to do this they need an understanding of the legal
framework.

Examples from BC CEAS

Louise Holland, Abandonnment or Automomy: How Do Social
Workers Know the Difference? (Masters of Social Work Thesis,
University of British Columbia Faculty of Social Work, 2011).

Vanguard Project
Capability
 With regard to medical care capability refers to an adult’s
ability to do certain tasks. Medical doctors and assessors
use a variety of assessment tools to determine capability.
 With regard to “legal rights” capability is a legal term.
Assessments can inform a legal determination regarding
capability but until there has been a legal determination
then he or she has the right to make the decision even if
the professionals and family members disagree.
 Anyone can lose capacity at any age. This could happen
through an accident or through a mental health issue. At a
later age there is a higher prevalence of dementia and
capacity issues can develop slowly over time.
Elder Issues – Capability
CAPABILITY – BASIC LEGAL TEST
 Degrees of capability
 Fluctuate, increase, decrease
 Focussed on specific decisions or kinds of decisions
To enter into a will
To marry
To manage finances
To refuse treatment or admission to care facility
To refuse a support and assistance plan if adult is being
abused or neglected/ self neglected (B.C.)
Elder Issues – Capability & Guardianship
CAPABILITY IS A LEGAL DETERMINATION
Able to understand and appreciate
the context of the decision (relevant information)
2. the consequences of the decision
1.
Any adult who is capable of making a decision is legally
capable of making it even if it is risky or unwise.
See, for example McCullen v McCullen, [2006] 49 R.P.R (4th)
112 (B.C.S.C.).
Elder Issues Capacity and Guardianship
Substitute Decision Makers.
If an adult is legally capable of making a decision he or
she has the right to do so. If not a substitute decision
maker makes the decision on the incapable older
adult’s behalf.
- Authority granted by older adult while still capable
pursuant to power of attorney or other advanced
planning document.
- Through a court order.
Elder Issues – Capability & Guardianship
ALTHOUGH THE “LEGAL
TEST” IS CLEAR, AT A
PRACTICE LEVEL ISSUES
CAN BE “GREY” DUE TO
CHANGING CAPABILITY
HOWEVER, AS A PERSON
LOSES CAPABILITY
A
u
t
o
n
o
m
y
REGARDING A DECISION
AUTONOMY OVER THAT
DECISION BY NECESSITY DESCREASES
Decreasing capability
Vulnerability
“Vulnerability” is a term that refers to vulnerability to abuse or harm. However, there is debate in the literature on who
is vulnerable and why a person is vulnerable.
1) One view: Term has been criticized as being paternalistic and for ascribing characteristics to a certain population. As
well, if “vulnerability” is defined broadly (eg. all adults over a certain age are vulnerable) the policy response can be to
create laws which allow greater intrusion into the lives of those over a certain age.
2) Another view: Vulnerability as situational factors (example: Provincial Strategy Document):

Current or historical abuse or neglect

Isolation, including both physical and social

Lack of supportive family, friends, and other people

Lack of education

Low income / poverty

Absence or uncertainty of citizenship

Recent immigration

Language barriers

Mental health diagnosis

Illness

Developmental disability

Physical challenges or frailty

Addiction

Other
Vulnerability & Capablity - Laws

Different jurisdictions deal with vulnerability differently. For example, some have
mandatory reporting of abuse to adult protection authorities. As well, in different
jurisdictions there are different laws regarding guardianship. Some laws are more
intrusive and others less intrusive. For a summary of different statutory adult
protection regimes in Canada see the Provincial Strategy Document, which is a paper
created as part of the VANGUARD research project.
See BC Abuse and Neglect Prevention Collaborative. The Provincial Strategy
Document (Vancouver: BC Abuse and Prevention Collaborative, 2009).

BC has no mandatory reporting and civil laws setting out protective measures only
apply if the older adult is unable to seek help and assistance on his own.

The BC model, through the approach taken by Vancouver Coastal Health will be used
as a case study of these concepts later in our presentation
VANGUARD
2 YEAR RESEARCH PROJECT
 Commissioned by groups of organizations,
professional bodies and policy makers who deal
with older adults who have capability challenges.
 The research project, focusing on the legal aspects,
examined abuse and neglect on the capability to
non capability continuum. Researchers: Charmaine
Spencer and the BC Law Institute.
 The “Collaborative” remained actively involved and
discussed practice based issues on an ongoing
basis.
VANGUARD OUTCOMES
Summary of the law on capability and adult protection in
Canada.
Recommendations for interagency response, and policy and
protocol development going forward.
A foundational understanding for building future educational
tools and developing intra-agency and cross – agency
protocols.
A two year multi-disciplinary “consensus building discussion”
of effective service delivery.
Legal research tools: matrix, charts, legal summaries, etc.
VANGUARD TOOLS
Given the lack of clarity on this issue tools coming out of the
VANGUARD Project can be used as tools to clarify key
concepts for those working in the area of mental health
Introduction
VANGUARD defined the term as:
- A social construct
- Not an inherent quality or individual flaw
- Vulnerability is based on social factors
VANGUARD TOOLS
More Vulnerable
This slide is
credited to
the
VANGUARD
Project’s
“Provincial
Strategy
Document”.
Mary
More Capable
Indira
VANGUARD TOOLS (CONT’D)
MARY’S STORY
 75 years old, rural community
 MS, but no cognitive impairments
 Long-time domestic abuse and violence – physical,
sexual, gas-lighting
 Son takes advantage – POA – abuse
 Little control, little safety
 Highly vulnerable, but capable
VANGUARD TOOLS CONTINUED
INDIRA’S STORY
 80 years old, urban setting, excellent
residential care home
 Friends and family – listen to her values,
wishes, lifestyle
 Comfortable assets, held safely
 Low capability, low vulnerability
Introduction to Next Section
One of the things that is unique about the British
Columbia context is that the health authority “wears
two hats”.
1) It provides health services to all older adults.
2) It has been designated to respond to reports of
abuse but only where the person may not be able to
seek help an assistance on his or her own. In that
situation, the health authority then puts on an
investigative “adult protection” hat.
Introduction to New Section (cont)
In BC the health authority has been given this role of responding to abuse under statute,
Adult Guardianship Act Part 3. S. 44, explains that the mandate applies to:
adults who are abused or neglected and who are unable to seek support and assistance
because of:
(a) physical restraint, (b) a physical handicap that limits their ability to seek help, or
(c) an illness, disease, injury or other condition that affects their ability to make decisions
about the abuse or neglect.
BC laws take a “middle ground approach”. However, this can lead to confusion among
health authority workers who are providing healthcare to the entire population, including
those with mental health problems that are capable, but have this secondary
investigation and intervention role with those who cant seek assistance on their own.
Having both roles in one agency is unique, and we are going to discuss the issue of
coordinated care in the BC context as it is an interesting illustration of these issues.
Vancouver Coastal
Health
Coordinated
Response Flow
Sheet for staff
caregivers
Re:act - Two Pivotal Questions
1. Is the adult abused,
neglected , or self
neglecting?
2. Are they able to seek
support and assistance?
Role of the Designated Responder
 Document at each step
 Interview the adult
 Assess the urgency of the situation
 Coordinate the collection of collateral
 Coordinate the assessment of abuse, neglect or
self-neglect
Role of the Designated Responder (cont’d)
 Coordinate the assessment of ability to seek/refuse
support and assistance
 Determine if the adult has a Representative,
Committee, or Power of Attorney
 Coordinate the development of a care plan to
provide support and assistance
SUPPORT AND ASSISTANCE PLAN
SECTION 1 – DESIGNATED AGENCY INFORMATION
- Who is making the plan and who will be responsible for follow up
SECTION 2 – PERSONAL INFORMATION AND CONTACT PEOPLE
Demographics, contact information, communication information, living situation
SECTION 3 – REASON FOR THE SUPPORT AND ASSISTANCE PLAN
details of the abuse/neglect/self-neglect, details about factors affecting ability to make
decisions about it
SECTION 4 – SIGNIFICANT PEOPLE IN THE ADULT’S LIFE
Formal substitute decision makers (full information about each) & support people: family,
friends, advocates, service providers
SECTION 5 – GETTING TO KNOW THE ADULT
The person’s history, Strengths and accomplishments, Interests values and beliefs
The adult’s wishes with regard to the situation
SUPPORT AND ASSISTANCE PLAN
(cont’d)
SECTION 6 – SUPPORT AND ASSISTANCE

Who was involved in the development of the plan

Details of each support and assistance offered

Description of service and length of time offered

Reason for offering this service

Consequences to the adult of refusing the service

Person responsible for implementation and follow up for this service
SECTION 7 – CONCLUSIONS

Was the adult involved or was the plan as fully explained as possible

Outcome:

accepted by the adult

not accepted but the situation is resolved

not accepted and the adult is believed to be capable of making this decision

not accepted, and they are believed to be incapable of making this decision, and there is abuse,
neglect, or self neglect and the case is being forwarded to the Public Guardian and Trustee for an
assessment of incapability and to determine if a Court Order for support and assistance should be
pursued.
Role of the Designated Responder (cont’d)
 Advise the most responsible physician of the
situation and actions taken
 Make reports as necessary to the PGT
 Report crimes to police
 Keep the identity of the person who made the
report confidential
 Use the tools in the legislation as a last resort if the
S & A is refused
Adult Guardianship Legislation - BC
 Power to investigate
 Access order
 Warrant to enter for purpose of interview
 Interim restraining order
 Support and assistance order
 Emergency provisions – including apprehension
The Journey through Care
– A Lifelong Journey
Introduction to Journey
Legal Perspective
Lawyers are concerned:

About the legal rights of their clients

That relevant legislation (laws) are followed

About representing the legal interests of their client

Lawyers may care deeply about the social and medical needs of the older
adult but may be restrained by their professional duties.
This perspective frames the way a lawyer looks at care planning and decisions.
Likewise the lawyer’s role will affect how the lawyer is involved and what he or
she can do. Is the lawyer representing a client, or is the lawyer representing
the health authority?
Introduction to Journey
Social Work Perspective
Autonomy of capable individuals
The CASW Code of Ethics:
Value # 1: Social work is founded on a long-standing commitment to respect the inherent dignity and individual
worth of all persons. When required by law to override a client’s wishes, social workers take care to use the minimum
coercion required.
Principles:

Social workers uphold each person’s right to self-determination, consistent with that person’s capacity and with
the rights of others.

Social workers uphold the right of society to impose limitations on the self-determination of individuals, when
such limitations protect individuals from self-harm and from harming others.

Social workers respect the client’s right to make choices based on voluntary, informed consent.

Social workers uphold the right of every person to be free from violence and threat of violence.
Value # 3: In professional practice, social workers balance individual needs, and rights and freedoms with collective
interests in the service of humanity.
I
n
t
r
u
s
i
o
n
Incapable
Coordinated care
– differing levels
of support and
intervention
Fluctuating or
partial incapability
Needs support but
cognitively capable
Prevalence
Legal and Social
Work aspects
continue
throughout
Legal
Intervention
Support services
continue
throughout
Adult Protection
Measures
(example:
investigation)
Community and Health
Supports
Capable Adult
•
•
•
all care planning and intervention is
voluntary
Abuse and neglect addressed with the
adult
adult can refuse any plans offered
Client and family meeting
Pension etc. applications
Financial and Banking Plans
Care Facility Lists
Connect to community supports
Powers of Attorney, Representation Agreements, Wills,
Guardianship for minor children
Fluctuating or partial capability
• Some protective measures need to be
considered…. Investigations of abuse/neglect and
of capability
• Adult may be able to accept/refuse plans in one
area and not in others
Informal adaptations
Support and Assistance Plans
Client, Family and Collateral Meetings
Powers of Attorney, Representation
Agreements, Mediation, Mental Health
Act Certification
Incapable Adult
• Proper Assessment and legal decision must be
considered if there is abuse and neglect
• Include as much as possible the adults previously
expressed values, beliefs, and choices
• Adult is not able to accept or refuse plans put in
place
Caregiver Support
Placement Advocacy
Follow up for court orders
Committee, Support and Assistance Orders
Assessments, Tools, and Guidelines
Capacity Assessment requires a coordinated and multidisciplinary response
 Must always include assessment of cognitive and executive
function, and then assessment of capacity in a specific area
 Multiple sources including self report from the adult,
collateral reports, and objective measures
 Must include a careful identification of the tasks/issues for
which capability is being considered
 Must be clearly documented and have standard
components in accord with the applicable local laws
Tools
 Specific tools: 3MS, MMS, PGT Functional and Decision
Making Form for PPA, Brief Abuse Screen for Elderly, Elder
Abuse Suspicion Index, Caregiver Abuse Screen, Frontal
Behavioural Inventory, MOCA
 Which tools you choose will depend on what you are
specifically assessing and what your professional discipline
is. It’s important to have a basic understanding of tools you
may not use yourself so that you can consider their findings
knowledgeably
Guidelines
http://www.vchreact.ca/resources.htm
 The Vancouver Coastal Health Re:act program web site as
many great resources
 Capability and Consent Tool (gives various different types of
consent situations, along with their various criteria, relevant
statutes, and who assesses them) – this is specific to British
Columbia but you can develop one for your own area
 The VCH Quick Assessment Guide (designed for physicians and
anyone else working with elders to consider the issue of abuse,
neglect, self neglect)
 The Re:act manual for VCH staff to assist them in dealing with
adult abuse and neglect
Available at www.vchreact.ca
Clinical Assessment Tools








VCH Quick Assessment Guide
Brief Abuse Screen for the Elderly (BASE)
Frontal Behavioral Inventory (FBI)
Geriatric Depression Scale
Indicators of Abuse Screen
Lawton and Brody IADL Scale
The Caregiver Abuse Screen (Reis-Nahmiash CASE)
Capability and Consent Tool - BC Edition
Journey of Care – Elder Mediation
Another Example of Capacity & Abuse; Autonomy &
Protection in a Practice Situation.
Elder mediation has been noted as a promising approach.
Rather than going to court to resolve disputes about
capacity, guardianship, care, etc. these issues can be
resolved by the family and other care givers with the help of
a neutral third party (mediator)
However, even though this approach has promises concern
has been expressed in the literature, especially around
issues of guardianship and vulnerability and specialized
training has been recommended for elder mediators.
Elder Mediation
Experts agree that older adults with capability issues should
participate in mediation to the maximum degree possible.
Accommodation may be needed such as attendance of a
support person, shorter sessions, scheduling mediations at
certain times of day, etc.
Although the mediator’s role is to assess capability to
participate there may be decisions within the mediation that
the older adult does not have the capability to decide. This
is an area where more research as needed as there is
insufficient guidance to mediators on this issue and there
are many ethical issues that may arise related to abuse or
capacity that the elder mediator should have policies and
best practices in place to deal with.
Elder Mediation
Key Strategies for dealing with abuse/ capacity
Pre-mediation meetings
See, for example, Joy Anne Braun, Child
Protection Mediation: Mediator Strategies for
Managing the Process (MSW Thesis, University
of British Columbia, 2007
Screening
Training and practice standards
Considering Your Practice
 Ongoing review of your own practice allows you to
continually improve your ability to assist people
with diminished capacity
Considering Your Practice
When confronted with adult abuse, neglect, or self neglect:
1.
I have a clear understanding of what the care need/service request is
2.
I have assessed whether there is an issue of abuse, neglect, or self neglect involved
3.
I have solicited and considered the wishes of the adult (whether capable or not)
4.
I have received a comprehensive assessment of the adult’s cognitive, executive, and functional capabilities in
instances where capacity is questioned, including the rationale for recommendations of (in)capacity
5.
I have solicited and considered the wishes of the adult’s informal and natural supports (both their ability and their
wishes) to the extent that I am allowed by law/indicated by the situation
6.
My plan involves the least intrusive, most effective interventions appropriate and available to the situation
7.
I have a clear written plan of care, including who will be responsible for each area and what will happen if the plan is
not implemented in that area
8.
I have a specific timeline for the review and revision of the plan.
9.
If I am considering a formal legal intervention I am considering the least intrusive option that will meet the needs of
the adult and have facilitated provision of legal counsel to the adult.
Contact Information
Maria Denholme
Social Worker/Designated Responder
maria.denholme@vch.ca
604-983-6020
Contact Information
http://wwwelmsbc.ca
braun@joanbraun.ca
604-780-4870
COORDINATED CARE PLANING
When putting together a coordinated care plan six guiding questions can
be used (Adapted from slides by Arlene Groh):
1.
Why is the situation causing concern/what is the concern?
2.
How do I (the service provider) feel about the situation?
3.
What are the relevant factors (including vulnerability and capability)?
4.
What are the service options/legal requirements?
5.
What are the values, wishes, and goals of the client?
6.
What is the response?
Are there any legal considerations or services in this case?
Case Example
Lydia Delacourte is 64 years old, married and has three grown
children. She is close to her younger daughter but she lives in
another town which is a short drive away from her home. She
has been estranged from her son for ten years. Her oldest
daughter has demonstrated a history of physical violence to
her siblings and parents, and stole a significant amount of
money from her mom. The oldest daughter, lived next door
until recently when she moved away after a physical alteration
with her mom. Three months later Lydia shows up at a health
clinic stating that she is quite depressed. Other than her
depression she seems to be functioning well both physically
and mentally.
CASE EXAMPLE – Stage 1
Concerns and Considerations from social work and legal
perspectives.
Social Work:
The key questions from Re:act
1)
Is she abused or neglected?
2)
Is she capable of making decisions in the area of
concern?
Case Example – Stage 1
 Any services are going to be voluntary
 Assess her level of depression (which is her presented concern),
and consider general health concerns, review of medication
 Discuss recent situation, what has changed, particularly is she
feeling safe, how does she feel about her current situation, is
there anything that she can identify that would help
 Consider natural and community supports (younger daughter,
friends, extended family faith community)
 Consider her day to day activities and connection to
community/others
 Consider referral to family doctor or other caregiver to treat
depression
Case Example (cont’d)

Lydia is now 75. She is widowed and remains close to her younger
daughter. Her daughter phones several times a week and visits once a
week.

Her daughter has become concerned because a neighbour has called
to say that her mother left the stove on when she went to the grocery
recently and set off the smoke detector (although there was no major
damage to the apartment). Lydia has also been complaining about her
arthritis and that it is difficult to get to the grocery and the bank. She
told her daughter that a nice young man from down the hall had
offered to do these tasks for her and that she had given the young man
her bank card to do the shopping. When asked about the bank card she
told her daughter that there was only a small amount of money in the
account so she was not worried about giving the man her card.

Lydia’s problems with depression have increased over the past few
years, but now she also seems to be having problems with short term
memory.
CASE EXAMPLE – Stage 2
Concerns and Considerations from social work and legal
perspectives.
Social Work:
The key questions from Re:act
1)
Is she abused or neglected?
2)
Is she capable of making decisions in the area of
concern?
Case Example – Stage 2
Social Work:

Assume Capacity and discuss with Lydia the fire and her financial
arrangements

Determine whether there is an issue of abuse or neglect to be dealt with.

Consider three formal assessments (depression, IADL’s, Financial interview)
depending on what Lydia says in the interview

Develop a plan for Lydia, with her consent if capable, only involving the
PGT if absolutely necessary (e.g. if her financial safety can’t be secured in
any other manner or her cognitive functioning/memory is impaired to the
point that she needs to be placed against her will)

Consider a formal support and assistance plan if it appears that Lydia
refuses supports and it looks like court intervention may be necessary
Case Example (cont’d)

Lydia is now 85. She still lives on her own but you (the service provider) have received a couple
of calls from concerned members of the community. The bank service manager called to say
that a neighbour has been coming to the bank to help Lydia with transactions and that Lydia
seems confused sometimes and may be under the influence of the neighbour. Lydia receives
support from a home care worker to help with household tasks but she needs more assistance
than she receives from her support worker due to several physical ailments. She also has
moderate dementia.

Her younger daughter comes over once a week to provide her mom with assistance and calls
regularly. She has noticed that recently her mom is very secretive about her money and her
relationship with the neighbour. The daughter discovered that the neighbour has been visiting
her home several times a week and that Lydia has given him money. Lydia does not have any
other friends. Lydia’s oldest daughter has reappeared in town and also has visited Lydia several
times over the objections of the younger daughter who fears for mom’s safety.

The daughter tried to speak to Lydia about the situation and to express concerns about Lydia’s
safety. She tried to propose Lydia move somewhere else where she could get additional
support. However, Lydia became very angry, said she was fine and that she did not want any
help or interference. She then did not speak to her youngest daughter for a few days. The
younger daughter has now called you to discuss the situation.
CASE EXAMPLE – Stage 3
Concerns and Considerations from social work and legal
perspectives.
Social Work:
The key questions from Re:act
1)
Is she abused or neglected?
2)
Is she capable of making decisions in the area of
concern?
Case Example – Stage 3
Concerns and Considerations from social work and legal perspectives.
Social Work:

Daughter has called me.. Get as much collateral as I can from her

Interview Lydia and consider formal capacity assessments: MMS, Frontal
Behavioural Index, Financial capacity interview

If capable, work with Lydia to come up with a support and assistance plan
(and lobby with service funders to provide adequate home care)

If incapable, apply through PGT for a financial SDM, consider certification
under MHA if suitable care cannot be negotiated

Depending on the situation with the daughter consider AGA options to
keep her away from Lydia (although these would have to be enforced by
someone else if Lydia is not capable)