PSA and Elder Abuse reporting: What medical providers need to know Susan B. Somers, Asst. Commissioner Bure

1. EMT NYC March 2005 PSA and Elder Abuse reporting: What medical providers  need to know   Susan B. Somers, Asst. Commissioner Bureau of Adult Services, NYS Office Children and Family Services Elder Abuse is the final frontier in the field of family violence, a paradox that flies in the face of our beliefs that old age should equate with the �golden Years�, not the black and blue years. Elder Abuse is the final frontier in the field of family violence, a paradox that flies in the face of our beliefs that old age should equate with the �golden Years�, not the black and blue years.

2. EMT NYC March 2005 Extent of the Problem U S national estimates vary � May be one-half million elderly victims National Elder Abuse Incidence Study( NASIS)

3. EMT NYC March 2005 Time Line: Elder Abuse 1990-Elder Abuse Task Force-HHS 1991 Nat. Inst. On Elder Abuse (NCEA) 1992 AMA guidelines 1992 JCAHO standards 1996 Nat study funded 1998 NEAIS released 2000 DOJ/HHS Symposium 2004 1st NYS Summit on Elder Abuse

4. EMT NYC March 2005 Trends in the U. S. 1986 to 1996 reports increase by 150% (Tatara & Kuzmeskus, 1997) Elderly Population increases by 10%

5. EMT NYC March 2005 Elder Abuse: a Hidden Problem Tip of the Iceberg Theory For every reported case, five remain unidentified (NEAIS)

6. EMT NYC March 2005 Types of Abuse:NYS Social Services Law Definitions Physical abuse Sexual abuse Emotional abuse Active or passive neglect Self neglect Financial exploitation

7. EMT NYC March 2005 Physical Abuse The non-accidental use of force that results in bodily injury, pain or impairment, including but not limited to, being slapped, burned, cut, bruised or improperly physically restrained.

8. EMT NYC March 2005 Sexual Abuse Non-consensual sexual contact of any kind, including forcing sexual contact

9. EMT NYC March 2005 Emotional Abuse Willful infliction of mental or emotional anguish May include threats, humiliation, intimidation Frightening or isolating an adult

10. EMT NYC March 2005 Active Or Passive Neglect May be �active� if done willfully, �passive� if it occurs because of inadequate caregiver knowledge or ability Deprivation of food, water, heat, clean clothing and bedding, eyeglasses, dentures Denial of health related services Abandonment

11. EMT NYC March 2005 Self Neglect An adult�s inability, due to physical or mental impairments, to perform tasks essential to self care Obtaining essential food, clothing, shelter and medical care and other services needed to maintain physical and mental health Inability to manage finances

12. EMT NYC March 2005 Financial Exploitation Improper use of an adult�s funds, property or resources by another individual Includes fraud, false pretenses, embezzlement, conspiracy, forgery, Falsifying records, coercing property transfers, denying access to assets

13. EMT NYC March 2005 Protective Services for Adults Provided to all adults, 18+ who: Have a reduced capacity for self-care because of a physical or mental impairment Are being harmed or are at risk of harm by others, or by their own actions or inaction Have no one else willing and able to assist in a responsible manner

14. EMT NYC March 2005 PSA: Statewide Mandated Program Provided through local County Dept.'s of Social Services and Human Resources Adm. in NYC. Without regard to income

15. EMT NYC March 2005 Services Investigation & assessment Counseling Advocacy & case management, including arranging for health services, applying for benefits, coordinating with other agencies Finding alternative living arrangements, including emergency room & board for 30 days

16. EMT NYC March 2005 Services, Cont. Financial management services, including serving as representative payee Homemaker and housekeeper/chore Crisis interventions such as access orders, STIPSO�s and orders of protection Long-term legal interventions, such as guardianship

17. EMT NYC March 2005 Social Services Laws:Article 9-B SSL 473 PSA authority to receive and investigate reports of abuse/neglect SSL 473(5) Requires PSA, to report crimes to police, and if requested, to the district attorney. SSL 473-(6) Defines Abuse.

18. EMT NYC March 2005 Social Service Laws:Cont�d SSL 473-a STIPSO short term involuntary protective services order SSL 473-b immunity from civil liability for good faith referral SSL 473-c order to gain access SSL 473-d community guardian

19. EMT NYC March 2005 Social Services LawsCont�d SSL 473-e Confidentiality of referral sources. SSL 144-a Requires financial institution to provide information on deposits, amount or value (See also NY Banking Law Section 4)

20. EMT NYC March 2005 PSA Clients: Who Are They? debilitated neglected frail elderly mentally ill, mentally retarded abused and exploited

21. EMT NYC March 2005 Profile of PSA Referrals in NYS (Abelman 1997) 26,000+ referrals yearly 55% are adults 60+ 1/3 abused by another adult 2/3 are self neglect

22. EMT NYC March 2005 Typical victim Over 75 years old 65% female Physical disability or frailty in 51% of cases Primary abuser - male

23. EMT NYC March 2005 Services Provided to Abuse Victims- 40% obtained public benefits 40% Financial management 38% Home care 36% Mental health services 36% Housing services 4% Legal and emergency interventions

24. EMT NYC March 2005 NEAIS: Who Are the Perpetrators For physical & emotional abuse cases: History of caregiver psychopathology Likely financial dependence on victim For neglect cases: Stressed caregiver Cognitively impaired victim

25. EMT NYC March 2005 Gender of Perpetrators Table 4-11 Selected Types of maltreatment (NEAIS) Neglect Emotional Financial Physical Men 47.6 60.1 59 62.2 Women 52.4 39.9 41 37.4 Neglect Emotional Financial Physical Men 47.6 60.1 59 62.2 Women 52.4 39.9 41 37.4

26. EMT NYC March 2005 Relationship of Perpetrators to Victims Figure 4.9 (NEAIS)

27. EMT NYC March 2005 Gender of Perpetrators(NEAIS & Profile of PSA Caseloads in New York) Figure 4-6.

28. EMT NYC March 2005 Barriers to Identification Hidden from view Confusion re: non-uniform definitions - 33 nation wide in US Fear of reporting leads to under reporting Frustration of service providers and other professionals

29. EMT NYC March 2005 Barriers to Identification Fear of retribution Shame, embarrassment Ageism Minimization Deadly ( NYS 1997 Profile study)

30. EMT NYC March 2005 Incidence - Neglect Cases High degree of mental impairment 93% had difficulty with self-care 75% suffered some degree of confusion Majority of self-neglect cases involve adults who are 80+

31. EMT NYC March 2005 High Risk Factors for Abuse/neglect Psychological and/or physical impairments in the elderly person Social isolation of the caregiver and of the elder Increasing dependency Refusal of elder and/or caregiver to accept help

32. EMT NYC March 2005 High Risk Factors- Cont. Substance or alcohol abuse by the elder or caregiver Inadequate resources and community support Little understanding of aging process Caregiver stress and role dissatisfaction Vulnerability increases with any kind of cognitive impairment

33. EMT NYC March 2005 Mental Impairment in Neglect Cases According to incidence study, in self-neglect cases, 80% of the adults showed signs of confusion, 20% did not In cases of neglect by others, 93% had signs of confusion, 7% did not

34. EMT NYC March 2005 Indicators of Physical Abuse Bruises, lacerations, rope marks Bone and skull fractures or breaks Untreated injuries Broken assistive devices, dentures, glasses A report of physical abuse

35. EMT NYC March 2005 Sexual Abuse Sudden change in mood- behavior Fear of touch Pain, itching, bruise - breasts or genitals Unexplained STD A report of sexual harassment or rape

36. EMT NYC March 2005 Behavioral Indicators of victim Injury does not match explanation Repeated �accidents� Delay seeking medical attention Consider or attempt suicide Sudden change in behavior

37. EMT NYC March 2005 Potential Abusers Minimize or deny abuse Blame victim Answer for Victim Turn family against victim Threaten to hurt pets Agree to change but never follows through

38. EMT NYC March 2005 Abuser�s Tactics Intimate Partner Violence Vulnerable Adult Abuse Elder Mistreatment and Abuse

39. EMT NYC March 2005 Abuser�s Tactics Include a pattern of coercive tactics Isolation Intimidation Threats Withholding, food, money, medications Physical Sexual abuse

40. EMT NYC March 2005 Risk Factors that signal abuse Gender: Females more vulnerable (NCEIS) Living with caregiver, �trusted other� (Pillemer & Finkelhor, 1988, Lachs et al, 1997) History of family Violence Emotional dependence

41. EMT NYC March 2005 Impact of Violence on the Elderly Causes traumatic responses Short and long term effects The more frequent and severe the abuse the more symptoms 2000 Study � Mark Lacks, M.D.

42. EMT NYC March 2005 Health Issues Many self-neglecting elderly develop serious health problems They may refuse home health care services Inconsistent use of prescription medications

43. EMT NYC March 2005 Interventions: Interdisciplinary Teams: yield the best results for victims of abuse Public Awareness and Professional Education: key to identification and reporting NYS OCFS Bureau of Adult Services recognizes

44. EMT NYC March 2005 Laws to Prevent and Prosecute Adult and Elder Abuse Adult Abuse Laws Domestic Violence Act Orders of Protection Power of Attorney Representative Payee Guardianship Guardians of People with MR and DD Community Guardian Health Care Devices Surrogate Decision Making Committees

45. EMT NYC March 2005 Criminal Prosecutions: �Kathy�s Law� enacted Dec 1998 260.25 Endangering the welfare of an incompetent or physically disabled person. (A Misd.) 260.32 Endangering the welfare of an vulnerable elderly person, 2nd degree (E Felony) 260.34 Endangering the welfare of an vulnerable elderly person, 3rd degree (D Felony)

46. EMT NYC March 2005 International Network for the Prevention of Elder Abuse (INPEA) Missing Voices: Views of older persons on elder abuse. A joint project of WHO and INPEA. Ist Latin American Train the Trainer April 2004 Lia Daichman, MD. Argentina, President INPEA 2004 Rosalie Wolf Memorial Award recipient. Ist International Day of Elder Mistreatment - June 15, 2006

47. EMT NYC March 2005 NYS OCFS Bureau of Adult Services wishes to acknowledge: Terry Fulmer, PhD, RN, FAAN Dir. CNYGEC for responding to the need and implementing this statewide Elder Mistreatment Training