Transcript Slide 1

A Best-practice Model for New Hampshire’s
Adult Protective Services (APS)
Program
The Structured Decision Making® (SDM)
System
Presented by:
Rachel Lakin
Administrator of Adult Protective Services Program
Sally Varney
Director of Quality Improvement
Overview of Presentation
1.
Describing adult and elder maltreatment and the role of
NH Bureau of Elderly and Adult Services (BEAS),
Adult Protective Services (APS) Program
2.
Describing APS’ decision support system known as
Structured Decision Making® or SDM®
3. Current Status, Challenges and Opportunities
Structured Decision Making® and SDM® are Registered in the U.S. Patent and Trademark Office by the
National Council on Crime and Delinquency
Adult Protective Services
•
APS programs were created by states to protect vulnerable
adults and the elderly with trained staff responding to and
investigating allegations of self-neglect and maltreatment by
others.
•
Per an AARP Public Policy Institute publication, March 2011,
“calls for APS have increased during the recent recession
which began in Dec. 2007. However, funding for these
services either remained flat or decreased in many states” in
recent years.
•
APS programs are generally under-funded and exist with no
federal funding. The current hope is that Congress will
appropriate funds for the Elder Justice Act passed as part of
the Affordable Care Act.
Adult Protective Services
Per a March 2011 GAO Report, Elder Justice, Stronger Federal Leadership
Could Enhance National Response to Elder Abuse:
“The Adult Protective Services (APS) program in each state is generally
responsible for identifying, investigating, resolving and preventing abuse of
adults”
“In addition, given state governments’ current fiscal crises, there is concern
that potential cuts in funding for APS will threaten these programs’ ability to
effectively respond to the needs of a rapidly growing older adult population
and the increased incidence of elder abuse that can come with it.”
NH’s APS Structured Decision Making® system is designed to assist in the
prioritization of cases based on severity of the incident(s), vulnerability of the
identified victim(s), and potential risk of future harm. In light of limited and
possibly reduced resources, SDM® information assists staff, supervisors and
administrators to direct resources to where they are the most needed.
NH APS Program
The APS Program in NH serves adults and elderly that are
determined to be incapacitated (see definition below). Many
states’ APS programs serve just the elderly.
A P S R e p o r ts : S ta te F is c a l Y e a r s 2 0 0 9 , 2 0 1 0
3000
2470
2541
2500
1720
2000
1726
1500
1000
750
815
500
0
T o ta l # o f p r o te c tiv e r e p o r ts
o f a d u lts 1 8 - 5 9
T o ta l # o f p r o te c tiv e r e p o r ts
o f a d u lts 6 0 a n d o ld e r
2009
T o ta l # o f r e p o r ts ta k e n
2010
NH’s APS Program is charged with providing protection for incapacitated adults who are
abused, neglected, or exploited (RSA 161-F:42). Incapacitated means that the physical,
mental, or emotional ability of a person is such that he is unable to manage personal, home,
or financial affairs in his own best interest, or he is unable to act or unable to delegate
responsibility to a responsible caretaker or caregiver (RSA 161-F:43, VII)
NH APS Program
The following are the types of maltreatment of incapacitated
adults that NH APS addresses:
Self-neglect: The failure of an adult to meet his/her own basic needs
of food, housing, clothing and medical care.
Neglect: The failure to meet an adult’s basic needs of food, housing,
clothing and medical care.
Emotional Abuse: Behaviors that harm an adult’s emotional well-being
and/or self-worth, e.g., name calling, scaring, embarrassing,
destroying property, not allowing a person to see friends and family.
Physical Abuse: Injuries such as hitting, kicking, pushing, slapping,
burning or other show of force or physical harm
Sexual Abuse: Forcing an adult to take part in sexual behavior when
he/she did not or could not consent
Exploitation: Illegal use of an adult’s money, property or other assets
NH APS Structured Decision Making® System
Newness:
Implemented in 2008.
Creativity:
Innovative use of research to support APS practices.
Effectiveness:
Supports decision making at the case, supervisory
and administrative levels.
Transferability:
Other state and county APS agencies have
implemented components of the system; others have expressed
interest in the system.
Significance:
improvement.
Represents an evidence-based approach to practice
NH APS Structured Decision Making® System
Why did NH APS design and implement an SDM® system?
•
•
•
•
To systematically assess adults’ safety, risk of future harm,
and service needs to determine the best response(s);
To establish consistency and accuracy in decision-making
throughout the life of APS cases;
To obtain quantitative information to measure and monitor
outcomes; to determine:
• immediacy of initial responses,
• safety (immediate harm)status,
• risk (future harm)status, and
• access to needed services.
To expand the APS information system for program planning,
evaluation, budgeting, workload allocation, staffing needs, and
quality improvement
NH APS Structured Decision Making® System
Intake
Does the report meet criteria for APS investigation
 Is the adult incapacitated?
 Is there evidence of self-neglect, neglect, abuse
and/or exploitation?
If so, how quickly does the investigation need to be initiated:
 Within 24 or 72 hours
Investigation
Upon initial contact, are there imminent threats to safety?
 Is the alleged victim safe, conditionally safe or
unsafe?
By the conclusion of the investigation, what is the risk level
and what course of action should be taken to mitigate the
risk?
 Is the victim at low, moderate or high risk of future
harm?
 Should a case be opened and, if so, how frequently
should the victim be contacted?
Ongoing
What is to be addressed in the case plan?
 What are the clients’ strengths and needs?
 What are the primary caretakers’ strengths and
needs?
NH APS Structured Decision Making® System
Development of the actuarial SDM® Risk Assessment
Goals were to:
 classify adults by the likelihood of experiencing future
maltreatment (abuse, neglect, self-neglect, or exploitation)
 inform case opening decisions and level of engagement
 low risk: services not provided/not offered
 moderate risk: services provided/offered with frequent
contact
• high risk: services provided/offered with very frequent
contact
The research was made possible by the National Institute of Justice grant 2008 IJ-CX-0025,
“Developing an Actuarial Risk Assessment for Adult Protective Services.”
NH APS Structured Decision Making® System
Explanation for Actuarial Risk Assessment chart on next slide:
The individual and case characteristics of a sample of 763 clients
investigated by APS were examined and compared to subsequent reports
involving the same clients during a period of six months (March-Sept. 2009).
Among the March – Sept. sample of clients,
• 5.2% classified as low risk had a subsequent APS investigation
• 9.4% classified as moderate risk had a subsequent APS investigation
• 23.9 % classified as high risk had a subsequent APS investigation
To continue:
• only 2.0% classified as low risk had subsequent APS investigations
substantiate the allegation(s)
• 4.7% classified as moderate risk had subsequent APS investigations
substantiate the allegation(s)
• 14.7% classified as high risk had subsequent APS investigations
substantiate the allegation(s)
Conclusion: these risk groups (low, moderate, high) demonstrate
significantly different rates of future maltreatment thus allowing APS to
respond accordingly to resolve problems, mitigate risk and reduce the
likelihood of repeat maltreatment.
NH APS Structured Decision Making® System
N = 763; base rate, investigation = 10.1%; base rate, substantiation = 5.2%.
National Institute of Justice grant 2008-IJ-CX-0025
NH APS Structured Decision Making® System
Risk Assessment Contact Guidelines
Risk Level
Low
Moderate
High
Decision
Case is not opened
Contact Guideline
One monthly face-to(exception to open allowed with
face contact if case is
supervisor approval)
opened
Case is opened
Two monthly face-to(exception to not open when client refuses face contacts and one
services)
collateral contact
Case is opened
Three monthly face(exception to not open when client refuses to-face contacts and
services)
two collateral contacts
Current Status, Challenges, Opportunities
With the four SDM® assessments in NH’s electronic case
management system, NH’s APS supervisors, administrators
and quality improvement staff have more easily accessible
data to not only manage APS work but also to monitor
implementation of the SDM® program.
For instance, the table below illustrates the rate of Level 1
(response within 24 hours of receipt of report to APS) and Level 2
(response within 72 hours) for the first four months of CY 2011.
Intake Outcomes
Jan '11
Feb '11
Mar '11
Apr '11
Level 1
response
Level 2
response
(within 24
hours)
(within 72
hours)
2%
4%
1%
2%
98%
96%
99%
98%
Current Status, Challenges, Opportunities
In reviewing this data with supervisors, we believe
all staff may not be consistent in their review of
the comprehensive definitions and policies
established to gain consistency and accuracy in
decision-making at critical points in the life of a
report to APS and, in doing so, the trend is to
identify intakes more as Level 2 than Level 1.
Current Status, Challenges, Opportunities
A review of Safety outcomes reveals a similar concern as
with Intake data that there is some misunderstanding of how
and when to complete a Safety Assessment leading to a trend
of a higher percentage of Safe outcomes. In speaking with
supervisors, we believe it is more likely that a higher
percentage of alleged victims are initially conditionally safe
or unsafe and quickly become safe due to the diligence of the
APS staff.
Safety Outcomes
Jan '11
Feb '11
Mar '11
Apr '11
Safe
88%
84%
79%
91%
Conditionally
Safe
Unsafe
8%
4%
8%
7%
18%
3%
6%
3%
Current Status, Challenges, Opportunities
The SDM® risk assessment data for the same time period is
more reliable due to the fact that the risk assessment
outcomes are established by an algorithm and, thus, less
subjective than the other assessments. This data can be
compared with the rate of case openings and will eventually
be compared with recitivism data. Since the Risk Assessment
was implemented August 1, 2010, the rate of victims
experiencing repeat maltreatment will begin to be evaluated
after August of this year.
Risk Outcomes
Jan '11
Feb '11
Mar '11
Apr '11
Low Risk
50%
40%
52%
45%
Moderate
Risk
High Risk
40%
10%
52%
8%
36%
13%
49%
7%
Current Status, Challenges, Opportunities
The APS SDM® Program has been successfully implemented with
all assessments in the electronic case management system.
 This was accomplished over three years with staff having
to initially complete assessmsents as Word documents: a
time-consuming process that did not provide easy and
timely access to comprehensive data.
APS administration is committed to ongoing dialogue with
supervisors and staff to ensure consistency of implementation
through adherence to definitions and policy and review of
data.
APS administration promotes the program with its internal and
external stakeholders thus building confidence in APS and
providing opportunities for dialogue regarding ongoing and
prevention-focused service needs.
Thank you
Thank you for your attention and the opportunity to highlight
New Hampshire’s Adult Protective Services Structured
Decision Making® Program.
We invite you to contact us should you have any questions.
Rachel Lakin
Administrator of Adult Protective Services
[email protected]
603 271-4347
Sally Varney
Director of Quality Improvement
[email protected]
603 271-3264