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Abstract
This article reflects the collective thoughts of the 20 projects supported by the Archstone Foundation Elder Abuse and Neglect Initiative on offering a vision for improving the response system for elder abuse and, in turn, the lives of older adults between now and the year 2020. Five key areas were identified as critically important for advancing the field in the next ten years: (a) increased public awareness and shifting public attitudes, (b) improved identification and triage of cases, (c) increased integrated service models, (d) improved justice system response, and (e) leveraging and utilizing emerging and untapped resources. The lessons learned from the experiences of these 20 projects in California can serve as demonstration models for other communities to adopt, adapt, and improve response systems for elder abuse and neglect.
ACKNOWLEDGEMENTS
The authors would like to acknowledge and thank all of the projects of the Archstone Foundation Elder Abuse and Neglect Initiative for their contributions to this article and for the work they do every day on behalf of abused and neglected older adults in California. It is an honor to partner with them in these efforts and share their successes in our vision for a world that is free from abuse and neglect.
Notes
1. The independent evaluation of the Initiative was conducted by The Measurement Group (see Huba et al., this issue). Many of the conclusions drawn in this article were derived from the data collected and summarized by the independent evaluators. The endnotes appearing in this article were written in collaboration with and approved for accuracy by the primary evaluators, Dr. George J. Huba and Dr. Lisa A. Melchior.
2. The Archstone Elder Abuse and Neglect Initiative (EANI) consists of 20 projects categorized as four Education and Training projects, one Financial Protection project, four Forensic Centers, one Legal Protection project, six Multidisciplinary Teams, one Long Term Care Ombudsman Services project, two Systems Analysis and Change projects, and one Convening and Technical Support project. The projects represent the broad and diverse service continuum that spans from prevention and identification to early intervention, to intervention with clinically advanced cases, and to legal interventions with perpetrators. The projects also broadly disseminated information on elder abuse to the general public, professional audiences, and older adults.
3. The EANI projects produced at least 949 unique, significant outcomes. These outcomes can be categorized into five major categories: 44.2% related to Expanding Systems Capacity, 25.9% related to Education and Training, 14.8% as Organizational Development, 12.4% as Service Innovations, and 12.0% related to Other Service Issues. See Huba et al. (this issue). This list is derived from the collective outcomes of the Initiative.
4. All 20 of the Archstone EANI projects engaged in some activities of increasing public awareness and shifting public attitudes. Examples included direct advocacy with stakeholders and policymakers, outreach to potential stakeholder groups, the development of training and information materials for the general public and providers, and a wide dissemination of materials. There was a broad consensus among the projects that issues of public awareness of the problem of elder abuse and neglect are key components to developing support for comprehensive and lasting systems of services. The projects were successful at using media to support the development of public awareness. Among the activities in the first three years were interviews with many newspapers including the New York Times, a bus sign campaign in San Francisco, interviews with local television stations, with many of these interviews archived on the Internet, producing newspaper inserts, and circulating flyers at health fairs and Senior Centers.
5. All 20 of the Archstone EANI groups worked on some aspects of identification and triage including training for providers or mandated reporters, referral networks, more comprehensive service networks, and developing and disseminating models. Identification and triaging were used in virtually all service provision contexts funded under the Initiative.
6. Sixteen of the 20 Archstone EANI projects worked to develop integrated service models including colocated services, multidisciplinary teams, Forensic Centers, networks with formal memoranda of understanding among agencies, and service systems in which providers were cross-trained. The consensus finding was that such services produced greater quality of life for the patients, were perceived favorably by the service recipients, and were generally cost-effective.
7. Eighteen of the 20 Archstone EANI projects worked on improving the justice system. Such improvements included the development of Forensic Centers and multidisciplinary teams to help in the identification of clients and prosecution of offenders, training judges and attorneys about elder abuse, and developing and advocating for more effective legal responses to elder abuse. There was a general consensus among EANI projects that a major opportunity for improving the overall service system lies with developing an improved justice system response to a variety of forms of elder abuse and neglect.
8. Nineteen of the 20 Archstone EANI projects were effective at leveraging their status as recognized projects in a variety of ways. Leveraging activities included receiving pro bono legal work, recruiting volunteers for a number of tasks, receiving support such as space and staff, receiving grants from a variety of sources, and having staff recognized as experts and invited to share their knowledge. It was found in EANI that for every dollar of Archstone money spent, an estimated $2.26 was obtained as new funding, and $9.39 in client resources were preserved.
9. As a consequence of being part of the Archstone EANI, all 20 projects improved their skills in careful observation and data collection, formal and informal data analysis, and reporting important findings. Combined with large national surveys and basic research studies funded by the federal government, there is an important place for Foundation-funded research and program evaluation. In part, the evaluation efforts of the Archstone Foundation and other smaller funders can inform definitive but costly surveys and research studies by the federal government.
10. One finding within EANI was that the multidisciplinary teams and Forensic Centers often identified caregiver issues—whether ones of lack of knowledge, an inappropriate individual, or intentional criminal activity—as important, especially when there was criminal activity or gross neglect. The caregiver issue continues to be an increasingly important one that will only grow in significance over the next ten years and beyond.
11. California has individuals that speak more than 20 languages, and many of the elders in these immigrant families do not speak English or have minimal acculturation to the traditional majority health and social service systems. Additionally, older adults who immigrated to the United States may have expectations about the role of the elder within a family and social network that differ from those held by those born in the United States. The EANI projects identified this as a major issue while at the same recognizing that large amounts of resources need to be committed to develop materials and appropriate staff expertise.
12. A significant finding in the Archstone EANI that came out in all of the types of projects is that there is a general lack of knowledge about the identification, prevention, and intervention issues in elder abuse and neglect among those who are already leaders in social, medical, and legal service provision. Significant training is needed both for existing professional leaders and for new cadres of developing leaders.
13. The data from the Archstone EANI demonstrate that there is large need for elder abuse and neglect services. The data show that the need exceeds the current capacity of the system to deal with all education, prevention, and treatment issues found. To accurately estimate prevalence and incidence of elder abuse and neglect, studies that are much larger in scope and cost than the entire Archstone EANI will be needed.
14. The Archstone EANI has demonstrated that services can be designed and implemented using current knowledge and available staff. While undoubtedly research will improve evidence-based practice over time, the EANI projects have demonstrated that the quality of life of many elders can be improved using current models developed in this Initiative, and the infrastructure for the development of lasting continua of services is possible with current knowledge and modest resources.
15. In the Archstone EANI Initiative, the program evaluation was instituted at the same time that the projects started. The program evaluation—demonstrated here in its effect on all of the projects and collective results—might be expanded by others in the future in order address more issues by including more participating agencies, older adults, and trainees so that more service and treatment models may be contrasted in formal research designs.
16. The Archstone EANI projects were able to demonstrate that training curricula and resources could be developed for more than 20 target groups of California mandated reporters and other service provider and community groups. The participants in the training ranged from representatives of law enforcement to clergy to participants at senior centers, to physicians, to psychologists, and to Adult Protective Service workers. Again, with modest resources, it is possible to develop and provide trainings that are rated as important and relevant by the participants.
17. The Archstone EANI projects found that it was relatively possible to generate large amounts of media attention on modest budgets with a dedicated and visionary staff. An article appeared in the New York Times on September 27, 2006, which was early in the history of the Initiative, about one project. Other projects were able to get television and radio coverage, and another participated in a bus sign effort.
18. One of the projects developed a paper-and-pencil screening tool for potentially identifying elder abuse and neglect. All of the Forensic Centers and multidisciplinary teams put into place professional networks for screening individuals for suspected abuse and neglect, with the result being that these cases were screened by a professional or committee in both informal and formal meetings. Those passing the screening then typically received more complete diagnostic work-ups including both health histories and assessments and in some cases, detailed psychological evaluations.
19. Most of the EANI projects were quite involved in service provider models and continua of services that were effective, to a greater or lesser extent, in sharing information between agencies. For those who did participate in such continua, there is a general consensus that the issue of information sharing is a difficult one that often requires the reconciliation of the confidentiality requirements of different professions and agencies.
20. A significant amount of effort of the EANI projects went into collaborating with other agencies. In fact, as is clear from the evaluation, for almost every project, efforts to develop and promote cross-agency collaborations used the greatest amount of project resources, second only to the activities addressing the primary purpose of the grant.
21. Many of the Archstone EANI projects expended significant efforts on the idea of “no wrong door,” with success. The difficulty with the model is that it works best in a “stable” service system where the staff helping to identify and deliver cases tends to remain with the same jobs. The model does require more resources when staff changes. Further work is needed in how to make such models efficient in those cases where staffing tends to be fluid, as is often the rule, rather than the exception.
22. The Archstone EANI projects were found to have used a significant proportion of their time and resources in attempting to develop lasting interagency working relationships that would transcend the duration of their grant funding. The interagency agreements, collaborative planning, and shared responsibility required by these models is very significant unless specific mechanisms can be developed. Collectively, the EANI projects ran and attended over 4,000 meetings designed to establish and maintain the relationships (see Huba et al., this issue).
23. Collectively, the four Forensic Center projects conducted 217 trainings for mandated reporters, reaching over 6,000 individuals; participated in 77 media events; conducted 1,170 brief assessment or screenings designed to identify victims needing more intensive assessment; provided 851 intensive medical and psychological assessments of potential elder abuse victims; and worked with local law enforcement to file 58 cases with the District Attorney (see Huba et al., this issue).
24. Four Forensic Center models were developed or adapted during the Archstone EANI. The impetus to create the centers came from academic medical centers in two of the four models, from the Office of the District Attorney and a local service agency. During the course of the Initiative, the projects worked to develop standard metrics, which may serve as the basis for future comparison.
25. A community coalition was developed—in some cases unexpectedly; in one case, an Archstone EANI project focused on training clergy in elder abuse and neglect since they had been identified as mandated reporters under California legislation but generally lacked the expertise to make referrals. In the process of developing trainings, a coalition of clergy from different faiths was formed, which gained momentum when lay (nonclergy) representatives from the various religions became involved, who then brought more lay volunteers into the group. Other projects in the Archstone EANI themselves joined various community coalitions in their communities.
26. One Archstone EANI project focused on first researching the ways that courts handle cases of elder abuse and neglect and then developing trainings for court staff. The project subsequently implemented trainings designed to help individual judges adjudicate cases in ways that are humane and responsive to the consequences of the elder abuse.
27. Justice in the sense of court prosecutions is just one piece of the puzzle. When family caregivers are identified as perpetrators of abuse, prosecuting the offenders may lead to an increased vulnerability for older adults who were victimized. Future interventions to be explored in conjunction with prosecution, or as an alternative to prosecution, may include behavior management counseling, drug and substance abuse training, mediation, and other innovative interventions.
28. Because the emerging victim advocate models are similar to case management models, it is likely that different localities will find it relatively easy to alter case management to also include victim advocate services. A key to the transition, however, is the addition of at least one individual or agency experienced in how the judicial system works. From the early experience within the Archstone EANI, it appears that the inclusion of legally-trained advocates is critical.
29. One general lesson learned within this Initiative is that if creative and highly-motivated organizations are given small grants to start or expand programs in the field of elder abuse, they find ways to discover additional resources or use the resources they are provided in a cost-effective way. For every dollar of Archstone Foundation funding, the projects preserved approximately $9.39 in older adults’ assets and leveraged approximately $2.26 in additional resources (see Huba et al., this issue).
30. Volunteer resources were a critical part of the success of the Archstone EANI projects. Professionals provided free or reduced-cost legal, geropsychological testing, medical, nursing, and social work services. Volunteers made presentations to other seniors, provided clerical assistance, and acted as members of advisory boards. While obtaining volunteer help is a difficult and time consuming task, it was also cost-effective, with seventeen of the projects recruiting a total of 549 volunteers (see Huba et al., this issue). The Archstone EANI projects demonstrate that it is possible to secure volunteer help, even within small and modestly-funded projects.