Texas Elder Abuse Prevention and Intervention Grants Aging in Texas conference June 17, 2013

1. Texas Elder Abuse Prevention and Intervention GrantsAging in Texas conferenceJune 17, 2013 Texas Department of Family and Protective Services WellMed Charitable Foundation University of Texas Health Science Center at Houston

2. Organization overview • ACL Grant Overview • Grant Projects • DFPS/WellMed • TEAM Institute • Outcome Measures Workshop overview

3. 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 overviewadult protective services

4. 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.) Organization overviewadult protective services

5. HOW TO MAKE A REPORT: 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 overviewadult protective services

6. 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 Organization overviewadult protective services

7. 2012 STATISTICS • 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 Organization overviewadult protective services

8. 50 primary care clinics (in-house lab, x-ray, pharmacy) with more than 100 physicians in Texas and Florida. WellMed – Organization Overview

9. 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 Shared incentives with physicians measured by annual quality metrics 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)

10. One Team, One Goal The WellMed Care Model Community Resources

11. “Stoplight” Stratification Process Approach for identifying the acuity level or hospitalization risk of a patient 11

12. Healthy Lifestyle Plan

13. 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 • 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 Wellmed overviewRobert Graham Center Study

14. 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 overviewGrant period:September 2012-October 2015

15. Alaska – Department of Health and Social Services • California – University of California, Irvine • 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 grant overviewfive states received awardsTexas received two

16. Validate a short 6-item screening tool to identify and prevent elder abuse and neglect in a primary care setting (EASI) • 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/WellMedGrant OverviewProject goals

17. 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 DFPS/Wellmed grant overviewProject goals

18. Elder Abuse Suspicion Index • 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 Tooloverview

20. 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 toolQuestions 1-3

21. Has anyone tried to force you to sign papers or to use your money against your will? • 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? Easi toolQuestions 4-6

22. 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 Dfps/wellmed grantPartners

23. The main objective is to pilot a tailored health promotion intervention to reduce medication non-adherence among (n=100) frail older adults in Harris County who self neglect. Team institute awardmain objective

24. Change personal and environmental determinants of medication non-adherence • Increase active participation in the self-management of chronic diseases • Reduce social isolation • Implement environmental supports Team institute awardsecondary objectives

25. 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 intervention Background

26. 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 instituteaward Team members

27. 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 awardTarget population

28. 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, self-efficacy, outcome expectations, perceived control, skills Team institute award activities, methods and strategies

29. Welcome to the matrix

30. 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 Evaluation and outcomes

31. 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/WellMedOutcomesperformance objectives

32. 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 Dfps/wellmed outcomes

33. 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 instituteperformance objectives

34. Increased medication adherence • Decreased social isolation • Decreased dependence • Decreased health problems • Reduced likelihood of re-referral to APS Team instituteoutcomes

35. 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 Contact Information