Adult Protective Services: Case Study of Seven Counties

By:

Brie Lusheck, Public Policy Associate

Emily Muttillo, Applied Research Fellow

William Tarter Jr., Policy Planning Associate and Community Advocacy

In the past five years, the state of Ohio has seen major policy changes related to Adult Protective Services (APS) which are detailed in Adult Protective Services: Providing Context in an Aging State by The Center for Community Solutions’ Public Policy Associate, Brie Lusheck. Legislation enacted between 2014 and 2017 saw the General Assembly make a one-time allocation of $10 million to APS, create an Adult Protective Services Funding Workgroup, develop I-Teams, implement a statewide data system for APS and required training on the implementation of APS statutes for all APS caseworkers and their managers.Each county in Ohio administers APS through their Department of Job and Family Services and must investigate reported abuse of residents aged 60 and older. Population and resources available to county APS offices vary greatly, requiring each county APS office to adjust to the specific needs of their community. This paper will explore APS in seven counties across Ohio; Cuyahoga, Delaware, Franklin, Hamilton, Jackson, Ottawa and Summit. Administrators in each of these counties were each asked a common set of questions. A summary of common interview themes is followed by a profile of each of the counties.

Nearly all of the administrators who were interviewed indicated they have seen a rise in reports of financial exploitation

FINANCIAL EXPLOITATIONNearly all of the administrators who were interviewed indicated they have seen a rise in reports of financial exploitation. An often repeated concern of APS administrators was when family members addicted to opioids move in with older adults and steal either money or medication from the older adults. Some reported more complex theft, involving accessing the bank account of the older adult. Another explanation for the rise in financial exploitation reporting is an increase in awareness. APS administrators stated they believe the general population has a better understanding of the need to report financial abuse to APS, as well as to law enforcement. In recent years, advocacy groups, including AARP and the National Council on Aging (NCOA), have launched awareness campaigns and training programs on how older adults can avoid scams and being victims of fraud. Financial institutions, such as banks and credit unions, have also become more adept at recognizing and reporting financial abuse. In September 2018, those working in the banking and financial sectors will be mandated reporters of elder abuse and administrators expect there will be a further rise in financial exploitation reports. There is currently pending legislation in the Ohio General Assembly (SB158), which would increase penalties for the financial exploitation of older adults.

Across all seven counties included in this paper, self-neglect is the most common type of case reported to APS

SELF-NEGLECTAcross all seven counties included in this paper, self-neglect is the most common type of case reported to APS. These reports are often made by professionals who regularly interact with the older adult and may notice a change in the person’s ability to care for themselves. These professionals include home health aides, nurses, doctors, meal providers, senior center staff and mail carriers among others. These professionals are well trained to recognize the signs of self-neglect and make an APS report. Reporting self-neglect does not implicate anyone other than the older adult, and is less likely to cause a disruption in family and caregiving dynamics. On the other hand, reporting physical, sexual or verbal abuse to authorities may occur less often because it is often at the hands of a caretaker. The victimized older adult may be the only person aware of the abuse, and may be physically or emotionally unable to make a report. In some instances, abuse may be suspected by others but reports are not made to due fear of making a false allegation and the anticipated chaos resulting from an abuse report. Caregiving for older adults, particularly when provided by family members, is often a complex balancing act that can fall apart with the slightest stressor. Family members may be reluctant to report one another for fear of disrupting the caregiving arrangement.

Almost all counties reported a need for housing interventions for older adults who have been victims of elder abuse.

HOUSINGAlmost all counties reported a need for housing interventions for older adults who have been victims of elder abuse. In the counties with larger populations, addressing homelessness among older adults was mentioned as an unmet need. Counties of all sizes, throughout the state are concerned about not having the resources to prevent homelessness when an older adult is evicted, foreclosed upon or forced into a dangerous living situation. Removing an older adult from his or her home brings many challenges when the older adult is being abused by a person they live with, particularly if the abuser owns the home or is on the lease. Finding new, safe housing quickly can be near impossible in many communities. Programs that offer temporary crisis housing would be well utilized by APS. Crisis housing, paired with more affordable housing that meets the needs of an older population with mobility impairments, would greatly improve an APS caseworker’s ability to prevent future abuse.

Many APS offices would like to increase their outreach efforts as a method of elder abuse prevention, however they have very limited or no resources to do this type of work.

COMMUNITY OUTREACHA common frustration of APS administrators interviewed was the lack of funding for community outreach and marketing. Many APS offices would like to increase their outreach efforts as a method of elder abuse prevention, however they have very limited or no resources to do this type of work. At least one county added that if awareness about elder abuse and marketing the presence of APS did increase, it would result in increased reporting and APS may not have the capacity to handle additional reports. Staffing levels would also need to be adjusted upward if more accurate reporting of abuse were to occur. Counties that experience more APS calls than they have the capacity to investigate in a timely matter should record unmet needs and use that data to advocate for more resources.

At least one county added that if awareness about elder abuse and marketing the presence of APS did increase, it would result in increased reporting and APS may not have the capacity to handle additional reports.

STATEWIDE REPORTING SYSTEMMany counties see the value in having a statewide IT system, but some administrators said they hope improvements will be forthcoming to make it more user-friendly and useful for county reporting. Others suggested having the APS statewide system mirror the setup of the child protective services statewide reporting system, as many caseworkers work with both adult and child protective services.ADULTS WITH DISABILITIES In 2012 three federal agencies, the Administration on Aging, Office on Disability and the Administration on Developmental Disabilities, merged into the Administration on Community Living. This merger furthered the joining of older adults, and adults with disabilities, as a single population eligible for supportive services provided through the Older Americans Act. Additionally, Aging and Disability Resource Centers (ADRC) were set up in Area Agencies on Aging, as well as county and city offices throughout the state of Ohio to serve both older adults and adults with disabilities. While eligibility for many programs have become more inclusive of both populations, Adult Protective Services continues to only be mandated for those over age 60. Only one county administrator interviewed works with adults with disabilities under age 60 and only if those individuals consented to a case being opened. Most of the APS administrators interviewed would like to expand their screening criteria to include individuals with a disability between the ages of 18 and 59, but do not currently have the capacity to do so.

Of the 88 counties in the state, Cuyahoga County has the largest number of residents aged 60 and older. With 23 percent of the population having reached age 60, Cuyahoga County expects to have more older adults than children within the next 10 years. Services for older adults will become increasingly important as demographics continue to shift.

With 23 percent of the population having reached age 60, Cuyahoga County expects to have more older adults than children within the next 10 years.

In Cuyahoga County, protective services for older adults are administered by Job and Family Services and delivered through the Division of Senior and Adult Services for residents age 60 and older and for individuals with disabilities between the ages of 18 and 59 who agree to accept services. If APS believes an individual over age 60 lacks the mental capacity to accept or refuse services, APS can go to court to request a state of evaluation and receive permission to pursue an APS investigation without the individual’s acceptance of services.APS administrators emphasized the intersection between behavioral health and elder abuse in Cuyahoga County, and the referral relationships APS has developed with behavioral health organizations. While APS administrators have not observed an increase in APS calls related to the opioid crisis, they did indicate the substances most likely to be identified as having an impact on an APS case loads are alcohol, marijuana and crack. In 2017, mental health diagnoses were disclosed during intake for 247 of the 1,944 of the APS clients served.Currently, APS in Cuyahoga County is funded by a state line item allocation and two Health and Human Services levies. If additional funding were to become available, APS administrators would like to see an effort to address homelessness among older adults in the county, and stabilize current housing in an effort to prevent homelessness. Cuyahoga County also has a shortage of guardians and would direct additional funds to recruiting and training guardians.

Cuyahoga County also has a shortage of guardians and would direct additional funds to recruiting and training guardians.

Self-neglect cases are the most common type of cases reported to APS, but recently, exploitation cases have increased, likely due to efforts to increase awareness that lead to more reports. Generally speaking, in Cuyahoga County, financial exploitation cases do not take any more resources than any other type of abuse reported to APS. While other counties report exploitation cases do require additional resources, Cuyahoga County’s Division of Senior and Adult services have investigators on staff, and long-standing, strong relationships with the County Prosecutor and Probate Court. The number of cases that APS accepts has provided the opportunity for APS workers and the court system to work together closely on a regular basis. Cuyahoga County APS also has a well-established I-team that has been in place for many years that is crucial when cross-agency cooperation is required.Cuyahoga County is currently in discussions with the state on how it can connect its data collection system with the new statewide APS reporting system.

Community involvement is key in Delaware County. Though it is not something they have at this time, the leadership of the County Department of Job and Family Services is working toward staffing one specific APS worker to handle APS specific cases. They did previously have someone in this position before staffing changes, and the county has struggled to fill the position. Until the APS caseworker position is filled, a group of child service workers, work on APS cases in addition to child protection cases. Delaware County’s median household income of $94,234 is $44,000 above the state average. This resource rich community has a relatively low percentage of the population that consists of older adults. Those older adults who do live in the community enjoy a full menu of social and supportive services funded through the Senior Services Levy. Strong supportive services can be a preventive measure for social isolation and neglect which may reduce prevalence of elder abuse, however, no community is immune to elder abuse and it remains important to have systems in place to protect vulnerable older adults. Delaware County Job and Family Services APS serves individuals age 60 and older. For those in need of services who are age 59 or younger, the county tries to guide them to other community resources through referrals.

Strong supportive services can be a preventive measure for social isolation and neglect which may reduce prevalence of elder abuse, however, no community is immune to elder abuse

Delaware County APS encounters older adults with a wide spectrum of mental health needs. Individuals with fewer needs, are referred to the local mental health system, while individuals with more complex needs are often evaluated for capacity, with the possibility of establishing a guardianship through the local courts. Though data is limited, Delaware County APS has not seen a substantial uptick in APS cases due to the opioid crisis.In Delaware County, APS is funded by variety of sources but primarily uses funds from the state APS line item. Additional funds are provided via Title XX and allocations made by county commissioners.If more resources were available, the administrator of Delaware County APS indicated they would focus efforts around additional outreach to the community. Though statistics vary on how many cases of abuse older Ohioans may experience, there is general consensus that the majority remain veiled, and more outreach to victims and, others who may witness it, is key to addressing the issue. If more cases were created as a result of outreach efforts, additional APS workers would be vital to the county. Additional APS workers could also further education on guardianship programs that are vital to assisting and protecting abused or neglected older adults.In Delaware County, officials stated the most common type of reported elder abuse is self-neglect. Officials said they believe there is a higher rate of financial exploitation in the community than is reported, and highlighted the difficulty of identifying this type of abuse. Due to the additional resources and time needed to uncover cases of financial exploitation, a more experienced type of case worker is often needed to find the origin of the exploitation, and without repeat offenses it can often be extremely difficult to uncover.The great relationships the Delaware County JFS has with Public Children’s Services Association of Ohio and the Ohio Job and Family Services Directors’ Association allows the county to access trainings and legislative updates to assist with staying up to date with APS state law changes.The ability to see data reported via the new statewide APS IT system would benefit the county because it would assist in the department’s efforts to understand and monitor the types of APS cases they see most often. The basic reporting requirement, that is a part of the new system, has been a struggle for the county.

In Franklin County, APS are for individuals age 60 and older. Those who do not meet the age criteria are referred to other organizations that may be helpful for an individual’s specific needs, such as Disability Rights Ohio. Franklin County, one of the most populous counties in the state with more than 1.2 million residents, has a median income of $45,289. Sixteen percent of residents are age 60 and older, which is the lowest percentage of older adults of any county in the state. Franklin County has strong community support for senior services, evidenced by 83 percent of voters supporting a senior services tax levy in its most recent appearance on a ballot (May 2017). With high levels of community support for the older adult population, residents of Franklin County may be open to learning more about elder abuse and how they can play a role in prevention.

Sixteen percent of Franklin County residents are age 60 or older, which is the lowest percentage of older adults of any county in the state.

Franklin County JFS is the administering agency for APS services. However, the county JFS contracts APS with the Franklin County Office on Aging. The Franklin County Office on Aging is then responsible for investigations that are funded through the contract that is paid for with Title XX and APS line item funding. There are two APS supervisors and 15 APS workers in Franklin County.The opioid crisis has significantly impacted calls to APS in Franklin County. A lot of the calls that come in have a danger in the home, which is often drugs. Due to the nature of these cases, APS workers are often exposed to the drugs themselves, prompting the department to provide training to workers. The workers have seen overdoses while responding to reports in the field. This led the department to provide naloxone for workers to carry, both for their own safety and for the safety of others they may come in to contact with over the course of an investigation.A large portion of the cases Franklin County APS receives include older adults with mental health needs. As these cases usually involve individuals with untreated mental health needs, workers connect individuals with local mental health providers through the Franklin County crisis line.If more funding was available to Franklin County APS, the administrator for the Office on Aging expressed a desire to extend prevention services so the issue gains more awareness in the community. Oftentimes the work that APS does in Franklin County is reactive rather than proactive. Office representatives said there would be a lot of value in outreach to assist and connect individuals with services before an issue arises. In addition to outreach, emergency housing services would be extremely beneficial to individuals served by Franklin County APS. Often, APS workers struggle to find safe emergency housing for an individual who may live with a perpetrator.Self-neglect cases have historically made up the largest percentage of the case load in Franklin County. However, due to the expansion of mandatory reporters into the financial sector, and the opioid epidemic, APS has seen a significant increase in exploitation cases. Financial exploitation cases do not seem to use more resources in Franklin County, as workers frequently see victims who do not wish to pursue the perpetrator through legal action. There is a case pending in front of the Supreme Court of Ohio where an individual chose to pursue charges against a lawyer who financial exploited them. When cases are pursued as such, they do use more resources going through the legal process.Franklin County APS stays very involved with statewide APS changes. Through workers’ involvement with Ohio Coalition for Adult Protective Services(OCAPS) and Ohio Humans Services Training System, they often play a central role in APS discussions at the state level.Franklin County has struggled with the new statewide IT system when compared to the efficiency and intuitive nature of the county’s former IT system. Though the state has been responsive to the needs of the county, there are things the county would like to see addressed in the new system. The county remains optimistic that in the future the new IT system will be beneficial both in Franklin County and statewide.

Hamilton County JFS is the administering and operating APS agency, and its services are funded through a local senior service levy in addition to funds appropriated to the county by the state APS line item. These dollars fund seven APS positions, including a supervisor. Twenty percent of Hamilton County residents are age 60 or older, and an estimated 165,223 older adults live within the county. The median income for the general population is $50,399. Hamilton County is one of the few counties in Ohio that use senior levy funding to address elder abuse.

Hamilton County is one of the few counties in Ohio that use senior levy funding to address elder abuse.

Although in the past Hamilton County would accept some cases that didn’t meet the criteria of the APS law in hopes of preventing abuse, neglect or exploitation from occurring, the county now only accepts APS cases that meet the criteria established by law for those age 60 and older. For those who do not meet the established criteria, APS does its best to refer individuals to other departments or services that may be of assistance for individual needs.The opioid crisis has impacted Hamilton County APS. Specifically the department has seen an increase in the financial exploitation cases it receives. There are instances of previously unacquainted individuals forming close relationships and often taking up residence and exploiting victims. These cases were not seen as frequently before to the opioid crisis. There are many instances of children and grandchildren exploiting older adults, which are often extremely damaging to family dynamics.There are an increasing number of individuals who receive APS in Hamilton County who are in need of mental health services. Often, these individuals are referred to a mental health provider at an initial screening because the specialists are better equipped to address the needs of the individual. There is a local provider that they often refer individuals to, however, the individual seeking services must make the initial contact with the agency. This provides a significant barrier, as many older adults with mental health issues who are encountered by APS are unwilling, or unable, to advocate for their personal mental health needs.If Hamilton County had more APS funding available, administrators said they would like to expand their community presence, in an effort to reach older adults before abuse occurs. Hamilton County would also like to hire more staff. Prior to staff reductions, there were two case aides which assisted APS to serve additional people in the community. Hamilton County seems to have a gap in the community for seniors who need help with smaller preventative work, such as assistance with housing, accessing identification and applying for Social Security or disability programs. Currently, with the resources the county has available, APS is only able to take severe cases.A majority of Hamilton County’s cases involve self-neglect, although county APS are seeing an increase in cases involving exploitation- in large part due to the opioid crisis, and an increase in the prevalence of scams. Cases of financial exploitation often include a small amount of funds stolen from a victim. Although these cases can be extremely burdensome for APS workers, it is often difficult to get these cases to rise to a level of importance with investigators. When cases are deemed significant enough, the Cincinnati Police Department has a financial crimes department that is extremely valuable in assisting APS with cases that involve financial exploitation.In Hamilton County, policy staff assists the agency to stay up to date on recent changes in state law.The recent rollout of the state IT system has room for improvement. Hamilton County had its own IT system that was developed before the mandatory transition to the state system. Although county officials see value in the state using one uniform system, they find the new system lacks the intuitive, streamlined and user-friendly functions their previous system had.

Jackson County has the smallest older adult population of the counties selected for this review, with just more than 7,000 residents age 60 or older. Although the county would like to be able to accept cases for adults with disabilities under age 60, Jackson County APS does not currently have the capacity to handle any population other than what’s mandated by the state. APS investigates about seven to 10 cases a month. Administered through the Jackson County Department of Job and Family Services, APS has one investigator who splits time equally between child and adult protective services, and one child investigator who spends 10 percent of his or her time on adult cases. The Sheriff’s Department also has a deputy on staff at JFS who is available to assist with cases when law enforcement is necessary.There has been a small increase in calls that seem to be related to the increased use of opioids in the community. Cases related to the opioid crisis involve family members moving in with older adults and stealing medication and possessions from them. Jackson APS has also seen instances where a child moves in with an older adult who is living in a senior building which puts the older adult at risk of eviction.When a case accepted by APS involves an older adult with a possible mental health need, referrals are made to other county agencies or nonprofit social services. APS does not have the resources to assist with mental health needs internally, and will arrange for a medical evaluation to determine capacity if necessary.If more financial resources were available, Jackson County APS administrators would like to see more medical professionals available to provide mental capacity evaluations. Currently it takes a long time to schedule and arrange an evaluation. If this process were easier, it would mean quicker intervention for an adult who lacks the mental capacity to care for him or herself. Jackson County APS officials would also like to host a senior health fair to share information and resources as a way to raise awareness and promote the prevention of elder abuse.The most common cases accepted by Jackson County APS are self-neglect, family exploitation and financial exploitation. Financial exploitation cases often take considerable resources to fully investigate. This is particularly true when older adults do not have a family member who can assist them through the process of working with law enforcement and banking institutions. Guardianship cases, that require going to court, also require more extensive involvement from APS workers.Jackson County has been using the statewide IT system and indicated additional training would be appreciated. The ability to track cases over time is a feature that the county did not previously have, and worked appreciate having the option to update cases as they progress.

In Ottawa County, APS focuses on adults age 60 and older, and does not currently have the capacity to work with anyone under that age. The county has a community case management system and is able to refer cases it cannot accept to other agencies or law enforcement. The county also works with other agencies to provide additional services to APS cases they accept. Ottawa County has the second highest percentage of adults age 60 or older of Ohio’s 88 counties. Thirty percent of the population meets the APS age criteria. Ottawa County Job and Family Services is the administrating agency for elder abuse reporting, and investigative functions are performed by the division of Child and Adult Protective Services.

APS encounters older adults with mental health needs on a regular basis. Typical case types, including hoarding and self-neglect, usually have a mental health component. When a mental health need is suspected, APS will bring in behavioral health service providers, as well as primary care physicians, to address the needs of each individual.APS receives state funding through the APS allocation, and federal funding through Title XX of the Social Security Act. Although Ottawa County has a senior services levy, those funds do not currently support APS. Levy funds are allocated to operate the senior centers, provide congregate meals, social support and home delivered meals. While the levy funding does not directly support APS, a substantial indirect benefit can be seen in the referrals made by agencies that provide those supportive services. Senior centers and meal providers see older adults on a regular basis and are perceptive to changes that could indicate abuse or neglect.Ottawa County accessed demonstration money in 2014 from a state innovation grant. Through this opportunity, the county was able to replicate child protective services for older adults by assisting with finding temporary housing and utility reconnection. Ottawa County officials would like to be able to offer this type of assistance on an ongoing basis for adults who enter the APS system but the county would need a source of additional funding in order to do so.Another area of need identified by Ottawa County APS is older adults who need crisis care but may not meet hospital admission criteria. APS has found that facilities with the ability to work with individuals in crisis are unwilling to admit someone that doesn’t have a clear payment source. This leaves individuals in crisis in a gray area, in which they are not safe to go home, but are not able to be admitted to a hospital nor accepted into a long term care (nursing home) facility. At times, these individuals may have assets that could pay for their care, but do not have the ability to access them in a time of crisis. Additional funding would allow APS to develop a solution for crisis intervention.The most common type of case accepted by Ottawa County APS is self-neglect, followed by neglect by others. Administrators suspect many cases of self-neglect or financial exploitation, are a result of a family member that is using drugs. However, this is not something that APS has tracked in a way that could specifically tie cases to opioid use of the older adult or of a family member. Exploitation cases are the third most common type of case reported. Smaller numbers of physical, emotional and verbal abuse cases are handled by APS. Last year, no cases of sexual abuse were reported.Financial exploitation cases tend to take more resources than other types of elder abuse cases. This is typically because of the number of individuals involved in the case which will often include a prosecutor, law enforcement, financial institutions and, most importantly, the older adult who has been exploited.Ottawa County APS has found the new statewide IT system to not be user-friendly and suggested it would be useful to have connections between child and adult reporting systems. Less populous counties often share adult and child protective service caseworkers, and have cases that involve the entire family. An IT system thus connected would better reflect the nature of their work Ottawa County officials said.Ottawa County has had a task force for the past six years that recruits and trains guardians. This effort, organized by the Ottawa County Probate Court, has support from multiple groups including court staff, hospice officials, sheriff’s office personnel and prosecutors, who all assist in recruitment efforts.

Summit County APS is administered through Job and Family Services, and also has contracts with Summit Public Health and the Battered Women Shelter of Medina and Summit County. Through the department of Public Health, APS has access to one part-time nurse, one full-time nurse and one part-time sanitarian. The sanitarian is available for investigations related to hoarding. The Battered Women’s Shelter is contracted to take after hours, weekend and holiday calls for APS. The Women’s Shelter also provides access to four stability workers to assist with post-investigation needs of the client. More than 22 percent of Summit County’s population is age 60 or older, with this rate expected to grow - peaking in the next 10-15 years. Summit County is the only county examined in this paper with no current county-wide senior levy. With no local funds available, Summit County APS is funded through the state line item and Title XX. APS accepts cases for adults aged 60 and older.

More than 22 percent of Summit County’s population is age 60 or older, with this rate expected to grow - peaking in the next 10-15 years.

APS in Summit County has seen the opioid crisis manifest in the exploitation of older adults by family members and caregivers who steal both medication and possessions from the older adult. There has also been an increase in grandparents taking care of grandchildren because the children’s parents cannot care for them as a result of their addiction. This arrangement can put the grandparent at risk of exploitation or abuse. When an older adult presents with a personal addiction or mental health issue, Summit APS works with the local mental health assessment provider, Community Support Services, to determine capacity for the individual and link them to appropriate services.While Summit County APS has made excellent use of partnerships to stretch the funding received from the state, they have clear ideas of how services could be improved with additional funding. APS officials would like to add investigators, and establish consistent supports designed to stabilize fragile older adults who have been referred to APS. Summit County APS is also interested in exploring a regionalization of the APS system to cover the same counties as Direction Home, the Area Agency on Aging that covers Wayne, Portage, Stark and Summit counties.Similar to other counties, the type of cases most often referred to APS are those of self-neglect and financial exploitation. The financial exploitation cases often require considerable resources once the case is turned over to law enforcement.Switching to the new APS statewide reporting IT system has been a frustrating experience for Summit County. Prior to the statewide requirement, Summit County APS had a large database of current and previous clients, these clients did not roll over into the new system. Due to the number of workers on staff and through contract, Summit County needs more than two licenses to the database that are made available by the state. Summit County APS suggested that a statewide adult reporting system that closely mirrored the reporting system format used for child protective services would be easier for counties, who often have investigators who work for both APS and CPS, to implement and use on a daily basis. Summit County hopes to work with the state on this topic in the near future, as it serves on a state committee that is seeking to address the IT issues.