Multidimensional Measurement Within Adult Protective Services: Design and Initial Testing of the Tool for Risk, Interventions, and Outcomes

Figures & data

FIGURE 1 Practice-based model of Adult Protective Services (PMAPS).

FIGURE 2 Tool for Risk, Interventions, and Outcomes (TRIO).

TABLE 1 APS Social Worker Survey Results Regarding TRIO Utilization

	Percent Agree/Strongly Agree
	Time 1 (n = 12)	Time 2 (n = 12)
With proper training the TRIO is easy to use	100.0%	100.0%
The TRIO is worth the time to complete	91.7%	100.0%
The TRIO increases ability to assess a case more thoroughly	91.7%	100.0%
The TRIO risk indicators guide referrals and interventions	91.7%	91.7%
Using the TRIO increases work satisfaction	75.0%	91.7%

TABLE 2 TRIO Inter-Rater Reliability Test Results

	TRIO	Agreement Among All			Agreement With Master
TRIO Section	Items (n)	FK	WK	ICC	CK	WK	ICC
Risks	68	.823			.861
Interventions	27	.900			.939
Outcomes	20	.726			.777
Risks, interventions, and outcomes	105	.837			.875
Protective outcome	1		.985	.998		.990	.995
Prognosis	1		.828	.980		.840	.913

Note. FK = Fliess’ kappa; WK = Weighted kappa; CK = Cohen’s kappa; ICC = Intraclass correlation.

TABLE 3 Prevalence of Select TRIO Items for Older Adults With Either Confirmed Self-Neglect or Confirmed Financial Abuse Episodes (n = 669)

TRIO Dimension	TRIO Item	Uniquely Associated With One Group	Confirmed Self-Neglect (n = 471)	Confirmed Financial Abuse (n = 198)	Sig.	Relative Difference in Prevalence
Risk	Confusion	No	39.3%(185)	30.8%(61)	*	1.3
Risk	Feels depressed	No	12.1%(57)	9.1%(18)		1.3
Risk	Passive behavior	No	9.1%(43)	7.1%(14)		1.3
Risk	Underweight/Frail	Yes	31.2%(147)	7.1%(14)	***	4.4
Risk	Hoarding	Yes	11.9%(56)	1.0%(2)	***	11.9
Risk	Unclean environment	Yes	25.9%(122)	2.5%(5)	***	10.4
Risk	Evidence of exploitation	Yes	1.5%(7)	67.2%(133)	***	44.8
Risk	Misuse of money	Yes	7.6%(36)	30.3%(60)	***	4.0
Intv.	Accepts education/information	No	61.6%(290)	53.0%(105)	*	1.2
Intv.	Established bond with social worker	No	72.6%(342)	72.2%(143)		1.0
Intv.	Nursing assignment	Yes	33.8%(159)	9.6%(19)	***	3.5
Intv.	FAST team	Yes	0.2%(1)	4.5%(9)	***	22.5
Outcome	Self-advocacy	No	27.8%(131)	28.3%(56)		1.0
Outcome	Improved mental health	No	9.1%(43)	8.6%(17)		1.1
Outcome	Financial stability	Yes	3.6%(17)	20.2%(40)	***	5.6
Outcome	Improved functioning	Yes	19.1%(90)	3.5%(7)	***	5.5

*p < .05; ***p < .001.

FIGURE 3 180-day APS recurrence prognosis category at case closure.

FIGURE 4 ROC curve for 180-day APS recurrence prognosis at case closure.

APPENDIX TRIO Item Information

TRIO #	TRIO Item	TRIO Section	Percent Agree^a
1.	History of referral	Risk: Precursor	96.3
2.	Lives alone	Risk: Precursor	100.0
3.	No regular physician	Risk: Precursor	100.0
4.	Lacks social support, isolation	Risk: Precursor	100.0
5.	Refuses help from others	Risk: Precursor	88.9
6.	Lack of resources or homeless	Risk: Precursor	100.0
7.	Marital, family conflict, codependency	Risk: Precursor	74.1
8.	Prior or current mental health services	Risk: Precursor	100.0
9a.	Severe physical disabilities	Risk: Precursor	74.1
9b.	Dependent for all ADLs	Risk: Precursor	92.6
10.	History of violence, abuse, neglect	Risk: Precursor	96.3
11a.	Alcohol/substance abuse by client	Risk: Precursor	96.3
11b.	Alcohol/substance abuse by caregiver	Risk: Precursor	100.0
11c.	Alcohol/substance abuse environment	Risk: Precursor	96.3
12.	Evidence of psychiatric disorder	Risk: Precursor	92.6
13a.	Economically dependent adult in the home	Risk: Precursor	100.0
13b.	Economically dependent transients in and out of home	Risk: Precursor	100.0
14.	Confusion or evidence of cognitive impairment	Risk: Precursor	96.3
15.	Poor or impaired judgment, poor decision making	Risk: Precursor	100.0
16.	Evidence of high-risk behavior	Risk: Precursor	88.9
17.	Unclean physical appearance, poor hygiene	Risk: Biological	100.0
18.	Odor of feces or urine	Risk: Biological	96.3
19.	Vague references to sexual assault or unwanted advances	Risk: Biological	92.6
20.	Vague or illogical explanation for injury	Risk: Biological	100.0
21.	Under or overuse or confusion about prescriptions or OTC medications	Risk: Biological	100.0
22.	Repetitive hospital admissions due to probable failure of health care surveillance	Risk: Biological	100.0
23.	Failure to respond to warning of obvious disease	Risk: Biological	100.0
24.	Painful body movements, limping, trouble sitting or standing (not illness related)	Risk: Biological	100.0
25.	Underweight, frail, or weak; frequent falls	Risk: Biological	100.0
26.	Inadequate food or meal preparation supplies in the home	Risk: Biological	96.3
27.	Various stages of healing of any bruising or fractures	Risk: Biological	96.3
28a.	Evidence of injury—admitted	Risk: Biological	100.0
28b.	Evidence of injury—unexplained bruising, welts, wounds, broken bones or sprains	Risk: Biological	100.0
29.	Presence of dehydration or decubiti	Risk: Biological	100.0
30.	Alert, oriented declaration by elder adult of physical, sexual abuse	Risk: Biological	100.0
31.	Self-blame for current situation or makes excuses for partner or caregiver behavior	Risk: Psychological	96.3
32a.	Feelings of shame, guilt, fear, or loneliness	Risk: Psychological	85.2
32b.	Feelings of depression	Risk: Psychological	100.0
33.	Sense of resignation and hopelessness with vague reference to mistreatment	Risk: Psychological	96.3
34a.	Appears anxious	Risk: Psychological	100.0
34b.	Appears clingy	Risk: Psychological	96.3
34c.	Appears afraid of someone or something	Risk: Psychological	100.0
35a.	Behavior that is passive	Risk: Psychological	92.6
35b.	Behavior that is helpless	Risk: Psychological	96.3
35c.	Behavior that is withdrawn	Risk: Psychological	100.0
36.	Hoarding	Risk: Psychological	100.0
37.	Alert oriented declaration of psychological abuse	Risk: Psychological	100.0
38.	Poorly maintained animals, odor of feces or urine	Risk: Social	100.0
39.	Communication cut off from family or friends	Risk: Social	96.3
40.	Lack of access availability or reliability of medical care or home health care	Risk: Social	85.2
41a.	Unclean or unsafe environment	Risk: Social	96.3
41b.	Environment infestation	Risk: Social	100.0
42.	Inadequate utilities; lack of heat, cooling, water, electricity, toilet facilities	Risk: Social	100.0
43.	Lack of access, availability, or reliability of transportation	Risk: Social	100.0
44.	Dependent on alleged perpetrator or vice versa for care of finances	Risk: Social	85.2
45.	Left alone in unsafe environment for extended periods of time without adequate support	Risk: Social	100.0
46.	Evidence of exploitation by others	Risk: Social	100.0
47.	Precipitous withdrawal of care by caregiver without adequate alternate arrangements	Risk: Social	100.0
48.	Overpayment for goods or services	Risk: Social	100.0
49.	Misuse of money	Risk: Social	100.0
50.	Reports of demands for goods in exchange for services	Risk: Social	100.0
51.	Unexplained changes in power of attorney, wills, or other legal documents	Risk: Social	100.0
52.	Neglect of household finances; unpaid bills; unopened mail	Risk: Social	100.0
53a.	Inability to account for money, property, utility shut off	Risk: Social	100.0
53b.	Eviction	Risk: Social	100.0
54.	Alert oriented declaration by elder adult of exploitation	Risk: Social	100.0
55.	Alert oriented declaration by elder adult of neglect by others	Risk: Social	100.0
56.	Alert oriented declaration by elder adult of abandonment	Risk: Social	100.0
1.	Accepts education, information	Intervention	92.6
2.	Establishing bond of trust, engage with social worker	Intervention	100.0
3.	Client accepts that a problem exists	Intervention	96.3
4a.	Referral to services	Intervention	100.0
4b.	Linking to services	Intervention	88.9
5.	Tangible support used to purchase necessary items	Intervention	100.0
6.	Client support system works with APS	Intervention	100.0
7.	Client agrees to case management services	Intervention	96.3
8.	Presentation to Rapid Response Team (MDT)	Intervention	100.0
9.	Consultation with mental health expert	Intervention	92.6
10.	Consultation with medical expert	Intervention	100.0
11.	In-home nursing assessment completed	Intervention	100.0
12.	In-home medical evaluation by a physician completed	Intervention	92.6
13.	In-home mental health, psychological evaluation completed	Intervention	96.3
14.	Presentation to Financial Abuse Specialist Team	Intervention	100.0
15.	Restraining order sought	Intervention	100.0
16.	Conservatorship sought	Intervention	100.0
17.	Recoup financial loss or property loss	Outcome	100.0
18.	Financial stability	Outcome	70.4
19.	Client demonstrates self-advocacy	Outcome	74.1
20.	Linked to housing	Outcome	100.0
21.	Stable and safer home environment	Outcome	63.0
22.	Restraining order obtained	Outcome	100.0
23.	Conservatorship obtained	Outcome	100.0
24a.	Short-term care placement	Outcome	100.0
24b.	Long-term care placement	Outcome	100.0
25.	Safety net services in place	Outcome	92.6
26.	Decrease in hospital use	Outcome	100.0
27.	Improved functional status	Outcome	70.4
28.	Improved nutritional status	Outcome	100.0
29.	Improved physical health, medical condition	Outcome	88.9
30.	Improved mental health	Outcome	77.8
31.	Reduce, eliminate use of alcohol, substance abuse	Outcome	100.0
32.	Accepts case closure	Outcome	100.0
33.	Agreed to partial services	Outcome	88.9
34.	Refused all services	Outcome	100.0
35.	Linked to public assistance	Outcome	96.3

^aAverage percent agreement between raters and master TRIO in the inter-rater reliability study.